Illness Script Template

Symptom or Diagnosis
Acute Cholecystitis Acute Otitis Media
Epidemiology  A syndrome of right upper quadrant pain, fever,  Peak incidence occurs between six and twelve months of life
and leukocytosis associated with gallbladder and declines after age five. .(2)
inflammation. (3)  Less common in adults than in children. (2)
 Typically develops in patients with a history of  Slightly more common in males than in females.(2)
symptomatic gallstones. (3)  Risk factors: Preceding upper respiratory tract infection, male
 Occurs in men and women. (3) gender, adenoid hypertrophy (obstructing), allergy, daycare
 Risk factors: attendance, environmental smoke exposure, pacifier use,
o Increases in women, obese patients, pregnant immunodeficiency, gastroesophageal reflux, parental history of
women, and patients in their 40s. (3) recurrent childhood OM, and other genetic predispositions. (2)
o Drastic weight loss or acute illnesses. (3)
o Can run in families. Other conditions that cause
the breakdown of blood cells, for example,
sickle cell disease. (3)
Pathophysiology Occlusion of the cystic duct or malfunction of the Begins as an inflammatory process after a viral upper respiratory
mechanics of gallbladder emptying. (3) tract infection. The inflammatory process causes edema in the
Eustachian tube and obstructs it causing decreased ventilation, which
then results in increasing negative pressure in the middle ear,
increasing exudate from the inflamed mucosa, and buildup of
mucosal secretions leading to the colonization of bacterial and viral
organisms in the middle ear. These microbe growths lead to
suppuration and frank purulence in the middle ear space
demonstrated clinically by a bulging or erythematous tympanic
membrane and purulent middle ear fluid. .(2)
Clinical  Typical complaints of abdominal pain, most  Otalgia, otorrhea, headache, fever, irritability, history of
Presentation – Hx commonly in the right upper quadrant or lethargy.(5)
epigastrium. (6)  Concurrent or recent symptoms of upper respiratory infection,
 Pain is steady and severe and is typically such as cough, rhinorrhea, or sinus congestion (5)
prolonged (greater than four to six hours). (6)  GI symptoms – Anorexia, nausea, vomiting, diarrhea. (5)
 Pain may radiate to the right shoulder or back. (6)  Passive (i.e., secondhand) exposure to tobacco smoke (5)
 Associated complaints may include fever, nausea,  Group daycare attendance (5)
vomiting, and anorexia. (6)  Higher in winter season and early spring than in summer and
 Often has a history of fatty food ingestion one early fall (5)
hour or more before the initial onset of pain. (6)  Supine bottle feeding (i.e., bottle propping) (5)

Clinical  Ill-appearing, febrile, tachycardic, and lie still on  Fluid-filled middle ear, ear pain. . (2)
Presentation – PE the examining table. (6)  Bulging, opaque, erythematous, and immobile tympanic
 Voluntary and involuntary guarding. (6) membrane.(4)
 Positive Murphy's sign. (6)
 Complications may have signs of sepsis
(gangrene), generalized peritonitis (perforation),
abdominal crepitus (emphysematous
cholecystitis), or bowel obstruction (gallstone
ileus). (6)
Diagnostic Tests  CBC, serum lipase and amylase, electrolytes, Pneumatic otoscopy (94% sensitive and 90% specific). (1)
ALT, AST, bilirubin, calcium, and albumin. (6) Tympanometry (70% to 94% sensitive and 90% specific). (1)
 Ultrasonography (6) Tympanocentesis (diagnostic standard) for identifying the causative
 HIDA scan (6) bacteria. (1)
 MRCP (6)
 Abdominal CT (6)
Typical Laparoscopic cholecystectomy. (3)  Observation for 48 to 72 hours without antibiotics in lower-risk
Treatment If complicated, may be open cholecystectomy. (3) children. (1)
Poor surgical candidate – percutaneous  Antibiotic therapy:
cholecystostomy or low-fat, low-spice diet. (3) o A 10-day course of antibiotics for age <2 years olds or with
severe symptoms. (1)
o A 5 to 7-day course for age >2 years or older and with less
severe symptoms. (1)

1
 o High-dose amoxicillin (80 to 90 mg per kg per day in two
divided doses) is a first-line therapy. (1)
o For penicillin or cephalosporin allergy risk, use Cefdinir or
azithromycin (Zithromax) as the first-line antibiotic. (1)

References:
1. Gaddey, H. L., Wright, M. T., & Nelson, T. N. (2019). Otitis Media: Rapid Evidence Review. American Family Physician,
100(6), 350–356. https://www.aafp.org/pubs/afp/issues/2019/0915/p350.html
2. Danishyar, A., & Ashurst, J. V. (2023, April 15). Acute Otitis Media. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK470332/
3. Jones, M. W., Genova, R., & O’Rourke, M. C. (2022). Acute Cholecystitis. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK459171/#:~:text=Acute%20cholecystitis%20is%20inflammation%20of
4. Mankowski, N. L., & Raggio, B. S. (2023). Otoscope Exam. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK553163/#:~:text=Acute%20Otitis%20Media%20(AOM)
5. Otitis Media Clinical Presentation: History, Physical Examination, Complications. (n.d.). Emedicine.medscape.com.
https://emedicine.medscape.com/article/994656-clinical
6. Zakko, S. F. & Afdhal, N. H. (n.d.). UpToDate. Retrieved March 3, 2024, from https://uptodate.com/contents/acute-
calculous-cholecystitis-clinical-features-and-diagnosis?search=acute
%20cholecystitis&source=search_result&selectedTitle=1~130&usage_type=default&display_rank=1#H6