Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: An 18-month-old toddler, Estaban, presents with his father for a sick visit. The child, who is typically healthy and up-to-date with immunizations, has had URI-like symptoms for the past 6 days with a congested cough and clear to yellow nasal discharge. Per parental report, Estaban is drinking fluids without difficulty and has slightly reduced appetite and had a single episode of post-tussive vomiting 3 days ago. 

For the past 36 hours, his father reports increased crankiness and intermittent fever to 102.6°F (39.2°C), with father stating “this is how he acted a few months ago when he had an ear infection.” Which of the two following findings are most suggestive in the diagnosis of acute otitis media in a toddler: 

A: Bulging tympanic membrane. 

B: Cough. 

C: Evidence of ear discomfort. 

D: Bilateral cervical lymphadenopathy.  

The correct answers are A and C. A: Bulging tympanic membrane and C: Evidence of ear discomfort. Where should we start? First, what kind of a question is this? And given that we're asked to come up with clinical findings in acute otitis media, this is a diagnosis question. First, a bit of background information. Acute otitis media, also known as AOM, is among the most frequent diagnoses noted in sick visits in children under the age of 15. 

The majority of AOM cases, defined as an acute inflammation of the middle ear, are caused by co-infection of bacteria and viruses and a much lower percentage, probably only 1 in 4 that are bacteria only and even a lower number that a virus only. Although AOM remains the most common childhood condition for which antibiotics are prescribed, the incidence of AOM is thankfully markedly decreased over the past decade, and this is in part due to increased rates of pneumococcal, RSV, and influenza vaccination, as well as a number of other factors. 

I do need to throw in there that little ones being passively exposed to cigarette smoke-that's a major risk factor for AOM, and with fewer people smoking and more people who do smoke being aware that they should not smoke around children, that likely has contributed to the drop as well. AOM in children usually present after a period of URI or untreated or poorly controlled allergic rhinitis or any other condition that allows for eustachian tube dysfunction and stasis of secretions in the middle ear. 

This is the situation we have with this little one, because he's been sick with a cold for a number of days. You'll also note that fever and crankiness did not start until about 36 hours ago, probably around the time that the otalgia or ear pain began. The ear pain in this little one is the direct result of the inflammation that goes along with the pathophysiology of AOM, and the origin of the inflammation is the infection, whether it's bacterial or viral. 

Another important part of this is that the patient states the child acted like this when he was sick with AOM in the past. That is such a helpful piece of information and it's a good lesson to remember: always listen to what the child's caregivers have to say. With this background information, let's take another look at the question. I'll cover acute otitis media for treatment in another podcast. 

I'm going to do something a little bit different with this question and go over breaking down the relevant history. So, please bear with me. Then I'll review the question and go over the different options. An 18-month-old Estaban presents with his father for a sick visit. The child, who is typically healthy and up-to-date with immunizations has had URI-like symptoms for the past 6 days with ingested cough and clear to yellow nasal discharge. 

So, what are we being told here? We're being told that this little one is typically healthy. He's up-to-date with the immunizations, which means he's received the vaccine that would minimize, but certainly not eliminate, his risk of acute otitis media. The vaccines that are most helpful at preventing AOM include the influenza and the pneumococcal vaccines. We are being told that he has fairly standard URI symptoms for the past 6 days. 

Nothing alarming being reported here. Per parental report Estaban is drinking fluids without difficulty and has a slightly reduced appetite in a single episode. A poster submitting three days ago. Here we're being told his GI function is intact. His appetite is down a little bit. That's very common with anyone of any age who doesn't feel well. 

In particular, don't be alarmed by that single episode of post-tussive vomiting. It's actually quite common in kids of this age where they cough to the point of vomiting. An isolated episode like this doesn't make me think that he's having a major GI dysfunction issue with anyone of any age. Planning on treating as an outpatient just this child would be assessing for intact GI function is critical to save care, and you want to include that in your clinical note as well. 

Back to the question. The past 36 hours, the father reports increased crankiness and intermittent fever to 102.6°F, or 39.2°C, with the father stating, “this is how we acted a few months ago when he had an ear infection.” As I mentioned, please listen to parents and caregivers and dads telling you this is how he acted when he had AOM before. 

Now, of course, you're going to go ahead and continue with your clinical assessment and confirm AOM findings, but this information is helpful and also there's no mention in the stem of the story of the question that the child was cranky before the last 36 hours, nor is there any mention of fever. This indicates that over the last day and a half, something has been brewing in addition to the URI. 

In other words, his signs and symptoms have changed. Now back to the question. Which of the two following findings are most suggestive of the diagnosis of acute otitis media in a toddler? And I'm going to add one more comment here prior to going into the options that this is generally how AOM presents, regardless of the patient's age. 

A: Bulging tympanic membrane. This is one of the correct options. On rare occasions, you get a board question that has more than one correct answer. But you'll always be told how many options to look for. On the board, there are no all of the above- or none of the above-type questions. And as I said, this question is in a format that doesn't crop up often. 

But usually, it's no more than two correct answers. Bulging TM. The results of inflammation and fluid stasis in the middle ear during acute otitis media is a hallmark of this condition. The TM is usually erythematous as well. So red TM, bulging TM. Those two together should make you think acute otitis media. 

But also remember, little squirts, if they're just plain crying and you're examining their eardrums, and their eardrums could be perfectly healthy. The eardrum might be a little bit pink if the kid is really yelling and we've all been there and he's got that toddler that just doesn't want their ears looked into. And so, sometimes that can give you a pinkish eardrum just because the child is crying but bulging TM-yeah, you're starting to think acute otitis media.  
 

B: Cough. That's not the correct answer. Well, quite often you'll hear a report of cough in your child with acute otitis media. And indeed, in this child there has been a report of cough. This is a nonspecific finding that goes along with the viral URI or poorly controlled allergic rhinitis or the like that is the contributor to the acute otitis media.  

C: Evidence of ear discomfort. This is another correct option. In a little one like this the child will usually age appropriately resist having the ear or ear is inspected like even more than they usually don't like having their ears looked at when they're this age because of discomfort. Think about it for a minute. 

A 6-year-old you go to inspect that child's ear with the otoscope and the ear is painful. The little one might say, ‘Stop looking in my ear, it makes it hurt’ or something along those lines. But an 18-month-old, they can't tell you that something hurts. But what they will do is often push you away. Cry even more. 

I swear, God bless them at 18 months that can develop the strength of ten adults. And I think they also grow a couple of extra arms and legs to push you away. But in all seriousness, pre-verbal children at this age will often rub the ears with the hand or rub their ear against the shoulder, their own shoulder. 

Or if they're hugged by an adult, they'll rub the ear up against the adults chest or shoulder. And that's really demonstrating that the child's uncomfortable. And that's where the crankiness comes from as well. Yeah, one thing that I do when I'm examining a little one, and I know I need to look in the little ones ears and particularly pre-verbal child where I can't talk my way through it in a way that I believe that they really understand what I'm saying. 

I always do tell them what I'm going to do, and then I'm going to take a quick look in their ears, and then I'll say, ‘Oh, puppy, how you feel? And oh, I'm so sorry. You've got this cold.’ I try to use a very soothing voice and say, ‘Let's take a look at these ears and see if I can find out why you don't feel good. 

Oh, you being such a good baby. Oh, aren't you beautiful?’ And I just I have this whole narrative that I go through that I find sometimes to actually soothe the child, to just soothe the child. Soothes me, soothes the parent. And then the parent knows that I'm trying to be considerate of the child. D: Bilateral cervical lymphadenopathy. While cervical lymphadenopathy can be present in acute otitis media, particularly when it's bilateral, it's a less sensitive and specific finding than the bulging TM and evidence of otalgia. 

Her key takeaway providing urgent care for the pre-verbal child is an important part of comprehensive health services. Knowing how to diagnose common conditions seen in children at this age is key to clinical practice success, as well as NP board success.  

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