Subjective Chief Complaint: cough congestion and difficulty breathing
History of present Illness: 2 years old Hispanic male brought in by mother, no translation needed c/o f/u cough congestion and difficulty breathing patient does not have a history of asthma and does not have a nebulizer machine at home. No diarrhea, no fever and no vomiting. Other siblings are not sick. No foreign travels stated. Illness is of moderate severity.
Medical history: Birth at Mexicali mex normal vaginal delivery at 38.5 weeks. BW 7.2 lbs BL 20.5 inches. Surgical history: none
Gynecology: male
Family history Grandmother has cancer, Father anemia and diabetes mother has hypertension
Social history: lives with both parents. No family members allowed smoking inside house
Current medicines: none
Allergies none
Objective
Vital signs: Height: 35 inches Weight: 31 lbs 2 oz BMI 17.79, Temperature 98.62F, Pulse 110 beats per minute, Respiratory rate 24 breaths per minute, O2 sat 95%. Head circumference 26 inches.
Physical Examination: Constitutional: Alert, cooperative, not sick appearing, Head normocephalic, AF closed Eyes: normal, Ears; normal Nose: rhinitis, Mouth: normal, Throat: injected Neck: normal, Lungs; rales , ronchi , wheazzing ++ Heart: normal, no murmur Chest / breast: normal no retractions good air exchange, Gastrointestinal: normal, Genitourinary: male, Lymphatic: normal, Musculoskeletal: normal full ROM, Skin: normal, Extremities: normal, Neurological/Psychiatry: normal, Head/Face: normal.
Assessment/Diagnosis: ICD-9 Codes 1. 465.9 URI 2. 4660 bronchitis 3. 462 pharyngitis
Plan /Procedures: 99214, 94760 o2 sat,
Medications: Prelone 15 mg/5ml oral syrup take 5 ml orally fro 3 times at day dispense 75 ml no refills
Amoxicillin 400 mg/5ml oral suspension reconstituted, take 5ml orally every 12 hrs dispense 100 ml no refill.
Care plan: Mother/ reassured.
Patient follows up in 1 week PRN.

Prelone 15 mg/5ml oral syrup take 5 ml orally fro 3 times at day dispense 75 ml no refills
Cephalexin 250mg/5ml oral suspension take 10 ml orally BID Dispense 200 ml no refills
Acetaminophen 160mg/5ml oral solution, take 5 ml orally every 12 hrs, dispense 100 ml no refills.
Amoxicillin 400 mg/5ml oral suspension reconstituted, take 5ml orally every 12 hrs dispense 100 ml no refill.
Ibuprofen 100mg/5ml oral suspensions take 15 ml orally every 6-8 hrs as needed dispense 240 ml no refills.
Sulfamethoxalote-trimethoprim 200-40 mg /5 ml oral suspension take 10 ml orally 2 times at day dispense 200ml no refills.
Pulmicort 0.5 mg/2ml inhalation suspension take 2 ml by inhalation every 12 hours dispense 60 no refills.
Singulair 4 mg oral tablet chewable, chew and swallow one tablet orally daily dispense 30 refills # 2.
Albuterol Sulfate (2.5mg/3ml) Inhalation nebulizer solution inhale 3 ml by inhalation every 4-6 hours dispense 2 no refills.
Zithromax 100mg /5ml oral suspension take 7.5 ml every 6-8 hrs as needed dispense 240 no refills
Gentamycin sulfate 0.3% ophthalmic ointment appy one application externally every 12 hours dispense 45 gm no refills.
Promethazine DM 6.25-15 mg/5ml oral syrup take 5 ml orally 3 times a day as needed fro cough dispense 180 ml no refills
Augmentin 250-62.5 mg/5 ml oral suspension take 7.5 ml orally 2 times at day dispense 150 ml no refills. Cortisporin 3.5-10000-1 otic solution instills 4 drops optically every 12 hours dispense 1 no refills. promethazine DM 6.25-15mg/5ml oral syrup take 5 ml orally 3 times a day take as needed for cough dispense 120ml no refills
Cefdinir 250 mg/5ml oral suspension take 4 ml orally daily dispense 40 no refills
Flonase 50mcg/act nasal suspension, inhale 1 spray nasally daily dispense 1 no refills
ProAir HFA 108990base) MCG/ACT inhalation aerosol solution Inhale 2 puffs by inhalation evry 4-6 hours as needed dispense 2 no refills.
Qvar 40 MCG/ACT inhalation aerosol solution Inhale 1 by inhalation 2 times a day dispense 1 no refills.
Singular 5 mg oral tablet chewable chew and swallow 1 tablet orally daily dispense 30 no refills. Cefdinir 250 MG/5ml oral suspension reconstituted Take 4.5 ml orally daily x 10 days dispense 45 ml no refills,