Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

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

Acct #: 72015178898 Enc. Date 12/16/2021

Progress Notes (continued) Progress Notes by James A. Wayne Jr., MD at 12/16/2021 9:30 AM (continued) days Dispense: 35 mL; Refill: 0

Pt with wheezing due to viral infection, Also with bilateral otitis media. Will treat OM with abx, however antibiotics will no affect congestion and cough. Albuterol 2.5mg neb given with excellent response. Improved air mvt, esepcially at right lung base and mild wheezing heard there. Pt fell asleep after the treatment. Tylenol (acetaminophen) or Motrin/Advil (ibuprofen) may be given for fever or discomfort and supportive care. Offer fluids to promote adequate hydration. Humidifier may help with nasal congestion. RTC/ER prn increased WOB, fever > 5 days, signs of dehydration or for parental questions or concerns.

Subjective:

HISTORY OF PRESENT ILLNESS: 22mo male with 4 day h/o congestion and cough. +post tussive emesis. + fever to 102 yesterday. + suprasternal retractions noted in addition to noisy breathing.

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, Use as directed for inhalation., Disp: 1 each, Rfl: 0 No current facility-administered medications for this visit.

Review of patient's allergies indicates: No Known Allergies

No past medical history on file.

Review of Systems Constitutional: Positive for appetite change and fever. Negative for activity change. 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: Positive for vomiting. Negative for abdominal pain, constipation and diarrhea. Musculoskeletal: Negative for myalgias.

Objective:

PHYSICAL EXAM: Vitals: Generated on 7/19/22 2:38 PM

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