KNEE REPLACEMENT PRE-Operative ORDER

Chart #: Estrellan, Fr. Bobby Rommel M/48Y.O.

7628
Diagnosis: Post traumatic osteoarthritis , Left knee

 Admit under the service of Dr. Ramon Gustilo,M.D.

 Regular diet or unless otherwise specified.
 Schedule for Total Knee arthroplasty , Left on May 7,2018 at 0700H
 Inform Operating room and secure patient consent for Surgery.
 Refer to Roger Alburo M.D. for anesthesia
 Refer to Michael Salvador for Cardio clearance
 Nothing by mouth after midnight (NPO) prior to surgery
 Shower the night before surgery
 Have BM the night before and empty bladder before going to surgery.
 Type and cross match ______ packed red blood cell for possible OR use

 Please attach all laboratory results

 Pre op antibiotics Cefuroxime 1.5grms in the OR before induction. Repeat 12
hrs. after surgery.
 Hemostan 1 gram/IV upon induction of anesthesia
 Inform the attending physician of this admission.
 Please inform relatives to wait outside of the operating room to talk to surgeon
after surgery is finished.

_______________________

Dr. Ramon B. Gustilo, MD

 KNEE REPLACEMENT PRE-Operative ORDER
Chart #: Panugaling, Patricio Villarcampo 67y/o/Male/ Married Clinic Visit #:
6425 November 11,2017

Reg. Date: Referral: Walk-in Occupation: Retired VMC Hospital Chart #:

11-11-2017
Carpenter

Knee Pre-Operative Form

 Admit under the service of Dr. Ramon Gustilo,MD/ Dr. Saeid Safaee
Chalkasra,MD/ Dr. Eric Piscawen,MD
 Regular diet or unless otherwise specified
 Get patient consent for -Total Knee Arthroplasty,Left December 14,2017 at
0800H
 Nothing by mouth after midnight (NPO) prior to surgery
 Shower the night before surgery and wash with soap and water from umbilicus to
knee of the schedule extremity wrap with clean towel.
 Have BM the night before and empty bladder before going to surgery.
 Type and cross match 1 unit of packed red blood cell for possible OR use
 Please attach all laboratory results.
 Hemostan 1 gram in OR and repeat ½ gm in about 6-12 hrs.
 Contact:
a. Admitting Surgeon- Ramon Gustilo,MD/ Saeid Safaee Chalkasra, MD/
Eric Piscawen, MD-09154438004/09177701844
b. Anesthesiologist- Roger Alburo,MD
c. Internist or Cardiologist- Fel Ronson Abejar,MD
 Preoperative anesthesia per Anesthesiologist
 Antibiotics: Cefuroxime 1.5 grms. In the OR before induction. Repeat 12 hrs.
after surgery.
 Please inform relatives to wait outside of the operating room to talk to surgeon
after surgery is finished.

_______________________

Dr. Ramon B. Gustilo, MD

 KNEE REPLACEMENT PRE-Operative ORDER
Chart #: Clinic Visit #:

Reg. Date: Referral: Occupation: Hospital Chart #:

Knee Pre-Operative Form

 Admit to room of choice.

 Regular diet or unless otherwise specified
 Get patient consent for _______________________________________
 Nothing by mouth after midnight (NPO) prior to surgery
 Shower the night before surgery and wash with soap and water from umbilicus to
knee of the schedule extremity wrap with clean towel.
 Have BM the night before and empty bladder before going to surgery.
 Type and cross match 1 unit of packed red blood cell for possible OR use
 Please attach all laboratory results
 Hemostan 1 gram in OR and repeat ½ gm in about 6-12 hrs.
 Contact:
d. Admitting Surgeon- Ramon Gustilo,MD/ Saeid Safaee Chalkasra, MD/
Eric Piscawen, MD
e. Anesthesiologist-
f. Internist or Cardiologist-
 Preoperative sedation per Anesthesiologist
 Antibiotics: Cefuroxime 1.5 grms. In the OR before induction. Repeat 12 hrs.
after surgery.
 Please inform relatives to wait outside of the operating room to talk to surgeon
after surgery is finished.

_______________________

Dr. Ramon B. Gustilo, MD