C09977947 / invoice 10000

HISTORY:
Presented for:
2.5mg one day then 1.25mg other day
appetite/thirst normal, no v/d+
normal energy levels
no other changes

EXAM:
Mentation:
BCS:
Hydration status:
Eyes:
Ears:
Nose:
Mouth:
MM:
Throat:
LNs:
CV: HR:
Resp:
Abdo:
MSK:
Integ:
Neuro:
Genitourinary:
Rectal:
T:

ASSESSMENT:

PLAN:

COMMUNICATION:

SUBJECTIVE: Seems to be doing well
Been on 2.5mg pred SID for 2 weeks

OBJECTIVE:B+A
MM Pink
chest NAD

ASSESSMENT:
Recheck IMHA

PLAN:
PCV 45 / TP 75
wait 4-5 days then reduce pred to 2.5mg day one, 1.25mg day two alternating
RV for chk 10 days after reduction
next reduction to 2.5mg EOD for 3 weeks
then 2.5mg twice weekly for 3 weeks then stop

CLIENT COMMUNICATION:

History:
Doing well at home
eating more than usual due to the pred
no concerns from the O
Currently on 3/4 pred tablet (3.75mg) PO SID for 10 days

Examination:
BAR
pink MM
CRT <2
lovely boy
weight 7.3kg -- was 6.5kg last visit

PCV/TP:47/84 (prev 44/70)

Assessment:
Dx IMHA
Doing well at home

Plan:
After 14 days total of 3.75mg pred PO SID, Drop to 2.5mg po SID for 14 days minimum then 1.25mg po sid then EOD