Pediatric Primary Care Case Studies (90 page)

You decide to bring Sam back for an ear recheck in 6 weeks to evaluate for resolution of the OME. On follow-up, the middle ear fluid has resolved. He continues to do well developmentally and his mother has no new concerns.

Key Points of the Case

1. Otitis media is a clinical diagnosis that requires both evidence of middle ear effusion and signs and symptoms of middle ear inflammation on physical examination.

2. Assessment of the child’s pain and an appropriate plan for pain control should always be addressed in the management of acute otitis media.

3. Treatment of otitis media with antibiotics varies based on the child’s age, risk factors, and the constellation of symptoms, but high dose amoxicillin is typically the first line antibiotic agent.

4. It is not uncommon to have evidence of middle ear effusion after successful treatment of AOM.

5. The majority of cases of AOM and OME can be managed by the primary care practitioner, but referral to an otolaryngologist may be required in cases of treatment failure.

REFERENCES

American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, Subcommittee on Otitis Media with Effusion. (2004). Otitis media with effusion.
Pediatrics, 113(5)
, 1412–1429.

American Academy of Pediatrics, American Academy of Family Physicians, Subcommittee on Management of Acute Otitis Media. (2004). Diagnosis and management of acute otitis media.
Pediatrics, 113(5)
, 1451–1465.

Block, S. L., Hedrick, J., Harrison, C. L., Tyler, R., Smith, A., Findlay, R., et al. (2004). Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media.
Pediatric Infectious Disease Journal, 23(9)
, 829–833.

Kerschner, J. E. (2007). Otitis media. In R. M. Kliegman, K. J. Marcdante, H. B. Jensen, & R. E. Behrman (Eds.),
Nelson essentials of pediatrics
(18th ed., pp. 2362–2646). Philadelphia: Elsevier Saunders.

Kum-Nji, P., Meloy, L., & Herrod, H. (2006). Environmental tobacco smoke exposure: prevalence and mechanisms of causation of infections in children.
Pediatrics, 117(5)
, 1745–1754.

Maxson, S., & Yamauchi, T. (1996). Acute otitis media.
Pediatrics in Review, 17
, 191–195.

Paradise, J. L., Rockette, H. E., Colborn, K., Bernard, B. S., Smith, C. G., Kurs-Lasky, M., et al. (1997). Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life.
Pediatrics, 99
, 318–333.

Pickering, L. K., Baker, C. J., Long, S. S., & McMillan, J. A. (Eds.). (2006).
Red book: 2006 report of the Committee on Infectious Diseases
(27th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Ramakrishnan, K., Sparks, R. A., & Berryhill, W. E. (2007). Diagnosis and treatment of otitis media.
American Family Physician, 76
(11), 1650–1658.

Rothman, R., Owens, T., & Simel, D. (2003). Does this child have acute otitis media?
Journal of the American Medical Association, 290
(12), 1633–1640.

Rovers, M. M., Schidler, A. G. M., Zielhuis, G. A., & Rosenfeld, R. M. (2004). Otitis media.
Lancet, 363
, 465–473.

Siegel, R. M., & Bien, J. P. (2004). Acute otitis media in children: a continuing story.
Pediatrics in Review, 25
, 187–193.

Sinai, L. N., & Biggs, L. M. (2003). Earache. In: M. W. Schwartz, L. M. Bell, P. M. Bingham, E. K. Chung, D. F. Friedman, & A. E. Mulberg (Eds.),
The 5-minute pediatric consult
(3rd ed., pp. 32–33). Philadelphia: Lippincott, Williams & Wilkins.

Spiro, D. M., & Arnold, D. H. (2008). The concept and practice of a wait-and-see approach to acute otitis media.
Current Opinion in Pediatrics, 20
(1), 72–78.

U.S. Department of Health and Human Services. (2006).
The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Chapter 23

The Athlete Who Experienced Syncope

Patrick E. Killeen

An episode of syncope in a child or adolescent always merits careful investigation by the primary care provider (PCP). The clinical question that must be quickly answered when the child or teen is first seen is whether the syncopal event (or events) represents a serious underlying medical problem or a non-life-threatening, temporary annoyance. The PCP must obtain a detailed history to accurately identify the underlying cause of a particular child’s syncope from the wide range of potential differential diagnoses associated with syncopal events. Omission of key questions may result in unnecessary and expensive diagnostic testing or failure to identify an underlying life-threatening medical problem. After having adequately explored essential historical questions and queried for significant associated symptoms with the child or teen and/or parent(s), a thorough physical examination is then performed. In addition to outlining history and physical findings that are critical elements of the assessment, this case study will also feature information about the often challenging issue of selecting diagnostic tests that should be ordered routinely or based on symptomatology and when to refer the child to a specialist for a definitive diagnosis or additional diagnostic work-up and management.

Educational Objectives

1.   Identify key historical questions that need to be asked when a teen has experienced a syncopal episode.

2.   Differentiate between signs and symptoms that point to a life-threatening syncopal condition versus a benign syncopal event.

3.   Understand the underlying mechanisms of vasovagal-induced syncope.

4.   Describe the key principles underlying the emergent evaluation of syncope in children and adolescents.

5.   Identify the initial screening diagnostic work-up for a female teen who presents in the emergency department (ED) with a first-time episode of syncope.

  Case Presentation and Discussion

Emma Kaplan is a 14-year-old female who “fainted” after a field hockey game. Emma arrives with her field hockey coach to the ED via ambulance. She is alert and conscious. The coach states that immediately after the game while all the girls were in a huddle Emma “stood up and passed out.” The coach states that Emma fell face down and was unresponsive for about 15–30 seconds or so. Emma states that she remembers playing the entire game while feeling hot, nauseated, sweaty, and short of breath. The last thing she remembers is suddenly feeling dizzy.

Before you proceed further, you need to review what you know about syncope episodes.

Overview of Syncope

Syncope is a sudden, brief loss of consciousness associated with loss of postural tone from which recovery is spontaneous (Kapoor, 2000). This abrupt loss of consciousness results from an interruption of energy sources to the brain, usually because of a sudden reduction of cerebral perfusion. Up to 15% of children experience a syncopal episode prior to the end of adolescence (Lewis & Dhala, 1999). Life-threatening causes of syncope can be identified by a detailed history and physical examination including family history and a few select diagnostic studies. There are multiple causes of syncope for the practitioner to consider, some of which may be life-threatening. (See
Table 23-1
.) Their origin can be:

•   Neurologic

   Seizure/migraine syndrome

   Cerebral concussion

•   Cardiac

   Cardiac arrhythmias including long QT syndrome

   Vasovagal

•   Pregnancy

•   Psychogenic

   Hyperventilation or breath holding