Toddler with Cough: Clinical Reasoning and Differential
Diagnosis Simulation
Pediatric Case Study: 18-Month-Old Male with Acute Otitis
Media
1. Patient Demographics & Identifying Data
Patient Initials: J.F. (Javier Flores)
Age: 18 months
Gender: Male
Ethnicity: Hispanic/Latino
Height: 2 ft 10 in (86 cm)
Weight: 28 lb (12.7 kg)
Occupation: Not applicable (toddler)
,Living Situation (Social History): Lives with both parents and an
older sister in a smoke-free home. Attends daycare five days per
week.
Source of Information: Mother, who is considered a reliable
historian.
2. Chief Complaint (CC)
"My son has been pulling on his right ear and has had a fever
for two days."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 2 days ago after a week of nasal congestion
and a runny nose.
Location
Pain is localized to the right ear.
Duration
Ear pain has been persistent over the past 48 hours and is
worse during the evening.
Characteristics
, Mother reports frequent ear pulling, crying, irritability, poor
sleep, and decreased appetite. The child has had intermittent
fever and occasional crying while lying down.
Aggravating Factors
• Lying flat
• Feeding
• Touching the right ear
• Nighttime
Relieving Factors
• Acetaminophen
• Holding the child upright
• Comfort measures
Treatment
Mother administered:
• Acetaminophen 160 mg orally every 6 hours as needed
• Warm compress to the affected ear
Symptoms have shown only temporary improvement.
Severity
Mother rates the child's discomfort as 7/10.
Diagnosis Simulation
Pediatric Case Study: 18-Month-Old Male with Acute Otitis
Media
1. Patient Demographics & Identifying Data
Patient Initials: J.F. (Javier Flores)
Age: 18 months
Gender: Male
Ethnicity: Hispanic/Latino
Height: 2 ft 10 in (86 cm)
Weight: 28 lb (12.7 kg)
Occupation: Not applicable (toddler)
,Living Situation (Social History): Lives with both parents and an
older sister in a smoke-free home. Attends daycare five days per
week.
Source of Information: Mother, who is considered a reliable
historian.
2. Chief Complaint (CC)
"My son has been pulling on his right ear and has had a fever
for two days."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 2 days ago after a week of nasal congestion
and a runny nose.
Location
Pain is localized to the right ear.
Duration
Ear pain has been persistent over the past 48 hours and is
worse during the evening.
Characteristics
, Mother reports frequent ear pulling, crying, irritability, poor
sleep, and decreased appetite. The child has had intermittent
fever and occasional crying while lying down.
Aggravating Factors
• Lying flat
• Feeding
• Touching the right ear
• Nighttime
Relieving Factors
• Acetaminophen
• Holding the child upright
• Comfort measures
Treatment
Mother administered:
• Acetaminophen 160 mg orally every 6 hours as needed
• Warm compress to the affected ear
Symptoms have shown only temporary improvement.
Severity
Mother rates the child's discomfort as 7/10.
