URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Carmie Middle Name: Cruz Last Name: Martin
Age: 28 Sex: F Status: Married Religion: Roman Catholic Hospital Unit No.
Address: 356 Nasipit Talamban Cebu City
Student No. Occupation: Housewife Birth Date: August 1, 1992
Birth Place: Cebu City Citizenship: Filipino Spouse: Ricky Martin
Name of Mother: Name of Father:

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Ricky Martin Relation: Husband
Address: 356 Nasipit Talamban Cebu City
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Scheduled C/S 5/14/20
Vital Signs: BP: 100/70 HR: 95 RR: 18 Temp: 36.4 O2 Sat: 98% Weight: 135 lbs
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 5/13/2020 Physician: Dr. Mercado
Department: OB Time Arrived: 11:01 AM
Time Seen: 11:30 AM Time out: 4 PM
Brief Clinical History, Physical Examination, laboratories, Impression, Management:

S- Day of Admission – patient came in for elective request CS, hypogastric pain mild-mod by 60 mins. by 60
Radiating to the LSA c̅ PS 1/10. No watery or bloody vaginal discharge, (+) A7M

Abd: FH: 34 cm
EFW: 3, 565 grams.

IE: 1 cm, 80 Eff, St -5, IBOW, Cephalic

A: G₂ P₁ (1001) PU 38 ⁵/₈ weeks AOG, CNIC, Prev. CS one for CPD (2014 CHH)

Admit
 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

5/13/20  Please admit under service
8:00 PM  Secure consent
 DAT
 NPO post-midnight
 Monitor V/S q 4 hours
 Monitor I & O q shift
 Start venoclysis: D5LR 1L at 30 gtts/min once on NPO
LABS:
DENIES o CBC ( same vein)
Fever, o Urinalysis ( midstream clean catch)
cough  Admitting CTG
No Control  Schedule for repeat LSTCS tomorrow May 14, 2020
c̅ COVID 19 9:00 AM per patient request
positive  Secure consent to procedure
 Anes: Dr. Chua – informed thru call
 Inform OR/DR
 Inform Pedia Service
 PRE-OP MEDICATIONS
1. Cefazolin (Fonvicol) 2 grams IVTTANST post
Induction of Anesthesia
2. Ranitidine 50 mg 1 amp IVTT → HOLD on call to OR
3. Metoclopramide 10mg 1 amp IVTT
 Patient refused possible blood transfusion due to religion beliefs
(Jehovah’s Witness), please secure waiver
 Will inform Dr. Mercado of this admission
 Refer Accordingly

May 13, 2020 CONFERRED WITH DR. SEMBLANTE

4:50 PM PRE-OP MEDICATIONS
1. Omeprazole 20 mg/cap 1 capsule at bedtime
2. Metoclopramide0 mg 1 amp IVTT prior to OR

____________________________ _____________________________
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
May 14, 2020  For baseline CXR-PA with abdominal shield
4:38 AM

5/14/20 POST-OP ANESTHESIA ORDERS

 Transport to PACU
 O₂ Inhalation via Nasal Prong at 2 LPM
For 1 hour in PACU then PRN
 NPO temporarily
 FLAT on bed until 3:00 PM
 IVF: PLR 1 L + 30 “u” oxytocin at 30 gtts/min
 MEDS:
1. Ketorolac 30 mg IVTT q 6H (12-6-12-6)
2. Tramadol 50 mg IVTT Very slowly q 6H x 4 doses (3-9-3-9)
3. Tramadol 50 mfg IVTT Very slowly for breakthrough pain
 I & O q shift
 Monitor V/S q 15 mins for 1 hour then q hourly until discharged
From PACU
 Please refer for unusualities
 Please refer accordingly
 Thank you

5/14/20 POST-OP ORDERS

 To RR temporarily
 TPR q 4 Hours
 NPO x 6 hours then may have sips of clear liquids
 Flat on bed for 6 hours then may turn to sides
 Medications
1. Cefazolin 1 gram IVTT q 6 hours
2. Metronidazole 500 mg IV drip 1 dose now
3. Tranexamic acid 1 gram IVTT now
 Monitor vital signs q 15 minutes for 2 hours, q 30 mins
For 2 hours then q hourly
 Refer if BP ≥ 140/90 mmHg , HR 100 bpm, RR ≥ 24 cpm
Temp ≥ 38ᵒ C, profuse vaginal bleeding
 Maintain
 I & O q hourly
 Repeat CBC at 5 AM tomorrow
 Apply abdominal binder snuggly
 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
5/14/20  IVTF:
11:00 AM 1. D₅LR 1L + 20 “u” oxytocin at 30 gtts/min
2. D₅NM 1L+ 20 “u” oxytocin at 30 gtts/min
3. D₅LR 1L + 10 “u” oxytocin at 30 gtts/min

5/14/20  May transport patient to the ward

1:30 PM
5/15/20  Remove FBC now
7:30 AM  Due to void 4-6 hours post FBC removal
 Breakfast: general liquids with crackers
 Lunch: Soft Diet
 Dinner: Full Diet
 Shift IVTT meds to P.O. after 3rd doses of antibiotics
1. Cefuroxime ( Altoxime) 500 mg 1 tab BID
2. Mefenamic Acid (Almefen) 500 mg 1 cap q 6ᵒ
3. MV + Iron (Beniforte) 1 cap OD P.O.
4. Calcium ( Osteo-D) 1 tab OD P.O.
 For wound dressing tomorrow
 For possible discharge tomorrow
 Full body bath prior to PE and wound dressing
 Terminate IVF once 3rd bottle is consumed

5/16/20  PE done
9:13 AM  Wound dressing done
 May Go Home
 Home Meds:
1. Cefuroxime ( Altoxime) 500 mg 1 tab BID P.O./ 6 more days
2. Mefenamic Acid (Almefen) 500 mg 1 cap q 6ᵒ
3. MV + Iron (Beniforte) 1 cap OD P.O./ x 3 months
4. Calcium + Vit. D ( Osteo-D) 1 tab BID P.O./ x 3 months
5. Vitamin C (Alto Cee) 1 tab OD P.O./ x 1 month
 Exclusive breastfeeding
 Daily wound dressing
 Home quarantine with S.O. for 14 days
 Call _____ if with covid symptoms
 Call RITU on May 13, 2020 for Phone follow-up
 Advised

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

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

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
5/13/20 2 100/70 95 18 36.4 98%
6 100/70 96 20 36.5 98%
5/13/20 8 100/70 90 20 36.7 97%
5/14/20 12 100/70 78 20 36.0 98%
4 100/70 85 19 36.4 98%
8 120/80 76 20 36.3 98%
11:30 117/53 77 15 36.2 995
11:45 117/53 75 15 36.0 99%
12:00 117/53 75 16 35.8 98%
12:15 117/53 76 16 36.4 99%
12:30 117/53 70 15 36.0 99%
12:45 117/53 74 16 35.8 98%
1:00 117/53 71 18 36.4 99%
1:15 117/53 71 18 36.0 98%
1:30 117/53 70 18 36.2 99%
1:45 117/53 70 16 36.2 99%
2:00 117/53 83 18 36.0 99%
2:30 110/60 78 19 36.9 99%
3:00 110/60 76 18 36.4 97%
3:30 120/60 75 19 36.5 98%
5/14/20 4:00 110/70 77 20 36.6 99%
8:00 100/80 80 20 37.0 98%
5/15/20 12:00 110/80 77 20 36.5 97%
4:00 110/70 75 20 36.2 97%
8:00 120/80 82 20 36.0 97%

DOH-SWUMed-NSD-F-073 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

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
12:00 120/80 80 20 36.3 97%
5/15/20 4:00 100/70 91 20 36.7 98%
8:00 100/80 87 20 36.4 97%
5/16/20 12:00 100/70 63 20 36.1 98%
4:00 120/80 74 20 36.0 99%

5/16/20 8:00 100/60 82 20 36.2 99%

12:00 100/60 80 19 36.0 99%

DOH-SWUMed-NSD-F-073 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

TEMPERATURE PULSE AND RESPIRATION RATE CHART

Patient Name: __________________________________________ Attending Physician: ________________________________________
Age: _______ Sex: _______ Room No. /Bed No. ___________ Hospital Unit No. ____________________________________________
Day of
Hospitalization
Post-Operative
Day No.
Date
RR PR Temp 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12

150 41

140 40
130
39
120
38
110
37

100 36

90 35

80

70 70

60 60

50 50

40 40

30 30

20

10

BLOOD PRESSEURE
6-2
2-10
STOOL 10-6
TOTAL
6-2
URINE 2-10
10-6
TOTAL
DOH-SWUMeD-NSD-F-007 Rev. 2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

NURSES NOTES
Name: _________________________________ Age: _______________________________________ Attending Physician: ________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ______________________
Date Shift Focus Time D = Date / A = Action / R = Response

DOH-SWUMed-NSD-F-004 Rev. 2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

FLUID INTAKE & OUTPUT MONITORING RECORD

Name: _________________________________ Age: _______________________________________ Attending Physician: ____________________________________

Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ___________________

DATE TIME INTAKE TOTAL OUTPUT TOTAL

PARENTE ORAL OTHERS URINE DRAINAGE OTHERS
RAL
5/13/20 2-6 0 0 0 50 50
6-10 s̅ IVF 420 420 150 150
10-6 540 NPO 540 210 210
Total: 960 Total: 410

5/14/20 6-8 240 NPO 240 200 200

9-11:30 1400 NPO 1,400 150 EBL 300 450
11:30-2:00 150 NPO 150 300 300
2:00-2:30 50 NPO 50 200 200
2:30-6:00 420 20 440 150 150
6-7 120 20 140 56 56
7-8 120 20 140 50 50
8-9 120 0 120 56 56
9-10 120 30 150 70 70
5/14/20 10-11 120 20 140 33 33
11-12 120 20 140 36 36
12-1 120 20 140 30 30
1-2 120 20 140 24 24
2-3 120 20 140 30 30
3-4 120 20 140 24 24
4-5 120 100 220 70 70
5-6 120 100 220 60 60
Total: 4,110 1,839

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
+63 32 4188410 to 14

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
5/15/20 6-7 120 60 180 258 258
7-2 700 500 1,200 750 750
2-6 300 200 510 190 190
6-10 c̅ HL 400 400 300 700
10-6 c̅ HL 800 800 650 650
Total: 3,090 Total: 2,548

5/16/20 6-2 c̅ HL 500 500 300 300

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
+63 32 4188410 to 14

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)
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
DOH-SWUMed-NSD-F-013 Rev.2

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

NAME: Carmie C. Martin AGE 28 CH S M W SEP. CASE NO.

ADDRESS: 356 Nasipit Talamban Cebu City FINAL DIAGNOSIS:
Date/Time of Admission: 5/13/2020 12:54 PM Reason for Admission: Elective Repeat CS
ADMITTING IMPRESSION: G₂P₁ (1001) PU 38 ⁵/₇ weeks AOG, CNIL, Previous CS once for CPD/ 2014, SHH

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

Miconazole
OBSTETRICAL G P (FT PR AB LC )
HISTORY:
Pregnancy Pregnancy Outcome YEAR Gestation Sex Birth Present Complications/
Completed Weight Status Abnormalities
1 1ᵒLSTCS for CPD 2014 39 weeks F 2, 500g Living None-SHH Dr. Rayo
2 Pregnancy Outcome
Order
(I.B.T. (wks)
SVD)
LSCS OR
LCS

Desired Family 1 2 3 4 5 more

Size:
Contraceptive History: None √ Pills IUD Condom Others
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 8/16/19 EDC 5/23/20
PMP + 2nd week 2019 AOG 38 ⁵/₇
Menstrual Cycle: 2-3 months interval x 3-4 days, 3-4 pads Date of Quickening: Dec. 2019 @ 16
Ultrasound: Date 3/24/20 AOG 32 ³/₇
Antenatal Visits: None 1-2 2-5 > 5 9
Health Care Providers: MCH DOH GO MD OTHERS
Immunizations: Tetanus TT₃ Dates: Jan. 8, 2020 (LHC)
Hepatitis Dates: N/A
TB Dates: N/A
Others Dates: N/A
Total Weight Gain: 15 lbs BP 90/60- HR 103 Urine Albumin negative Sugar negative
120/80
Medications: Vitamins √ Fe √ Ca √ Others

DOH-SWUMed-NSD-F-058 Rev.1
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
LABORATORY