Domain – Rural Health (case)

You are a GP in a town of 15,000 people. Sally presents with her three-year-old daughter, Jasmine, who has been unsettled and feverish for the past two days. Everyone in the family has a ‘cold’. Jasmine woke up this morning with a discharge from her left ear. She has been swimming in the local pool most days.

What are the important considerations in communicating with Sally and Jasmine?

How would you change your communication if Sally were Jasmine’s 16-year-old sister or if Sally were not fluent in English? What if Sally and Jasmine were Aboriginal or Torres Strait Islander, and Sally were Jasmine’s grandmother?

What if this were a telehealth consultation? How would you adapt your history-taking?

When communicating with Sally and Jasmine, a few key considerations should be addressed:

1. Establishing a Comfortable Environment: Ensure that Sally and Jasmine feel comfortable. Use a warm and friendly tone, and try to engage Jasmine to make her feel at ease. For example, you can use toys or pictures to distract her during the consultation.
2. Active Listening: Listen carefully to Sally’s description of Jasmine’s symptoms and their family history. Encourage Sally to elaborate on any concerns she has.
3. Clear and Simple Language: Use language that is easy to understand, avoiding medical jargon. For instance, instead of saying “otitis media,” you could say “an infection in Jasmine’s ear.”
4. Empathy and Reassurance: Reassure Sally that many children experience ear infections and that with proper treatment, Jasmine should recover well.
5. Education: Explain the potential cause of Jasmine’s symptoms, such as a possible ear infection from swimming in the local pool. Discuss the importance of hygiene and ear protection when swimming.
6. Follow-up: Explain the treatment plan clearly and discuss what symptoms to watch for that might require further medical attention.

Adjusting Communication for Different Scenarios

1. Sally as Jasmine’s 16-Year-Old Sister:
   • Maturity Consideration: Recognize that a 16-year-old might not have the same experience or confidence in managing a young child’s illness.
   • Support and Guidance: Provide additional support and clear instructions to help her manage Jasmine’s care.
   • Parental Involvement: If appropriate, involve another adult (e.g., parent or guardian) in the conversation to ensure Jasmine gets the best care possible.
2. Sally Not Fluent in English:
   • Use of Interpreter Services: If available, use a professional interpreter to ensure accurate communication.
   • Visual Aids: Use pictures, diagrams, or translated materials to explain Jasmine’s condition and treatment.
   • Simple Language and Patience: Speak slowly, use simple words, and be patient. Check for understanding frequently.
3. Sally and Jasmine as Aboriginal or Torres Strait Islander, and Sally as Jasmine’s Grandmother:
   • Cultural Sensitivity: Be aware of cultural norms and practices. Show respect and understanding of their cultural background.
   • Family Involvement: Recognize the role of extended family in the care of the child. Engage with other family members if appropriate.
   • Community Resources: Utilize local Aboriginal and Torres Strait Islander health services and community resources for support and culturally appropriate care.
   • Respect and Trust: Build trust by showing respect and acknowledging Sally’s role as the grandmother.

Telehealth Consultation Adaptations

1. Technical Setup: Ensure that both Sally and Jasmine are comfortable with the technology being used. Provide clear instructions on how to join the telehealth session.
2. Visual Cues: Pay extra attention to visual cues since physical examination is limited. Observe Jasmine’s behavior, appearance, and any visible symptoms.
3. Detailed History: Take a thorough history, asking detailed questions about Jasmine’s symptoms, onset, and any potential triggers like swimming.
4. Parental Guidance: Instruct Sally on how to perform basic checks (e.g., checking Jasmine’s temperature, looking for discharge) and describe findings.
5. Follow-up Plans: Emphasize the importance of follow-up appointments, whether in-person or via telehealth, to monitor Jasmine’s progress.

What further history do you need? Is Jasmine’s immunisation status relevant?

Why or why not?

What specific aspects of examination are important in Jasmine?

Further History

To effectively assess Jasmine’s condition, additional history is needed:

1. Detailed Symptom History:
   • Onset and duration of the fever and ear discharge.
   • Severity and characteristics of the discharge (color, consistency, odor).
   • Presence of other symptoms (cough, congestion, sore throat, rash, vomiting, diarrhea).
   • Any changes in behavior, such as increased irritability, lethargy, or decreased appetite.
2. Medical History:
   • Past medical history, including any previous episodes of ear infections or other significant illnesses.
   • Family history of recurrent ear infections or other respiratory conditions.
3. Swimming History:
   • Frequency and duration of swimming.
   • Any use of ear protection while swimming.
4. Environmental Factors:
   • Exposure to smoke, allergens, or sick contacts.
   • Living conditions, such as daycare or school attendance, which might increase exposure to infections.
5. Medications and Treatments:
   • Any medications or treatments already tried for the current illness, including over-the-counter medications.

Immunization Status

Jasmine’s immunization status is relevant for several reasons:

1. Prevention of Vaccine-Preventable Diseases:
   • Ensuring Jasmine is up to date on her vaccinations helps rule out serious diseases that can present with similar symptoms, such as measles, which can cause ear infections.
2. Assessment of Risk:
   • Knowing her immunization status helps assess her risk for complications from certain infections, like influenza, which can lead to secondary bacterial infections such as otitis media.
3. Guiding Treatment:
   • Certain vaccines (e.g., pneumococcal and Haemophilus influenzae type b) reduce the risk of infections that commonly cause otitis media, guiding the clinician’s differential diagnosis.

Specific Aspects of Examination

During the physical examination of Jasmine, the following aspects are important:

1. Vital Signs:
   • Temperature, heart rate, respiratory rate, and oxygen saturation to assess the severity of the illness.
2. Ear Examination:
   • Otoscopic examination to check for signs of otitis media (e.g., erythema, bulging tympanic membrane, presence of fluid or pus in the middle ear).
   • Note any pain or discomfort during the examination.
3. Head and Neck Examination:
   • Inspect for signs of lymphadenopathy, which may indicate a concurrent infection.
   • Examine the throat and nasal passages for signs of congestion or pharyngitis.
4. Respiratory Examination:
   • Auscultate the lungs to rule out any lower respiratory tract involvement, such as pneumonia, which can sometimes accompany or complicate upper respiratory infections.
5. General Appearance and Behavior:
   • Observe Jasmine’s general appearance, level of distress, and activity level.
   • Assess for signs of dehydration, such as dry mucous membranes or decreased skin turgor, especially if she has reduced oral intake or increased fluid loss from fever or sweating.
6. Skin Examination:
   • Look for any rashes or skin lesions that could suggest a viral exanthem or other underlying conditions.

By obtaining a thorough history and conducting a detailed physical examination, you can make a more accurate diagnosis and develop an appropriate treatment plan for Jasmine.

What is the most likely diagnosis?

What if there were no obvious focus for Jasmine’s infection?

How would your decision-making differ if this were the fourth time Jasmine presented with otitis media with perforation in the past three months? In the past six months?

What difference would it make to your diagnosis list if Jasmine were an Aboriginal or Torres Strait Islander?

Most Likely Diagnosis

Based on the provided history and symptoms, the most likely diagnosis for Jasmine is acute otitis media (AOM) with perforation. This is suggested by her fever, ear discharge, recent upper respiratory infection (URI) symptoms, and history of frequent swimming, which can predispose her to ear infections.

If There Were No Obvious Focus for Jasmine’s Infection

If there were no obvious focus for Jasmine’s infection, the differential diagnosis would need to be broadened. Considerations would include:

1. Urinary Tract Infection (UTI): Especially in young children, UTIs can present with fever without a clear source.
2. Viral Infections: Many viral infections can present with fever and general malaise without a specific focus initially.
3. Bacteremia or Sepsis: Although less common, a serious bacterial infection could present with fever without a clear focus.
4. Meningitis: A serious consideration in any febrile child without an obvious source of infection.
5. Other Sources of Infection: Thorough examination for signs of skin infections, gastrointestinal infections, or respiratory infections beyond the ear.

Recurrent Otitis Media

If Jasmine had presented with otitis media with perforation four times in the past three months or six times in the past six months, the approach would change as follows:

1. Chronic/Recurrent Otitis Media: Recurrent episodes indicate a need to evaluate for underlying causes, such as:
   • Eustachian tube dysfunction.
   • Allergies or sinusitis.
   • Adenoid hypertrophy.
   • Immunodeficiency.
   • Anatomical abnormalities.
2. Referral to Specialist: Consider referral to an otolaryngologist (ENT specialist) for further evaluation and management, including possible tympanostomy tube placement.
3. Hearing Assessment: Assess for any hearing impairment due to recurrent infections, as chronic otitis media can impact hearing and speech development in young children.
4. Prophylactic Measures: Discuss potential preventive measures, including avoiding known triggers, improving hygiene, and possibly antibiotic prophylaxis in select cases.

Considerations for Aboriginal or Torres Strait Islander Children

When considering a diagnosis list for an Aboriginal or Torres Strait Islander child, additional factors should be considered due to higher prevalence and different health risks:

1. Higher Prevalence of Ear Infections: Aboriginal and Torres Strait Islander children have a higher incidence of otitis media and its complications.
2. Chronic Suppurative Otitis Media (CSOM): This condition is more common and can lead to chronic ear discharge, hearing loss, and other complications. Consider CSOM if Jasmine presents with chronic ear discharge.
3. Socioeconomic and Environmental Factors: Consider the impact of living conditions, access to healthcare, and potential exposure to smoke or pollutants, which can exacerbate respiratory and ear infections.
4. Cultural Sensitivity: Ensure culturally appropriate communication and care, utilizing available Aboriginal and Torres Strait Islander health services and resources.
5. Broader Differential Diagnosis: Include conditions more prevalent in this population, such as skin infections, rheumatic fever, and other infections related to social determinants of health.

Summary

• Most Likely Diagnosis: Acute otitis media with perforation.
• No Obvious Focus: Broaden differential diagnosis to include UTI, viral infections, bacteremia/sepsis, and meningitis.
• Recurrent Otitis Media: Evaluate for underlying causes, refer to ENT, assess hearing, and consider prophylactic measures.
• Aboriginal or Torres Strait Islander Considerations: Higher incidence of otitis media and CSOM, impact of socioeconomic and environmental factors, and ensuring culturally sensitive care.

What treatment would you recommend?

If Jasmine were an Aboriginal or Torres Strait Islander, would that change your treatment/management?

How might working in a rural context affect management? If Jasmine were under six months old, how would that affect your decision-making?

What if Sally mentioned she was concerned about Jasmine’s language development?

Would that prompt you to consider other investigations? How would you explain the diagnosis of recurrent otitis media to Sally and Jasmine?

What if Sally insisted Jasmine needs to be able to swim? What advice would you give?

How would your management change if Sally and Jasmine live out of town and can only come in on the community bus once a week?

Treatment Recommendations

For Jasmine’s current presentation of acute otitis media with perforation, the following treatment plan is recommended:

1. Antibiotics:
   • Oral antibiotics such as amoxicillin are typically first-line treatment. For penicillin-allergic patients, alternatives like cefdinir or azithromycin can be considered.
   • Ear drops with antibiotics and corticosteroids may be used if there is significant discharge and the tympanic membrane is perforated.
2. Pain Management:
   • Analgesics such as panadol or ibuprofen to reduce fever and relieve pain.
3. Hydration and Rest:
   • Ensure Jasmine stays well-hydrated and gets adequate rest.
4. Follow-Up:
   • Schedule a follow-up appointment to reassess Jasmine’s condition and ensure the infection is resolving.

Considerations for Aboriginal or Torres Strait Islander Patients

When treating Aboriginal or Torres Strait Islander children, additional considerations include:

1. Enhanced Monitoring:
   • Closer follow-up due to the higher prevalence of complications from otitis media, such as chronic suppurative otitis media (CSOM).
2. Community Resources:
   • Utilize Aboriginal and Torres Strait Islander health services and community health workers for support and follow-up.
3. Cultural Sensitivity:
   • Ensure that treatment plans are culturally appropriate and explained in a culturally sensitive manner.

Rural Context Impact on Management

Working in a rural context may affect management in several ways:

1. Access to Specialist Care:
   • Limited access to ENT specialists might necessitate more proactive primary care management and telehealth consultations.
2. Medication Availability:
   • Ensure that prescribed medications are available at local pharmacies or consider providing the medications directly if feasible.
3. Follow-Up:
   • Emphasize the importance of follow-up visits and arrange convenient times or alternative follow-up methods (e.g., telehealth).

Management for Infants Under Six Months

For infants under six months old, decision-making includes:

1. Higher Risk:
   • Young infants are at higher risk for severe infections and complications. Immediate and aggressive treatment is warranted.
2. Hospitalization Consideration:
   • In some cases, especially if the infant appears very unwell, consider hospitalization for closer monitoring and intravenous antibiotics.
3. Careful Monitoring:
   • Closer follow-up and monitoring due to the increased risk of complications and the importance of ensuring proper growth and development.

Concerns About Language Development

If Sally is concerned about Jasmine’s language development:

1. Hearing Assessment:
   • Conduct a hearing assessment to rule out any hearing loss caused by recurrent ear infections, which could impact language development.
2. Developmental Evaluation:
   • Refer Jasmine for a developmental evaluation to assess her language and other developmental milestones.
3. Speech Therapy:
   • If hearing loss or developmental delays are identified, referral to a speech therapist may be appropriate.

Explaining Recurrent Otitis Media to Sally and Jasmine

When explaining recurrent otitis media:

1. Simple Explanation:
   • Explain that recurrent otitis media means Jasmine has had multiple ear infections within a short period.
2. Causes and Triggers:
   • Discuss potential causes and triggers, such as frequent colds, allergies, or exposure to smoke.
3. Impact on Health:
   • Explain how recurrent infections can affect hearing and overall health.
4. Management Plan:
   • Outline a management plan, including prevention strategies, possible treatments, and the need for follow-up.

Advice if Sally Insists on Swimming

If Sally insists that Jasmine needs to swim:

1. Ear Protection:
   • Recommend using ear plugs or a swim cap to prevent water from entering Jasmine’s ears.
2. Post-Swimming Care:
   • Advise drying Jasmine’s ears thoroughly after swimming and consider using drying ear drops if recommended by a healthcare provider.

Management for Limited Access to Healthcare

If Sally and Jasmine live out of town and can only come in once a week:

1. Extended Supply of Medications:
   • Provide an extended supply of medications to ensure continuity of treatment.
2. Telehealth Follow-Up:
   • Utilize telehealth for follow-up consultations if in-person visits are not feasible.
3. Detailed Instructions:
   • Provide detailed written and verbal instructions for home care and signs that require immediate medical attention.
4. Community Support:
   • Engage local community health workers or services to assist with follow-up and support in between visits.

By addressing these factors, you can ensure comprehensive and effective management for Jasmine while accommodating the unique aspects of her case.

Describe shared decision-making as it relates to otitis media in children. Are there resources to help you?

Does the rural location impact your shared decision-making?

What would you need to consider if the presentation was otitis externa and it was the fourth case you had seen this week?

The common thread was all patients had been swimming at the local pool.

Do you have any concerns? What would you do next?

Shared Decision-Making in Otitis Media in Children

Shared decision-making is a collaborative process in which healthcare providers and patients (or their caregivers) make decisions together, considering the best clinical evidence available, as well as the patient’s values and preferences. For otitis media in children, shared decision-making involves:

1. Explaining the Condition: Providing clear information about otitis media, its causes, symptoms, and potential complications.
2. Discussing Treatment Options: Presenting the benefits and risks of different treatment options, such as watchful waiting versus antibiotic therapy.
3. Considering Preferences: Listening to the caregiver’s concerns, preferences, and priorities regarding their child’s treatment and incorporating these into the decision-making process.
4. Setting Expectations: Clearly explaining what outcomes to expect from each treatment option and the importance of follow-up.
5. Supporting Informed Choices: Providing resources and support to help caregivers make informed decisions, such as printed materials or reputable online resources.

Resources in Australia

Australia has several resources to assist in shared decision-making for otitis media in children:

1. Australian Government Health Websites:
   • Healthdirect Australia (www.healthdirect.gov.au) provides reliable information about otitis media and treatment options.
   • National Health and Medical Research Council (NHMRC) guidelines offer evidence-based recommendations.
2. Clinical Guidelines:
   • The Australian Therapeutic Guidelines (eTG) provide detailed guidance on managing otitis media in children.
3. Patient Education Materials:
   • The Royal Children’s Hospital Melbourne offers accessible fact sheets and resources for parents and caregivers.
4. Aboriginal and Torres Strait Islander Health Services:
   • Specific resources and culturally appropriate care information are available through services like the Australian Indigenous HealthInfoNet.

Impact of Rural Location on Shared Decision-Making

In a rural location, shared decision-making can be impacted by several factors:

1. Access to Healthcare: Limited access to specialists and healthcare facilities can influence treatment choices, emphasizing the need for practical, locally available solutions.
2. Availability of Medications: The availability of medications and resources may affect treatment options and follow-up care.
3. Transportation and Logistics: Travel distances and the availability of transport can impact the feasibility of follow-up appointments and ongoing care.
4. Community Resources: Utilizing local community health workers and telehealth services can support shared decision-making in a rural context.

Recurrent Otitis Externa and Concerns about the Local Pool

If you had seen four cases of otitis externa in a week, all linked to swimming in the local pool, there are several concerns and steps to take:

1. Public Health Concern: Multiple cases suggest a potential issue with the local pool, such as contamination or poor maintenance practices.
2. Investigation:
   • Report to Health Authorities: Notify local public health authorities or environmental health services to investigate the pool’s water quality and maintenance.
   • Patient History: Gather detailed history from affected patients to identify any common factors or behaviors contributing to the infections.
3. Pool Inspection:
   • Ensure that the pool is inspected for water quality, chlorine levels, and adherence to hygiene standards.
   • Recommend temporary closure of the pool if necessary, until the issue is resolved.
4. Preventive Measures:
   • Advise swimmers on preventive measures, such as avoiding swimming with ear infections, using ear plugs, and ensuring proper ear hygiene after swimming.
   • Provide information on ear care and recognize symptoms of otitis externa early to prevent further cases.
5. Education and Awareness:
   • Educate the community about the potential risks and preventive strategies for otitis externa associated with swimming.

Next Steps

1. Contact Authorities: Report the cluster of otitis externa cases to the local public health unit to initiate an investigation.
2. Collaborate with Pool Management: Work with the pool management to address potential issues, ensuring the pool’s water quality is safe for swimmers.
3. Community Communication: Inform the community about the potential risk and the steps being taken to ensure safety.
4. Follow-Up: Ensure follow-up with the affected patients to monitor their recovery and provide guidance on preventing future infections.

By taking these steps, you can address the immediate health concerns, prevent further cases, and support the overall health and safety of the community.

During your consultation with Jasmine, your receptionist calls you to say that a patient has arrived with chest pain. You are the only doctor in your practice today. What would you do? It is the next day and you are at the supermarket.

What if Sally’s mother (Jasmine’s grandmother) approached you for an update on her granddaughter? How would you manage that?

Sally is the family day carer for your young son. How might this impact your relationship and/or this consultation?

What strategies/guidelines do you use to treat and manage friends, family or employees? What other challenges might you face in a rural context?

How might you manage these challenges? If you were working rurally, how would you access courses to increase your skills? How would you determine what skills you need?

Managing the Chest Pain Emergency

1. Assess the Situation Quickly:
   • Excuse yourself from the consultation with Jasmine, explaining briefly that an emergency requires your immediate attention.
   • Reassure Sally and Jasmine that you will return as soon as possible.
2. Prioritize the Emergency:
   • Attend to the patient with chest pain immediately, as this could be a life-threatening condition.
   • Perform a quick assessment to determine the severity and need for urgent intervention.
3. Delegation and Support:
   • If possible, delegate tasks to your receptionist or other staff, such as calling an ambulance if necessary or monitoring Jasmine and Sally until you can return.
4. Communication:
   • Communicate clearly with both patients to manage their expectations and ensure they understand the situation.

Approached by Jasmine’s Grandmother for an Update

1. Maintain Professional Boundaries:
   • Politely explain that you cannot discuss Jasmine’s medical information in a public setting and without Sally’s permission.
   • Suggest that she contact Sally directly for updates or make an appointment to discuss any concerns.
2. Respect Confidentiality:
   • Emphasize the importance of patient confidentiality and privacy.

Impact of Sally Being Your Son’s Family Day Carer

1. Professional Boundaries:
   • Maintain professional boundaries and treat Sally and Jasmine like any other patients.
   • Be transparent about any potential conflicts of interest and ensure that your medical decisions are based solely on clinical judgment.
2. Disclosure and Transparency:
   • If necessary, disclose your relationship with Sally to relevant parties to avoid any appearance of bias or favoritism.
3. Balancing Roles:
   • Clearly separate your professional role as a doctor from your personal role as a parent and community member.

Strategies for Treating and Managing Friends, Family, or Employees

1. Ethical Guidelines:
   • Follow ethical guidelines that recommend avoiding treating close friends, family, or employees whenever possible due to potential conflicts of interest.
2. Referrals:
   • Refer friends, family, or employees to another healthcare provider for their care to maintain objectivity and professionalism.
3. Clear Communication:
   • If you must treat them, ensure clear communication about the limits of the professional relationship and emphasize confidentiality and professional standards.

Challenges in a Rural Context and Management

1. Limited Resources:
   • Limited access to specialists and diagnostic facilities can be challenging.
   • Use telehealth services and establish strong referral networks with urban centers to address these limitations.
2. Community Relationships:
   • Navigating dual relationships in small communities where personal and professional roles often overlap can be challenging.
   • Maintain clear boundaries and seek support or advice from colleagues or professional bodies if needed.

Accessing Courses and Skill Development

1. Online and Distance Learning:
   • Take advantage of online courses, webinars, and distance learning programs offered by medical schools, professional organizations, and continuing education providers.
2. Professional Development Programs:
   • Participate in rural health professional development programs, which often offer tailored courses and support for rural practitioners.
3. Needs Assessment:
   • Conduct a self-assessment to identify areas where you need further skills or knowledge.
   • Seek feedback from colleagues, review your case history, and consider the specific needs of your patient population.
4. Professional Networks:
   • Engage with professional networks and rural health associations to stay informed about available training opportunities and to gain insights into essential skills for rural practice.

By implementing these strategies, you can navigate the complexities of rural healthcare practice, maintain professional boundaries, and ensure you have the necessary skills to provide high-quality care to your patients.

If Sally does not bring Jasmine for her follow-up appointment, how would you manage that?

What practice management systems do you have to alert you to a missed appointment?

Current guidelines for managing acute otitis media suggest Jasmine should be reviewed in four days. If you were planning to be away on leave and there is no locum to replace you, what would you recommend?

Do you know how to access allied health services in your community?

Managing Missed Follow-Up Appointments

1. Contact Sally Directly:
   • If Jasmine misses her follow-up appointment, contact Sally directly via phone to inquire about the reason for the missed appointment and to reschedule as soon as possible.
   • Express concern for Jasmine’s health and emphasize the importance of the follow-up visit to ensure her recovery.
2. Practice Management Systems:
   • Appointment Reminder System: Use an automated reminder system to send SMS or email reminders to patients before their appointments.
   • Follow-Up Alerts: Implement a system to flag missed appointments so that staff can follow up with the patient or caregiver promptly.
   • Patient Records: Ensure that electronic health records (EHR) include alerts for important follow-ups, and use these to track patient compliance.

Managing Follow-Up During Your Leave

1. Alternative Arrangements:
   • If you are planning to be on leave and there is no locum to replace you, arrange for another local healthcare provider to see Jasmine for her follow-up.
   • Communicate with Sally about the temporary change and provide contact information for the covering healthcare provider.
2. Telehealth Option:
   • If no in-person alternative is available, consider scheduling a telehealth appointment to review Jasmine’s progress.
3. Detailed Instructions:
   • Provide Sally with detailed instructions on what to monitor and when to seek immediate medical attention.
   • Advise her to bring Jasmine to the nearest healthcare facility if any concerning symptoms arise.

Accessing Allied Health Services in the Community

1. Local Health Networks:
   • Familiarize yourself with local health networks and community health services that offer allied health support, such as audiologists, speech therapists, and physiotherapists.
2. Referrals:
   • Use established referral pathways to connect patients with necessary allied health services. This may involve using electronic referral systems or direct communication with allied health providers.
3. Community Resources:
   • Collaborate with community health centers, Aboriginal and Torres Strait Islander health services, and local hospitals to identify and access allied health services.
4. Professional Associations:
   • Engage with professional associations, such as the Australian Allied Health Professionals Association, for resources and referral information.
5. Telehealth and Outreach Programs:
   • Utilize telehealth services for allied health consultations when in-person visits are not feasible.
   • Look for outreach programs that bring allied health services to rural communities.

By proactively managing missed appointments, planning for continuity of care during your leave, and leveraging community resources, you can ensure comprehensive and effective healthcare for Jasmine and other patients in your rural practice.

Detailed Step-by-Step Guidance

Missed Follow-Up Appointments:

• Initial Follow-Up Call: If Jasmine misses her follow-up, the receptionist should call Sally within 24 hours to reschedule.
• Second Attempt: If no response, make a second attempt within another 24 hours, perhaps using a different communication method (e.g., SMS).
• Documentation: Document all attempts to contact Sally in Jasmine’s medical record.

Preparing for Leave:

• Identify Alternative Providers: Reach out to nearby clinics or healthcare providers to arrange coverage.
• Communication: Inform Sally of the alternative provider and ensure she has all necessary contact information.
• Provide Instructions: Give Sally clear written instructions on what symptoms to monitor and when to seek immediate help.
• Schedule Follow-Up: Set a tentative follow-up appointment for after your return, ensuring Sally knows to keep monitoring Jasmine in the meantime.

Accessing Allied Health Services:

• Community Health Centers: Contact local health centers for lists of available allied health professionals.
• Referrals: Establish relationships with these professionals for smooth referral processes.
• Utilize Technology: Implement telehealth solutions to access distant allied health services when needed.
• Outreach Programs: Identify and collaborate with any programs that bring allied health services to rural areas.

By implementing these steps, you ensure that Jasmine receives appropriate follow-up care, maintain continuity of care during your absence, and effectively utilize available allied health services in your community.

How do you do an ear, nose and throat examination in a three year old?

What if Jasmine were an adult with a discharging ear thought to be from otitis externa? What is involved in aural toilet and ear wicks?

If Jasmine had a fever but no ear signs, how might you collect specimens to help you make a diagnosis?

Ear, Nose, and Throat Examination in a Three-Year-Old

Performing an ear, nose, and throat (ENT) examination in a young child requires a gentle and patient approach to ensure cooperation and accurate assessment.

1. Preparation:
   • Explain the procedure to both the child and the caregiver in simple terms to reduce anxiety.
   • Have the caregiver hold the child in a comforting position, such as sitting on their lap.
   • Use distraction techniques, such as toys or videos, to keep the child engaged.
2. Ear Examination:
   • Inspection: Start with visual inspection of the external ear for any signs of redness, swelling, or discharge.
   • Otoscopy: Gently insert the otoscope into the ear canal while stabilizing the child’s head. Look for:
     • Condition of the ear canal (e.g., redness, swelling, foreign objects).
     • Tympanic membrane appearance (e.g., bulging, retraction, perforation, fluid levels).
   • Tip: Use a smaller speculum appropriate for the child’s ear size and ensure the otoscope light is bright and clear.
3. Nose Examination:
   • Inspection: Look at the external nose for any signs of swelling or deformity.
   • Anterior Rhinoscopy: Use a nasal speculum and a light source to examine the nasal cavity. Look for:
     • Mucosal color and condition (e.g., erythema, edema).
     • Presence of discharge, polyps, or foreign bodies.
   • Tip: Ask the child to sniff or blow their nose gently to assess patency and check for nasal obstruction.
4. Throat Examination:
   • Inspection: Ask the child to open their mouth wide and say “ahh” to visualize the oropharynx.
   • Use of Tongue Depressor: If necessary, use a tongue depressor to better visualize the throat, including the tonsils, uvula, and posterior pharynx. Look for:
     • Redness, swelling, exudate, or lesions on the tonsils and pharynx.
   • Tip: Be quick and gentle to minimize discomfort and gagging.

Management of Otitis Externa in an Adult

For an adult with a discharging ear due to otitis externa, appropriate management includes aural toilet and potentially using ear wicks.

1. Aural Toilet:
   • Preparation: Explain the procedure to the patient and ensure they are comfortable.
   • Equipment: Use an otoscope, suction device, or small curette.
   • Procedure:
     • Gently remove any visible debris, discharge, or cerumen from the ear canal.
     • Suction may be used to clear the ear canal of fluid or debris.
     • Ensure that the ear canal is as clean and dry as possible to promote healing.
   • Tip: Be gentle to avoid causing trauma to the sensitive ear canal.
2. Ear Wicks:
   • Indication: Ear wicks are used when the ear canal is very swollen, and topical medications cannot penetrate.
   • Procedure:
     • Insert a sterile ear wick (usually made of compressed cellulose) into the ear canal.
     • The wick expands when it absorbs the ear drops, helping to deliver medication directly to the inflamed area.
     • Change the wick as needed, typically every 24-48 hours, until the swelling subsides.
   • Tip: Ensure the patient knows how to use ear drops effectively and the importance of follow-up care.

Specimen Collection for Fever without Ear Signs

If Jasmine has a fever but no ear signs, the following specimens might be collected:

Blood Tests:

• Complete Blood Count (CBC): Check for signs of infection or inflammation.
• Blood Cultures: Identify any bacterial infections in the bloodstream.

Urine Tests:

• Urinalysis: Check for signs of a urinary tract infection (UTI).
• Urine Culture: Identify the specific bacteria causing the infection.

Other Specimens:

• Throat Swab: For respiratory infections.
• Nasal Swab: For viral or bacterial pathogens.
• Chest X-ray: If respiratory symptoms suggest pneumonia.

The result of Jasmine’s ear swab M/C/S (microscopy, culture and sensitivity) is likely to take a week to return. Her previous ear swab showed multiple antibiotic-resistant Pseudomonas aeruginosa. How will you manage Jasmine?

Managing Jasmine with Antibiotic-Resistant Pseudomonas

Given Jasmine’s previous ear swab showed multiple antibiotic-resistant Pseudomonas aeruginosa and the current swab results will take a week to return, the following management steps are recommended:

Immediate Management:

• Antibiotic Choice: Based on previous resistance patterns, consider using antibiotics known to be effective against Pseudomonas, such as ciprofloxacin ear drops.
• Symptomatic Treatment: Use analgesics (e.g., panadol or ibuprofen) to manage pain and fever.
• Aural Toilet: Clean the ear canal if there is significant discharge or debris to enhance the effectiveness of topical treatments.

Close Monitoring:

• Follow-Up: Schedule a follow-up appointment within a few days to monitor Jasmine’s response to treatment.
• Emergency Plan: Advise Sally on signs of worsening infection or complications that would require immediate medical attention (e.g., increased pain, fever, or spread of infection).

Consultation:

• Specialist Referral: Consider referring Jasmine to an ENT specialist if her condition does not improve or if complications arise.

Preventive Measures:

• Swimming Precautions: Advise against swimming until the infection is resolved. Once she resumes swimming, recommend ear protection (e.g., ear plugs) to prevent future infections.

Education:

• Care Instructions: Provide Sally with clear instructions on administering medications, keeping the ear dry, and monitoring for any changes in Jasmine’s condition.

You have diagnosed otitis media in Jasmine. What are the potential risky sequalae?

What are the signs and symptoms of a deteriorating child that would cause you concern?

What serious illness would you need to exclude in a child or young person with a fever?

If you were the only doctor in the area, how would you manage the deteriorating child?

Who would you call on and what resources would you use to inform your decisions? Do you know where to find these resources at short notice?

Potential Risky Sequelae of Otitis Media

Otitis media can lead to several complications if not properly treated. These include:

1. Chronic Otitis Media: Recurrent infections can lead to persistent fluid in the middle ear, affecting hearing and speech development.
2. Hearing Loss: Temporary or permanent hearing loss due to chronic fluid accumulation or damage to the structures of the middle ear.
3. Mastoiditis: Infection of the mastoid bone, which can cause severe pain, swelling behind the ear, and potentially spread to other areas.
4. Tympanic Membrane Perforation: Persistent infection can lead to a hole in the eardrum, which may result in chronic drainage and hearing loss.
5. Intracranial Complications: Rarely, the infection can spread to the brain, causing meningitis, brain abscess, or encephalitis.
6. Facial Nerve Paralysis: Infection can impact the facial nerve, causing paralysis on one side of the face.

Signs and Symptoms of a Deteriorating Child

Signs and symptoms that would cause concern in a deteriorating child include:

1. High Fever: Persistent high fever (above 39°C or 102.2°F) despite treatment.
2. Lethargy and Poor Responsiveness: Child is unusually drowsy, difficult to wake, or unresponsive.
3. Increased Irritability: Excessive crying, inconsolability, or irritability.
4. Breathing Difficulties: Rapid, labored breathing, grunting, or apnea.
5. Poor Feeding: Refusal to eat or drink, leading to dehydration.
6. Decreased Urine Output: Fewer wet diapers or significant decrease in urination.
7. Persistent Ear Pain: Severe or worsening ear pain despite treatment.
8. Swelling and Redness: Around the ear or on the face, indicating possible spread of infection.
9. Neurological Symptoms: Seizures, stiff neck, or bulging fontanelle (in infants).

Serious Illnesses to Exclude in a Child with Fever

In a child or young person with fever, it is crucial to exclude serious illnesses, including:

1. Sepsis: A severe, body-wide response to infection that can lead to organ failure and death.
2. Meningitis: Inflammation of the protective membranes covering the brain and spinal cord, which can be bacterial or viral.
3. Pneumonia: Infection of the lungs causing breathing difficulties.
4. Urinary Tract Infection (UTI): Infection of the urinary system, which can lead to pyelonephritis if untreated.
5. Appendicitis: Inflammation of the appendix, which can rupture and cause peritonitis.
6. Bone and Joint Infections: Osteomyelitis or septic arthritis can present with fever and localized pain.

Managing a Deteriorating Child as the Only Doctor in the Area

Immediate Management Steps:

1. Stabilization:
   • Ensure the child has a clear airway, adequate breathing, and circulation (ABCs).
   • Administer oxygen if needed, and establish intravenous (IV) access for fluids and medications.
2. Assessment:
   • Perform a thorough clinical assessment to identify the source of infection and any signs of systemic involvement.
3. Initiate Treatment:
   • Start empirical IV antibiotics if sepsis or bacterial meningitis is suspected.
   • Provide antipyretics to reduce fever and analgesics for pain management.

Calling for Help:

1. Ambulance/Emergency Services:
   • Call emergency services for immediate transport to a higher-level care facility if necessary.
2. Consultation:
   • Contact a pediatrician or infectious disease specialist for advice on managing the case.
   • Use telehealth services to consult with specialists if available.

Resources for Decision Making:

1. Clinical Guidelines:
   • Refer to local or national clinical guidelines for managing pediatric infections and sepsis, such as the Australian Therapeutic Guidelines or the Royal Children’s Hospital Clinical Practice Guidelines.
2. Online Medical Resources:
   • Utilize trusted online medical resources such as UpToDate, Medscape, or BMJ Best Practice for real-time information.
3. Local Health Network:
   • Engage with the local health network, including nearby hospitals, community health centers, and allied health services.

Finding Resources at Short Notice

1. Clinical Guidelines and Protocols:
   • Keep printed or digital copies of important clinical guidelines and protocols readily accessible in the clinic.
2. Emergency Contact List:
   • Maintain an updated list of emergency contacts, including specialists, nearby hospitals, and ambulance services.
3. Professional Networks:
   • Establish connections with colleagues in nearby areas and professional networks for quick consultation and support.