Republic of the Philippines
Province of Benguet
KARDEX
Hospital Number:191129346
Name: CATU CINDY Age: 62 Sex: F Ward: Medical
SURNAME GIVEN NAME MIDDLE NAME
Admitting diagnosis: patient present to her primary care provider stating she has been “very tired” the past month and
thinks she has a “bladder infection” due to her frequent urination.
Admitting physician:
Final diagnosis:
Date of admission: September 9, 2021 Date of discharge:
SPECIAL INSTRUCTIONS/ENDORSEMENTS DATE LABORATORY
Diet:
Please Transfuse 1 u FFP 09/10/202 For repeat CBC
1
Monitor VSq15 until stable then q hourly while on BT
Monitor VS q 2h
Log rolling q 2h
DATE IV FLUIDS DATE PRN MEDICATIONS
9/10/202 PNSS 1L @ 100 cc/hr x 2 cycles
1
DATE IV MEDICATIONS DATE ORAL MEDICATIONS
9/10/2021 Diphenhydramine pre-BT
Furosemide 40mg IV 1hr post BT with BP precaution
9/10/2021
DATE NEBULIZATION
Republic of the Philippines
Province of Benguet
MONITORING SHEET
Hospital Number: 191129346
Name: Catu Cindy Age: 62 Sex: F Ward: Medical
SURNAME GIVEN NAME MIDDLE NAME
DATE & Input Output
TIME BP CR/PR RR TEMP (mL) (mL) Misc/NVS/Wt Remarks
Republic of the philippines
Province of Benguet
CLINICAL FACE SHEET
Hospital Number:__191129346_
NAME: BIRTH DATE: AGE: SEX: WARD/ROOM
08/28 62 y/o
/ 1959 □ MALE Medical Ward
Cindy Catu □ FEMALE
FIRS MIDDLE
LAST T NAME (MM/DD/YYYY)
ADDRESS: CIVIL STATUS PATIENT CLASSIFICATION ADMISSION TIME
#143 Love St. Valentine DATE:
□ S □ Ch CLASS __________________ 12:00 AM
City 09/9/2021
□ M □ W PHIC ______ MEMBER ______ PM
DISCHARGED TIME
□ Sep. ______ DEPENDENT DATE:
BIRTHPLACE: RELIGION: ___SSS ___ Paying mem. ______ AM
___GSIS ___ Life Time mem. ______ PM
#143 Love St. Valentine Roman catholic ___ OWWA ___ Sponsored mem. TYPE OF ______ OLD
City ADMISSION:
___ Non Member _____ NEW
OCCUPATION: CONTACT NUMBER: NATIONALITY: TOTAL PATIENTS DAYS:
Filipino
Retired postal 09123456789
worker SERVICE
NAME OF EMPLOYER`S ADDRESS: CONTACT NUMBER: _______ OB _______ MEDICINE
EMPLOYER: _______ GYNE _______ SURGERY
INFORMANT: ADDRESS OF INFORMANT CONTACT NUMBER: RELATIONSHIP TO PATIENT
NEXT OF KIN OR WHOM TO ADDRESS OF NEXT OF KIN CONTACT NUMBER: TRANSFERRED DATE:
NOTIFY:
REFERRING HEALTH WORKER: REFERRING HEALTH WORKER`S ADDRESS:
ADMITTING DIAGNOSIS: ADMITTED BY:
patient present to her primary care provider stating she has been “very tired” the past month and
thinks she has a “bladder infection” due to her frequent urination. Dr. Cabrera
PRINCIPAL DIAGNOSIS: CODE NUMBER
OTHER DIAGNOSIS: CODE NUMBER
OPERATIVE PROCEDURE:
DISPOSITION: □ DISCHARGED □ HAMA □ RECOVERED □ UNIMPROVED □ DIED □ -48 HRS
□ TRANSFERRED □ ABSCONDED □ IMPROVED □ AUTOPSIED □ +48 HRS
IN CASE OF ACCIDENTS: THE PATIENTS WAS BROUGHT BY: CONTACT NUMBER RELATIONSHIP TO PATIENT
DRIVER VEHICLE AND PLATE POLICE INVESTIGATOR ADDRESS CONTACT NUMBER
NUMBER
MEDICAL OFFICER III MEDICAL OFFICER III MEDICAL OFFICER III
MEDICAL MEDICAL
SPECIALIST II MEDICAL SPECIALIST II SPECIALIST I
CHIEF OF HOSPITAL
Republic of the Philippines
Province of Benguet
Hospital No.: _191129346__
CONSENT TO CARE
Note: This authorization must be signed by the patient or by the next of kin in case of a minor or when the patient is
physically and/or mentally incompetent.
I, Cindy Catu , hereby authorized Dr. Cabrera and other staff of Northern
(Name of patient)
Benguet District Hospital to perform the treatment and procedures deemed necessary for my care.
I also give authorization for the staff to supply information from my medical record to my insurance carrier/or
lawyer.
I shall obey the rules, regulations and policies of the hospital and the instruction of the staff.
MANDY CATU 09/10/2021 CINDY CATU
Name & signature of witness Date Name & signature of patient
Hospital No.: __________________
Patient is a minor of .
Age
Patient is unable to sign because .
I, , being next of kin of hereby
(name of guardian or parent) (name of patient)
authorized Dr. and other staff of Northern Benguet District Hospital to perform the treatment and
procedure deemed necessary for his/her care.
I also give authorization for the staff to supply information from my medical record to my insurance carrier/or
lawyer.
I shall obey the rules, regulations and policies of the hospital and the instruction of the staff.
Name & signature of witness Date Name & signature of parent/guardian
Republic of the Philippines
Province of Benguet
ADULT HISTORY AND PHYSICAL EXAMINATION
Hospital Number: 191129346
Name: Cindy Catu Age: 62 Sex: F Ward: Medical
CHIEF COMPLAINT/S:
HISTORY OF PRESENT ILLNESS:
PAST MEDICAL HISTORY:
FAMILY HISTORY:
SOCIAL/ENVIRONMENTAL/OCCUPATIONAL HISTORY:
PHYSICAL EXAMINATION:
GENERAL SURVEY:
VITAL SIGNS: BP: 150/90 mmHg PR: 84 bpm RR: 14 cpm T: 37.2 °C WT:175 lbs HT: 5 ft. 4 in.
SKIN:
HEAD:
EENT:
NECK:
CHEST/BREAST/LUNGS:
HEART/CARDIOVASCULAR:
ABDOMEN:
GENITO-URINARY:
RECTAL:
MUSCULO-SKELETAL:
EXTREMITIES:
NEUROLOGICAL/NERVOUS:
LYMPHATIC:
ADMITTING IMPRESSION: ATTENDING PHYSICIAN:
Republic of the Philippines
Province of Benguet
DOCTOR’S ORDER
Hospital Number:191129346
Name: Catu Cindy Age:62 Sex: F Ward: Medical
SURNAME GIVEN NAME MIDDLE NAME
DATE TIME PROGRESS NOTES DOCTOR’S ORDER
09/10/2021 1:50 Pm Admit under white service
Secure consent
TPR with BP q4
DB diet, low salt, low fat
LABS:
CBC
Creatinin
Sodium
Potassium
FBS in AM
U/A
Meds:
Ceftriaxone 750mg IV q 8h ANST ()
Paracetamol 500mg tab q4 RTC x 24h. then PRN for T>37.8 degree Celsius
RI 10 ‘iu’ for CBG> 140 mg/dl
Lisonopril 20 mg po OD
Hydrochlorothiazide 25mg OD
CBG monitoring TID ac
I and O q shift
Refer
09/10/2021 6:00 Pm Low hgb, hct Secure consent
To secure 2 units of PRBC for BT and Please transfuse once available and 1 FFP of patient’s
blood type for stand by
For repeat CBC. Please include serum, Na+, K+, Ca+ determination post BT
Meds:
Diphenhydramine pre-BT
Furosemide 40mg IV 1hr post BT with BP precaution
IVF TF PNSS 1L @ 100cc/hr x 2cycles
For IFC insertion
For repeat U/A
Refer accordingly
09/10/2021 4:00 AM Left sided weakness For CT scan of the head @7:30 AM, consent secured
BP 180/110 ECG 12L
For NGT insertion, consent secured
Ensure 200 cc q4h
Monitor I & O qh and record
Please transfuse 1 u FFP
Monitor VSq15 until stable then q hourly while on BT
For repeat CBC
Monitor VS q 2H
Log rolling
Refer accordingly
Republic of the Philippines
Province of Benguet
LABORATORY RESULTS
Hospital Number: 191129346
Name: Catu Cindy Age:62 Sex: F Ward: Medical
SURNAME GIVEN NAME MIDDLE NAME
Republic of the Phillipines
Province of Benguet
TEMPERATURE RECORD
Hospital Number: Bed No. Doctor:
Year: Month: Name of Patient:
Da y of Month
Da y of di s e as e
No. of hospital days
Wei ght
R PU T
E L E
S S M
P E P
42 42
41
40
39
38
180 37
36
160 35
140
120
100
50 80
40
30 60
20
10
8-4 s hift
URINE 4-12 s hift
12-8 s hift
8-4 s hift
STOOL 4-12 s hift
12-8 s hift
Republic of the Philippines
Province of Benguet
TREATMENT SHEET
Hospital Number: 191129346
Name: Cindy Catu Age: 62 Sex: F Ward: Medical
Medicines/ Date 9/10/21
Dosage/ Route of
Administration &
Shift Time Time Time Time Time Time Time
Frequency
8-4
Diphenhydramine 4-12
pre-BT
12-8 6/J
M
Furosemide 40mg IV 1hr post
BT with BP precaution
8-4
4-12
12-8 8/J
M
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
Republic of the Philippines
Province of Benguet
INTRAVENOUS FLUID SHEET
Hospital Number: 191129346
Name: Catu Cindy Age: 62 Sex: F Ward: Medical
SURNAME GIVEN NAME MIDDLE NAME
IV FLUID DATE & TYPE OF IV FLUID DRUG NEEDLE GAUGE & FLOW DATE & NURSE’S REMARKS
TIME AND VOLUME ADDITIVES SITE OF INSERTION RATE TIME SIGNATURE
BOTTLE STARTED CONSUMED
NO.
1 09/11/2021 1L PNSS 18 gauge 33 gtts/min 09/12/2021 J.E
7:50 AM Left metacarpal vein 5:50 PM
Republic of the Philippines
Province of Benguet
NURSE’S NOTES
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME
DATE& TIME FOCUS DATA, ACTION, RESPONSE
10/9/2021 F1: Blood transfusion D: bloody CT drain of 100ml/hr, patient is pale looking, hemoglobin level taken 9g/L.
A: blood transfusion of 525 mL started at 1000H to run for 4hours. Initial VS taken prior to transfusion.
R: Blood transfusion ended at 1500H. Patient is stable, with no untoward s/s
F2: NGT insertion and feeding D: Patient is unable to swallow
Patient feels tired
A: Performed NG insertion
Fed the patient
R: The patient feels more energized.
F3: Log rolling D: Patient is in bed for 6hrs already
A: Performed log rolling
Assesed for spinal allignment and ulcerations
R: Patient is comfortable in her position
Republic of the Philippines
Province of Benguet
DISCHARGE SUMMARY
NAME: AGE: SEX: HOSP. NO:
DATE ADMITTED: DATE DISCHARGE:
ADMITTING PHYSICIAN:
ADMITTING DIAGNOSIS:
CHIEF COMPLAINS:
BRIEF CLINICAL HISTORY AND PERTINENT P.E.:
LABORATORY FINDINGS (INCLUDE ECG, X – RAY, AND OTHER DIAGNOSTIC PROCEDURES):
COURSE IN THE WARD: (INCLUDE MEDICATIONS):
FINAL DIAGNOSIS:
DISPOSITIONS: (INDICATE HOME MEDICATIONS, SPECIAL INSTRUCTION AND FOLLOW-UP)
PREPARED BY:
_____________________________ _____________________ ____________________________ M.D.
(Signature Over Printed Name) Date ATTENDING PHYSICIAN
(Signature Over Printed Name)
