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03-16-2025 (20)
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| N39.0 | | | | | | Follow-up for Urinary tract infection, site not specified, reported no medication compliance. | 73 year old male, with PMH of: Metabolic encephalopathy (Primary, Admission), Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Atherosclerotic heart•¨disease of native coronary artery without angina pectoris, Gastro-esophageal reflux disease without esophagitis, Unspecified atrial fibrillation, Disorientation, unspecified, Unspecified psychosis not due to a substance or known physiological condition, Sepsis, unspecified organism, Generalized anxiety disorder. The patient was evaluated today because the nurse reported Periods of forgetfulness. The patient had a UTI, and they reported no medication compliance. Education was given about the importance of medication. The patient reported no pain or burning sensation. The lung was clear on auscultation, and no edema was noted. S1 and S2 present. | No known drug allergies, Iodine, Shellfish | Linezolid 03/09-03/22 | N39.0 Urinary tract infection, site not specified | Linezolid 03/09-03/22 | Staying well-hydrated by drinking plenty of water can help flush bacteria from the urinary tract. The patient should avoid alcohol, caffeine, and acidic or spicy foods that may irritate the bladder. Proper hygiene, including urinating after sexual activity and wiping front to back, can help prevent reinfection. Monitoring for symptoms such as fever, worsening pain, blood in the urine, or difficulty urinating is essential, and medical attention Should be sought if these occur. A follow-up with a healthcare provider may be necessary to confirm the infection has resolved and to evaluate for any underlying conditions that could contribute to recurrent UTIs. Recommendation was linezolid tablet; 600 mg; amt: 600 mg; oral Special Instructions: Dx UTI. Twice A Day. The patient continue no medication compliance. | 99308 | YES | | 0 |
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| N39.0 | | | 99309 | | | Follow-up for Urinary tract infection, site not specified in the context of a patient with chronic illness and poor overall outcomes. Monitor Levofloxacin. | 65 y/o male was seen at the bedside with a medical history of Respiratory Disorder, Chronic obstructive pulmonary disease, unspecified Dementia, Essential (primary) hypertension, and Human immunodeficiency virus [HIV] disease seen for a follow-up for Urinary tract infection, the site not specified. The patient denies SOB, chest pain, painful urination, and frequency. The patient was seen and evaluated today and was in no acute distress. The patient is awake and alert and in stable condition. The patient was seen at the bedside to provide medically necessary care due to extensive comorbidities requiring a complex interdisciplinary approach. The patient's lung is clear on auscultation. He and art S1 and S2 are present—last BM 03/15/25. The abdomen soft and bowel sound present in all four quadrants. The patient uses a cane for ambulation; the patient is blind and has a bilateral hearing problem. | No known allergies | Levofloxacin tablet; 500 mg; amt: 500 mg; oral Begin; 03/12/2025 -03/19/2025
End: 03/19/2025 | N39.0 Urinary tract infection, site not specified | Levofloxacin tablet; 500 mg; amt: 500 mg; oral Begin; 03/12/2025 -03/19/2025
End: 03/19/2025 | It is essential to complete the full course of prescribed antibiotics, even if symptoms improve early, to fully clear the infection and prevent resistance. Staying well-hydrated by drinking plenty of water helps flush bacteria from the urinary tract. The patient should avoid alcohol, caffeine, and acidic foods that may irritate the bladder. Proper hygiene, including urinating after sexual activity, can help prevent reinfection. Monitoring for symptoms such as fever, worsening pain, blood in the urine, or difficulty urinating is important, and medical attention Should be sought if these occur. | 99309 | YES | 24 | 1 |
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| L08.9 | | | 99309 | | | Monitor Nystatin cream 03/14/25- 03/25/2025 | A 71 y/o male with stable chronic illness as Parkinson's, HLD, DM, HTN, and mental disorders was seen today for a local infection of the skin and subcutaneous tissue, unspecified. The patient, with no S/S of acute distress, was found in bed. Denies SOB, chest pain, dizziness, abdominal discomfort, or headaches. As per the nursing staff, the patient has been compliant with treatment. Keep track until 03/25/2025 for better control. Education was given to the patient and nurse on the importance of redirecting the patient and keeping safe precautions and fall precautions with him. Education was provided on the significance of daily showering. The patient was seen today to monitor nystatin treatment. The patient feels better, and there are no new events. The rash on his inguinal area is improving. No itching was reported. No swelling was present. The patient denies pain. Lung clear on auscultation. Heart S1 and S2 present.
| Pollen Extracts, Ragweed | Nystatin cream; 100,000 unit/gram; amt: 1 g; topical. Begin: 03/14/2025 - 03/25/2025
End; 03/25/2025 | L08.9 Local infection of the skin and subcutaneous tissue, unspecified | Nystatin cream; 100,000 unit/gram; amt: 1 g; topical. Begin: 03/14/2025 - 03/25/2025 (Antifungal)
End; 03/25/2025 | Follow the prescribed antifungal treatment as directed, ensuring the full course is completed to prevent recurrence or complications. Keeping the affected area clean and dry is essential, and the patient should avoid scratching or touching the infection to prevent further irritation or spreading. Monitoring for signs of worsening infection, such as increased redness, swelling, warmth, pus, or fever, is important, and medical attention Should be sought if these symptoms develop. Maintaining good hygiene, wearing loose-fitting clothing, and managing underlying conditions such as diabetes can help prevent future infections. | 99309 | YES | 24 | 1 |
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| J18.9 | | | 99309 | | | Monitor for pneumonia, unspecific organism. Monitor for Azithromycin. | The patient was evaluated today, lying in a hospital bed. Muscle weakness and general condition deterioration were noted during the physical examination. will continue monitoring the patient's respiratory status. The patient's Mechanical ventilation setting: high pressure 60, low pressure 10, low min V 2.0, Peep 5, breath rate 10, total volume 450, press control 15, inspiration time 1.0, and press support 15. I didn't see any respiratory distress. S1 and S2 present. Tracheostomy dressing and PEG tube were intact. Information was obtained from the Patient, Primary nurse, and chart. The patient's chart was reviewed with the nurse. The patient's RN was educated on the importance of complying with the treatment established. The patient had a decorticate posture.
| n/a | Azithromycin 03/13- 03/20 | J18.9 Pneumonia, unspecified organism | Azithromycin 03/13 -03/20 | Careful airway management, infection control, and respiratory support. Ensure proper tracheostomy care by regularly suctioning secretions, maintaining humidification to prevent mucus plugging, and monitoring for signs of respiratory distress or worsening infection. Education was given about the importance of oral care to prevent infection and continue with the antibiotic treatment. | 99309 | YES | 24 | 1 |
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03-18-2025 (17)
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| J18.9 | | | 99309 | | | We evaluated the patient today for a follow-up infectious diseases consult. The patient remains stable in a skilled nursing facility. The Peg Tube and tracheostomy are in place without a problem. The patient continued with the antibiotic Ertapenem until 3/23/2025. Aspiration precaution reinforce. Education was provided about proper suctioning techniques to clear secretions and maintain a patent airway. The patient tolerated the Ertapenem antibiotic without difficulty. | Gaehring, Federico G is a 64 y/o male patient admitted on 02/28/25 with PMH of Acute respiratory failure, unspecified whether with hypoxia or hypercapnia, Pneumonia, unspecified organism, Tracheostomy status Procedure on 9/20/24, Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side, Metabolic encephalopathy, Encounter for surgical aftercare following surgery on the nervous system, Gastrostomy status, Procedure on 9/20/24, Other epilepsy, not intractable, with status epilepticus, Unspecified diastolic (congestive) heart failure, Essential (primary) hypertension, Hyperlipidemia, unspecified, Acute kidney failure with tubular necrosis, Pleural effusion, not elsewhere classified, Chronic embolism and thrombosis of unspecified popliteal vein, Gastro-esophageal reflux disease without esophagitis, Presence of other vascular implants and grafts, Dysphagia, oropharyngeal phase, Aphasia, Aphasia following cerebral infarction, Dyspha...More... | No known allergies | Ertapene recon soln; 1 gram; amt: 1 g; intravenous one a day. (03/10/2025 to 03/23/25)
End day: 03/23/2025 | J18.9 Pneumonia, unspecified organism | Ertapene recon soln; 1 gram; amt: 1 g; intravenous one a day. (03/10/2025 to 03/23/25)
End day: 03/23/2025 | Careful airway management, infection control, and respiratory support. Ensure proper tracheostomy care by regularly suctioning secretions, maintaining humidification to prevent mucus plugging, and monitoring for signs of respiratory distress or worsening infection. Education was given about the importance of oral care to prevent infection. | 99309 | YES | 24 | 1 |
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| N39.0 | | | 99309 | | | Follow-up for Urinary tract infection, site not specified. | The patient is an 89-year-old female with PMH of Unspecified fracture of left patella, subsequent encounter for closed fracture with routine healing, History of falling, Type 2 diabetes mellitus without complications, HTN, HLD. The patient is currently on Levofloxacin (3/10 - 3/17). No dysuria or discomfort during urination was reported. The patient reported improvement in her urinary symptoms. No acute distress was reported by the nursing staff. The patient is AAOX3. Unable to actively participate in their care due to underlying conditions. She denies sob or chest pain—medication review in the chart. V/S reviewed and are WNL. The care team continues to express concerns regarding the patient's frailty and chronic health deterioration. The patient’s family reported concern that the patient needed assistance going to the bathroom. The patient has a history of falls; education was given to prevent falls. I spent time with the nurses to educate them about the importance of assisting t...More... | Estrogens, meperidine, Penicillin's (PCN), tramadol, shellfish | Levofloxacin oral tablet; 500 mg; amt: 500 mg daily PO x 7 days. (Begin: 03/10/2025 - 03/17/2025)
End: 03/17/2025 DC | N39.0 Urinary tract infection, site not specified | Levofloxacin oral tablet; 500 mg; amt: 500 mg daily PO x 7 days. (Begin: 03/10/2025 - 03/17/2025)
End: 03/17/2025 DC | Take the full course of medication, even if you start feeling better. Drinking plenty of water can help flush out bacteria, and avoiding irritants like caffeine and alcohol may ease discomfort. Daily shower, Wearing loose, breathable clothing—especially cotton underwear—can help prevent irritation and allow airflow, reducing moisture buildup that can contribute to bacterial growth. Eliminate the use of tight clothing. The patient was educated on the importance of asking for assistance to go to the bathroom as soon as they feel the urge to urinate, to avoid holding in urine for too long. Holding urine can promote bacterial growth and increase the risk of urinary tract infections. Regularly emptying the bladder helps flush out bacteria and maintain urinary tract health. | 99309 | YES | 24 | 1 |
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| J18.9 | | | 99309 | | | Follow-up for Pneumonia, unspecified organism in the context of a patient with chronic illness and poor overall outcomes. Monitor for Azithromycin antibiotic. | 73 y/o male patient with PMH of Acute respiratory failure with hypoxia, Tracheostomy status, Chronic obstructive pulmonary disease, unspecified, Nicotine dependence, cigarettes, uncomplicated, Pneumonia, unspecified organism, Malignant neoplasm of larynx, unspecified, Anemia, Major depressive disorder, single episode, Unspecified atrial fibrillation, Morbid (severe) obesity due to excess calories, Heart failure, unspecified. In addition to addressing the main reason for this visit, I reviewed all the patients' diagnoses and treatments. The patient communicated using a notebook. The patient was alert time 4. Rales on auscultation. Herat S1 and S2 present. Increase of secretion: the inner cannula was full of secretion, and a new inner cannula was inserted. No distress was noted. No pain was reported. The PEG tube is clean and intact. Wound care was consulted; the patient has a stage 1 pressure ulcer on the sacral area. The wound care team applied a dressing. This comprehensive revi...More... | Levofloxacin, phenytoin, banana | Azithromycin 03/14-03/21 DC
Order: Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg; amt: 800-160 mg ( 1 tab); gastric tube Twice A Day Begin: 03/19/25- 03/23/25
Ending: 03/23/25 | J18.9 Pneumonia, unspecified organism | Azithromycin 03/14-03/21 DC
Order: Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg; amt: 800-160 mg ( 1 tab); gastric tube Twice A Day Begin: 03/19/25- 03/23/25
Ending: 03/23/25
Sputum from Bronchial wash was ordered.
Comprehensive panel Lab was ordered 03/19/25 at 04:00 AM
| Crucial to follow the prescribed antibiotic treatment fully, even if symptoms improve before completion. Rest and hydration are essential to aid recovery, along with maintaining good nutrition to support the immune system. The patient should monitor for symptoms such as persistent fever, worsening shortness of breath, chest pain, or confusion. Education was given about the importance of oral care and change position every two hour to prevent skin breakdown. Daily shower is recommended. | 99309 | YES | 24 | 1 |
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| N39.0 | | | 99309 | | | Follow-up for Urinary tract infection, site not specified in the context of a patient with chronic illness and poor overall outcomes. Monitor Levofloxacin. The patient reported palpitation. | 65 y/o male was seen at the bedside with a medical history of Respiratory Disorder, Chronic obstructive pulmonary disease, unspecified Dementia, Essential (primary) hypertension, and Human immunodeficiency virus [HIV] disease was seen for a follow-up for Urinary tract infection; the site not specified. The patient denies SOB, chest pain, painful urination, and frequency. The patient was seen and evaluated today and was in no acute distress. The patient is awake, alert, and in stable condition. The patient reported palpitation. The patient was seen at the bedside to provide medically necessary care due to extensive comorbidities requiring a complex interdisciplinary approach. The patient's lung is clear on auscultation. He and art S1 and S2 are present—last BM 03/15/25. The abdomen soft and bowel sound present in all four quadrants. The patient uses a cane for ambulation; the patient is blind and has a bilateral hearing problem. | No known allergies | Levofloxacin tablet; 500 mg; amt: 500 mg; oral Begin; 03/12/2025 -03/19/2025
End: 03/19/2025 | N39.0 Urinary tract infection, site not specified | Levofloxacin tablet; 500 mg; amt: 500 mg; oral Begin; 03/12/2025 -03/19/2025
End: 03/19/2025
EKG was ordered.
Cardiology consult was ordered. | It is essential to complete the full course of prescribed antibiotics, even if symptoms improve early, to fully clear the infection and prevent resistance. Staying well-hydrated by drinking plenty of water helps flush bacteria from the urinary tract. The patient should avoid alcohol, caffeine, and acidic foods that may irritate the bladder. Proper hygiene, including urinating after sexual activity, can help prevent reinfection. Monitoring for symptoms such as fever, worsening pain, blood in the urine, or difficulty urinating is important, and medical attention Should be sought if these occur. | 99309 | YES | 24 | 1 |
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| L08.9 | | | 99309 | | | Monitor Nystatin cream 03/14/25- 03/25/2025 | A 71 y/o male with stable chronic illnesses such as Parkinson's, HLD, DM, HTN, and mental disorders was seen today for a local infection of the skin and subcutaneous tissue, unspecified. The patient, with no S/S of acute distress, was found in bed. Denies SOB, chest pain, dizziness, abdominal discomfort, or headaches. As per the nursing staff, the patient has been compliant with treatment. Keep track until 03/25/2025 for better control. Education was given to the patient and nurse on the importance of redirecting the patient and keeping safe precautions and fall precautions with him. Education was provided on the significance of daily showering. The patient was seen today to monitor nystatin treatment. The patient feels better, and there are no new events. The rash on his inguinal area is improving. No itching was reported. No swelling was present. The patient denies pain. Lung wheezing on auscultation. Right lung worse than left lung. Heart S1 and S2 present. | Pollen Extracts, Ragweed | Nystatin cream; 100,000 unit/gram; amt: 1 g; topical. Begin: 03/14/2025 - 03/25/2025
End; 03/25/2025 | L08.9 Local infection of the skin and subcutaneous tissue, unspecified | Nystatin cream; 100,000 unit/gram; amt: 1 g; topical. Begin: 03/14/2025 - 03/25/2025 (Antifungal)
End; 03/25/2025
Chest x-ray 2 views
Albuterol sulfate solution for nebulization 2.5 mg/3 ml (0.083 %) amt: 2.5 mg/3 ml inhalation every 8 hours Start: 03/18/25
Pulmonary consult was ordered. | Follow the prescribed antifungal treatment as directed, ensuring the full course is completed to prevent recurrence or complications. Keeping the affected area clean and dry is essential, and the patient should avoid scratching or touching the infection to prevent further irritation or spreading. Monitoring for signs of worsening infection, such as increased redness, swelling, warmth, pus, or fever, is important, and medical attention Should be sought if these symptoms develop. Maintaining good hygiene, wearing loose-fitting clothing, and managing underlying conditions such as diabetes can help prevent future infections. | 99309 | YES | 24 | 1 |
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| J18.9 | | | 99309 | | | Monitor for pneumonia, unspecific organism. Monitor for Levofloxacin. | The patient was evaluated today, lying in a hospital bed. Muscle weakness and general condition deterioration were noted During the physical examination. We will continue monitoring the patient's respiratory status. The patient's proper chest dialysis port dressing was intact. Mechanical ventilation setting: high pressure 60, low pressure 10, low min V 2.0, Peep 5, breath rate 10, total volume 450, press control 15, inspiration time 1.0, and press support 10. I didn't see any respiratory distress. S1 and S2 present. The tracheostomy dressing and PEG tube were intact. Amputation of the lower Left leg was noticed, and a stage 4 pressure ulcer on his sacrum and left hip was present. Wound care followed and treated him. Information was obtained from the Patient, Primary nurse, and chart. The patient's chart was reviewed with the nurse. The patient's RN was educated on the importance of complying with the treatment established. | No known allergies | Levofloxacin tablet; 500 mg; amt: 500 mg; oral Special Instructions: levofloxacin tab 500mg(1 tab QD)X 7 DAYS Dx:Pneumonia Once A Day Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025 | J18.9 Pneumonia, unspecified organism | Levofloxacin tablet; 500 mg; amt: 500 mg; oral Special Instructions: levofloxacin tab 500mg(1 tab QD)X 7 DAYS Dx:Pneumonia Once A Day Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025
Wound care.
Social worker consult | Careful airway management, infection control, and respiratory support. Ensure proper tracheostomy care by regularly suctioning secretions, maintaining humidification to prevent mucus plugging, and monitoring for signs of respiratory distress or worsening infection. Education was given about the importance of oral care to prevent infection and continue with the antibiotic treatment. Reposition the patient every two hours. Change dressing and assessment on his sacrum area and left hip. Continue wound care treatment. | 99309 | YES | 24 | 1 |
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| J18.9 | | | 99309 | | | Follow up for Pneumonia, unspecified organism. Monitor for Levofloxacin. | 75-year-old male. The patient was seen at the bedside today for Pneumonia, an unspecified organism. The patient's tracheostomy in situ is currently mechanically ventilated, secondary to acute and chronic respiratory failure. The patient is presently not sedated. Past medical history Metabolic encephalopathy, Acute respiratory failure with hypoxia, Sepsis, Hypothyroidism, Malignant neoplasm of unspecified part of unspecified bronchus or lung, DM, Seizures, Cerebral edema, HTN, Anemia, GERD, PNA, malignant neoplasm of brain. Patient AAOX1 does not follow commands. The patient is synchronous with the ventilator and is hemodynamically stable. Lung clear on auscultation. I didn't see any acute distress. In addition to addressing the main reason for this visit, I have reviewed all the patient's diagnoses. | No known allergies | levofloxacin oral tablet; 750 mg; amt: 750; oral Begin; 03/09/2025 - 03/15/2025
End: 03/15/2025 DC | J18.9 Pneumonia, unspecified organism | levofloxacin oral tablet; 750 mg; amt: 750; oral Begin; 03/09/2025 - 03/15/2025
End: 03/15/2025 DC | The patient should receive proper ventilator care, including regular suctioning and humidification, to prevent complications such as ventilator-associated pneumonia. Maintaining good oral hygiene and following infection control measures are essential in reducing bacterial buildup. Adequate hydration and nutrition support immune function, while repositioning the patient regularly can help improve lung expansion. Avoiding exposure to respiratory irritants is important, and deep breathing exercises or chest physiotherapy may be beneficial if recommended by the healthcare team. The patient Should be closely monitored for worsening symptoms, such as increased respiratory distress, fever, changes in sputum color, or confusion. | 99309 | YES | 24 | 1 |
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| A41.9 | H01.0 | | 99309 | | | Monitor for Gentamicin Eye drops | The patient was assessed at the bedside. Trach in situ does not follow commands, and both eyes are open. No discharges were noted on his eyes at this time. Productive cough with copious yellow phlegm. Lungs: Diminished breath sounds, +Rhonchi. Cardiovascular: RRR, S1 and S2. No evident chest pain, palpitations, SOB, chills, or diaphoresis noted. Continue with current antibiotic treatment. Tolerating well. | No known allergies | Gentamicin drops; 0.3 %; amt: 1 drop; ophthalmic (eye). Begin: 03/10/2025 - 03/20/2025
End: 03/20/2025
| A 41.9 Sepsis, unspecified organism, H01.0 Blepharitis | Gentamicin drops; 0.3 %; amt: 1 drop; ophthalmic (eye) four times a day for 10 days DX: Blepharitis
Four Times A Day. Begin: 03/10/2025 - 03/20/2025
End: 03/20/2025
| Adherence to prescribed treatments. Sepsis is a serious condition that requires completing the full course of antibiotics, maintaining proper hydration, and monitoring vital signs for any worsening symptoms such as fever, confusion, difficulty breathing, or low blood pressure. In addition, Blepharitis Should be managed with good eyelid hygiene, including warm compresses and gentle cleaning with a prescribed solution or baby shampoo to reduce inflammation and bacterial buildup. Avoiding eye rubbing and using prescribed topical medications, if applicable, can help control symptoms. Continue with the Gentamicin drops until 03/20. | 99309 | YES | 24 | 1 |
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| H66.91 | | | 99309 | | | Right ear pain and itching. | Rivera Viera Noel is a 52cy/o male patient with PMH of Acute respiratory failure with hypoxia, Tracheostomy status, Dependence on respirator [ventilator] status, Pneumonia, unspecified organism, Acute pulmonary edema, Pleural effusion, not elsewhere classified Heart failure, unspecified, Down syndrome, Type 2 diabetes mellitus without complications, Hypothyroidism, Anemia. The patient will be evaluated today for medical needs to avoid future complications. Today, the patient was lying in a hospital bed and followed simple commands. He had decreased respiratory sounds in both lung bases, and no accessory muscle was noted. The patient's right ear was noticed to be improved and cleaning with NS was applied. The patient was with discomfort. I ordered and reported to the RN and the Supervisor that the patient should have Meropenem 1 g iv q12 hour for 7 days and Doxycycline 100 mg po bid for 7 days. The RN cleaned the patient's right ear, and a dressing was applied to prevent more episod...More... | Penicillin and cephalosporins | Meropenem 1 g iv q12 hours for 7 days and Doxycycline 100 mg po for 7 days
Starting: 03/17/25 at 06:00 AM
Ending: 03/23/25 | H66.91 Otitis media, unspecified, right ear | Meropenem 1 g iv q12 hours for 7 days and Doxycycline 100 mg po for 7 days
Starting: 03/17/25 at 06:00 AM
Ending: 03/23/25 | Careful airway management, infection control, and respiratory support. Ensure proper tracheostomy care by regularly suctioning secretions, maintaining humidification to prevent mucus plugging, and monitoring for signs of respiratory distress or worsening infection. Education was given about the importance of oral care to prevent infection and continue with the antibiotic treatment. Education was given to RN to assess for pain to be able to minimize patient discomfort and administer PRN pain medication. Continue round to evaluate patient condition. | 99309 | YES | 24 | 1 |
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| N48.1 | R78.81 | | 99309 | | | Fluconazole tablet 03/14-03/16 & Mupirocin ointment | A 57 y/o male with a PMHx of anemia, T2DM, HTN, heart failure, muscle spasms, ESRD on HD, and osteomyelitis was seen today for follow-up to monitor after Fluconazole treatment and Mupirocin. The patient is
in bed, and no S/S of acute distress was noted. No SOB, palpitations, fever, dizziness, or n/v. Admitted on IV ABX due to bacteremia, no adverse effects. Follow-up for Balanitis on his penis. No discharge, itching, or pain was reported during the examination. However, irritation was reported. The patient is on Dialysis at the bedside (M, W, and F). Continue to monitor the patient's
status. Education was given about proper hygiene, avoiding irritants, and using prescribed treatments to help manage symptoms and prevent complications. The patient's lung is clear on auscultation, and heart S1 and S2 are present.
| No known allergies | Fluconazole oral tablet; 150 mg: amt: 150 mg: oral Special Instructions: fluconazole tab 150 mg (1 tab QD) x 3 day Once A Day. Begin: 03/14/2025 - 03/16/2025
End: 03/16/2025 DC
Mupirocin ointment; 2 %; amt: 2 %; topical Three Times A Day. Begin; 03/05/2025 - Open ended
End: Open ended | N48.1 Balanitis & R78.81 Bacteremia | Fluconazole oral tablet; 150 mg: amt: 150 mg: oral Special Instructions: fluconazole tab 150 mg (1 tab QD) x 3 day Once A Day. Begin: 03/14/2025 - 03/16/2025
End: 03/16/2025 DC
Mupirocin ointment; 2 %; amt: 2 %; topical Three Times A Day. Begin; 03/05/2025 - Open ended
End: Open ended | Patient should maintain good genital hygiene by gently washing the affected area with warm water and avoiding harsh soaps or irritants. If prescribed, topical antifungal or antibiotic creams Should be applied as directed to treat the underlying cause. Keeping the area dry and wearing loose-fitting, breathable underwear can help prevent further irritation. The patient should avoid sexual activity until symptoms resolve to prevent discomfort and potential transmission of infection. If symptoms persist, worsen, or recur frequently, follow-up with a healthcare provider is necessary to rule out underlying conditions such as diabetes or infections. | 99309 | YES | 24 | 1 |
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| C34.11 | B96.20 | | 99309 | | | The patient came from the Hospital. Positive for Escherichia Coli on sputum from Bronchial wash. Monitor for Ceftriaxone IV. | An 81-year-old female who came on 03/17/25 was admitted from the Hospital. The patient's lung was clear on auscultation. The patient was evaluated today, lying in a hospital bed. Muscle weakness and general condition deterioration were noted During the physical examination. We will continue monitoring the patient's respiratory status. The patient has an intact PICC line, and the midline dressing on her right arm was intact. Mechanical ventilation was noted. I didn't see any respiratory distress. S1 and S2 present. The tracheostomy dressing and PEG tube were intact. Information was obtained from the Patient, Primary nurse, and chart. The patient's chart was reviewed with the nurse. The patient's RN was educated on the importance of complying with the treatment established. | Atorvastatin, bacitracin, doxycycline hyclate | Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Special Instructions: DX: Pneumonia Begin: 03/18/2025 - 03/20/2025.
End: 03/20/2025 | C34.11 Malignant neoplasm of upper lobe, right bronchus or lung & B96.20 Unspecified Escherichia coli [E. coli] | Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Special Instructions: DX: Pneumonia Begin: 03/18/2025 - 03/20/2025.
End: 03/20/2025 | Concurrently, the E. coli infection must be identified at its source and treated with appropriate antibiotics based on culture sensitivity. Supportive care, including pain management, pulmonary rehabilitation, and nutritional support, is essential. Close monitoring for infection resolution and oral care is recommended to prevent pneumonia. | 99309 | YES | 24 | 1 |
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| R21 | | | 99309 | | | Follow-up for Rash and other nonspecific skin eruption. Monitor for Fluconazole tablet. | A 71-year-old male with a medical history of Diabetes mellitus, Cellulitis, cerebral infarction, muscle weakness, and hypertension. The patient was seen today for a Rash and other nonspecific skin eruption on bilateral feet. The patient was lying in bed with no signs or symptoms of distress; The patient denied headache, chest pain, abdominal pain, nausea or vomiting, fever, or any other symptomatology. The patient was educated about the importance of taking the medication as prescribed and the implications of not taking the medication. Education was given on the significance of hand washing and daily showering. The patient verbalized understanding.
| No known allergies | Fluconazole tablet; 150 mg; amt: 150 mg; oral Special Instructions: Take one tablet every Wednesday for 4 weeks. Begin: 03/05/2025 - 03/27/2025
End: 03/27/2025 | R21 Rash and other nonspecific skin eruption | Fluconazole tablet; 150 mg; amt: 150 mg; oral Special Instructions: Take one tablet every Wednesday for 4 weeks. Begin: 03/05/2025 - 03/27/2025
End: 03/27/2025 | The patient should keep the affected skin clean and dry, avoiding excessive scratching to prevent further irritation or infection. Wearing loose-fitting, breathable clothing can help reduce discomfort. Monitoring for worsening symptoms, such as spreading rash, pain, swelling, fever, or signs of infection, is essential, and medical attention Should be sought if these occur. Education was given on the significance of hand washing and daily showering. The patient verbalized understanding. | 99309 | YES | 24 | 1 |
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| L08.9 | | | 99309 | | | Follow-up for Local infection of the skin and subcutaneous tissue, unspecified. Monitor Bactrim (sulfamethoxazole-trimethoprim) antibiotic until 03/17/2025 Completed | A 69-year-old male with PMH of nicotine dependence, GERD, vascular dementia, hypertension, PVD, sleep disorder, and encephalopathy was seen today for a follow-up on ABT treatment for a Local infection of the skin and subcutaneous tissue, unspecified. The patient denies SOB, chest pain, dizziness, abdominal discomfort, fever, n/v, or diarrhea. Tolerating therapy with no adverse effects. Reinforce to nursing staff the importance of monitoring patient behavior during ABT therapy; there are no other issues.
In addition to addressing the main reason for this visit, I reviewed all the patients' diagnoses and treatments. This comprehensive review aims to prevent future patient health complications and avoid potential medication interactions. The patient's left foot dressing was intact and clean. The patient refused to remove his dressing to assess the left big toe. The patient reported, " I see my left big toe is black." The patient reported pain in the back on his left big toe only when...More... | No known allergies | Bactrim (sulfamethoxazole-trimethoprim) oral tablet; 400-80 mg; amt: 400-80 mg; oral Special Instructions: Dx. Skin infection. Every 12 Hours. Begin: 03/11/2025 - 03/17/2025
End: 03/17/2025 Completed | L08.9 Local infection of the skin and subcutaneous tissue, unspecified | Bactrim (sulfamethoxazole-trimethoprim) oral tablet; 400-80 mg; amt: 400-80 mg; oral Special Instructions: Dx. Skin infection. Every 12 Hours. Begin: 03/11/2025 - 03/17/2025
End: 03/17/2025 Completed | Patient should keep the affected area clean and dry, Completing the full course of prescribed antibiotic treatment is essential to prevent the infection from worsening or recurring. Avoiding scratching or touching the infected area can help prevent further irritation and the spread of infection. The patient should monitor for signs of worsening infection, such as increased redness, swelling, warmth, pus, fever, or pain. Maintaining good hygiene, and daily shower to prevent infection. | 99309 | YES | 24 | 1 |
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| H61.20 | | | 99309 | | | Impacted cerumen, unspecified ear. Monitor for Ofloxacin drops | Eugene is a 74 y/o male patient with PMH of Acute respiratory failure, Type 2 diabetes mellitus without complications, Essential (primary) hypertension, Acute kidney failure, and Dysphagia. The patient was examined, and the patient was oriented to the person and made eye contact. The nurse denies fever in the patient, vomiting, or acute respiratory distress. We will continue to monitor the patient's ears. No cerumen was noted. No pain was reported. The patient reported pain of 7/10 on his left upper abdomen. The patient's abdomen was distended. The last BM was 03/17/25. Acute Care Consult was notified. An abdomen ultrasound was ordered. The patient chart was reviewed with the nurse. The nurse tells us that the patient is complying with the medication therapy as indicated. The nurse tells us that the patient is tolerating the medications well. Education given on the importance of complying with treatment established | No known allergies | Ofloxacin drops; 0.3 %; amt: one drop; otic (ear) Special Instructions: Dx. Cerumen impaction Once A Day
Mupirocin ointment; 2 %; amt: 2 %; topical Special Instructions: Applied to patient's under his right nostril Twice A Day | G61.20 Impacted cerumen, unspecified ear | Ofloxacin drops; 0.3 %; amt: one drop; otic (ear) Special Instructions: Dx. Cerumen impaction Once A Day
Mupirocin ointment; 2 %; amt: 2 %; topical Special Instructions: Applied to patient's under his right nostril Twice A Day
Acute Care consult
Abdomen ultrasound complete was ordered 03/19/25 | Oral care, daily shower, and continue with ambulation with assistance. | 99309 | YES | 24 | 1 |
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| J18.9 | B36.9 | | 99309 | | | Monitor pneumonia and nystatin cream | Esterlin, Annette is a 62 pleasant African American female patient admitted on 03/03/25 with PMH of Tracheostomy status, Pleural effusion, Unspecified asthma, Pneumonia, unspecified organism, Methicillin susceptible Staphylococcus aureus infection, unspecified site, Type 2 diabetes mellitus without complications, Nontraumatic subarachnoid hemorrhage, Vitamin deficiency, Essential (primary) hypertension, Sickle-cell disease without crisis. I have reviewed all the patients' diagnoses and treatments. The patient was evaluated due to the patient's medical needs and to avoid future hospitalizations. The patient is currently on oxygen at 4LPM via Trach. The patient was assessed today while lying in a hospital bed. Today, the physical examination reveals diminished lung sounds, muscle weakness, and deterioration of the general condition. The patient was suctioned several times. The patient is on Nystatin cream for fungus on the right side of the lower back. Wound care ordered and follow ...More... | No known allergies | Nystatin cream; 100,000 unit/gram; amt: 100,000 unit/gram; topical Special Instructions: Dx. Fungus (Right side lower Back) Once A Day. Begin: 03/12/2025 - Open Ended
End: Open-Ended | J18.9 Pneumonia, unspecified organism | Piperacillin-tazobactam recon soln; 3.375 gram; amt: 3.375 gram; intravenous Special Instructions: Administer intravenously for 10 days DX: Pneumonia Every 8 Hours. Begin: 03/05/2025 - 03/15/2025
End; 03/15/2025 Completed
Nystatin cream; 100,000 unit/gram; amt: 100,000 unit/gram; topical Special Instructions: Dx. fungus (Right side lower Back) Once A Day (Antifungal). Begin: 03/12/2025 - Open Ended
End: Open Ended
Wound care | Patient should complete the full course of prescribed antifungal medications to ensure proper treatment. Rest, staying well-hydrated, and maintaining a balanced diet are essential to support the immune system. For pneumonia, using a humidifier, practicing deep breathing exercises, and avoiding respiratory irritants like smoking can help improve lung function. The patient should monitor for worsening symptoms such as persistent fever, increased shortness of breath, chest pain, or fatigue and seek medical attention if these occur. For superficial mycosis, keeping the affected skin clean and dry, avoiding tight clothing, and using prescribed antifungal creams or medications as directed will help manage the condition. Proper hygiene and follow-up with a healthcare provider are necessary to monitor recovery and prevent complications. | 99309 | YES | 24 | 1 |
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| J18.9 | | | 99309 | | | Monitor Levofloxacin. Monitor for unspecific organisms. | The patient is a 69-year-old male with PMH of Muscle wasting and atrophy, not elsewhere classified, multiple sites, Alcohol abuse with intoxication, unspecified, Essential (primary) hypertension, Muscle weakness (generalized), Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation, adult failure to thrive, Chest pain, unspecified. The patient is lying down and remains in stable condition. No acute distress was reported by the nursing staff. The patient is AAOX2. Unable to actively participate in their care due to underlying conditions. Medication review in the chart. Tolerating levofloxacin medication well. The patient's lungs are clear on auscultation, and heart S1 and S2 are present—the last bowel movement was 03/17/25. No pain, nausea/ vomiting, or SOB were reported. No edema was present. The patient was sitting on his bed after the examination. The patient is alert time 2. The patient's abdomen is soft and not distended. No edema present. | No known allergies | Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500 mg (1 tab QD) X 7 days .Dx: Pneumonia Once A Day. Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025 | J18.9 Pneumonia, unspecified organism | Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500 mg (1 tab QD) X 7 days .Dx: Pneumonia Once A Day. Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025 | Diet: LCS/NAS, Mechanical Soft. Oral care, ambulation with assistance, good nutrition, and complete the antibiotic. | 99309 | YES | 24 | 1 |
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| J18.9 | | | 99309 | | | Monitor for pneumonia, unspecific organism. Monitor for Azithromycin. | The patient was evaluated today, lying in a hospital bed. Muscle weakness and general condition deterioration were noted during the physical examination. will continue monitoring the patient's respiratory status. The patient's Mechanical ventilation setting: high pressure 60, low pressure 10, low min V 2.0, Peep 5, breath rate 10, total volume 450, press control 15, inspiration time 1.0, and press support 15. I didn't see any respiratory distress. S1 and S2 present. The tracheostomy dressing and PEG tube were intact. Information was obtained from the Patient, Primary nurse, and chart. The patient's chart was reviewed with the nurse. The patient's RN was educated on the importance of complying with the treatment established. The patient had a decorticate posture. | No known drug allergies | Azithromycin 03/13- 03/20 | J18.9 Pneumonia, unspecified organism | Azithromycin 03/13 -03/20 | Careful airway management, infection control, and respiratory support. Ensure proper tracheostomy care by regularly suctioning secretions, maintaining humidification to prevent mucus plugging, and monitoring for signs of respiratory distress or worsening infection. Education was given about the importance of oral care to prevent infection and continue with the antibiotic treatment. | 99309 | YES | 24 | 1 |
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| B36.9 | | | 99308 | | | "Expired patient" | | No known allergies | Nystatin cream; 100,000 unit/gram; amt: 100,000 unit/gram; topical Special Instructions: Dx. Fungus (Right side lower Back) Once A Day. Begin: 03/12/2025 - Open Ended
End: Open-Ended | B36.9 Superficial mycosis, unspecified | DC. Piperacillin-tazobactam recon soln; 3.375 gram; amt: 3.375 gram; intravenous Special Instructions: Administer intravenously for 10 days DX: Pneumonia Every 8 Hours. Begin: 03/05/2025 - 03/15/2025
End; 03/15/2025 Completed
Nystatin cream; 100,000 unit/gram; amt: 100,000 unit/gram; topical Special Instructions: Dx. fungus (Right side lower Back) Once A Day (Antifungal). Begin: 03/12/2025 - Open Ended
End: Open Ended
Wound care | | | YES | | 0 |
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| J18.9 | | | 99309 | | | Follow-up for Pneumonia, an unspecified organism in the context of a patient with chronic illness and poor overall outcomes. Monitor for Ceftriaxone antibiotic. | An 89-year-old female with a history of acute respiratory failure with hypoxia and asthma recently experienced an asthma exacerbation, which has improved following respiratory treatments over the past week. On examination today, she is alert and oriented to person, with no deformities, well-ventilated lungs, equal chest expansion, and no signs of shortness of breath. A comprehensive review of her diagnoses and treatments was conducted to prevent future complications and avoid potential medication interactions. Dressing PEG tube clean and dry. No edema present. Capillary refill less than 2 sec. pulse 2+ equal bilaterally. Her chart was reviewed with the nurse, and both the patient and nurse were educated on the importance of adhering to the prescribed treatment and Plan of Care. The current care plan and medications will be continued. | Aspirin (ASA) | Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Every 12 Hours. Begin: 03/17/2025 - 03/23/2025
Ending: 03/23/2025 | J18.9 Pneumonia, unspecified organism | Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Every 12 Hours. Begin: 03/17/2025 - 03/23/2025
Ending: 03/23/2025 | It is recommended that the patient continue her current care plan and medications while maintaining close monitoring for any signs of respiratory distress or exacerbation. Regular follow-ups Should be scheduled to assess her respiratory status and adjust treatment as needed. She should avoid known asthma triggers, adhere to prescribed inhalers and medications, and practice breathing exercises to optimize lung function. Additionally, patient and caregiver education Should be reinforced to ensure compliance with treatment and early recognition of worsening symptoms. If any respiratory symptoms recur or worsen, prompt medical evaluation is advised. | 99309 | YES | 24 | 1 |
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| J18.9 | L08.9 | | 99308 | | | Monitor the patient for pneumonia. Monitor Nystatin cream 03/14/25- 03/25/2025
Levofloxacin 03/20 to 03/29
Ciclodan 03/18 to 04/01 | A 71 y/o male with stable chronic illnesses such as Parkinson's, HLD, DM, HTN, and mental disorders was seen today for a local infection of the skin and subcutaneous tissue, unspecified. The patient, with no S/S of acute distress, was found in bed. Denies SOB, chest pain, dizziness, abdominal discomfort, or headaches. As per the nursing staff, the patient has been compliant with treatment. Keep track until 03/25/2025 for better control. Education was given to the patient and nurse on the importance of redirecting the patient and keeping safe precautions and fall precautions with him. Education was provided on the significance of daily showering. The patient was seen today to monitor nystatin, levofloxacin, and ciclodan treatment. The patient feels better, and there are no new events. The rash on his inguinal area is improving. No itching was reported. No swelling was present. The patient denies pain. Lung inspiratory wheezing on auscultation. Right lung worse than left lung. Heart ...More... | Pollen Extracts, Ragweed | Nystatin cream; 100,000 unit/gram; amt: 1 g; topical. Begin: 03/14/2025 - 03/25/2025
End; 03/25/2025
Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500mg (1 tab QD X 0 Days) Dx: Pneumonia. Once A Day
Ciclodan (ciclopirox) solution; 8 %; amt: 1 application; topical Special Instructions: Apply to right hand ring finger nail. Once A Day. Begin:
03/19/2025 - 04/01/2025
Ending: 04/01/2025 | J18.9 Pneumonia, unspecified organism & L08.9 Local infection of the skin and subcutaneous tissue, unspecified | Nystatin cream; 100,000 unit/gram; amt: 1 g; topical. Begin: 03/14/2025 - 03/25/2025 (Antifungal)
End; 03/25/2025
Chest x-ray 2 views
Albuterol sulfate solution for nebulization 2.5 mg/3 ml (0.083 %) amt: 2.5 mg/3 ml inhalation every 8 hours Start: 03/18/25
Pulmonary consult was ordered.
Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500mg (1 tab QD X 0 Days) Dx: Pneumonia. Once A Day
Ciclodan (ciclopirox) solution; 8 %; amt: 1 application; topical Special Instructions: Apply to right hand ring finger nail. Once A Day. Begin:
03/19/2025 - 04/01/2025
Ending: 04/01/2025 | Follow the prescribed antifungal treatment as directed, ensuring the full course is completed to prevent recurrence or complications. Keeping the affected area clean and dry is essential, and the patient should avoid scratching or touching the infection to prevent further irritation or spreading. Monitoring for signs of worsening infection, such as increased redness, swelling, warmth, pus, or fever, is important, and medical attention Should be sought if these symptoms develop. Maintaining good hygiene, wearing loose-fitting clothing, and managing underlying conditions such as diabetes can help prevent future infections. | 99308 | YES | 18 | 1 |
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| J18.9 | | | 99309 | | | Monitor for pneumonia, unspecific organism. Monitor for Levofloxacin. | The patient should continue her current care plan and medications while being closely monitored for any signs of respiratory distress or exacerbation. Regular follow-ups are essential to evaluate her respiratory status and adjust treatment. She should avoid asthma triggers, adhere to prescribed inhalers and medications, and practice breathing exercises to support lung function. Ongoing education for both the patient and caregiver is crucial to ensure treatment compliance and early recognition of worsening symptoms. If any respiratory issues arise or worsen, I would recommend you give immediate medical attention. The patient is alert time 1. During the evaluation, the patient was seated in a wheelchair. No signs of respiratory noted at this time. The patient was in nasal cannula 4 l/min. No pain was reported. Diminish lung sound on auscultation. No edema present. A radial Pulse 2+ bilaterally. Continue monitor the patient. | Codeine sulfate, Erythromycin, Sulfonamides (Sulfa), Fish, Shellfish | Levofloxacin tablet; 750 mg; amt: 750 mg; oral Special Instructions: Dx: Pneumonia. Begin: 03/20/2025 - 03/22/2025
Ending: 02/22/2025 | J18.9 Pneumonia, unspecified organism | Levofloxacin tablet; 750 mg; amt: 750 mg; oral Special Instructions: Dx: Pneumonia. Begin: 03/20/2025 - 03/22/2025
Ending: 02/22/2025
Hand Washing.
Daily shower
Oral care | The patient should maintain her current treatment regimen and continue regular monitoring for any changes in respiratory status. It is important to avoid potential asthma triggers and ensure proper use of prescribed inhalers and medications. Encouraging pulmonary rehabilitation exercises may help improve lung function and prevent future exacerbations. Regular follow-ups Should be scheduled to assess progress and make necessary adjustments to the care plan. Additionally, ongoing education for both the patient and caregiver is essential to reinforce adherence to treatment and early identification of worsening symptoms. Immediate medical attention Should be sought if respiratory symptoms reappear or worsen. | 99309 | YES | 24 | 1 |
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| N48.1 | R78.81 | | 99308 | | | Fluconazole tablet 03/14-03/16 Completed
Mupirocin ointment | A 57 y/o male with a PMHx of anemia, T2DM, HTN, heart failure, muscle spasms, ESRD on HD, and osteomyelitis was seen today for follow-up to monitor after Fluconazole treatment and Mupirocin. The patient is
in bed, and no S/S of acute distress was noted. No SOB, palpitations, fever, dizziness, or n/v. Admitted on IV ABX due to bacteremia, no adverse effects. Follow-up for Balanitis on his penis. No discharge, itching, or pain was reported during the examination. However, irritation was reported. The patient is on Dialysis at the bedside (M, W, and F). Continue to monitor the patient's | No known allergies | DC. Fluconazole oral tablet; 150 mg: amt: 150 mg: oral Special Instructions: fluconazole tab 150 mg (1 tab QD) x 3 day Once A Day. Begin: 03/14/2025 - 03/16/2025 Completed
End: 03/16/2025 DC Completed
Mupirocin ointment; 2 %; amt: 2 %; topical Three Times A Day. Begin; 03/05/2025 - Open ended
End: Open ended | N48.1 Balanitis & R78.81 Bacteremia | DC. Fluconazole oral tablet; 150 mg: amt: 150 mg: oral Special Instructions: fluconazole tab 150 mg (1 tab QD) x 3 day Once A Day. Begin: 03/14/2025 - 03/16/2025 Completed
End: 03/16/2025 DC Completed
Mupirocin ointment; 2 %; amt: 2 %; topical Three Times A Day. Begin; 03/05/2025 - Open ended
End: Open ended | Patient should maintain good genital hygiene by gently washing the affected area with warm water and avoiding harsh soaps or irritants. If prescribed, topical antifungal or antibiotic creams Should be applied as directed to treat the underlying cause. Keeping the area dry and wearing loose-fitting, breathable underwear can help prevent further irritation. The patient should avoid sexual activity until symptoms resolve to prevent discomfort and potential transmission of infection. If symptoms persist, worsen, or recur frequently, follow-up with a healthcare provider is necessary to rule out underlying conditions such as diabetes or infections. | 99308 | YES | 18 | 1 |
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| C34.11 | B96.20 | | 99308 | | | The patient came from the Hospital. Positive for Escherichia Coli on sputum from Bronchial wash. Monitor for Ceftriaxone IV. | An 81-year-old female who came on 03/17/25 was admitted from the Hospital. The patient's lung was clear on auscultation. The patient was evaluated today, lying in a hospital bed. Muscle weakness and general condition deterioration were noted During the physical examination. We will continue monitoring the patient's respiratory status. The patient has an intact PICC line, and the midline dressing on her right arm was intact. Mechanical ventilation was noted. I didn't see any respiratory distress. S1 and S2 present. The tracheostomy dressing and PEG tube were intact. Information was obtained from the Patient, Primary nurse, and chart. The patient's chart was reviewed with the nurse. The patient's RN was educated on the importance of complying with the treatment established. | Atorvastatin, bacitracin, doxycycline hyclate | DC. Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Special Instructions: DX: Pneumonia Begin: 03/18/2025 - 03/20/2025.
End: 03/20/2025 Completed | C34.11 Malignant neoplasm of upper lobe, right bronchus or lung & B96.20 Unspecified Escherichia coli [E. coli] | DC. Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Special Instructions: DX: Pneumonia Begin: 03/18/2025 - 03/20/2025.
End: 03/20/2025 Completed | Concurrently, the E. coli infection must be identified at its source and treated with appropriate antibiotics based on culture sensitivity. Supportive care, including pain management, pulmonary rehabilitation, and nutritional support, is essential. Close monitoring for infection resolution and oral care is recommended to prevent pneumonia. | 99308 | YES | 18 | 1 |
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| J18.9 | | | 99308 | | | Monitor Levofloxacin. Monitor for unspecific organisms. | The patient is a 69-year-old male with PMH of Muscle wasting and atrophy, not elsewhere classified, multiple sites, Alcohol abuse with intoxication, unspecified, Essential (primary) hypertension, Muscle weakness (generalized), Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation, adult failure to thrive, Chest pain, unspecified. The patient is lying down and remains in stable condition. No acute distress was reported by the nursing staff. The patient is AAOX2. Unable to actively participate in their care due to underlying conditions. Medication review in the chart. Tolerating levofloxacin medication well. The patient's lungs are clear on auscultation, and heart S1 and S2 are present—the last bowel movement was 03/17/25. No pain, nausea/ vomiting, or SOB were reported. No edema was present. The patient was sitting on his bed after the examination. The patient is alert time 2. The patient's abdomen is soft and not distended. No edema present. | No known allergies | Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500 mg (1 tab QD) X 7 days .Dx: Pneumonia Once A Day. Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025 | J18.9 Pneumonia, unspecified organism | Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500 mg (1 tab QD) X 7 days .Dx: Pneumonia Once A Day. Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025
Daily shower
Oral care
Hand washing | Diet: LCS/NAS, Mechanical Soft. Oral care, ambulation with assistance, good nutrition, and complete the antibiotic. | 99308 | YES | 18 | 1 |
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| H61.20 | | | 99308 | | | Impacted cerumen, unspecified ear. Monitor for Ofloxacin drops | Eugene is a 74 y/o male patient with PMH of Acute respiratory failure, Type 2 diabetes mellitus without complications, Essential (primary) hypertension, Acute kidney failure, and Dysphagia. The patient was examined, and the patient was oriented to the person and made eye contact. The nurse denies fever in the patient, vomiting, or acute respiratory distress. We will continue to monitor the patient's ears. No cerumen was noted. No pain was reported. The patient chart was reviewed with the nurse. The nurse tells us that the patient is complying with the medication therapy as indicated. The nurse tells us that the patient is tolerating the medications well. Education given on the importance of complying with treatment established | No known allergies | Ofloxacin drops; 0.3 %; amt: one drop; otic (ear) Special Instructions: Dx. Cerumen impaction Once A Day
Mupirocin ointment; 2 %; amt: 2 %; topical Special Instructions: Applied to patient's under his right nostril Twice A Day | G61.20 Impacted cerumen, unspecified ear | Ofloxacin drops; 0.3 %; amt: one drop; otic (ear) Special Instructions: Dx. Cerumen impaction Once A Day
DC. Mupirocin ointment; 2 %; amt: 2 %; topical Special Instructions: Applied to patient's under his right nostril Twice A Day
Daily shower
Oral care
| Oral care, daily shower, and continue with ambulation with assistance. | 99308 | YES | 18 | 1 |
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| N39.0 | | | 99309 | | | Monitor Ciprofloxacin | Follow the patient with a urinary tract infection on antibiotic therapy. The patient was assessed at the bedside AAOX3. The patient denies chest pain, palpitations, SOB, chills, confusion, headache, blurry vision, diaphoresis, and pain in urination. Continue the current antibiotic treatment; the last dose will be today, 03/21/25. The patient is tolerating it well. No adverse or allergic reactions were reported. According to the nurse, the patient is compliant with the treatment, and there have been no overnight events. Continue to monitor intake and output. The patient was educated about daily showering, hand washing, and oral care. | No known allergies | Ciprofloxacin HCl tablet; 500 mg; amt: 500 mg; oral Special Instructions: Dx. UTI. Twice A Day. Begin: 03/19/2025 - 03/28/2025
Ending: 03/28/2025 | N39.0 Urinary tract infection, site not specified | Ciprofloxacin HCl tablet; 500 mg; amt: 500 mg; oral Special Instructions: Dx. UTI. Twice A Day. Begin: 03/19/2025 - 03/28/2025
Ending: 03/28/2025 | It is recommended to continue monitoring the patient’s progress with the urinary tract infection (UTI) while they are completing their antibiotic therapy. The patient remains alert and oriented (AAOX3) and has denied any concerning symptoms such as chest pain, palpitations, shortness of breath, chills, confusion, headache, blurry vision, diaphoresis, or pain with urination. The patient has tolerated the antibiotic treatment well, with no adverse or allergic reactions reported, and is compliant with the prescribed regimen. The last dose of antibiotics will be administered today, 03/21/25, and the patient should complete the full course of treatment. It is important to continue monitoring the patient's intake and output, ensuring proper hydration. Additionally, reinforce the importance of maintaining good hygiene practices, including daily showering, regular hand washing, and oral care, to help prevent further infections. Follow-up assessments Should be scheduled to evaluate the pat...More... | 99309 | YES | 24 | 1 |
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