{"id":4747,"date":"2024-11-27T00:01:00","date_gmt":"2024-11-27T00:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=4747"},"modified":"2025-10-01T11:38:23","modified_gmt":"2025-10-01T19:38:23","slug":"usmle-step-2-question-of-the-day-ear-pain","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day:\u00a0Ear pain"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain\/#Major_Takeaway\" >Major Takeaway\u00a0<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain\/#References\" >References\u00a0\u00a0<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>Just in time with a new USMLE\u00ae Step 2 CK Question of the Day!\u00a0<em>Today&#8217;s case involves a 3-year-old boy with ear pain in his right ear along with a cough and nasal congestion. The patient is on high-dose amoxicillin and acetaminophen, but returns 48 hours later for reassessment. What&#8217;s the best next step in managing his treatment?<\/em><\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 3-year-old boy is brought to his primary pediatrician\u2019s office for evaluation of ear pain. The parent reports that the patient has been holding the right ear in discomfort for the past 24 hours. They report an associated cough and nasal congestion. The patient was born full-term and has otherwise been healthy since birth. Temperature is 39.4\u00b0C (103\u00b0F), blood pressure is 107\/55 mmHg, pulse is 102\/min, respiratory rate is 32\/min, and oxygen saturation is 99% on room air. Physical examination demonstrates an erythematous, bulging tympanic membrane with a purulent effusion and impaired mobility following insufflation. There is no otorrhea present. The patient is started on high-dose amoxicillin and acetaminophen for analgesia. Forty-eight hours later, the patient returns for reassessment with persistent ear discomfort. Repeat otoscopic examination demonstrates persistent erythema, bulging, and purulent effusion of the tympanic membrane. Which of the following is the best next step in management?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Complete the course of amoxicillin<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Change amoxicillin to amoxicillin-clavulanate<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Reassess in 48 hours<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Administer topical corticosteroids<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Administer topical neomycin<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Change amoxicillin to amoxicillin-clavulanate<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t A, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Complete the course of amoxicillin<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This patient presents with persistent symptoms of otitis media following an initial treatment regimen with high-dose amoxicillin. This patient should receive broadened antibiotic therapy to adequately treat the infection.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Reassess in 48 hours<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This patient presents with persistent symptoms of otitis media following an initial treatment regimen with high-dose amoxicillin. This patient should receive broadened antibiotic therapy to adequately treat the infection.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Administer topical corticosteroids<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Topical corticosteroids are not indicated in the treatment of acute otitis media. Topical corticosteroids can be administered to patients with otitis externa.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Administer topical neomycin<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Topical neomycin is not indicated for this patient with acute otitis media. Topical neomycin can be considered for patients with otitis externa only if it can be confirmed that the tympanic membrane is intact.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"624\" height=\"338\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/image_e3be3a.png\" alt=\"ACUTE OTITIS MEDIA\nHigh dose Amoxicillin\n- 90 mg\/kg\n- Divide 2X daily\n- Taken orally\n\nAmoxicillin in past 30 days \nOR\nPurulent Conjunctivitis\nAntibiotic with beta Lactamase\n- e.g., Amoxicillin-clavulanate\n\nAmoxicillin Allergy\n3rd Gen Cephalosporin\n- e.g., Cefdinir\n\nFail to Improve with Amoxicillin, Calvulanate, or Cefdinir\n- IM Ceftriaxone\n- Adequately treat infection\" class=\"wp-image-4748\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/image_e3be3a.png 624w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/image_e3be3a.png?resize=300,163 300w\" sizes=\"auto, (max-width: 624px) 100vw, 624px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This pediatric patient presents with acute ear pain and findings suggestive of <strong>acute otitis media<\/strong>. Diagnosis of acute otitis media is dependent on direct otoscopy of the tympanic membrane, which, in this case, revealed an<strong> erythematous, bulging tympanic membrane with impaired mobility<\/strong>. This patient has evidence of <strong>severe otitis media<\/strong> based on his fever &gt;39 \u00b0C, <strong>mandating antibiotic therapy. <\/strong>Given the <strong>inadequate clinical response<\/strong> to initial treatment with <strong>high-dose<\/strong> <strong>amoxicillin<\/strong>, the best next step in management is to<strong> broaden antibiotic coverage <\/strong>by<strong> changing amoxicillin to amoxicillin-clavulanate.&nbsp;<\/strong>&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Once a diagnosis of <strong>acute otitis media<\/strong> is established, severity can then be assessed by age and duration of illness. Patients with symptoms greater than 48 hours, moderate to severe otalgia, or a temperature &gt;39 \u00b0C can be diagnosed with severe acute otitis media and require antibiotic therapy with high-dose<strong> amoxicillin<\/strong>. In contrast, patients with symptoms less than 48 hours, mild otalgia, or a temperature &lt;39 \u00b0C can be diagnosed with <strong>non-severe acute otitis media<\/strong> and may or may not require antibiotic therapy based on the patient&#8217;s age and the presence of unilateral vs bilateral symptoms. Patients who are <strong>two years and older<\/strong> with <strong>non-severe<\/strong> AOM may be watched for 48-72 hours with analgesia alone or prescribed high-dose amoxicillin with follow-up at 48-72 hours to determine treatment response. In contrast, children aged <strong>6-23 months<\/strong> with bilateral symptoms and non-severe AOM require antibiotics, while those with unilateral symptoms can be offered the option of treatment vs. close observation. Those with <strong>persistent or worsening symptoms<\/strong> <strong>at 48-72 hours <\/strong>should receive amoxicillin if it has not yet been tried, or they should start on <strong>broadened antibiotic therapy<\/strong> with either <strong>amoxicillin-clavulanate <\/strong>or a <strong>third-generation cephalosporin<\/strong>.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In contrast, treatment of <strong>otitis externa<\/strong> is more straightforward. Patients\/parents should receive counseling regarding ear hygiene and should be provided with oral analgesia, topical antibiotics (e.g. polymyxin, neomycin, fluoroquinolone), with consideration of a topical corticosteroid if there is significant associated swelling.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway\u00a0<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">In patients with otitis media, if clinical improvement has not occurred within 48-72 hours of antibiotic treatment with high-dose amoxicillin, the antibiotic coverage should be broadened to amoxicillin-clavulanate or cefdinir.&nbsp;&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video: <a href=\"https:\/\/www.osmosis.org\/learn\/Anatomy_and_physiology_of_the_ear\">Anatomy and physiology of the ear<\/a><\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References\u00a0\u00a0<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>For the diagnosis and management of otitis media with effusion. AAP. <a href=\"https:\/\/doi.org\/10.1542\/peds.113.5.1412\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/doi.org\/10.1542\/peds.113.5.1412<\/a>&nbsp;<\/li>\n\n\n\n<li>(2013). Guidance for the diagnosis and management of acute otitis media. AAP. <a href=\"https:\/\/doi.org\/10.1542\/peds.2012-3488\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/doi.org\/10.1542\/peds.2012-3488<\/a>&nbsp;<\/li>\n\n\n\n<li>(2013). Guidance for the diagnosis and management of otitis externa. AAP. <a href=\"https:\/\/doi.org\/10.1542\/pir.34-3-143\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/doi.org\/10.1542\/pir.34-3-143<\/a>&nbsp;<\/li>\n\n\n\n<li>American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. <em>Pediatrics<\/em>. 2004;113(5):1412-1429. doi:10.1542\/peds.113.5.1412&nbsp;<\/li>\n\n\n\n<li>Long M. Otitis externa. <em>Pediatr Rev<\/em>. 2013;34(3):143-144. doi:10.1542\/pir.34-3-143&nbsp;<\/li>\n\n\n\n<li>Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media [published correction appears in Pediatrics. 2014 Feb;133(2):346. Dosage error in article text]. <em>Pediatrics<\/em>. 2013;131(3):e964-e999. doi:10.1542\/peds.2012-3488<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/create\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/Blog_Display_Ads_MOBILE1_2023.png\" alt=\"\" class=\"wp-image-4749\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/Blog_Display_Ads_MOBILE1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/Blog_Display_Ads_MOBILE1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more &nbsp;USMLE\u00ae Step 2 CK practice questions?&nbsp;Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and discover why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Just in time with a new USMLE\u00ae Step 2 CK Question of the Day!\u00a0Today&#8217;s case involves a 3-year-old boy with ear pain in his right ear along with a cough and nasal congestion. The patient is on high-dose amoxicillin and acetaminophen, but returns 48 hours later for reassessment. What&#8217;s the best next step in managing [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":4750,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[27,10,11,34,16,1370,45],"tags":[],"class_list":["post-4747","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-clinical-skills","category-comlex","category-omm","category-do","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day:\u00a0Ear pain - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-ear-pain\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day:\u00a0Ear pain - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Just in time with a new USMLE\u00ae Step 2 CK Question of the Day!\u00a0Today&#8217;s case involves a 3-year-old boy with ear pain in his right ear along with a cough and nasal congestion. The patient is on high-dose amoxicillin and acetaminophen, but returns 48 hours later for reassessment. 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