Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015194439 Enc. Date 12/20/2021

Progress Notes (continued) Progress Notes by James A. Wayne Jr., MD at 12/20/2021 9:00 AM (continued)

Current Outpatient Medications: • albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler, Give 2 puffs every 6hrs for 3 days, then give 2 puffs every 6hrs as needed for shortness of breath or cough, Disp: 6.7 g, Rfl: 0 • cefdinir (OMNICEF) 250 mg/5 mL suspension, Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 days, Disp: 35 mL, Rfl: 0 • dextromethorphan 15 mg/5 mL syrup, Take 10 mLs by mouth 4 (four) times daily as needed for Cough., Disp: , Rfl: • inhalation spacing device (RITEFLO AEROCHAMBER), Use as directed for inhalation., Disp: 1 each, Rfl: 0

Review of patient's allergies indicates: No Known Allergies

History reviewed. No pertinent past medical history.

Review of Systems Constitutional: Negative for activity change, appetite change and fever. HENT: Positive for nasal congestion, rhinorrhea and sneezing. Eyes: Negative for discharge. Respiratory: Positive for cough. Negative for wheezing. Cardiovascular: Negative for chest pain. Gastrointestinal: Negative for abdominal pain, constipation, diarrhea and vomiting. Musculoskeletal: Negative for myalgias.

Objective:

PHYSICAL EXAM: Vitals:

12/20/21 0910

Temp:

(!) 95.3 °F (35.2 °C)

TempSrc:

Tympanic

Weight: Height:

5.579 kg (12 lb 4.8 oz)

2' 10.5" (0.876 m)

General: Alert and vigorous. Good color. No distress. Skin: No rashes or cyanosis. Eyes: No redness or injection. Discharge: None

ENT: Ears: Normal pinna/lobes. Left TM clear. Right TM bulging and slightly erythematous with purulent effusion Nasopharynx: Clear rhinorrhea and audible nasal congestion. Mouth/Throat: No oral lesions. Throat: no redness or tonsil enlargement. Neck: Supple, with no masses. Full range of motion present. Lymphatic: No adenopathy in anterior cervical or posterior cervical lymph node regions. Lungs/Chest: Clear to auscultation bilaterally. No wheezes or crackles. Good air flow, and no retractions. Heart: Normal sinus rhythm and regular rate. No murmurs.

Generated on 7/19/22 2:38 PM

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