URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Trixie Middle Name: Cruz Last Name: Araneta
Age: 25 Sex: F Status: Married Religion: Roman Catholic Hospital Unit No.
Address: 48 Salinas Drive Lahug, Cebu City
Student No. Occupation: Supervisor Birth Date: March 22, 1994
Birth Place: Cebu City Citizenship: Filipino Spouse: Ronald Araneta
Name of Mother: Name of Father:

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Ronald Araneta Relation: Husband
Address: 48 Salinas Drive Lahug, Cebu City
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Iatrogenic Ruptured bag of water
Vital Signs: BP: 110/80 HR: 72 RR: 18 Temp: 36.2 O2 Sat: 98% Weight: 104 lbs
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 2/11/20 Physician: Dr. Ubal
Department: OB-Gyne Time Arrived: 12:35 PM
Time Seen: 12:40 PM Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:

LMP: May 20, 2019 E: 02/24/20

EBW: 31 M: 13 y.o.
FH:142 29-30-day cycle
AOG 38 ¹/₇ 5-day period
O: G₁P₀ 2-3 pads/day
L: May 28, 2019 (=) dysmenorrhea

S: Patient was scheduled for prenatal visit today in SWU MC and upon 12:40 RHU Center was asked to perform IE there was
iatrogenic rupture of bag of water. Thus advised for admission.

IE: 1 cm, slightly effaced -5post, firm,

O: alert, awake, oriented

A: G₁P₀, PU 38 ¹/₇ weeks AOG, cephalic in latent phase of labor

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

2/11/20  Please admit pt. under service
1:15 PM  Secure consent to care
 TPR q 4 hours, I & O q shift
 NPO once in active labor
 IVF: D₅LR 1L at 30 gtts/min
 Labs:
 CBC
 HGT
 U/A
 Admitting CTG
 Meds:
1. Ampicillin (Ampitrex) 2 grams IVTT ANST q 6ᵒ 1st dose at 5:00 PM
 Monitor progress of labor
 Monitor V/S q hourly, FHT and UC q 15 mins
 Please inform Pedia about this admission
 Refer accordingly

2/11/20  Please infuse 6.5 units of oxytocin to ongoing IVF then regulate at 10
5:05 PM gtts/min to be titrated accordingly

2/11/20  O2 supplementation via face mask at 6-10 LPM

10:00 PM

2/12/20  Hold oxytocin drip

6:10 AM  Hook PLR 1L, run 200 cc MFD, then regulate at 30 gtts/min
 Let patient have light breakfast and personal hygiene

2/12/20  Hold PLR

9:45 AM  Resume oxytocin drip, starting at 10 gtts/min

2/12/20  IVFTF: 10 units of oxytocin infused in 1L D₅LR to run in 15 gtts/min

2:30 PM  Thank you

___________________________ _____________________________
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
2/12/20 1. POSTPARTUM ORDERS
8:07 PM 2. S/P NSVD
3. TPR q 4 Hours
4. I & O q shift
5. Venoclysis: D₅LR 1L + 20 units oxytocin to run 200 ml as MFD then regulate to 30
30 gtts/min
6. Diet: DAT
7. Monitor V/S q 15 min for 1 hour then 30 min for 1 hour then refer for any
Unusualities at recovery room
8. Meds:
1. Methylgonometrine 1 amp, give 1 amp IM now
2. Cefuroxime 500 mg/tab 1 tab BID P.O.
3. Mefenamic Acid (Almefen) 500 mg/tab 1 tab q 6H then PRN for pain
4. MV + Iron ( Benifort)1 cap OD P.O.
5. Ca + Vit D (OSTEO-D) 1 tab BID P.O.
6. Perineal Care BID
7. Urine Output after 4-6 hours postpartum
8. Ice pack at perineum
9. Refer Accordingly
10. Thank you

2/13/20  For P.E. tomorrow if no unusualities

8:15 AM  Full Body bath prior to P.E.
 Refer accordingly

2/14/20  For P.E. today

6:30 AM

2/14/20  MGH
 Seen and examined
 Remove heplock
 Meds:
1. Cefuroxime 500 mg/tab 1 tab BID (Altoxime) P.O. x 5 days
2. MFA (Almefen) 500/cap q 6 H P.O. x 5 days
3. MV + Iron (beneforte) 1 cap BID P.O. x 3 months
4. Cal + Vit. D (Osteo-D) 1 tab BID P.O. x 3 months
 Perineal Care BID and give pro wash
 Follow up after 1 week discharge 2/21/20
 Refer accordingly, Thank you

_________________________ _____________________________
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
2/11/20 12:30 120/70 99 19 35.9 99%
4:00 120/80 78 19 36.3 99%
8:00 120/80 79 19 36.1 99%
2/12/20 12:00 110/80 88 19 35.4 99%
4:00 120/80 68 19 36.5 99%
8:00 120/80 76 20 35.7 99%
12:00 120/80 83 22 36.1 99%
4:00 120/80 80 20 36.3 96%
8:00 100/80 85 19 36.0 96%
9:15 130/70 91 19 36.1 97%
9:30 120/70 92 20 36.4 98%
9:45 120/80 91 20 36.3 98%
10:00 120/60 94 18 36.3 96%
10:15 120/80 81 20 36.4 96%
10:30 120/80 75 20 36.5 97%
11:00 130/70 69 19 36.9 97%
2/13/20 12:00 120/80 71 20 37.1 98%
4:00 120/80 63 20 36.6 97%
8:00 120/80 78 20 36.7 97%
12:00 120/80 76 20 36.4 97%
4:00 120/70 79 20 36.0 98%
8:00 110/60 94 20 36.3 99%
2/14/20 12:00 100/80 77 20 36.1 99%
4:00 110/80 69 20 36.0 99%
8:00 110/70 70 20 36.1 99%
12:00 110/80 75 20 36.5 99%
4:00 110/80 70 19 36.4 99%

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
2/11/20 12-2 100 --- 100 0 0
2-10 400 300 760 440 440
10-6 300 200 500 300 300
Total: 1,360 Total: 740

2/12/20 6-2 550 200 750 300 300

2-6 240 100 340 100 100
6-10 450 ---- 450 ___ EBL 300
10-6 500 1,000 1,500 250 250
Total: 3, 040 Total:

2/13/20 6-2 290 500 790 300 300

2-6 c̅ HL 800 800 250 250
6-10 c̅ HL 410 410 390 390
10-6 c̅ HL 600 600 520 520
Total: 2,600 Total: 1, 460

2/14/20 6-2 c̅ HL 1000 1,000 680 680

2-4 c̅ HL 620 620 420 420
Total: 1, 620 Total: 1, 100

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)
DOH-SWUMed-NSD-F-013 Rev.2
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
LABORATORY RESULTS