CLINICAL FACE SHEET

_________2022-001________

Case Number

Name: Wella Abad Santos Age: Date of Birth: Place of Birth: Category of
38 y/o 01/15/1984 Ilocos Sur Gabriela Silang Patient:
General Hospital PhilHeath
Home Address: Mindoro, Vigan City Sex: F Civil Status: Religion: Nationality:
Common Roman Filipino
Law Partner Catholic
Next of Kin: Paul H. Santos Relationship: Address: Mindoro, Vigan City Contact No.: 09559677777
husband
Date Admitted: 02/28/22 Time: Date of Discharge: Time: No. of Hospital Days:
___9:00 A.M. ________ A.M.
________ P.M. ________ P.M.

Ward: OB Ward 1 Attending Physician: Admitting Nurse:

Dr. OB Carl Julius Concordia, SN

ADMITTING DIAGNOSIS:

Severe Pre-eclamplsia

FINAL DIAGNOSIS: ICD 10 Code:

Condition on Discharge: Disposition:

[ ] recovered [ ] died [ ] discharged [ ] absconded

[ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD
[ ] unimproved [ ] not autopsied [ ] home against for follow up advice

COMPLICATIONS:

OPERATION/PROCEDURE DONE:

Review for completeness:

__________________Dr. OB___________________ ______________ __________________

Signature over Printed Name Signature over Printed Name
of Attending Physician (Record Officer)
 VITAL SIGNS MONITORING SHEET

Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____

Date Time Shift BP PR RR Temp 02 sat FHT REMARKS

02/28/22 9:00 AM 170/100 81 15 36.4 96% 135

9:30 AM 170100 80 16 36.2 96% 132
 INTAKE & OUTPUT MONITORING SHEET

Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____

INTAKE OUTPUT
Date Time Shift IVF Drain/
Oral/NGT TOTAL Urine stool TOTAL
02/28/22 7-7 AM 360cc 1200cc 1560cc 4x (360cc) 0 360cc
 PATIENT’S DATA
1. Name of Patient 2. PIN
Santos Wella Abad
Last Name First Name Middle Name 3. Age
5. Chief Complaint 38 y/o
Pain and abrasions at left hip
4. Sex
Male Female
/ /
6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code
Severe Pre-eclampsia
8. b. 2nd Case Rate Code

9. a. Date Admitted: 9. b. Time Admitted:

l_0_l_2__l ¯ l_2__l_8__l ¯ l_2_l__0_l_2__l__2_l l_0_l 9_l ¯ l__0_l_0_l AM PM
month day year hour min
10. a. Date Discharged: 10. b. Time Discharged:
l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM
month day year hour min
REASON FOR ADMISSION
1. History of Present Illness:
Patient Wellla is a 38 y/o female was rushed in the ER, few hours PTA the patient was just doing some morning stretching
exercises at their home in Mindoro, Vigan City and then there was a sudden development of edema in the face and upper, and
lower extremities along with severe headache.
Then his husband Paul decided to drive her at the hospital of Ilocos Sur Provincial Hospital Gabriela Silang and transferred
patient via wheelchair.

2. a. Pertinent Past Medical History:

The patient was a smoker and drinker, but she stated that ever since she finds out she is pregnant so, she stops smoking and
drinking alcohol. According to her during her childhood she had suffer from chicken pox, measles, and mumps. She manages
this by wearing black shirt knowing that it will makes all lesions erupt and dry. For measle they tried burning a dried onion skin
and believe that the smoke coming from it halt the eruption of the measle. For her mumps, they applied gentian violet and “akot
akot” and no complications was noted. The client claimed that these traditional ways of treatment were effective. The client also
experiences common illnesses such as common cough and cold, fever and headache wherein it is managed by OTC drugs like
paracetamol tablets for fever and headache, carbocisteine for cough and bioflu for colds. The patient also had her menarche
when she was 12 y/o. Her past obstetric history is remarkable for recurrent miscarriages. She had two miscarriages at 6-8 weeks
and one ectopic pregnancy a year and a half ago which miscarried naturally at 10 weeks.

2. b. OB/GYN History:
G_4_ P__0__ (__0___-__0__-__3__-___0__) LMP:07/17/21 NA

3. Pertinent Signs and Symptoms on Admission (Check applicable box/es):

 Altered Mental Sensorium  Diarrhea  Hematemesis  Palpitations

 Abdominal cramp/pain  Dizziness  Hematuria  Seizures
 Anorexia  Dysphagia  Hemoptysis  Skin rashes
 Bleeding gums  Dyspnea  Irritability  Stool, bloody/black tarry/mucoid
 Body weakness  Dysuria  Jaundice  Sweating
 Blurring of vision  Epistaxis  Lower extremity edema  Urgency
 Chest pain/discomfort  Fever  Myalgia  Vomiting
 Constipation  Frequent urination  Orthopnea  Weight loss
 Cough  Headache  Pain: Low back pain (6/10)  Others: _vaginal bleeding___

4. Referred from another Health Care Institution (HCI): No Yes, Specify Reason _____________________________________________________
Name of Originating HCI ____________________________________________

5. Physical Examination on Admission (Pertinent Findings per System)

General Survey:  Awake and alert  Altered sensorium,_______________________

Vital Signs: BP:__170/110__________ HR:____81________ RR:___15__________ Temp.;__36.4__________ Wt.:_______________(pedia patients)

HEENT:  Essentially normal  Abnormal pupillary reaction  Cervical lymphadenopathy  Dry mucous membrane
 Icteric sclerae  Pale Conjunctiva  Sunken eyeballs  Sunken fontanelle

Others:_____________________________________
 GRAPHIC RECORD

Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____

DATE 02/28/22
No. of Days in
Hospital
7 7 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7
RR PR T

42

41

160 40

150 39

140 38

130 37

120 36

110 35

100

90

50 80

40 70

30 60

20 50

10
 7-7

URINE 7-7

7-7
STOO 7-7
L
170/110
BP
 IV FLUID SHEET

Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____

MAIN LINE
Time Time
Date IV Fluids Regulation Started Consumed
REMARKS
02/28/2 PLRS 1L x KVO 10gtts/min 9:05/CJC
1

ANOTHER LINE / SIDE DRIP

Time Time
Date IV Fluids Regulation REMARKS
Started Consumed
 DOCTOR’S ORDER

Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____

Date C A R E D TIME POSTED

And Progress Notes Doctor’s Order AND
SIGNATURE
time
2/28/22 COMPLAINTS:  Low Salt Low Fat Diet 
9:30AM
edema in the  Diagnostics: 
face and CBC, platelet
upper and lower Urinalysis
extremities along ABO Typing
with a severe FBS
headache Lipid Profile
BUN
Vital Signs: Creatinine
BP:150/90 SGPT
PR:87 SGOT
RR:22 BUA
TEMP:37.0C  IVF to follow; PLRS 1L at KVO
o2 sat: 96%  Medications:
1. Nifedipine 10mg tab SL OD
2. Hydralazine 10mg tab TID
3. Labetalol 100mg tab every 12 hours for
every 3 days
 Continue Multivitamins 1 tab OD
 Monitor FHT every 2 hours and record
 I and O every shift and record
 Monitor VS every 2 hours and record
 Refer accordingly
Dr. OB
 C-Carried-out
A-Administered
R- Requested
E-Endorsed
D-Discontinued

MEDICATION SHEET

Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____

Name of Drug, Dosage, Date and Time Given:

Route, & Frequency 02/28/22
Nifedipine 10mg 1 9/CJC
tab SL OD

Hydralazine 10mg 1 9/CJC

tab TID 12/CJC
8/CJC

Labetalol 100mg 1 tab 9/CJC

every 12 hours for 3 8/CJC
days

Multivitamins 1 tab 9/CJC

OD
Ferrous Sulfate 1 tab 9/CJC
OD
 NURSE’S NOTES

Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____

Date-Shift FOCUS Data – Action – Response

02/28/22 Post Admission Care >D: patient came to ER via wheelchair with a body weakness and low back pain (6/10) with a chief
7-7 complaint of edema in the face and upper and lower extremities along with a severe headache; initial
9:00 vital signs BP:170/110 PR:81 RR:15 TEMP:36.4C o2 saturation: 96%, FHT: 135
A: Seen and examined by the admitting physician Dr. OB with orders made and carried out for
admission; admitted patient in OB ward; instructed pt. and SO for LSLF diet; laboratory diagnosistics
requested CBC (normal full blood count), platelet; UA; ABO Typing; FBS; Lipid profile; BUN(0.37
mmol/l); Creatinine (44 mg/mmol); SGPT; SGOT; and BUA; hooked IVF of PLRS 1L x KVO infusing well
at left metacarpal vein; administered medications Nifedipine 10mg 1 tab OD; administered Hydralazine
10mg 1 tab TID; administered Labetalol 100mg 1 tab every 12 hrs for 3 days; continued medication
Multivitamins 1 tab OD and FeSO4 1 tab OD; raised side rails and lock the bed wheels
R: Patient seen lying in bed with still on edema +2, still on severe headache (8/10)
. CJC
CARL JULIUS CONCORDIA
>D: vital signs BP:170/100 PR:80 RR:16 TEMP:36.2C o2 saturation: 96%, FHT: 132
A: instruct patient on DBE and listen to music and other relaxation and distraction activities; monitor and
record VS; observe skin color, pain, temperature, and capillary refill time; provide calm environment;
monitor pt.. for response of medications to control BP
9:30 R: Decreased BP from 170/100 tp 140/90, pt. seen lesser in severe pain 6/10 into moderate pain 4/10,
Hypertension
still weak in appearance, edema in her face and upper and lower extremities, lower deep tendon reflexes
are brisk but without any involuntary muscle contraction, capillary refill within 4 seconds
. CJC
CARL JULIUS CONCORDIA
>D: patient still in moderate headache 5/10
A: instructed pt to maintain bed rest; provided pt with relaxation and diversional activities; assisted pt
with ambulation
R: Decreased moderate pain at 5/10 to 3/10., (-) contraction
CJC
12:30 CARL JULIUS CONCORDIA
Acute pain
 KARDEX
NAME: _Wella Abad Santos____________________ AGE:_38_ SEX:__F__ STATUS:_Common Law Partner___WARD._OB 1__

ADDRESS:__Mindoro, Vigan City__________________ CLASSIFICATION:_PhilHealth__ WEIGHT:__67kg__

ADMITTING PHYSICIAN:___Dr. OB________ DATE/TIME ADMITTED:_02/28/22_9:00_BLOOD TYPE:_B+__

ATTENDING Physician. OB________________

COMPLAINT:_ edema in the face and

upper and lower extremities along with a severe headache_____________________________________________________

IMPRESSION DIAGNOSIS:_ Severe Pre-eclampsia__________________________________

SURGERY DONE:___________________________________ DATE/TIME: SURGERY:____________________

MENTAL STATUS: Activities: Diet: Tubes: Special Info:

_/_Conscious ___ambulant ___NPO ___Foley Catheter ___Weigh Daily
___drowsy __dangle and sit up ___DAT ___thoracic tube ___BP q shift
___stupor ___bedrest with BRP ___Soft ___NGT ___Neuro V/S
___unconscious ___CBR w/o BRP ___clear liquids ___CVP ___abdominal girth
___comatose Others:___________ ___ gen. liquids Others:__________ Others:__________
Others:_Low Salt
Low Fat Diet

Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND

ordered Ordered TIME
DISCONTINUED
02/28/22 Nifedipine 10mg 1 tab SL OD 02/28/22 PLRS 1L x KVO
Hydralazine 10mg 1 tab TID
 Labetalol 100mg 1 tab every 12 hours
for 3 days
Multivitamins 1 tab OD
Ferrous Sulfate 1 tab OD

DATE PRN TREATMENTS/MEDICATION DATE Medical Treatment/ Date Done

Ordored ORDERED Laboratories/Diagnostics
02/28/22 CBC, platelet
UA
ABO Typing
FBS
Lipid Profile
BUN
Creatinine
SGPT
SGOT
BUA

Cbg monitoring
Name:__Wella Abad Santos_______________Age/Sex/CS:_38, F, Common law partner_Ward/Room: OB 1____
Date and time CBG REMARKS

CONSENT FOR SURGERY

KNOWN ALL MED BY THESE PRESENTS:

That I, _ _________________________ _________ ______ Filipino, of legal age,

Single/married/widow, and a resident of ______________ ____________________, do
Hereby submit myself freely and voluntarily, without any influence, coercion, for or intimidation by any person to
have an operation performed to me/my __________________________________________,
For the following operation/s_______________________________________________________
By Dr. ________________ and Anesthesia by Dr. ___________ ____________

These said operation has been fully explained to me by the surgeon as to the type of operation; its necessity;
its complications that may arise, directly or indirectly therefrom. Likewise, the type of anesthesia and all its
complication directly and indirectly, have been explained to me by my anesthesiologist.

It is understood that the surgeon/ anesthesiologist performing the operation/anesthesia will not be liable for
any charge that I oy my relative/s or guardian may claim as a result of the operation/ anesthesia or treatment.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ _ _____day of ________ __,
20_________ at Vigan, Ilocos Sur.

IN THE PRESENCE OF

_______________________ _____________________________
Witness         Signature of patient/
        person giving consent

PREOPERATIVE CHECKLIST
Last Name: ____ Age:    _   Hospital #: ____
Given Name: _________ Sex: Ward/Room: ______
 N/
YES NO REMARKS
A
1. Consent for surgery signed, witnessed and documented
2. Consent for blood transfusion signed, typed and cross-matched ______unit/s
confirmed
3. CP clearance/ Pedia clearance done and on chart
4. Laboratory reports on chart
5. ECG report on chart
6. X-ray/ CT scan report on chart
7. Identification bracelet accurate and affixed to wrist/ ankle
8. Allergies checked and documented on chart.
9. Patient shower/ bath completed as ordered, dressed in hospital gown
10. Jewelries, hairpin, contact lenses, prosthesis, underwear removed.
Disposition: Son – James Garcia

11. Oral Hygiene/care completed

12. Operative site prepared
13. Cleansing enema done
14. Nail polish/ make-up removed
15. Vital signs taken and recorded
BP:120/90 mmhg PR:86 bpm RR:19 cpm TEMP: 37.0⁰C O2 SAT:97%

16. Patient voided at 4:15am

Has Foley catheter: __n/a_

17. Dentures removed

18. Patient on NPO since _________
19. OR notified: ___________________
20. Anesthesiologist notified
21. Pre-op medication/s given:

__________________________________

Nurse of Duty

________________________________

Date and Time

 OR SLIP
NAME: _________________
AGE: ____________ SEX: __ RM NO.______
ATTENDING PHYSICIAN: _________________
Procedure: ________________________
DATE: _________ TIME:____________
SURGEON: ___________
ANESTHESIOLOGIST: __________
TYPE OF ANESTHESIA: ______________
CP CLEARANCE: _____________
PREPARED BY: _________________________
SIGNATURE: ___________________________
 Name: Wella Abad Santos Age: 38/F Name: Wella Abad Santos Age: 38/F

Nifedipine 10mg 1 tab SL OD Hydralazine 10mg 1 tab TID

OB 1

OB 1
8AM
8AM-12PM-8PM

Concordia, Carl Julius T. Concordia, Carl Julius T.

Name: Wella Abad Santos Age: 38/F Name: Wella Abad Santos Age: 38/F

Labetalol 100mg 1 tab every 12 Multivitamins 1 tab OD

OB 1
OB 1

hours for 3days

8AM
8AM-8PM

Concordia, Carl Julius T. Concordia, Carl Julius T.

Name: Wella Abad Santos Age: 38/F

Ferrous Sulfate 1 tab OD

OB 1

8AM

Concordia, Carl Julius T.