BT is a 5 y.o. male who came to the clinic with his mother for a wellness exam. The patient's last physical was 2 years ago, and he is behind on vaccinati ons. He currently has no known allergies and not taking any medic
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BT is a 5 y.o. male who came to the clinic with his mother for a wellness exam. The patient's last physical was 2 years ago, and he is behind on vaccinati ons. He currently has no known allergies and not taking any medications. BT is overall healthy, active, social, and eats a balanced diet. He had regular bowel movements, takes his multivitamins, and has a great family dynamic. The patient had no history of family illnesses, no hospitalizations, and problems with his sleep. Plan: Therapeutic - Pharmacological: - Administration of the following vaccinations: - MMR 0.5 mL Subcut right deltoid - IPV 0.5 mL Subcut left deltoid - Influenza 0.5 mL IM right anterolateral thigh - DTap 0.5 mL IM left anterolateral thigh - Varicella 0.5 mL Subcut left deltoid Non-pharmacological: - Children’s multivitamin once daily - 6-8 fluid oz. of water - 10-13 hours of sleep each night - If sent to ED or directly admitted, ensure the child is receiving supportive care through eating his favorite foods, resting, and reassuring the child is safe with the parent. Prevent separation with child, allow child to feel at home by providing similar at-home routines, monitor the child for depression or change in behavior. Social Determents of Health: - Ensure the child has appropriate air-conditioning at home and school – heat can cause inability to focus or sleep due to discomfort. - Ensure the child has safe transportation to school and back. - Ensure the child is in a safe at home free of drugs and violence. - Ensure the child has access to nutritional foods and clean filtered water. - Ensure the child has smoke-free environment at home and in the car. - Ensure the child does not have access to alcohol and drugs.
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