CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL

Lacson – Burgos Streets, Bacolod City

DOCTOR’S ORDER/PROGRESS NOTES

NURSES’ COMPLIANCE SHEET
(Authenticate all Orders)

Name of Patient ALIGATO, DONTAO Hospital No.

Address Bacolod City Ward / Room Ortho – Floor 2
Age 51 Sex Male Admission Date 04 January 2024
C- CARRIED A-ADMINISTERED R-REQUEST MADE E-ENDORSED D-DISCONTINUED
Date TIME
Progress Notes Doctor’s Order C A R E D
Time SIGNATURE
CC: Ulcerated wound, right leg
04 Please admit patient to ORTHO WARD at FLOOR 2 under
JAN HPI: Adult service of Doctors Albelda / Dedel
4 years ptc (2020) onset of rash at right medial malleolus
2024 area, patient noted it to be pruritic with fluid excretions Secure signed consent of care
extending to the right lateral side of the leg. Patient
3:30 treated it with Mupirocin. Noted minimal relief.
Monitor vital signs q shift
am Diet – As tolerated, to include 1 boiled egg per meal
However, rash started to progress, patient sought consult
at a private institution and was given unrecalled antibiotics IVF – 1L PNSS to run 120ml per hour x 3 cycles
and was requested with labs and imaging (doppler). Diagnostics –
Unremarkable findings as claimed by the patient.
□ CBC with blood typing
Interim, nonhealing wound, patient managed it with
Betamethasone, Gentamicin ointment.
□ Bun Crea Na K
□ Serum Albumin, Hba1c
2 years PTC, patient came home from Manila, patient
sought consult with orthopaedic surgeon (Dr Gladys Tan.
□ FBS, Lipid profile
was prescribed with unrecalled antibiotic. Noted relief. □ Chest Xray PA
5 months PTC, patient scraped right lateral side of leg,
□ 12 Lead c/o Heart station once at ward
patient applied Betamethasone, Gentamicin ointment. □ CBG TID premeals for the 1st 24 hours and record
Noted minimal relief. No consult done.
Medications –
Interim, patient did daily wound care. However, wound □ Omeprazole 40mg tablet PO, OD
appeared to be non healing.
□ Paracetamol 500mg tablet PO, q4 PRN for fever
Odc, patient sought consult at a private orthopaedic □ Celecoxib 200mgm capsule PO, BID PRN for Pain
surgeon (Dr Gladys Tan) and Was advised admission.
□ Cefuroxime 1.5grams IV as loading dose then
Past Medical History: 750mg iv q12
(-) Previous admission
(-) Previous surgery
□ Clindamycin 600mg IV q8
(-) FDA □ Beneprotein powder, 2 scoops in 1 glass water, TID
Family History:
□ Ascorbic Acid 500mg tablet PO, OD
(+) paternal- htn Special Orders -
Personal History: □ OR plan : For Debridement, NPWT at OR setting
Occasional alcohol beverage drinker □ Secure consent for procedure
Non-smoker
□ To secure compressive stockings and apply to Leg
(+) hyperpigmentation of foot up to the middle 3rd leg, □ Keep bilateral legs elevated at all times
right
(+) ulcerating wound 4x2cm medial aspect of ankle □ Deep tissue GS/CS specimen sent, follow up results
(+) ulcerating wound 4x4cm lateral aspect ankle up to □ For Doppler ultrasound scheduling
distal leg
(+) erythematous borders □ Refer to IM-IDS for comanagement
2+ posterior tibial pulse □ Refer to IM for CP clearance once all labs in
2+ dorsalis pedis pulse
No sensory deficit □ Refer to Rehab for General body conditioning
□ To secure 1 unit PRBC, for OR use
Labs:
Hgb 155 Hct 9.44 WBC 11.7 □ Secure dressing materials once at ward
BUN 13.20 Crea 0.86 Na 137.20 K 3.70 □ Refer accordingly
Albumin 4.3 Awaiting HbA1c

Diagnosis: Infected venous stasis ulcer medial and lateral

aspect of ankle and distal leg, Right sec to chronic venous
_________________, MD
insufficiency CEAP C6 Admitting Resident
Plan -
For debridement at OR setting
Refer to IM for CP eval
For deep tissue GSCS
Compression dressing

Doctor’s Orders Form

CLMMRH-MRS.F.032
Issued: 2/5/14
Issue .No. 001
 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL
Lacson – Burgos Streets, Bacolod City

DOCTOR’S ORDER/PROGRESS NOTES

NURSES’ COMPLIANCE SHEET
(Authenticate all Orders)

Doctor’s Orders Form

CLMMRH-MRS.F.032
Issued: 2/5/14
Issue .No. 001