DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient presents today with her dad with fever and irritability for the last couple of days. According to dad, the patient had some upper respiratory symptoms for about nine days; runny nose, got thick at one point but now it seems to be much clearer. The patient had a little bit of a cough but no shortness of breath or noticeable difficulty breathing. The patient was actually seen in our office back last week and lungs were clear at the time. She was diagnosed with a virus and advised to follow up if anything got worse. Yesterday, she developed a temperature of 104.6, and this morning, it was again 104. The patient had been eating well until about two days ago and now is not eating so well, but she is drinking lots of milk, according to the dad. The patient has had fairly normal wet diapers and soft stool. The patient has no known ill contacts.
OBJECTIVE: Vital signs revealed a temperature of 102.2 degrees axillary. In general, this is a minimally to mildly ill-appearing little girl who is crying and agitated with the examination, but in no acute distress. HEENT examination revealed anterior fontanelle was closed. The pupils were equal, round, and reactive to light. Extraocular movements were intact. The right tympanic membrane was red. Left tympanic membrane was pink. Oropharynx was red, especially the right tonsil. No exudates were noted. No petechiae noted. Mucous membranes were moist. Neck was supple and had full range of motion. No significant lymphadenopathy. Lungs were clear throughout with good aeration throughout. Heart revealed regular rate and rhythm. No murmurs were appreciated. The skin revealed no significant rash to examination.
LABORATORY DATA: Rapid strep was negative.
ASSESSMENT: Right otitis media.
PLAN:
1. Amoxicillin 200 mg per 5 mL 1 teaspoon b.i.d. x10 days.
2. Dad will alternate with Tylenol and ibuprofen throughout the day to keep the fever down, and hopefully, this will help her to take in some solid food.
3. The patient will follow up here in two weeks to ensure resolution of the ear infection, or sooner if any of her symptoms persist or worsen despite above.
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is brought in by her mom today. She has had an unfortunate two weeks. She was seen for her routine physical and felt to have an early otitis media. Because the family was going away on vacation, she was put on amoxicillin 250 mg 1 teaspoon 3 times a day. At that visit, she was also given her MMR. The patient began running a low-grade fever. She as well was having some conjunctivitis. She was prescribed sodium sulfacetamide drops and was placed on azithromycin. The patient continues to have fever, copious nasal drainage and a junky cough. Her eyes have cleared. She is here now for further evaluation.
The patient’s appetite has been okay. She is somewhat clingy but will otherwise act appropriately.
OBJECTIVE: The patient’s axillary temperature was 101.6 degrees. HEENT: There is bilateral erythema of the tympanic membranes. There is copious mucopurulent nasal discharge. Oropharynx: Clear. Neck reveals bilateral shotty adenopathy.
ASSESSMENT: Otitis media, unresponsive to plain amoxicillin and azithromycin, question of amoxicillin-resistant Haemophilus influenzae.
PLAN: The patient weighs 19 pounds. Her calculated Augmentin dose is 161 mg twice a day. The patient is, therefore, given 200 mg/teaspoon Augmentin 3/4 teaspoon twice a day for 10 days. The patient will follow up if her symptoms persist.
