09-22-1955
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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