NURS676 week 1 discussion: Prescription Writing

NURS676 week 1 discussion: Prescription Writing

Prescription code: 37311

Patient name: Abigail Thompkins               DOB: 11/21/16           Age: 5years

Address: 8219 S. Lamar Drive, Bakersfield, CA 98504

Phone: 620-924-1189                                     Today’s date: 12/29/21

Diagnosis: Right acute serous otitis media    Treatment: Amoxicillin

Dosage: 500 mg                      Duration: 10 days                  Route: Oral

Frequency: three times a day                        Refills: 0

Doctor’s name: Wanda Vearhau                    Doctor’s phone: 650-988-1254

Doctor’s address: 1933 S. Chanell Road Bakersfield, CA 98504

Doctors signature:

Special instruction: Amoxicillin capsules should be taken orally with a full glass of water. Do not chew or break them.

Prescription code: 37312

Patient name: Abigail Thompkins               DOB: 11/21/16           Age: 5 years

Address: 8219 S. Lamar Drive, Bakersfield, CA 98504

Phone: 620-924-1189                                     Today’s date: 12/29/21

Diagnosis: Right acute serous otitis media    Treatment: Acetaminophen

Dosage: 240mg                       Duration: 3 days                    Route: oral

Frequency: three times a day                        Refills: 0

Doctor’s name: Wanda Vearhau                  Doctor’s phone: 650-988-1254

Doctor’s address: 1933 S. Chanell Road Bakersfield, CA 98504

Doctors signature:

Special instruction: do not excessed the prescribed dose for the child as it can result in serious liver problems.

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Week 1 Discussion: Prescription Writing Assignment

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By Wednesday of Week 1, 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 fusy 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 RELEVENT

SOCIAL HISTORY: No Smoking in home. Lives with mom and dad and 2 older siblings

RELEVENT MEDICAL HISTORY: None

RELEVENT 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, regular rate and rhythm

ABDOMEN: Soft and no tenderness noted

SKIN: pink, warm, dry, free of rash.

NEURO: Speech clear, Oriented MS: Good muscle strenght

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