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COURSE IN THE WARD

Date & Time 1/11/12 1 pm NOTES/ORDERS/PRESCRIPTION (+) Bed sore, not healed by antibiotic and cream (+)DM BP: 100/60 mmhg HR: 100 bpm RR: 21 cpm TEMP: 36.6 OC (+) non healing wound, Right foot 5th day Pls admit to ward 17 under the service of Dr Ligom/Volita Pls secure consent for admission and management of TPR every shift Monitor V/S every 4 hours and pls record Insert NGT DM Diet: Regular diabetes of based diet at 1800 kcal/day IVF: Plain NSS 1 Litter at 80 cc/hr Pls provide watcher at bedside for 2 hours and alternate DM foot, Right NIDDM Type 2 Diagnostics CBC, PC, PTPA BUN,NA,K,CALCIUM,ALBUMIN ECG XR of Right Foot ABG -DM Therapeutics: IVF as previously orders Ampicilin Sulbactam 1.5 mg IV now then every 8 hours Clindamycin 300 mg IV now then every 6 hours Case endorsed to Dr Vilita Pls follow up laboratory extracted at E ward

Refer Patient to Ortho Inform Dr. Volita, patient is at the ward Refer

1/11/12 6:00 pm

Patient was seen and examined Please facilitate process order DM foot, Right DM type 2 For FBS, lipid profile in the morning For HbA1C Daily wound care Follow up laboratory result BP: 100/80 mmhg HR: 70 bpm RR:19 cpm Temp: 36.1 o C DM foot, right DM type 2 Please facilitate laboratory request in morning Daily wound care Apply Muporicin(Bactroban) ointment on affected area, BID Celecoxib 200 mg, 1 tab PRN refer accordingly BP:100/80 mmhg HR:51 bpm RR: 19 cpm Temp: 36.4 o C DM foot, Right DM type 2 Follow up labs result Metformin 500 mg, 1 tablet, BID Daily wound care May remove NGT Shift to DM diet BP: 110/70 HR: 82 bpm RR: 18 cpm Temp: 36.5 oC

1/12/12 4:00 pm

1/13/12 12:30 pm

01/14/12 8:00 AM

DM foot, Right DM type 2 Continue Mupiricin And Sulbactam 1.5 grams IV every 8 hours Continume Clindamycin 300 mg IV every 6 hours Metformin 500 mg, 1 tab BID Apply bactroban ointment on affected area Daily wound care Reinsert NGT For referral to ortho 1/15/12 3:00 PM 1/16/12 11:00 AM DM Foot, Right For Repeat CBC 1/17/12 9:30 am BP:100/70 HR:80 bpm RR: 16 cpm Temp: 36.4 O C DM type 2 DM foot, Right Resume low salt,low fat, regular diet at 1800 kcal/ day Please Facilitate repeat CBC IV fluid continue Shift to heplock Refer Accordingly

BP: 120/80 mmhg HR: 78bpm RR:19 cpm Temp: 36.5 OC WBC: 9.47 cu/mm Continue Mupiricin And Sulbactam 1.5 grams IV every 8 hours Daily wound care Follow up referral to ortho BP:100/60 mmhg HR: 76bpm RR:19 cpm Temp: 36.3 o C No headache, no dyspnea Patient had loss of appetite Please reinsert NGT

1/18/12 10:30 PM

Start regular diabetic diet at 1800 kcal/day Refer accordingly Ampicilin and Sulbactam 1.5 g IV every 8 hours Metformin 500 mg 1 tab BID Bactroban ointment BID Celecoxib 200 mg, 1 tab OD PRN For HbA1C D/C CBG monitoring