Administered by:
Dr. Emily White, General Practitioner
Date:
1 November 2024
Medication Administered:
Name:
Amoxicillin
Dose:
500 mg
Route:
Intramuscular
Site:
Left deltoid muscle
Batch number:
AMX789012
Expiry date:
15 February 2026
Indication for administration:
Treatment of acute bacterial sinusitis, unresponsive to oral antibiotics.
Duration of therapy required:
7 days
Pre-administration assessment:
Vital signs:
Pulse: 72 bpm, Blood Pressure: 120/80 mmHg, Temperature: 37.1°C, Respiratory Rate: 16 breaths/min
Allergies:
Patient reports no known drug allergies. Confirmed no contraindications to Amoxicillin.
Patient consent:
Informed consent obtained, patient understood the purpose and potential side effects of the medication.
Other relevant observations:
Patient appeared calm and cooperative. No signs of distress or anaphylaxis risk factors noted.
Post-administration monitoring and observations:
Patient tolerated the injection well. No immediate adverse reactions observed (e.g., rash, swelling, difficulty breathing). Patient remained in clinic for 15 minutes post-administration for observation.
Follow-up instructions / advice given:
Advised patient to complete the full course of Amoxicillin as prescribed. Counselled on potential side effects (e.g., nausea, diarrhoea) and to seek urgent medical attention if experiencing signs of allergic reaction (e.g., severe rash, swelling of face/throat, difficulty breathing). Follow-up appointment scheduled for 5 November 2024 to assess treatment efficacy.
Administered by:
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Date:
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Medication Administered:
Name:
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Dose:
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Route:
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Site:
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Batch number:
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Expiry date:
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Indication for administration:
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Duration of therapy required:
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Pre-administration assessment:
Vital signs:
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Allergies:
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Patient consent:
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Other relevant observations:
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Post-administration monitoring and observations:
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Follow-up instructions / advice given:
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