Follow- up for Local infection of the skin and subcutaneous tissue, unspecified. Monitor Bactrim (sulfamethoxazole-trimethoprim) antibiotic until 03/17/2025
A 69-year-old male with PMH of nicotine dependence, GERD, vascular dementia, hypertension, PVD, sleep disorder, and encephalopathy was seen today for a follow-up on ABT treatment for a Local infection of the skin and subcutaneous tissue, unspecified. The patient denies SOB, chest pain, dizziness, abdominal discomfort, fever, n/v, or diarrhea. Tolerating therapy with no adverse effects. Reinforce to nursing staff the importance of monitoring patient behavior during ABT therapy; there are no other issues.
In addition to addressing the main reason for this visit, I reviewed all the patients' diagnoses and treatments. This comprehensive review aims to prevent future patient health complications and avoid potential medication interactions. The patient's left foot dressing was intact and clean. The patient refused to remove his dressing to assess the left big toe. The patient reported, " I see my left big toe is black." The patient reported pain in the back on his left big toe only when he presses it. Education was given about hand washing and daily showers. The patient verbalized understanding.
No known allergies
Bactrim (sulfamethoxazole-trimethoprim) oral tablet; 400-80 mg; amt: 400-80 mg; oral Special Instructions: Dx. Skin infection. Every 12 Hours. Begin: 03/11/2025 - 03/17/2025
End: 03/17/2025
L08.9 Local infection of the skin and subcutaneous tissue, unspecified
Bactrim (sulfamethoxazole-trimethoprim) oral tablet; 400-80 mg; amt: 400-80 mg; oral Special Instructions: Dx. Skin infection. Every 12 Hours. Begin: 03/11/2025 - 03/17/2025
End: 03/17/2025
Patient should keep the affected area clean and dry, Completing the full course of prescribed antibiotic treatment is essential to prevent the infection from worsening or recurring. Avoiding scratching or touching the infected area can help prevent further irritation and the spread of infection. The patient should monitor for signs of worsening infection, such as increased redness, swelling, warmth, pus, fever, or pain. Maintaining good hygiene, and daily shower to prevent infection.