During a routine visit to the nursing home to manage the patient's chronic conditions, the patient was observed resting comfortably. No shortness of breath (SOB) or acute respiratory distress was noted during the physical exam. The patient was alert and oriented to person and place (X2). There were no reports of nausea or diarrhea, and the nursing staff did not report any recent falls or significant events. Lab work has been completed. The patient's condition remains stable, and there are no acute concerns at this time. Today, during the physical examination, the patient has no deformities, is well-ventilated, and has equal expansion. The patient continues with nystatin suspension for thrush, tolerating the medication well. No adverse or allergic reactions were reported. In addition to addressing the main reason for this visit, I reviewed all the patients' diagnoses and treatments.
An acute care visit was conducted today to follow up on a patient receiving antifungal medication for thrush. At the bedside, the patient was assessed and found to be alert and oriented to person and place (AAOX2). The patient denies experiencing chest pain, palpitations, shortness of breath, chills, confusion, headache, blurry vision, or diaphoresis. The patient continues on nystatin suspension, tolerating it well, with no reported adverse or allergic reactions. Nursing staff reported that the patient was compliant with treatment, and no overnight events were noted. In addition to addressing the primary concern of this visit, a thorough review of the patient’s diagnoses and treatments was conducted to mitigate potential health complications and medication interactions. The patient’s chart was reviewed with the nurse, and education was provided to both the patient and nurse regarding treatment adherence and the established plan of care. The current care plan and medications will be continued.
No known allergies
Nystatin suspension; 100,000 unit/mL; amt: 10ml; oral Begin: 03/01/25 - Open ended.
B37.0 Candidal stomatitis
Nystatin suspension; 100,000 unit/mL; amt: 10ml; oral ( Antifungal ) Begin: 03/01/25 - Open ended.
Maintaining good oral hygiene by cleaning the tongue regularly is essential. Limiting sugar and yeast-rich foods, staying hydrated, and eating a balanced diet can help prevent fungal overgrowth. Denture wearers should clean and disinfect them daily, while avoiding irritants like alcohol, tobacco, and spicy foods can reduce discomfort. Continue the treatment. It is essential to complete the full course of treatment as prescribed, even if symptoms improve before finishing the medication. Nystatin or Fluconazole, work best when taken consistently for the full duration.