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Otitis Media Decision Tool with Note

by Mark Morgan on January 11, 2011

Tagged as: aom, calculator, note-template, otitis-media, uri

summary, references, & relevant links
Summary: This decision tool applies the American Academy of Pediatrics Guideline Subcommittee on Management of Acute Otitis Media (2004) Pediatrics 113: 1451-65 for diagnosing and managing acute otitis media.
A similar paper-based encounter tool is available at Ebell (2004) Am Fam Physician 69: 2896-98 .

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Age group*
- 2 to 6 months
- 6 months to 2 years
- Over 2 years
Visit timing*
- Initial visit for otitis
- Otitis follow up after observation
- Otitis follow up after after antibiotic treatment
AAFP information on drug allergy Reidl (2003) Am Fam Physician 68: 1781-91
Penicillin allergy*
- No penicillin allergy
- Penicillin allergy
History of Present Illness
*** day history of ear pain. pain is rated at ***/10. Over-the-counter medications tried at home include ***. Sick contacts include ***. pertinent positives: *** fever. *** chills. *** nausea. *** vomiting. *** diarrhea. *** sore throat. pertinent negatives: *** taking liquids well. *** active.
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Physical examination
General: Alert, appropriate Eyes: Conjunctiva not injected Nose: Normal mucosa, no discharge Pharynx: Normal pharynx and tonsils Lungs: Clear to auscultation bilaterally Skin: No rash or lesions
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Acute onset? *
- Yes
- No
Acute onset: Recent, usually abrupt onset of signs and symptoms of middle-ear inﬂammation and effusion.
American Academy of Pediatrics Slidebook of otoscope images
Bulging of the tympanic membrane?*
- None
- Left
- Right
- Both
Middle ear effusion signs.
Limited or absent mobility of the tympanic membrane*
- None
- Left
- Right
- Both
Middle ear effusion signs.
Otorrhea?*
- None
- Left
- Right
- Both
Middle ear effusion signs.
Air fluid level?*
- None
- Left
- Right
- Both
Middle ear effusion signs.
Signs of middle ear effusion are present
- Middle ear effusion is present
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No signs of middle ear effusion are present
- No signs of middle ear effusion
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Distinct erythema at tympanic membrane?*
- None
- Left
- Right
- Both
Sign of middle ear inflammation.
Significant otalgia?*
- No
- Yes
Symptom of middle ear inflammation: Distinct otalgia (discomfort clearly referable to the ear[s] that interferes with or precludes normal activity or sleep).
Signs/symptoms of middle ear inflammation are present
- Middle ear inflammation is present
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Signs/symptoms of middle ear inflammation are absent
- Middle ear inflammation is absent
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Severity*
- Temperature IS NOT above 39 degrees Celsius/102.2 Fahrenheit. Moderate to severe otalgia IS NOT present
- Temperature at or above 39 degrees Celsius/102.2 Fahrenheit
- Moderate to severe otalgia
- Temperature at or above 39 Celsius/102.2 Fahrenheit AND Moderate to severe otalgia is present