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. We will continue monitoring the patient's respiratory status. Information was obtained from the Patient, the Primary nurse, and the chart. The patient's chart was reviewed with the nurse. Education is given on the importance of complying with the treatment established. Heart S1 and S2 were present.
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, B36.9 Superficial mycosis, unspecified
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
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.