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)