N48.1
R78.81
99308
Fluconazole tablet 03/14-03/16 Completed Mupirocin ointment
A 57 y/o male with a PMHx of anemia, T2DM, HTN, heart failure, muscle spasms, ESRD on HD, and osteomyelitis was seen today for follow-up to monitor after Fluconazole treatment and Mupirocin. The patient is in bed, and no S/S of acute distress was noted. No SOB, palpitations, fever, dizziness, or n/v. Admitted on IV ABX due to bacteremia, no adverse effects. Follow-up for Balanitis on his penis. No discharge, itching, or pain was reported during the examination. However, irritation was reported. The patient is on Dialysis at the bedside (M, W, and F). Continue to monitor the patient's
No known allergies
DC. Fluconazole oral tablet; 150 mg: amt: 150 mg: oral Special Instructions: fluconazole tab 150 mg (1 tab QD) x 3 day Once A Day. Begin: 03/14/2025 - 03/16/2025 Completed End: 03/16/2025 DC Completed Mupirocin ointment; 2 %; amt: 2 %; topical Three Times A Day. Begin; 03/05/2025 - Open ended End: Open ended
N48.1 Balanitis & R78.81 Bacteremia
DC. Fluconazole oral tablet; 150 mg: amt: 150 mg: oral Special Instructions: fluconazole tab 150 mg (1 tab QD) x 3 day Once A Day. Begin: 03/14/2025 - 03/16/2025 Completed End: 03/16/2025 DC Completed Mupirocin ointment; 2 %; amt: 2 %; topical Three Times A Day. Begin; 03/05/2025 - Open ended End: Open ended
Patient should maintain good genital hygiene by gently washing the affected area with warm water and avoiding harsh soaps or irritants. If prescribed, topical antifungal or antibiotic creams Should be applied as directed to treat the underlying cause. Keeping the area dry and wearing loose-fitting, breathable underwear can help prevent further irritation. The patient should avoid sexual activity until symptoms resolve to prevent discomfort and potential transmission of infection. If symptoms persist, worsen, or recur frequently, follow-up with a healthcare provider is necessary to rule out underlying conditions such as diabetes or infections.
99308
YES
18
1
Powered by © https://quintadb.com