Follow-up for Pneumonia, unspecified organism in the context of a patient with chronic illness and poor overall outcomes. Monitor for Azithromycin antibiotic.
73 y/o male patient with PMH of Acute respiratory failure with hypoxia, Tracheostomy status, Chronic obstructive pulmonary disease, unspecified, Nicotine dependence, cigarettes, uncomplicated, Pneumonia, unspecified organism, Malignant neoplasm of larynx, unspecified, Anemia, Major depressive disorder, single episode, Unspecified atrial fibrillation, Morbid (severe) obesity due to excess calories, Heart failure, unspecified. In addition to addressing the main reason for this visit, I reviewed all the patients' diagnoses and treatments. The patient communicated using a notebook. The patient was alert time 4. Rales on auscultation. Herat S1 and S2 present. Increase of secretion: the inner cannula was full of secretion, and a new inner cannula was inserted. No distress was noted. No pain was reported. The PEG tube is clean and intact. Wound care was consulted; the patient has a stage 1 pressure ulcer on the sacral area. The wound care team applied a dressing. This comprehensive review aims to prevent future patient health complications and avoid potential medication interactions. The patient was evaluated due to the patient's medical needs and to prevent future complications and hospitalizations.
Levofloxacin, phenytoin, banana
Azithromycin 03/14-03/21 DC
Order: Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg; amt: 800-160 mg ( 1 tab); gastric tube Twice A Day Begin: 03/19/25- 03/23/25
Ending: 03/23/25
J18.9 Pneumonia, unspecified organism
Azithromycin 03/14-03/21 DC
Order: Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg; amt: 800-160 mg ( 1 tab); gastric tube Twice A Day Begin: 03/19/25- 03/23/25
Ending: 03/23/25
Sputum from Bronchial wash was ordered.
Comprehensive panel Lab was ordered 03/19/25 at 04:00 AM
Crucial to follow the prescribed antibiotic treatment fully, even if symptoms improve before completion. Rest and hydration are essential to aid recovery, along with maintaining good nutrition to support the immune system. The patient should monitor for symptoms such as persistent fever, worsening shortness of breath, chest pain, or confusion. Education was given about the importance of oral care and change position every two hour to prevent skin breakdown. Daily shower is recommended.