CLINICAL FACE SHEET

______________________
Case Number

Name: Hilda Alucard Age: Date of Birth: Place of Birth: Category of

55 yrs 11/28/1965 Manangat, caoayan Patient:
old ilocos sur
Home Address: Manangat Caoayan Ilocos sur Sex: Civil Status: Religion: Nationality:
Female Married Filipino

Next of Kin: Relationship: Address: Contact No.:

Date Admitted: Time: Date of Discharge: Time: No. of Hospital Days:

12/02/2020 8;25 A.M. ________ A.M.
________ P.M. ________ P.M.

Ward: Attending Physician: Admitting Nurse:

Dr. Harley Sir Balmond

ADMITTING DIAGNOSIS:
Diabetes Melitus Type 2 uncontrolled hypertension

FINAL DIAGNOSIS: ICD 10 Code:

Condition on Discharge: Disposition:

[ ] recovered [ ] died [ ] discharged [ ] absconded

[ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD
[ ] unimproved [ ] not autopsied [ ] home against for follow up advice

COMPLICATIONS:

OPERATION/PROCEDURE DONE:

Review for completeness:

___________________________________________ __________________________________________
Signature over Printed Name Signature over Printed Name
of Attending Physician (Record Officer)
 VITAL SIGNS MONITORING SHEET

Name: Hilda Alucard Age/Sex/CS: 55 Yrs Old/ Female/ Ward/Room: Private Room 202

BP
Date Time Shift PR RR Temp REMARKS
12/2/202 8;25 AM 160/100 89 20 36.7 Clonidine 75mg sublingual is
0 given (8:40 AM)
12/2/2020 3:00 PM 120/70 72 12 36.7
 INTAKE & OUTPUT MONITORING SHEET

Name:__Hilda Alucardd _______________________Age/Sex/CS:_ 55/ female ___Ward/Room:__private 202 ___

INTAKE OUTPUT
Date Time Shift IVF Drain/
Oral/NGT TOTAL Urine stool TOTAL
12/02/202 7:00- AM 406.25cc 1030cc 1,436.25cc 1100cc once 1100cc
0 3;00
 PATIENT’S DATA
1. Name of Patient 2. PIN
Alucard Hilda
Last Name First Name Middle Name 3. Age
5. Chief Complaint 55
Dizziness, chest heaviness, shortness of breath
4. Sex
Male Female

6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code

Diabetes Melitus Type 2 uncontrolled hypertension
8. b. 2nd Case Rate Code

9. a. Date Admitted: 9. b. Time Admitted:

l_1_l_2_l ¯ l_0_l_2_l ¯ l_2_l_0_l_2_l_0_l l_8_l___l ¯ l_2_l_5_l AM PM
month day year hour min
10. a. Date Discharged: 10. b. Time Discharged:
l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM
month day year hour min
REASON FOR ADMISSION
1. History of Present Illness:
Diabetes Melitus Type 2

2. a. Pertinent Past Medical History:

2. b. OB/GYN History:
G_____ P_____ (_____-_____-_____-_____) LMP:_________________ NA
3. Pertinent Signs and Symptoms on Admission (Check applicable box/es):

• Altered Mental Sensorium  Diarrhea  Hematemesis  Palpitations

• Abdominal cramp/pain  Dizziness  Hematuria  Seizures
• Anorexia  Dysphagia  Hemoptysis  Skin rashes
• Bleeding gums  Dyspnea  Irritability  Stool, bloody/black
• Body weakness  Dysuria  Jaundice tarry/mucoid
• Blurring of vision  Epistaxis  Lower extremity edema  Sweating
• Chest pain/discomfort  Fever  Myalgia  Urgency
• Constipation  Frequent urination  Orthopnea  Vomiting
• Cough  Headache  Pain, ____________ (site)  Weight loss
 Others: ____Chest Heaviness___

4. Referred from another Health Care Institution (HCI): No Yes, Specify Reason ____For Cardiovascular assessment________________
Name of Originating HCI: _________________________________
5. Physical Examination on Admission (Pertinent Findings per System)

General Survey:  Awake and alert  Altered sensorium,_______________________

Vital Signs: BP:__160/100 _____ HR:__89 ___ RR:_20 ______ Temp.;__36.7 ____ Wt.:_______________(pedia patients)

HEENT:  Essentially normal  Abnormal pupillary reaction  Cervical lymphadenopathy  Dry mucous membrane
 Icteric sclerae  Pale Conjunctiva  Sunken eyeballs  Sunken fontanelle

Others:_____________________________________
 GRAPHIC RECORD
Name:_____Hilda Alucard ___________________________Age/Sex/CS:__55/female ______Ward/Room:_private 202 _____
DATE 12/02/2020
No. of Days in
Hospital
7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7
RR PR T

42

41

160 40

150 39

140 38

130 37

120 36

110 35

100

90

50 80

40 70

30 60

20 50

10

1100
7-3 cc

URINE 3-11
11-7
1 once
7-3

STOOL 3-11
11-7
160/100 120/70
BP
 IV FLUID SHEET

Name:________Hilda Alucard____________Age/Sex/CS:__55/female _____Ward/Room:__private 202 _

MAIN LINE
Time Time
Date IV Fluids Regulation Started Consumed
REMARKS
12/02/2 PNSS 1L 20-21 gtts/min 8;30 am
020

ANOTHER LINE / SIDE DRIP

Time Time
Date IV Fluids Regulation REMARKS
Started Consumed
 DOCTOR’S ORDER

Name:_____Hilda Alucard_________________Age/Sex/CS:_55/Female _Ward/Room: private 202____

Date C A R E D TIME POSTED

And Progress Notes Doctor’s Order AND
SIGNATURE
time
Complaints: Admit to room of choice
12/2/20 Dizziness, chest Secure consent
✔
8;25 AM heaviness, shortness VS q shift
of breath DIET: LSLF DM DIET; NPO POST MIDNIGHT

VS: Diagnostics:
BP 160/100 • CBC, U/A
PR 89 • CHEST X-RAY PA VIEW
RR 20 • BUA,BUN, CREATININE
Temp 36.7 • FBS, LIPID PROFILE
O2 sat. 95 % • 12 LEADECG 8;25 AM/BML
• CBG: 269 MG/DL

Treatment:
• IVF PNSS1L X 16 HOURS (MACROSET)
8;30AM/ BML
• REGULAR INSULIN 5 UNITS SQ NOW
8;22AM/ BML
• CLONIDINE 75 MG/TAB 1 TAB SUBLINGUAL NOW
(8;40 AM)
• LOSARTAN 50 MG/TAB P.O OD AM (12PM)
• METFORMIN 500MG/ 1 TAB P.O BID (12PM)
• REPEAT CBG AFTER 30 MINUTES THEN TID PRE-
MEALS (CBG : 110 AT 9 AM)
• HOOKED O2 INHALATION VIA NASAL CANNULA 2-
3 LPM
• MONITOR BP Q SHIFT
• REFER CARDIOLOGIST
• REFER ACCORDINGLY

DR. HARLEY

C-Carried-out
A-Administered
R- Requested
E-Endorsed
D-Discontinued
 MEDICATION
SHEET

Name: HILDA ALUCARD _________________________Age/Sex/CS:55 YRS OLD/

FEMALE_______Ward/Room:PRIVATE 202____

Name of Drug, Dosage, Route, Date and Time Given:

& Frequency 12/02/2020
Regular insulin, 8;30 am
5 units
NOW CPA

Clonidine 75mg/ tab 8;40 am

Sublingual
NOW CPA

Losartan 50mg/ tab 12 pm

1 tab P.O O.D AM
CPA

Metformin 500mg/tab 12 pm
P.O BID
CPA
 KARDEX
NAME: HILDA ALUCARD ______AGE:_55 _ SEX: FEMALE HOSPITAL NO._____________________

ADDRESS:__Manangat Caoayan Ilocos sur ___________ CLASSIFICATION:___________ WEIGHT:________

ADMITTING PHYSICIAN:___Dr. harley ____________ DATE/TIME ADMITTED:_12/2/2020 8;25 AM ___BLOOD TYPE:_____

_____________________________________________________________________

COMPLAINT:_ dizzinesss, chest heaviness, and shortness of breath

IMPRESSION DIAGNOSIS:__Diabetes mellitus type 2 uncontrolled hypertension ______________________________

SURGERY DONE:____________________________________________________DATE/TIME: SURGERY_____

MENTAL STATUS: Activities: Diet: Tubes: Special Info:

___Conscious ___ambulant ___NPO ___Foley Catheter ___Weigh Daily
___drowsy ___dangle and sit up ___DAT ___thoracic tube ___BP q shift
___stupor ___bedrest with BRP ___Soft ___NGT ___Neuro V/S
___unconscious ___CBR w/o BRP ___clear liquids ___CVP ___abdominal girth
___comatose Others:___________ ___ gen. liquids Others: NASAL Others:__________
Others:LSLF DM CANNULA
DIET

Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND

ordered Ordered TIME
DISCONTINUED
12/02/20 Regular insulin 5 units now 12/02/20 PNSS1L x 16 Hours
20 20 20-21gtts/min
12/02/20 Clonidine 75mg/tab now
20
12/02/20 Losartan 50mg/tab P.O
OD AM (12PM)
20
12/02/20 Metformin 500mg/tab P.O
BID 12(PM)
20

DATE Medical Treatment/ Date Done

ORDERED Laboratories/Diagnostics
12/2/20 CBC, U/A 12/2/20
8:25 AM 3:00 PM
12/2/20 Chest x-ray PA View Requested
12/2/20 BUA, BUN,CREATINE 12/2/20
8:25 AM 3:00 PM
12/2/20 FBS, Lipid profile Requested
12/2/20 12 lead ECG 12/2/20
 12/2/20 CBG; 269 mg/dl (high) 12/2/20
12/2/20 BUA: 9mg/dl (high) 12/2/20
12/2/20 CBG monitoring TID Pre-Meals
12/2/20 02 Inhalation Via NC @ 2-
3LPM

NURSE’S NOTES
Name:______Hilda Alucard____________________Age/Sex/CS:___55yrsold/female _____Ward/Room:_private 202__

Date-Shift FOCUS Data – Action – Response

12/02/2020 Admission care
Data: Received from ER through stretcher with ongoing IVF of PNSS 1L x 16 hours at 20-21 gtts/min
7 AM hooked with o2 inhaltion via nasal cannula at 2-3 LPM with complaints of dizziness, chest heaviness,
shortness of breath. With initial vital signs of BP 160/100, PR: 89, RR: 20 , TEMP: 36.7. O2 sat. 95% -----
--------------------------------------------------------------------------------------------

Action: Placed on bed comfortably; positioned high back rest; vital signs monitored and recorded; NPI
8:40 AM established; IVF regulated accordingly; o2 inhalation regulated accordingly, encourage deep breathing
9:00 AM exercise; seen and examined by doctor Harley with order made carried out.started clonidine 75 mg/ tab 1
sublingual. Started losartan 50mg/tab od and metformin 500mg/tab bid. Repeat cbg done; , cbc, u/a, bua,
bun, creatinine done relay to ap; chest x-ray and 12 lead ecgdone to follow result; LSLF DM DIET; NPO
post midnight instructed, rest provided; I and O monitored and recorded--------------------------------------------
-----------------------------------------
Response: (-) dizziness, (-)chest heaviness. (-) Shortness of breath as verbalize by the patient. Latest Vital
3:00 PM signs; 120/70, PR: 72, RR: 12 , TEMP: 36.7 , O2 sat. 97%--------------------------------------------------------------
--------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------CPA
------------------------------------------------------------------------------------------------Ryrey Pacamana
 Cbg monitoring
Name:_ Hilda Alucard ___________Age/Sex/CS:_55/female __Ward/Room:_private 202 __
Date and time CBG REMARKS
12/2/2020

9:00 AM 110mg/dl Normal