URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Grace Marie Middle Name: Torres Last Name: Renegado
Age: 26 Sex: F Status: Married Religion: Roman Catholic Hospital Unit No.
Address: Pook, Talisay City, Cebu
Student No. Occupation: Businesswoman Birth Date: January 8, 1994
Birth Place: Talisay City Citizenship: Filipino Spouse: Eugene Renegado
Name of Mother: Name of Father:

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Eugene Renegado Relation: Husband
Address: Pook, Talisay City Cebu
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Watery Vaginal Discharge
Vital Signs: BP: 130/80 HR: 92 RR: 24 Temp: 37.1 O2 Sat: 98% Weight: 117 lbs
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 6/17/20 Physician: Dr. Ubal
Department: OB-Gyne Time Arrived: 5:09 AM
Time Seen: Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:

G₁P₀ Pregnancy Uterine 39 ⁴/₇ weeks AOG, cephalic, in labor

GDM- diet controlled
Epilepsy

FH – 20 cm
FHT – 140
EFW – 2, 945 gms
6 cm dilated. 80% eff.

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

6/17/20  A case of G. R. 26 y.o. G₁P₀ PU 39 ⁴/₇ weeks AOG
5:00 AM LMP: 9/13/19, EDC: 6/20/20 admitted at SWU-MC due to labor pains
HPI: 5 hours PTA, patient noted to trace intermittent leaking hypogastric
Pain radiating at the back.
 PNC started at 13 ⁴/₇ weeks AOG at RHU
 Total number of visits: 10
 Meds Taken: Fe SO₄, Calcium, B complex
 Illness: GDM-DC
 TWG: 29 lbs
 Usual BP: 110/60 mmHg
Menstruation  Menarch at 12 y.o. x26-30 days x3-4 daysx 3-4 pads/day
Minimally soaked, (-) dysmenorrhea
Sexual Hx  Intercourse at 18 y.o. c̅ 2 partners since, STI (-)
 Contraceptives: Pills, condom
Past Medical Hx  (+) epilepsy – last attack H.S., Maintenance Levetiracetam OD
 (-) HPN, (-) DM, (-) BA
Personal/Social Hx  Patient is college graduate - Education
 Currently employed under as a teacher
 (-) vices, (-) illegal drug user

6/17/20  Please admit under service

5:00 AM  Secure consent to care
 TPR q hourly
 NPO
 Start IVF c̅ Plain LR 1L at 30 gtts/min
 Labs:
CBC, UA, COVID 19 test, SGPT, SGOT, S. Creatinine, LDH
 For Epidural Anestheisa c/o Dr. Ubal
 Secure signed consent for epidural
 Monitor V/S q hourly to include FHT and UC q 15
 Refer accordingly6/17

___________________________ _____________________________
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
6/17/20  Co-management with IM ( Re. Epilepsy)
6:25 AM  Dr. Ray Siton

6/17/20  Infuse 7.5 units oxytocin to ongoing IVF to be titrated accordingly

7:30 AM

6/17/20  Stop ongoing drip, Hook Plain LR 1L regulate to 30 gtts/min

8:25 AM

6/17/20  Thank you for the referral

7:50 AM  Dr. Siton informed through call with acknowledgement
 History and P.E. reviewed
 Start Levetiracetam 500mg in 100cc PNSS to run for 30 minutes now then q 12
 Start Folic acid 500 mg OD

9:30 AM  May give Levetiracetam 500 mg /tab 1 tab BID once on diet
 Folic Acid 1 tab OD

6/17/20 POST PARTUM ORDERS

10:48 AM  S/P NSVD + ME + Repair of 3rd degree
 To RR temporarily
 DAT
 IVF: PLR + oxytocin a total of 20 units to run 200 cc then regulate at 30 gtts/min
 IVFTF: PLR 1L + oxytocin 10 units at 30 gtts/min
Medication:
1. RhoGam 300 mg/1500 IU IM in prefilled syringe now
(must be given within 72 hours post-delivery)
2. Cefuroxime 50 mg 1 tab BID (Altoxime)
3. Tramadol + Paracetamol (Altotram) 37.5mg/325 mg tab 1 tab TID
4. Multivitamins + Ferrous Sulfate 1 tab OD
5. Calcium 1 tab BID
6. Vitamin C 1 tab OD
7. Carboprost 125 mg 1 amp IM now
8. Tranexamic Acid 1 gram IVTT now

_________________________ _____________________________
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
6/17/20  Remove epidural catheter prior to transport c/o OBROD
10:48 AM  Monitor V/S q 15 x 2 hours, q 30 mins x 2 hours, q hourly x 2 hours,
Then q 4 hours until stable
 Monitor I & O q Shift
 Refer for BP > 140/90. HR >100, RR >20, T: >38ᵒ C, profuse vaginal bleeding,
Or any unusualities
 Encouraged exclusive breastfeeding
 Keep uterus well contracted
 Due to void 4-6 hours postpartum, Refer if no urine output thereafter
 Perineal Wash BID
 Refer Accordingly

6/17/20  Apply ice pack hypogastric area

11:00 AM  Keep uterus well contracted
 May transfer to ward
 Lactulose 30 ml OD at HS
 Methylergometrine Maleate ( METHERGIN) 1 amp now
 Revise Levetiracetam drip to 500 mg 1 tab PO BID

6/17/20  Rounds with Dr. Siton

6:16 PM  Case and plans discussed
 Continue Levetiracetam and Folic acid tabs
 No objection to discharge
 OB service for final decision
 For EEG , awake and sleep as OPD
 Follow up AP after 1 week with EEG result
 Please provide photocopy of all labs
 Please provide medical certificate
 Advised

6/18/20  AP updated
6 AM  Continue Management
 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
6/18/20  May Go Home once with COVID PCR result
8:20 AM  Meds:
1. Cefuroxime (Altoxime) 500 mg 1 tab BID x 6 days
2. Tramadol + Paracetamol (Altotram) 37.5mg/325 mg tab 1 tab TID as needed
for pain
3. Multivitamins + Iron (OB CARE) 1 cap OD x 3 months
4. Calcium (OSTEO-D) I tab OD x 3 months
5. Lactulose 30 ml OD HS x 2 weeks
 FF-up via call/viber to OB Department Phone after 1 week

6/19/20  COVID result in ( NEGATIVE)

 May process for dischrage
 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

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
6/17/20 5:15 130/80 92 24 37.1 99%
8:00 130/70 93 20 36.4 99%
10:30 119/58 79 20 36.7 99%
10:45 117/51 75 20 36.2 99%
11:00 126/63 69 20 36.3 99%
11:15 129/72 73 20 37.0 99%
11:30 119/61 71 20 36.9 99%
12:00 110/60 77 20 37.3 96%
4:00 110/70 82 22 36.7 96%
8:00 100/60 79 21 37.4 97%
6?18/20 12:00 100/60 73 20 36.7 98%
4:00 110/70 69 20 36.4 98%
8:00 90/60 77 22 36.6 96%
12:00 100/60 81 24 36.1 96%
4:00 110/70 78 20 36.0 97%
8:00 110/70 80 20 36.3 97%
6/19/20 12:00 120/70 82 20 36.8 98%
4:00 120/80 69 20 36.6 97%
8:00 110/80 78 20 36.4 97%
12:00 110/70 67 21 36.4 97%
4:00 110/70 78 20 36.4 98%

DOH-SWUMed-NSD-F-073 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
6/17/20 5-6 100 --- 100 50 50
6-2 640 --- 640 310 310
2-10 900 1,000 1,900 1,500 1,500
6/18/20 10-6 650 800 1,450 700 700
Total: 4,090 Total: 2,560

6/18/20 6-2 c̅ HL 700 700 500 500

2-10 c̅ HL 500 500 300 300
10-6 900 900 700 700
Total: 2, 100 Total: 1, 500

4/5/20 6-2 c̅ HL 1,500 1, 500 600 600

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

LABORATORY RESULTS

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

NAME: Grace Marie Renegado AGE 26 CH S M W SEP. CASE NO.

ADDRESS: Pook, Talisay City, Cebu FINAL DIAGNOSIS:
Date/Time of Admission: 6/17/20, 5:09 AM Reason for Admission: Labor Pains
ADMITTING G₁P₁ PU 39 ⁴/₇ weeks AOG, Cephalic in labor, PROM
IMPRESSION:
6 cm -dilated
epilepsy

Blood Type: O RH: negative VDRL: Non-reactive HbSAg: NR Antibiotics: -

OBSTETRICAL HISTORY: G 1 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 9/13/19 EDC 6/20/20
PMP June 8, 2019 AOG 39 ⁴/₇
Menstrual Cycle: 12x 28-30 x 3-4 days in 7 x 3-4 pads/day Date of Quickening:
Ultrasound: Date AOG
Antenatal Visits: None 1-2 2-5 5 √
Health Care Providers: MCH DOH GO MD OTHERS
Immunizations: Tetanus Dates: TT₂ December 2019
Hepatitis Dates:
TB Dates:
Others Dates:
Total Weight Gain: 29 lbs. BP 100/60 HR 90 Urine Albumin - Sugar -
Medications: Vitamins ✔ Fe ✔ Ca ✔ Others ---

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

P.O.G.S. OBSTETRICS SHEET (2)

NAME: ____Grace Marie Renegado_________ AGE: ___26___ 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
+63 32 4188410 to 14

P.O.G.S. OBSTETRICS SHEET (3)

NAME_____________________ 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 _______6/17/20_________ Time _____9:17 AM____ Attend: _____Dr. Ubal_________
Manner: Vaginal Vaginal OS
Spontateous Spontaneous
Assisted Forceps
Partial Complete Breech (Marvel / Breech to Head) ___________________________________________(Mins.)
√ With or Without Episiotomy √ Laceration 3 degree
rd

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 _________6/17/20______________________ Time ___9:21 AM__________ By: _____Dr. Ubal______
Manner: √ Spontaneous Manual Extraction
Mos Crede Elective
Brand Andrews Retained ( ) Incarcerated
( ) Accrega
POSTPARTUM BLOOD PRESSURE: ______125/67_mmHg
Blood Loss ______300___________(cc) Cause _______________ Atony _______________ Others _____________________
Replacement __________________________ Blood ____________________________(cc) Retained ____________________
Placenta ____Duncan mechanism___________________________________________________________________________________________________
IV Fluids __D5 NM 1L at 30 gtts/min_______________(cc) Laceration ________________________________________

ANALGESIA / ANESTHESIA:
None Local Infiltration Psycho-prophylaxis
√ Regional General
Spinal Sadle Penthotal or IV Birth Weight __2, 770 mgs__________
√ Epidural – Cauda N20202 Sex __Female________________
√ Pudendal Others APGAR Score ___9, 9_______
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: __Grace Marie Renegado___ AGE: __26__ CH. ____S_____M_____W_____Sep._____ CASE NO. _________________

LABOR: ONSET: TIME ____5:09 AM_________ DATE ___6/17/20____ TOTAL DURATION

Full Dilation ____8:35 AM_______ First Stage _______3 hours and 35 mins________________(hrs.)
Delivery ____9:17 AM_______ Second Stage ______52 minutes________________(hrs.)
Placenta ___9:21 AM________ Third Stage ______ 4 minutes____________________(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
+63 32 4188410 to 14

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
2nd
3rd
4th
5th

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
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

Laboratory Results
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14