Impacted cerumen, unspecified ear. Monitor for Ofloxacin drops
The patient was evaluated on bed. No distress or SOB was noted. The patient's lung is clear on auscultation. Heart S1 and S2 are present. The last BM was on 03/15/25. The abdomen is soft and distended. The skin shows scars from drug use, as the patient reported. Not reported pain in his ears. I don't see any discharge or cerumen noted. The patient reported: " The ear drop help me, I am feeling better." The patient was alert time 4. Continue monitoring the patient.
Ofloxacin drops
G61.20 Impacted cerumen, unspecified ear
Ofloxacin drops
Oral care, daily shower, and continue with ambulation with assistance.