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.
2 Right ear tympanic membrane is bulging with ear wax. Threat minimal to date. 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.
3 Schedule return appt. in 2 weeks for a recheck. Sue. Everett 8/10/20XX 10:15AM.
