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Case 2
Case 2
+63 32 4188410 to 14
EMERGENCY ROOM RECORD
PATIENT DATA:
First name: Jennifer Middle Name: Tan Last Name: Lee
Age: 23 Sex: F Status: Married Religion: Roman Catholic Hospital Unit No.
Address: Inayawan, Cebu City
Student No. Occupation: HR personnel Birth Date: October 21, 1997
Birth Place: Cebu City Citizenship: Filipino Spouse: Jet Lee
Name of Mother: Jenny Tan Name of Father: Lucio Tan
PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Jet Lee Relation: Husband
Address: Inayawan, Cebu City
Contact Details:
PATIENT’S PROBLEM:
Complaints(s) Labor pain
Vital Signs: BP: 110/70 HR: 104 RR: 21 Temp: 36.2 O2 Sat: 98% Weight: 109lbs
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 5/14/2020 Physician: Dr. Montefaclcon
Department: OB Time Arrived: 10:00 AM
Time Seen: 10:00 AM Time out: 12:30 PM
Brief Clinical History, Physical Examination, laboratories, Impression, Management:
G1P0
LMP: 8/1st week/2019
EDC: May 26, 2020
AOG: 38 ¹/₇
S: 10 hours PTL, noted onset of crampy hypogastric pain radiating to Lumbosacral area, associated with mucoid bloody
discharge noted and persistence of symptoms thus decided to seek consult
Abd: FH: 28
FHT: 135
EFW: 2680 grams
IE: 6 cm, 90% eff., St-2, IBOW, Cephalic
A: G1P0, PU, 38 ¹/₇ weeks AOG
Cephalic in Active Labor
Admit
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
HPI: 10 hours PTA, Pt. experienced strong hypogastric pain radiating to the
LSA associated with bloody mucoid discharges, persistence of the
Condition prompted Pt. to seek consult and was eventually admitted.
Antenatal Hx:
1st Prenatal at APS clinic: 15 weeks AOG
Total Prenatal visits: 6 visits
Vital Signs: BP: 100/70
Took FA, MV + Iron and calcium OD
Illnesses: vulvovaginal candidiasis – 15 ¹/₇
c̅ Fluconazole 150 mg/cap once a month x3 months
Bacterial vaginosis at 17 weeks AOG
c̅ Neo-penotran Vag-supp HS x 1 week
Total weight gain: 2.3 lbs.
Menstrual Hx: 13 y.o. irregular x 4-7 days, 3-4 pads/day, (-) dysmenorrhea
OB Hx: Primipara
PMH: M – (-)
M –(-)
A – (-)
S –(-)
H –(-)
____________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE
DOH-SWUMed-NSD-F-005 Rev.2
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE
DOH-SWUMed-NSD-F-005 Rev.2
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
_________________________ _____________________________
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.
______________________
DOH-SWUMed-NSD-F-073 Rev.2
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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150 41
140 40
130
39
120
38
110
37
100 36
90 35
80
70 70
60 60
50 50
40 40
30 30
20
10
BLOOD PRESSEURE
6-2
2-10
STOOL 10-6
TOTAL
6-2
URINE 2-10
10-6
TOTAL
DOH-SWUMeD-NSD-F-007 Rev. 2
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
NURSES NOTES
Name: _________________________________ Age: _______________________________________ Attending Physician: ________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ______________________
Date Shift Focus Time D = Date / A = Action / R = Response
DOH-SWUMed-NSD-F-004 Rev. 2
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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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
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Signature Specimens:
(Provide signature beside full name in print)
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
DOH-SWUMed-NSD-F-013 Rev.2
Order
(I.B.T. SVD) (wks)
LSCS OR LCS
DOH-SWUMed-NSD-F-058 Rev.1
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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Age Status:
Pelvic Exam:
Ext. Genitalia: ___________non gaping, no lesions____________________________________________________________
Clinical Pelvimetry:
Remarks: ________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
DOH-SWUMed-NSD-F-059 Rev.1
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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LABORATORY RESULTS