URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14

EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Rachel Middle Name: Saldivar Last Name: Agapito
Age: 23 Sex: F Status: Single Religion: Roman Catholic Hospital Unit No.
Address: 45 Lawaan, Talisat City, Cebu
Student No. Occupation: Sales Agent Birth Date: October 27, 1997
Birth Place: Citizenship: Filipino Spouse:
Name of Mother: Name of Father:

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Dionisia Agapito Relation: Mother
Address: 45 Lawaan, Talisay City, Cebu Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Watery Va ginal 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 /26/ 20 Physician: Dr. Yu
Department: OB-Gyne Time Arrived: 7:03 PM
Time Seen: Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:

G1P0
LMP: 7/28/2019
AOG: 39 weeks (LMP)
EDC: 5/5/20
37 6/7 weeks by 1st UTZ

S: 5 hours PTL, Patient noted soaked underwear, onset of watery vaginal discharges, associated with hypogastric pain
radiating to lumbosacral area, with uterine contraction every 30 minutes, condition persisted thus opted consult.

Abdomen: FH: 34 cm
EFW: 3565 grams
FHT; 145 bpm
SPE: (+) minimal whitish discharges at posterior fornix area, foul smell
IE: 1 cm, UE ST -5, Leaking BOW, Cephalic, posterior, firm, BISHOP score: 1 A:
G1P0, 39 weeks AOG, Cephalic in latent phase of labor, PROM
P: 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
4/26/2020  Please admit patient under Dr. Yu
8:00 PM  To secure consent to care
 TPR q 4 hours
 DAT
 NPO once active labor
 Start venoclysis with D5LR 1 Liter at 30 gtts/min
 Start Ampicillin 2 grams IVTT, ANST now then every 6 hours
 Pedia Dr. Pizarra
 Monitor progress of labor

4/26/2020  Please insert Dinoprostone 0.5 mg gel endocervically

8:30 PM

4/27/2020  For co-management with Dr. Hermogenes

4:00 AM  IVFTF: D5LR 1L at 30 gtts/min

4/27/2020  For CBC and U/A

5:00 AM

4/27/2020  Give HNBB 1 amp + 1 cc sterile water

5:00 AM  Slow IVTT, 1st 2 doses at 1 hour apart then every 4 hours

4/27/2020  Run 200 cc of D5LR at MFD

3:20 PM  IVFTF: D5LR 1L + 10 units oxytocin at 10 gtts/min
Titrate accordingly
 Refer accordingly

4/27/2020  Evening primrose oil 6 capsules per vagina

8:30 PM

4/28/2020  Close off oxytocin drip

3:15 AM  Hook PLR 1L in 200 cc as MFD then regulated at 30 gtts/min
 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

_________________________ _____________________________
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
 Meds:
1) Ampicillin 2 grams IVTT q 6 hours
2) Ketoralac 1 amp IVTT q8ᵒ hr to start at 8 PM tonight
3) Tramadol 1 amp IVTT q 8ᵒ hr to start at 6 PM tonight
 Monitor V/S q 15 mins x 2ᵒ, q30 mins x 2ᵒ, q hourly until stable
 Refer if BP ≥ 140/100, < 90/60, PR > 100, RR > 20
T > 38ᵒ C, profuse vaginal bleeding or any unusualities
 Maintain FBC
 I & O q hr
 Repeat CBC tom 5 AM ( April 29, 2020)
 Apply abdominal binder accordingly
 Refer accordingly
4/28/2020  May transfer to room
4:45 PM  Dr. Yu, Dr. Hermogenes informed thru text
 Refer for any unusualities

Addendum
 Metronidazole 500 IV drip q 8 hours for 2 more doses
then discontinue

4/29/2020  May have soft diet

 Shift Cefuroxime 500/tab 1 tab TID PO
 Dolcet 1 tab TID PO, Metronidazole last dose
 For billing
 Give Dulcolax 2 tab tonight if No BM
 For dressing tomorrow and continue dressing
 MGH tomorrow AM
 Follow-up clinic Wednesday

4/29/2020  MGH tomorrow morning

7PM  Defer Dolcet
 Take Home Meds
1) Celecoxib 200 mg 1 cap BID x 1 week
2) Cefuroxime 500 mg 1 tab BID x 7 days
 Follow up at APS clinic on May 6, 2020

_________________________ _____________________________
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
4/26/2 9:03 90/100 96 19 36.5 98%
0
8:55 110/70 87 19 36.3 99%
4/27/2 12:00 100/70 83 21 35.9 97%
0
4:00 110/70 82 20 36.2 97%
8:00 110/80 80 19 36.6 98%
12:00 110/80 83 20 36.4 98%
4:00 100/80 87 20 36.6 97%
8:00 110/70 71 18 36.6 98%
4/28/2 12:00 110/70 73 19 36.0 97%
0
4:00 100/70 83 20 36.0 96%
4/28/2 8:00 110/80 97 19 36.1 97%
0
12:00 90/60 81 20 36.1 98%
4/28/2 4:00 104/69 67 18 36.4 99%
0
5:00 100/90 71 18 36.4 99%
6:00 100/90 76 20 36.6 99%
7:00 110/80 60 20 36.6 98%
8:00 100/80 65 21 36.7 98%
9:00 110/80 62 21 36.5 98%
10:00 110/80 68 21 36.5 98%
12:00 110/80 75 20 36.5 98%
4:00 110/70 68 20 35.8 98%
4/29/2 8:00 110/70 66 19 36.0 96%
0
12:00 100/60 76 20 36.5 95%
4:00 100/60 92 20 36.5 98%
8:00 100/70 95 20 37.0 99%
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

12:00 100/60 78 20 36.9 98%

4:00 120/80 75 20 36.5 99%
4/30/20 8:00 90/60 98 20 36.0 98%
12:00 100/60 90 20 36.5 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

4/26/20 7-9 100 1500 1600 250 250
9-10 120 0 120 0 0
Total: 1,720 Total: 250

4/26/20 10-6 800 100 900 450 450

Total: 2,620 Total: 700

4/27/20 6-2 550 800 1350 840 840

2-10 350 400 750 600 600
10-6 480 50 530 150 Vomitus 250
100
Total: 2,630 Total: 1,690

4/28/20 6-2 1420 NPO 1420 400 FBC 300 700

4/28/20 2-3 120 120 200 200
3-4 120 120 250 250
4-5 120 120 250 250
5-6 120 120 100 100
6-7 120 NPO 120 15 15
7-8 120 20 140 10 10
8-9 120 30 150 10 10
9-10 120 20 140 15 15
Total: 1,030 Total: 850

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

4/28/20 10-11 120 0 120 25 25
11-12 120 0 120 15 15
12-1 120 30 150 20 20
1-2 120 20 140 15 15
2-3 120 20 140 15 15
3-4 120 30 150 20 20
4-5 120 20 140 10 10
5-6 120 120 20 20
Total: 1,080 Total: 150

4/29/20 6-7 120 0 120 20 20

7-8 120 100 220 19 19
8-9 120 0 120 27 27
9-10 120 120 240 40 40
10-11 120 0 120 28 28
11-12 c̅ 0 40 40
HL

12-1 c̅ 150 150 50 50

HL

1-2 c̅ 0
HL

2-6 c̅ 600 600 520 520

HL

6-10 c̅ 420 420 150 150

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

10-6 c̅ 400 400 280 280

HL

2,390 1,174
4/30/20 6-2 c̅ 1000 1000 1000
HL

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

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

Signature Specimens:
(Provide signature beside full name in print)
DOH-SWUMed-NSD-F-013 Rev.2 LABORATORY
RESULTS
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

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

NAME: Rachel Agapito AGE 23 CH S M W SEP. CASE NO.

ADDRESS: 45 Lawaan talisay City, Cebu FINAL DIAGNOSIS:
Date/Time of Admission: 4/26/2020. 8:05 PM Reason for Admission: Watery Vaginal Discharge
ADMITTING IMPRESSION: G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor
Prelabor rupture of membrane

Blood Type: A RH: tve VDRL: - HbSAg: NA Antibiotics: -

OBSTETRICAL HISTORY: G 1 P 0 (FT PR AB LC )
Pregnancy Pregnancy YEAR Gestation Sex Birth Present Complications/
Outcome Completed Weight Status Abnormalities
Present pregnancy
Order
(I.B.T. SVD) (wks)
LSCS OR LCS
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

Present Pregnancy: LMP

PMP
Menstrual Cycle:
Ultrasound: Date
Antenatal Visits: None
Health Care Providers: Immunizations:

TB
Others
Total Weight Gain: 10 kg

DOH-SWUMed-NSD-F-058 Rev.1