prescription script
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West Coast University *
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530
Subject
Medicine
Date
Apr 3, 2024
Type
docx
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3
Uploaded by DoctorLyrebird2273
Prescription based on AAP recommendations of 80-90 mg/kg/day orally divided into 2 doses x 10 days. This dose falls at 83.81mg/kg/day, it has been adjusted to make it easier for the patient’s mother to measure and administer. Pharmacies supply oral syringes with a 10ml capacity.
PATIENT:
Abigail Thompkins
8219 S. Lamar Drive, Bakersfield, CA 98504
DOB:
11/21/16
Age:
5 year old
Date of service:
12/29/21
CHIEF COMPLAINT: Right Ear Pain
HISTORY OF PRESENT ILLNESS: Abigail presents with her mother. She has been fussy over the last 3 days a
Today she felt warm to touch and temperature at home was 99.8. No other signs or symptoms other than mom no
CURRENT MEDICATIONS: Tylenol as needed
DRUG ALLERGIES: NKDA RELEVANT
SOCIAL HISTORY: No Smoking in home. Lives with mom and dad and 2 older siblings
RELEVANT MEDICAL HISTORY: None
RELEVANT FAMILY HISTORY: None noted
REVIEW OF SYSTEMS CONSTITUTIONAL: Energy generally good, Weight stable, Eating and drinking fine
HEENT: No sore throat, No nosebleeds, No drainage or congestion except earlier in the week.
RESPIRATORY: No cough, No dyspnea, No wheezing
CARDIOVASCULAR: No chest pain
GI: No abdominal pain, No vomiting, No diarrhea
GU: No drainage or bleeding noted
SKIN: No rash
NEURO: No mental status changes
PHYSICAL EXAM WEIGHT: 42 pounds
VITALS: Temp: 101.2, Resp: 24, HR: 96
GENERAL: Awake, Alert
HEENT: Clear rhinorrhea, No erythema or exudate in throat, No conjunctival injection, left TM pearly gray, righ
RESPIRATORY: No distress heard
CARDIOVASCULAR: regular rate and rhythm
ABDOMEN: Soft and no tenderness noted
SKIN: pink, warm, dry, free of rash.
NEURO: Speech clear, Oriented MS: Good muscle strength
DIAGNOSIS/DIFFERENTIALS: Right acute serous otitis media
PLAN/Rx: 1st line antibiotic Amoxicillin Please re-connect for another online visit or see an in-person provider FOLLOW UP/REFERRALS: Return for ear check in 14-20 days. Mom voiced understanding and agreed to plan
Wanda Vearhaus, FNP-C Vearhaus Family Practice
1933 S. Chanell Road Bakersfield, CA 98504
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