URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Kaille Middle Name: Abad Last Name: Santos
Age: 28 Sex: F Status: Married Religion: Roman Catholic Hospital Unit No.
Address: 96 F Llamas St. Cebu City
Student No. Occupation: Teacher Birth Date: May 16, 1992
Birth Place: Citizenship: Filipino Spouse:
Name of Mother: Name of Father:

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Mark Santos Relation: Husband
Address: 96 F. Llamas St. Cebu City
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Watery Vaginal Discharge
Vital Signs: BP: 90/60 HR: 96 RR: 19 Temp: 36.5 O2 Sat: 98% Weight: 63 kg
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 4/13/20 Physician: Dr. Coja
Department: OB-Gyne Time Arrived: 1:29 PM
Time Seen: Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:

G₂P₁ (1101)
37 ²/₇ weeks AOG

S: 5 hours PTA, Patient noted sudden onset of watery vaginal discharges, clear associated with intermittent hypogastric pain,
every 5-10 minutes thus consult.
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

PATIENT’S NAME :___________________________________ AGE:_________ ROOM:_________CASE NUMBER:______________

DATE DOCTOR’S ORDERS PROGESS NOTES

4/03/20  Please admit under service
 Secure consent to care
 TPR q 4 Hours
 Diet as Tolerated
 IVF: D₅LR 1 L @ 30 gtts/min
 Labs:
 CBC, Urinalysis, Serum Potassium, Creatinine, admitting CTG
 Medications:
1. Ampicillin(Apitrex) 2 grams IVTT q 6 hours ANST
 Refer to IM service for co-managment doctor
 Monitor FHT and uterine contraction q 15 minutes
 Monitor Vital Signs q 4 hours
 I and O q 4 hours
 Refer accordingly

4/03/20  Refer to IM for co-managment RE: Hypokalemia (IM-Nephro)

4:30 PM  Refer Accordingly

4/3/20  Thank you for this referral for co-managment

6:10 PM  History and PE reviewed
 Start KCL drip: D₅W 200 cc + 40 meq KCL 28 KCL drip for 12 hours
In cycle until delivery
 Start KCL tab, 1 tab PO 3x /day
 Start Vitamin B complex tab, 1 tab PO OD
 Include 1 banana/meal
 Decrease IVF rate to 20 gtts/min
 Repeat Urinalysis and Serum Potassium in AM and every
morning thereafter
 Give Anmum 3 servings/day
 For ECG 12 L
 Thank you

4/3/20  Insert Dinoprostone 0.5 mg intracervical gel now

9:15 PM  For reassessment after 6 hours
 Attach for CTG now then intermittently

____________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

DATE DOCTOR’S ORDERS PROGESS NOTES
4/3/20  Monitor for tachysystole, uterine hypertonus, FHR changes and other
9:15 PM unsualities
 Refer Accordingly

4/4/20  IVFTF: D₅LR 1 L at 30 gtts/min

4:00 AM

4/4/20  IM MD
7:40 AM  Continue KCL drip until further orders
 Please facilitate repeat Serum potassium now
 Please relay result to IMROD once in
 Thank you
 Dr. Coja updated

4/4/20  S/P NSVD

7:00 AM  To RR temporary
 TPR q hourly
 DAT
 Infuse 20 ‘u’ oxytocin to present IVF, 200 cc MFD then regulated @ 30gtts/min
 IVFTF: c̅ D₅ LR 1 L + 20 ‘u’ oxytocin at 30 gtts/min, TC if no unusualities
 Meds:
1. Cefuroxime (Altoxime) 500 mg cap BID
2. MFA (Almefen) 500 mg cap q 6ᵒ
3. FeSO₄ + MV (OB-Care) cap OD
4. Calcium + Vit. D (Osteo-D) tab BID
5. Mefen Ergometrine Maleate 1 IM now then
Ergonovine tab q 4 hours x6 doses
 Monitor VS q 15 x 2 hours, q 30 mins x 2 hours, q hourly until stable
 Refer if BP >140/100, <90/60, PR > 100, RR > 20, T≥ 38 ᵒC,
profuse vaginal bleeding, and any unusualities
 Catheterize especially if unable to void, p 4-6 hours
 Self purical ones BID
 Refer accordingly

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

DATE DOCTOR’S ORDERS PROGRESS NOTES
4/4/20  May transfer to ward
8:36 AM  Refer accordingly

4/4/20  KCL IV drip to consume then terminate

3:45 PM  Reduce mainline IVF to follow to D₅NM 1 L + 40 mg
KCL incorporate x 12 gtts/min in cycle
 Continue oral KCL and Cefuroxime PO
 Repeat S. potassium and Urinalysis on Monday 4/6/20 AM
 Ordered KUB Ultrasound on Monday if available

4/5/20  IVF rate to KVO

4/5/20  Continue Meds

7:30 AM  Continue VS monitoring
 For PE tomorrow if c̅ no unusualities

4/5/20  Pelvic Exam done

12 NN  May Go Home
 Please inform IM service
 Home Medications:
1. Cefuroxime (Altoxime) 500 mg /cap/ 1 cap BID x 5 days
2. Mefenamic Acid (Almefen) 500 mg/cap 1 cap q 6 hours, PRN for pain
3. Ferrous SO₄ + MV (OB-CARE) 1 cap OD x 2 months
4. Calcium + Vitamin D (OSTEO-D) 1 tab BID x 2 months
5. Vitamin C (Altocee) 1 cap OD x 2 months
 Follow up at RHU after one week
 Refer accordingly

4/5/20  Dr. Coja updated

12 NN  Ok to discharge
 Home Meds:
1. Cefuroxime 500 mg/tab 1 tab BID to complete 14 days
2. Vitamin B Complex 1 tab OD for 2 months
3. Potasium citrate (Tascit) 12 meq/tab 1 tab OD with lunch for 2 weeks
 Follow up Dr. Coja at the clinic after 2 weeks
 Repeat Serum / CT and UA after 2 weeks
 For KUB Ultrasound OPD brings results upon follow up

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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MONITORING SHEET
Name: _________________________________ Age: _______________________________________ Attending Physician:
________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No.
______________________

Date Time BP PR RR Temp. Mental Status Remarks Signature

O₂ Sat
4/3/20 1 120/80 86 20 35.3 98%
4 110/70 70 19 36.8 98%
8 110/70 82 20 36.7 98%
4/4/20 12 110/60 80 20 36.6 98%
4 120/80 72 20 36.3 98%
4/4/20 8 116/78 63 20 36.8 98%
12 130/80 79 21 36.1 98%
4 120/90 70 21 36.4 98%
8 110/70 74 20 36.4 98%
4/5/20 12 100/70 70 20 36.8 98%
4 100/70 75 20 36.5 98%
8 110/70 80 21 35.4 99%
12 110/80 72 21 35.6 98%
4/5/20 4 90/70 75 20 36.8 98%
8 110/70 78 21 35.6 99%
4//6/20 12 90/60 78 20 36.0 99%
4 110/70 75 20 36.4 98%

DOH-SWUMed-NSD-F-073 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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FLUID INTAKE & OUTPUT MONITORING RECORD

Name: _________________________________ Age: _______________________________________ Attending Physician: ____________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ___________________

DATE TIME INTAKE TOTAL OUTPUT TOTAL

PARENTERAL ORAL OTHERS URINE DRAINAGE OTHERS
4/3/20 12:43-2 50 100 150 50 50
2-10 600 300 900 300 300
10-6 500 --- 500 400 400
Total: 1,550 Total: 750

4/4/20 6-9 300 ----- 300 0 0

9-2 480 1,200 120 KCL drip 1,800 300 300
2-10 960 2,500 192 3,652 1,200 1,200
10-6 672 300 972 580 580
Total: 6,724 Total: 2,080

4/5/20 6-2 320 1000 1,320 420 420

2-10 300 200 500 250 250
10-6 320 400 720 500 500
Total: 2,540 Total: 1,170

6-2 = 6-2 =
2-10 = 2-10 =
10-6_ __=______________ 10-6 =_________________
24H Total = 24H Total =
Fluid Balance = _____________________________

DOH-SWUMed-NSD-F-012 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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MEDICATION ADMINISTRATION RECORD (MAR)

Name: _________________________________ Age: _______________________________________ Attending Physician:
________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No.
______________________

MEDICATION: Dosage, Date: Date: Date: Date:

Route, Frequency Time NOD NOD Time NOD NOD Time NOD NOD Time NOD NOD
1 2 1 2 1 2 1 2

Signature Specimens:
(Provide signature beside full name in print)
DOH-SWUMed-NSD-F-013 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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LABORATORY RESULTS

P.O.G.S. OBSTETRICS SHEET (1)

NAME: Kallie A. Santos AGE 28 CH S M W SEP. CASE NO.

ADDRESS: 96 F Llamas St. Cebu City FINAL DIAGNOSIS:
Date/Time of Admission: 4/3/20 1:29 PM Reason for Admission: Watery Vaginal Discharge
ADMITTING IMPRESSION: G₂P₁ (1101) PU 37 ²/₇ weeks AOG, Cephalic in LPL, PROM
Hypokalemia in pregnancy, R/O RTA

Blood Type: A RH: + VDRL: Non-reactive HbSAg: NA Antibiotics: -

OBSTETRICAL HISTORY: G 2 P 1 (FT 1 PR 0 AB 0 LC 1)
Pregnancy Pregnancy YEAR Gestation Sex Birth Present Complications/
Outcome Completed Weight Status Abnormalities
NSVD 2018 October FT F 6 lbs. alive --------
Order
(I.B.T. SVD) (wks)
LSCS OR LCS

Desired Family 1 2 3 4 5 more

Size:
Contraceptive None Pills IUD Condom √ Others
History:
Educational Profile: None: Primary Secondary College √ Others
Socio-Economic Profile: Dependent/Unemployed Income: Below Min. Wage
Employed/Self-Employed √ Minimum Wage
Others Above Min. Wage √
Present Pregnancy: LMP July 08, 2019 EDC April 15, 2020
PMP June 8, 2019 AOG 37 ²/₇/ Utz
Menstrual Cycle: 12, regular, 4-5 days, using 3-4 mod-soaked. Occ.dysmenorrhea Date of Quickening: 12 ⁵/₇ weeks
Ultrasound: Date October 14, 2019 AOG
Antenatal Visits: None 1-2 2-5 5 √ 10x
Health Care Providers: MCH DOH GO MD OTHERS
Immunizations: Tetanus Dates: TT₂ December 2019
Hepatitis Dates:
TB Dates:
Others Dates:
Total Weight Gain: 14 lbs. BP 110/60-80 HR 90 Urine Albumin - Sugar -
Medications: Vitamins ✔ Fe ✔ Ca ✔ Others ---

DOH-SWUMed-NSD-F-058 Rev.1
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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P.O.G.S. OBSTETRICS SHEET (2)

NAME: _________________________________ AGE: ______ CH. ____S_____M_____W_____Sep._____ CASE NO. _________________

Antenatal Problems: HbSag __________ Fetal wastage __________

Previous Cs / Surgery __________ IUGR __________
Infections IG __________ Infertility __________
Nutritional (2 dose/week) __________ Others __________

Age Status:
Physical Examination: Date __4/3/20__ Time __1 PM__________ Examination ____________________________________
Temp. _36.8___ RR ____19____ HR ____70____ BP __110/70____ Wt. ___158 lbs__ HT. __5’3_Ft__
General Status Level of Sensorium: ______√____ Conscious ___x_______ Anxious
______√____ Coherent ____√______ Cooperative
______x____ Unconscious ___x_______ Others

HEENT: Chest _____Equal chest expansion____________ Heart __distinctive_________________________

Breast ________________________________________________ Lungs ___clear breath sounds________________
Abdomen: LSK ___________________________ EFU ____2, 790 g__________________ PHB ______140___________________
Fundal Ht. ____29 cm________________________ Position _____10+________________ Floating/Engaged _____________
Presentation ___________vx____________________________________________________________________________________

Pelvic Exam:
Ext. Genitalia: ______no lesions_________________________________________________________________

Vagina: _____ no lesions_________________________________________________________________

Cervix: Length: _________2____________(cm) Dilation ________2_____________ Effacement ________40%__________

Position: _____________________ Anterior _____________ Midline _____________ Posterior _____√________

Presentation: Position ________________________ Membrane Intact √ Ruptured

Station _________________________ Amniotic Fluid Clear
Sutures ________________________ Meconium Stained

Clinical Pelvimetry:

Contracted Inlet Borderline √ ____adequate_________

Midline Trial Labor Outlet

Remarks:
L1_Duncan_________________________________________________________________________________________________________________________________
L2 _L laterally directed_____________________________________________________________________________________________________________________
L3__unengaged______________________________________________________________________________________________________________________________
L4 cephalic_prominence, R

DOH-SWUMed-NSD-F-059 Rev.1
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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P.O.G.S. OBSTETRICS SHEET (3)

NAME: ___Kallie A. Santos___4/3/20_____________________ AGE: ______ CH. ____S_____M_____W_____Sep._____ CASE NO.
_________________
Fetal Status: Normal
Distress
Bradycardia Auscultation
Tachycardia Late Deceleration
Fetal Monitor Variable Late
Decelaration
Delivery of Fetus: Date ______________4/4/20___________________ Time _____6:22 AM____ Attend: _____Dr. Coja____________
Manner: Vaginal Vaginal OS
Spontateous Spontaneous
Assisted Forceps
Partial Complete Breech (Marvel / Breech to Head) ___________________________________________(Mins.)
With or Without Episiotomy Laceration
Abdominal
Primary OS ( ) Low Transvers Vertical
( ) Classical ( ) W/T Ligation
Indication _______________________________________________________________________________________________
REPEAT OS ( ) Low Transverse Vertical
( ) Classical ( ) W/T Ligation
Indication _______________________________________________________________________________________________
( ) CS Hysterectomy ( ) Sub-total
Indication _______________________________________________________________________________________________
Delivery of Placenta: Date __________4/4/20______________________ Time ___6:25 AM__________ By: _____Dr. Coja________
Manner: Spontaneous Manual Extraction
Mos Crede Elective
√ Brand Andrews Retained ( ) Incarcerated
( ) Accrega
POSTPARTUM BLOOD PRESSURE: _____________________________mmHg
Blood Loss ______200___________(cc) Cause _______________ Atony _______________ Others _____________________
Replacement __________________________ Blood ____________________________(cc) Retained ____________________
Placenta ____schultz mechanism___________________________________________________________________________________________________
IV Fluids __D₅_LR 1 L+ 20 ‘u’oxytocin at 30 gtts/min_______________(cc) Laceration ________________________________________

ANALGESIA / ANESTHESIA:
None √ Local Infiltration Psycho-prophylaxis
Regional General
Spinal Sadle Penthotal or IV Birth Weight __2, 375 mgs__________
Epidural – Cauda N20202 Sex ___Male________________
Pudendal Others APGAR Score ___9, 10________
Complications__________None_______________________________________________________________________________________
POSTPARTUM CONDITION √ Good Fair Poor
DOH-SWUMed-NSD-F-060 Rev.1
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

P.O.G.S. OBSTETRICS SHEET (4)

NAME: ____Kallie A. Santos_________ AGE: __28____ CH. ____S_____M_____W_____Sep._____ CASE NO. _________________

LABOR: ONSET: TIME ____4 AM___________ DATE ___4/4/20____ TOTAL DURATION 21 hours and 25 minutes(hrs.)
Full Dilation ____6 AM_______ First Stage _______21 hours____________________(hrs.)
Delivery ____6:22 AM_______ Second Stage ______22 minutes________________(hrs.)
Placenta ___6:25 AM________ Third Stage ______3minutes____________________(hrs.)

NORMAL LABOR CURVES: ACTIVE PHASE

Contraction
Induction Spontaneous Pit Augmentation

Membrane and Amiontic Fluid √ Ruptured Intact

√ Prom ________________(hrs.)
Erom Amniotomy
Cord Prolapse Clear
Amnionitis Meconium Ileus
Thin
Thick

Progress of Labor Normal Abnormal

Precipitate
Prolonged
Latent Phase
Dysfunctional
Arrest of Dilation
Protected Descent
DOH-SWUMed-NSD-F-061 Rev.1
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
Partograph
Name Gravida
+63 32 4188410 to 14
Para. Hospital no.
Date of admission Time of Admission Ruptured membranes hours
180
170
Fetal 160
heart 150
rate 140
130
120
110
100
Liquor
Moulding
10 Active Phase
9
Cervix
(cm ) 8
slot x 7
6
5
Descen 4
Latent Phase
t of hed 3
[plot 0]
2
1
Hours 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time
5
Construction
4
per 3
10 mins
2
1
Oxytocin U/L
Drops/min

Drugs
given
and
IV fluids
180
170
160
150
140
130
120
110
100

90
80
70

60
Temp 0C

protein
Urine acetone
volume
Source: WHO. Used by permission

DOH-SWUMed-NSD-F-062 Rev.1
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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PUERPERIUM RECORD
NAME: __________________________________ AGE: ______ WARD/BED NO. _________________ CASE NO. ___________________
ATTENDING PHYSICIAN / RESIDENT: ________________________________ DELIVERY DATE: _________________________

A – POSTPARTUM OBSERVATION:
DATE BREAST UTERUS LOCHIA EPISIOTOMY BPT MEDICATIONS
1st enlarged Well contracted minimal (-) well coaptated KCL drip

2nd KCL tab

3rd Vitamin B complex

4th Cefuroxime

5th Mefenamic Acid

Fe SO₄ + MV
Calcium
B – COMPLICATION OF THE PUERPERIUM:

None

C – DISCHARGE PHYSICAL EXAMINATION DISCHARGE VAGINAL EXAMINATION:

1. Head and Neck ___________________________________ 1. Vulva No Lesions___________
2. Heart and Lungs _________________________________ 2. Perineum _No hematoma___
3. Thyroid Gland ____________________________________ 3. Vagina ______no mass/lessions___
4. Breasts ____________________________________________ 4. Cervix _2 cm up_____________
5. Abdomen __________________________________________ 5. Uterus (+) mid introverted________
6. Vital signs: Temperature ______36.5______________________ Blood Pressure _________100/70_______________
Pulse/Heart Rate ___75_____________________ Respiratory Rate _____20______________________

D – ADVICE AND MEDICINE PRESCRIBED:

E – CONDITION ON DISCHARGED:
Good _________√_______ Poor_____________________
Fair ________________________Critical __________________
Died _______________________ Discharge on __________
_______________________________________ or transferred
to ______________________________________________________
on _____________________________________________________.
OB PGI / Senior Clerk : ______________________________________________________________________
Attending OB Resident: __________________________________________________________(Signed)

DOH-SWUMed-NSD-F-063 Rev.1
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LABORATORY RESULTS