BIRTHDATE: January 23, 1996 ADDRESS: #35 Upper Pinget, Bagulo City OCCUPATION: Grocery store cashier EDUCATIONAL ATTAINMENT: College Graduate ‘SPOUSE: ADARNA, Edwin DATEANDTIMEOF ADMISSION; ADMITTING PHYSICIAN: Dr. Jenny Chan ATTENDING PHYSICIAN: Dr. Filipinas Ramos CHIEF COMPLAINT: Abdominal P HISTORY OF PRESENT ILLNE! Present condition started 10 hours prior to consult as intermittent abdominal pain which occurs imeqularly. Characterized as irreqular and mild to moderate in intensity. Pain is initially relieved. ibulation. No medications were taken. 3 hours prior to consult, pail fanging from moderate to severe not relieved by ambulation radiating from the abdomen towards the back. With noted minimal brownish vaginal discharge. No medications taken. Increasing intensity prompted the patient to seek consultation hence admission. ADMITTING VITAL SIGNS: INITIAL ASSESSMENT: (ADMITTING DOCTOR'S NOTES) LM IE done at 4-5 cms 40% effaced station -2; contractions occurring every 15-20 minutes with 20- 30 secs duration, moderate to severe in intensity, FHT: 140-150, IMPRESSION: G1P0 PU 37 weeks AQG, in active labor. Scanned with CamScanner——__ OOS Cl\ PHYSICIAN’S ORDERS Date | Time |Prob. No. -— WRITE ACCORDING TO PROBLEMS — Time | Nurse > PLS. ADMIT PATIENT UNDER THE SERVICE OF DR. RAMOS > MONITOR LABOR, MONITOR VS & FET EVERY HOUR & RECORD > DIET: DAT. > ACTIVITY: CBR WITH ASSISTED BRP'S > G1PO PU 37 WEEKS A0G IN LABOR Pé1 LABOR > DIAGNOSTICS: = CBC = URINALYSIS T BASELINE CTG, ULTRASOUND > THERAPEUTICS: TENSERT IV LINE: DSLRSI L +10 "U’ OXYTOCIN X 24 “START HnBB 1 TAB G1 X10 DOSES > REFER ACCORDINGLY > DR. RAMOS PATIENT'S IDENTIFICATION: ADARNA, NAME: on tr ace:__25_ sex 402 Ward or Unit: 408 —_— Registry N 0 SLUHGH Form WR No. 0 WE PHYSICIAN’S ORDER Scanned with CamScannerDATE OF ADMISSION DATE SPECIAL ENDORSEMENT DATE DRDERED | (Ordered Procedures, Monitoring, Referrals, etc.) REMARKS DATE | DIET ‘CBC, UA done UTZ, CTG- done Monitor iabor Monitor FHT 7 DATE ‘MEDICATION / TREATMENT DATE DRDERED | (Indicate ifto start, on hold, revised, | ORDERED discontinued, etc.) MEDICATION / TREATMENT (Indicate if to start, on hold, revised, discontinued, ote.) HnBB 7 tab q 1x 10 doses DATE | No INTRAVENOUS FLUID DATE | No INTRAVENOUS FLUID ‘ORDERED | . (Main Line) 7 (Side Drip) ORDERED 4 | DSLRS 1+ 10 oxytocin x 24h No BLOOD TRANSFUSION AME: ADARNA, Angel HOSPITAL No.: 1111, DIAGNOSIS: PU G1P0 37 weeks AOG, In Labor AGE: 25 SEF z MEDICATION SHEET oa ‘YEAR MONTH. ne DATE a MEDICATION ORDER a ATT TOTAL Scanned with CamScanner