Transcription of Family Practice Progress Notes
1 Family Practice Progress Notes Name Jennifer Winkle DOB 6/15/20XX. Date Notes 08/10/20XX Jennifer is a well known patient to our office. She is here for an earache. orally P-82-R-16. She is in moderate distress sitting in her mother's lap. Pt. made no eye contact. However, when asked which ear she pointed to her R. ear. Sue. Everett 8/10/20XX 10:15AM. 08/10/20XX Jennifer 4 y/o white female is here with her mother. Patient is complaining of Right ear pain for 2 days. She had an elevated temp, which mom has treated with children's Advil which has also controlled the ear pain somewhat. Right ear tympanic membrane is bulging with ear wax. Threat minimal to date.
2 Cloudy post nasal drip. Lungs clear. Impression: Right acute perousotitis media. Will start on Augmenten today for 7 days. Return in 2 wks. for a recheck or sooner if symptoms do not improve. Steve Harvey MD 10:45AM. 08/10/20XX Prescription for Augmentin, 250mg. J10 x 7 days. Mother was given instruction for administering the medication, earcare, sign 9 symptoms to watch for & monitor for temperature. Mom is to call the office if symptoms worsen. Schedule return appt. in 2 weeks for a recheck. Sue. Everett 8/10/20XX 10:15AM.
