Impacted cerumen, unspecified ear. Monitor for Ofloxacin drops
Eugene is a 74 y/o male patient with PMH of Acute respiratory failure, Type 2 diabetes mellitus without complications, Essential (primary) hypertension, Acute kidney failure, and Dysphagia. The patient was examined, and the patient was oriented to the person and made eye contact. The nurse denies fever in the patient, vomiting, or acute respiratory distress. We will continue to monitor the patient's ears. No cerumen was noted. No pain was reported. The patient reported pain of 7/10 on his left upper abdomen. The patient's abdomen was distended. The last BM was 03/17/25. Acute Care Consult was notified. An abdomen ultrasound was ordered. The patient chart was reviewed with the nurse. The nurse tells us that the patient is complying with the medication therapy as indicated. The nurse tells us that the patient is tolerating the medications well. Education given on the importance of complying with treatment established
No known allergies
Ofloxacin drops; 0.3 %; amt: one drop; otic (ear) Special Instructions: Dx. Cerumen impaction Once A Day
Mupirocin ointment; 2 %; amt: 2 %; topical Special Instructions: Applied to patient's under his right nostril Twice A Day
G61.20 Impacted cerumen, unspecified ear
Ofloxacin drops; 0.3 %; amt: one drop; otic (ear) Special Instructions: Dx. Cerumen impaction Once A Day
Mupirocin ointment; 2 %; amt: 2 %; topical Special Instructions: Applied to patient's under his right nostril Twice A Day
Acute Care consult
Abdomen ultrasound complete was ordered 03/19/25
Oral care, daily shower, and continue with ambulation with assistance.