REASON FOR ENCOUNTER: Initial treatment for mild dehydration.
SUBJECTIVE Background (Description and history of the present illness or medical condition including previous approaches to treatment and responses; include other medical problems, medication experience per patient, drug allergies, current meds, etc.)
Medical conditions: TA is a 3-year-old white male who needs to be treated with his oral rehydration. He has 4 watery stools in the past 24 hours and no blood in the stools. The diarrhea was mild at first but increased in frequency and volume. He did not urinate from 6 hours ago when he got up.
He has general malaise, dry-sticky mouth, tiredness, less active, dry skin, mild headache.
He can eat soft food and drink fluid without vomiting.
Past …show more content…
Avoid irritating food such as caffeine, high-fiber, spicy and high-fat foods. Avoid drinking sports drinks such as Gatorade, Powerade, because they replace the loss of fluid through sweating rather diarrhea. Also, avoid drinking milk, caffeinated beverages, fruit juices, because these may not helpful with diarrhea or even make it worse. Follow-up Evaluation (include date, format (e.g. phone call or office visit) and what specific monitoring parameters and information will be evaluated to assess effectiveness and safety at the next contact):
One day from today by phone, call sooner if questions or concerns. Evaluate for the elimination of symptoms or signs of dehydration such as dry mouth and headache (effectiveness), evaluate for side effects such as vomiting. (safety). If any side effects happen, contact pharmacy sooner.
Diarrhea two ways to treat (pharmacy letter): 5ml every 5min
SUBJECTIVE Background (Description and history of the present illness or medical condition including previous approaches to treatment and responses; include other medical problems, medication experience per patient, drug allergies, current meds, etc.)
Medical conditions: TA is a 3-year-old white male who needs to be treated with his oral rehydration. He has 4 watery stools in the past 24 hours and no blood in the stools. The diarrhea was mild at first but increased in frequency and volume. He did not urinate from 6 hours ago when he got up.
He has general malaise, dry-sticky mouth, tiredness, less active, dry skin, mild headache.
He can eat soft food and drink fluid without vomiting.
Past …show more content…
Avoid irritating food such as caffeine, high-fiber, spicy and high-fat foods. Avoid drinking sports drinks such as Gatorade, Powerade, because they replace the loss of fluid through sweating rather diarrhea. Also, avoid drinking milk, caffeinated beverages, fruit juices, because these may not helpful with diarrhea or even make it worse. Follow-up Evaluation (include date, format (e.g. phone call or office visit) and what specific monitoring parameters and information will be evaluated to assess effectiveness and safety at the next contact):
One day from today by phone, call sooner if questions or concerns. Evaluate for the elimination of symptoms or signs of dehydration such as dry mouth and headache (effectiveness), evaluate for side effects such as vomiting. (safety). If any side effects happen, contact pharmacy sooner.
Diarrhea two ways to treat (pharmacy letter): 5ml every 5min