PRESENTING WITH EAR PAIN AND FEVER AT
OUTPATIENT PEDIATRIC CLINIC WITH LABORATORY AND
OBSERVATIONAL CAPABILITIES
,PATIENT INFORMATION
Name: Not provided
Age: 2 years
Sex: Male
Height: 2′9″ (84 cm)
Weight: 27.0 lb (12.3 kg)
Location: Outpatient pediatric clinic with laboratory and observational capabilities
Reason for Encounter: Ear pain and fever
The patient is a 2-year-old male brought by his caregiver due to acute onset of fever and right ear
pain associated with irritability, ear-tugging, and poor appetite.
, REASON FOR ENCOUNTER
The patient presents with acute ear pain and fever requiring evaluation for acute otitis media or
other infectious etiologies. The goal is to identify the cause, relieve pain and fever, prevent
complications, and ensure proper follow-up.
Component Description
Encounter type Outpatient pediatric visit
Chief complaint Ear pain and fever
Onset Acute, 2 days
Duration Persistent
Location Right ear
Characteristics Irritability, ear-tugging, crying
Aggravating factors Touch, lying down
Relieving factors Analgesics provide partial relief
Associated symptoms Runny nose, mild dry cough
Systemic concerns Fever ~101–103°F
Patient goals Reduce symptoms, identify infection