We evaluated the patient today for a follow-up infectious diseases consult. The patient remains stable in a skilled nursing facility. The Peg Tube is in place without a problem. The tracheostomy was present with a mucus plug in the tracheostomy tube. Tracheostomy care, suction, and sterile saline solution into the tracheostomy tube were applied, and the inner cannula were changed. The patient was stable after the tracheostomy care. 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, Dysphagia following cerebral infarction. I have reviewed all the patients' diagnoses and treatments. The patient was evaluated due to the patient's medical needs and to avoid future complications and hospitalizations. Patient is currently on oxygen at 4LPM via Trach .Patient was evaluated today lying in hospital bed ,awake but minimal response , patient with SOB and labored breathing at the time of the visit . Today to the physical examination Rhonchi in left and right lung , Crackles ( coarse, fine) in right lungs, muscle weakness and deterioration of general condition. O2 sat 91% with currently on oxygen at 4LPM via Trach, excessive amount of yellow-green respiratory secretion with bad smell , (CBC,CMP and Xray and sputum culture ordered). Respiratory treatment was administered with Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML via Neb for 15 min and patient was suctioned several time .After that the O2 sat was over 96% at 4LPM . Wi will continue monitoring the patient respiratory status. Information obtained from Patient, Primary nurse, and chart. Patient chart reviewed with nurse . Education given on the importance of complying with treatment established.
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.