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 EBW: 31 E: 02/24/20

FH:142 M: 13 y.o.
AOG 38 ¹/₇ 29-30-day cycle 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: Date: Date: Date: Date:
Dosage, Route,
Time NOD NOD Time NOD NOD Time NOD NOD Time NOD NOD
Frequency 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