A41.9
H01.0
99309
Monitor for Meropenem and Gentamicin.
The patient was assessed at the bedside. Trach in situ does not follow commands, and both eyes are open. No discharges were noted on his eyes at this time. Productive cough with copious yellow phlegm. Lungs: Diminished breath sounds, +Rhonchi. Cardiovascular: RRR, S1 and S2. No evident chest pain, palpitations, SOB, chills, or diaphoresis noted. Continue with current antibiotic treatment. Tolerating well.
No known allergies
Gentamicin drops; 0.3 %; amt: 1 drop; ophthalmic (eye). Begin: 03/10/2025 - 03/20/2025 End: 03/20/2025 Meropenem recon soln; 1 gram; amt: 1 gram; intravenous. Begin: 03/08/2025 - 03/14/2025 End: 03/14/2025
A 41.9 Sepsis, unspecified organism, H01.0 Blepharitis
Gentamicin drops; 0.3 %; amt: 1 drop; ophthalmic (eye) four times a day for 10 days DX: Blepharitis Four Times A Day. Begin: 03/10/2025 - 03/20/2025 End: 03/20/2025 Meropenem recon soln; 1 gram; amt: 1 gram; intravenous Every 8 Hours. Begin: 03/08/2025 - 03/14/2025 End: 03/14/2025
Adherence to prescribed treatments. Sepsis is a serious condition that requires completing the full course of antibiotics, maintaining proper hydration, and monitoring vital signs for any worsening symptoms such as fever, confusion, difficulty breathing, or low blood pressure. In addition, Blepharitis Should be managed with good eyelid hygiene, including warm compresses and gentle cleaning with a prescribed solution or baby shampoo to reduce inflammation and bacterial buildup. Avoiding eye rubbing and using prescribed topical medications, if applicable, can help control symptoms. Continue with the Gentamicin drops until 03/20.
99309
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