DSF Medical Center
Prince Sultan Street, Al Basateen Dist, Jeddah
Patient : Fatimah Ali Majed Kabbani Visit Date : 06-Nov-2024
MR No : 40082847 Visit Status : Authorized
Age & Gender : 4m , Female
DOB : 01-Jul-2024
Dr. Jamal Ahmed Omer (00009125) Start Date : 06-Nov-2024 20:28 End Date : 06-Nov-2024 20:31
Chief Complaint\Title: 4 month vaccine
History and Physical Exam
Pediatric Assessment
Histrory of Present Illness : Fatimah is case of cow milk Proteins Allergy ( Severe body rash, Abdominal distention, Bloody diarrhea and
vomiting) on breast milk with restricted intake for mother as well as case of Gastroesophageal reflux disease on omeprazole
came for 4 month vaccine
Past History : Cow MIlk Protein Allergy
Family History : none
Newborn-18 Month
Vaccination
up to date
Nutrition and Feeding
Breast
Vitamin supplement, vit D, Omeprazole
Developmental History
Normal
Duration of illness : 1Week (s)
Physical Exam
looks well vitally stable
chest and CVS: normal
abdomen soft lax
Clinical Warning
No Clinical Warning
Diagnosis & Plan
DIAGNOSIS CODE
Z27.8, Need for immunisation against other combinations of infectious diseases (Primary)
Status : InActive, Date of updation : 22-Nov-2024
DIAGNOSIS DETAILS AND TREATMENT PLAN
4 month vaccine
Patient Family Education or Material given : Yes
CPOE
Other Clinical Procedures
1) IM/SC (intramuscular or subcutaneous) injection
Proposed Date : 06-Nov-2024 20:29.
Diagnosis : Need for immunisation against other combinations of infectious diseases(Z27.8).
Medication CPOE :
New Orders
1) DIPHTHERIA/ TETANUS / PERTUSSIS / HAEMOPHILUS INFLUENZA B / HEPATITIS B PEDIATRIC/ INACTIVATED POLIOVIRUS 0.50 ML
SYRINGE - IM INJECTION-(Once Only) at 9:00 - Second Dose - 06-Nov-2024 20:30 - 06-Nov-2024 23:59
Reason :Need for immunisation against other combinations of infectious diseases [Z27.8]
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DSF Medical Center
Prince Sultan Street, Al Basateen Dist, Jeddah
Patient : Fatimah Ali Majed Kabbani Visit Date : 06-Nov-2024
MR No : 40082847 Visit Status : Authorized
Age & Gender : 4m , Female
DOB : 01-Jul-2024
2) PNEUMOCOCCAL POLYSACCHARIDE(PCV 13) 0.50 ML
SYRINGE - IM INJECTION-(Once Only) at 9:00 - Shake well, IM injection in deltoid/vastus lateralis - Second Dose - 06-Nov-2024 20:30 - 06-
Nov-2024 23:59
Reason :Need for immunisation against other combinations of infectious diseases [Z27.8] ,
Reason for duplication :Clinically Indicated
Interaction Overriding Reasons :
Drug to Drug Interaction
----------------------------
a) Drug - PARACETAMOL
3) HUMAN ROTAVIRUS G1,P[8] 1.50 ML
SYRINGE - ORAL-(Once Only) at 9:00 - Orally towards inner cheek - Second Dose - 06-Nov-2024 20:30 - 06-Nov-2024 23:59
Reason :Need for immunisation against other combinations of infectious diseases [Z27.8] ,
Reason for duplication :Clinically Indicated
4) VITAMIN D3 400 UNIT
DROP - ORAL-(Once Only) at 9:00 - Add drops to food or drink. - 06-Nov-2024 20:30 - 03-Dec-2024 23:59
Reason :Need for immunisation against other combinations of infectious diseases [Z27.8] ,
IDF Diagnosis : Sequelae Of Unspecified Nutritional Deficiency [E64.9]
5) PARACETAMOL 120 MG
DROP - ORAL-(PRN QID) - Give when fever - Take without regard to meals - 06-Nov-2024 20:31 - 10-Nov-2024 23:59
Reason :Need for immunisation against other combinations of infectious diseases [Z27.8] ,
IDF Diagnosis : Fever, Unspecified [R50.9]
Interaction Overriding Reasons :
Drug to Drug Interaction
----------------------------
a) Drug - PNEUMOCOCCAL POLYSACCHARIDE(PCV 13)
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