Monitor pneumonia, piperacillin-tazobactam/ Pneumonia / SOB
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. Patient is currently on oxygen at 4LPM via Trach. Patient was evaluated today lying in hospital bed. Today to the physical examination Crackles (coarse, fine) in right lungs, muscle weakness and deterioration of general condition. The patient was suctioned several times. Patient on piperacillin-tazobactam recon soln; 3.375 gram; amt: 3.375 gram and Nystatin cream for fungus right side lower back. Special Instructions: Administer intravenously for 10 days DX: Pneumonia 03/05/25 to 03/15/25. We 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.
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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
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
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 antibiotics and 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.