Date & Time

Informed by SN that patient complaint of discomfort at the wound site. Attended stat.

Upon attendance, patient is comfortable, no other active complaints.

O/E; Alert, not septic
Temperature;
BP; PR; RR;

GM (if diabetic)

WI (wound inspection).

Dressing soaked ++ with seropurulent discharge.

10x7cm wound at plantar surface of right foot,
slough+++ with pus+++ and maggots +++
Necrotic edges at lateral side of the wound, with surrounding erythematous tissues.

Dressing done with turpentine & copious normal saline.

Plan;
1- For wound debridement under LA as planned (awaiting minor OT call)
2- Diabetic diet.
3- KIV refer medical if GM not well controlled.

See the difference? 😏

Which kind of doctor you wanna be?

Decide & prepare yourself well!

(P/s If you do not know, the least you can do is to ASK around how to document things😣, kalau tak tahu, jangan buat-buat tahu!)

3 comments

aininsoraya
Dr, what is GM stand for?
Thank you Dr