Follow up DFASM2 4 – Irritability in An Infant

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Irritability in An Infant

 

Where?:

 Primary care physician’s office

Doctor’s name and Position

THOMAS BURLEY and
Primary Care Physician

Patient’s name:

Anthony Carlston

Age:

10 months and then 15 months

Presenting complaint:

- Low grade fever
- Irritability + fussiness

Past medical history:

Cold previous week

O/E:

- No sign of teething
- Normal throat
- Temperature 37.8°C
- Fontanelles + lymph nodes + abdominal exam = normal
- 28.7 inches
- 20.3 lbs
- Bulging + discolored eardrums

Diagnosis:

Middle ear infection

Treatment:

- ATB: amoxicillin twice daily over 10 days
- Tylenol

Risk factors for amoxicillin resistance:

Daycare, older siblings, recent history of ATB use, young age

Prognosis:

Symptoms should start to resolve over the next 48 to 72 hours

Second visit : O/E - Treatment - What treatment is not recommended? - Prognosis:

O/E: Fluid in Anthony’s ears

 Treatment: à Wait and see

 What treatment is not recommended? ATB, decongestants and antihistamines

 Prognosis: Anthony will probably be fine but observation for hearing loss. Check up in 3 months.

 

Transcript