Complete Shadow Health Pediatric Assessment for David Carter. Acute otitis media — erythematous tympanic membrane, decreased mobility, ear tugging, fever 38.4°C. Complete pediatric history, growth chart plotting, developmental screening and family-centred care documentation. Used in GCU, STU and Aspen pediatric nursing courses.
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David Carter is a 4-year-old male brought in by his mother for right ear pain for 2 days and fever. He has been tugging at his right ear, has decreased appetite and disrupted sleep. Temperature is 38.4°C. He attends daycare and had a URI last week — a common preceding illness for otitis media.
The Pediatric Assessment covers the complete pediatric history including birth history, immunization status, growth and development, family history, and the paediatric physical examination. Growth chart plotting confirms weight and height in the 50th percentile for age. Developmental screening using age-appropriate milestones is documented. Otoscopic examination reveals erythematous tympanic membrane with decreased mobility on right.
Right TM: erythematous, decreased mobility. Temp 38.4°C. Diagnosis: Acute otitis media, right ear. Amoxicillin prescribed, analgesic for pain, return precautions and parent education documented.