Abigail presents with her mother. She has been fussy over the last 3 days and 2 days ago started tugging at her right ear.
Abigail presents with her mother. She has been fussy over the last 3 days and 2 days ago started tugging at her right ear.
Week 1 Discussion: Prescription Writing Assignment
Write and upload (Word doc or pdf) a prescription based on the chart information below. Include all of the necessary information to send a prescription to the pharmacy.
- Discuss with your peers areas of consideration for improvement on your prescription and others.
| PATIENT: Abigail Thompkins | 8219 S. Lamar Drive, Bakersfield, CA 98504 | 620-924-1189 |
| 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 and 2 days ago started tugging at her right ear. Today she felt warm to touch and temperature at home was 99.8. No other signs or symptoms other than mom noting she had a cold last week. 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, right TM erythematous and bulging. 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 should your symptoms worsen or persist. 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 | 650-988-1254 |
Requirements: See Instructions
Masters Nursing
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