NEW CASE

Name I/C R/N Age Address Diagnosis : Miss Anisah Jehmah : A843982 : 681431 : 51 years : Tajung Che Mas, Tumpat, Kelantan. : Right foot fasciitis

AM SHIFT 23/06/2012 8.30 AM New case admitted to ward from casualty at 7.15am via stretcher accompanied by PPK and relatives u/L DM x10 years. Not on proper treatment. Condition patient on admission weak and pale. Case referred from Hospital Tumpat due to complain of Right Foot Ulcer. X 1/12 started as blister peeled by patient and develop ulcer over Right Heel. Vital Sign checked BP : 140/90 mmHg, Pulse : 112/min, Temp : 38c. case seen by Dr.Hafiz at A&E and odered to start Iv unasyn 1.5gm TDS,Tab Metformin 1gm BD and Tab Daonil 10mg BD. Plan for Wound Debridement Right Foot SA/GA once optimized. Gm done 22.4mmol/L 23/06/2012 10.20.AM - Seen by Dr.Azrul -51 years, female, malay - Right Foot Necrotising fasciitis, u/L Dm not on proper treatment. Previously on Tab Metformin 1gm BD, Tab Daonil 10mg BD. c/o Right Foot Swelling x 1/52 a/w blister x 1 by pus discharge -low grade fever x 3/6, poor oral intake - no bleeding tendency

Plan

: w/hold OHA : s/c actrapid 10u TDS : Dressing with Povidone Iodine + H2 O2 daily : IVD 3O N/saline : keep NBM after lunch

AM SHIFT 24/06/2012 7.00.AM - general condition alert and conscious. No complained to pain. Patient rest in bed. IVD in progress. Vital Signs taken and recorded. 24/06/2012 10.05 AM - patient stable. Seen by Dr.Azrul. Continue currently management as planned. Tolerating orally as tolerated.

MEDICATION
-IV unasyn 1.5gm TDS - S/C actrapid 10u TDS - Tab Metformin 1gm BD - Tab Daonil 10mg BD

OLD CASE
Name I/C R/N Age Address Diagnosis : Che Rahmah Bt Awang : 530402-03-5010 : 679512 : 59 years : 16300 Bachok, Kelantan :Necrotising Fascitis of Right Leg in Sepsis : Uncontrolled DM + HPT AM SHIFT 12/06/2012 7.30 AM Patient rest in bed. No other complain General condition pale. No SOB on O2 3L/min via Nasal Prong. On Sliding Scale with hourly GM. 4hourly CVP reading. Prepare for OP today. For extensive wound debridement of right Leg SA/GA today. Censent up. Last meal at 5.00 AM. 9.00AM -Seen by Dr.Hidayah to inform OT to transfused another 4 FFB 10.15AM -MO Anaest noted by Dr. Nurul 11.30AM -Received call from OT to sent patient to OT BP Pulse : 173/80mmhg : 90/min

Temp : 40c

-Dr. anaest noted to given Tab atenolol 100mg given

12.00 Noon - Send patient to OT. Confirmed with staff blood bank. Plan : NBM : IV Pethidine 50mg : IV Midazolam 2mg : Iv Morphine 2mg Plan -Seen by Dr.Zulfakal at 8.30 AM as plan -Review PRN - Review chest physio -Not for extubation yet - continue Iv Morphine 1cc hourly - KIV for Iv preced if patient wrestles - keep NBM - To monitor i/o - To monitor vital sign

MEDICATION
-Tab Simvastatin 20mg ON -Tab Enalapril 20mg OD -Mist KCL 15ml TDS -Tab Atenolol 100mg OD -ORS II/II TDS -s/c insulatard 10u ON

DISCHARGE
NAME i/c R/N Age Address Diagnosis : Wan Mah Bt Yaacob : 601118-03-5422 : 681207 : 52 years : Kg kuchelong, 16070 Bachok, Kelantan. : Lt diabetic foot ulcer

25/06/2012 7.30AM - patient rest in bed. Patient condition stable. Plan for w/D L heel SA/GA- today consent up. Counter sign Mo- required IVD 3 n/saline in progress. Relative request memo for wheel chair. Review by Dr. Hanif. Patient request ADR discharge. Expalained done by Dr.Hanif. 9.45AM - Seen by Mr.Sanusi- allow AOR discharge. TCA 1/52, 3/7/12@ 10.00 AM oral antibiotics x 1/52 with analgesic. Daily dressing wuth povidone Iodine at Local Clinic Plan : Allow AOR : TCA 1/52 : with oral antibiotics x 1/52 with analgesic : daily dressing with povidone Iodine

MADICATION

-S/C actrapid 16u TDS -Tab daonil 10mg BD -Tab Augmentin 625mg BD

-Tab Metformin 1gm BD -Tab Tramadol 50mg TDS