URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+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

OE: awake, afebrile, NRD

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
PATIE
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

NT’S
NAME
:_____
___Je
nnifer
Lee__
_____
_____
____
AGE:_
___23
__ ROOM:
____3
21___
CASE
NUMB
ER:___
_____
_____
DATE DOCTOR’S ORDERS PROGESS NOTES
5/14/20 A case of J.L. 23 y.o from Inayawan, Cebu City: LMP unrecalled, AOG: 38 ¹/₇
12:00 PM Weeks by ultz, EDC: May 26, 2020, admitted for the 1st time in the institution.

CC: hypogastric pain

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 once a month x3 months
mg/cap
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

Sexual Hx: 19 y.o. x 5 sexual partners since then

(-) dyspareunia, (-) post coital bleeding
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

OB Hx: Primipara

PMH: M – (-)
M –(-)
A – (-)
S –(-)
H –(-)

____________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev.2
DATE DOCTOR’S ORDERS PROGRESS NOTES
PSH: College Grad. B.A. works as an HR personnel, Pt started working at
19 y.o. until 21
Occasional alcoholic beverage drinker

Family Hx: DM + HPN - maternal

PE: awake, conscious, coherent
BP: 100/70, HR: 100, RR: 21, T: 36.2, Wt.: 109 lbs.
Skin; warm , good turgor
HEENT: ALS, PPC
C/I: CCE, CBS
CVS: DHS, (-) mur
Abd: FH 28 (2635 grams)
FHT: 130
LOT
IE: 6 cm, 90% Eff, St. -2, I/C
Ext: (-) Edema
IMP: G1P0 PU 38 ¹/₇ weeks AOG, Cephalic in active phase of labor

5/14/20  Please admit patient under service of Dr. Montefalcon

11:38 AM  Secure signed consent
 TPR q 4 hours
 NPO
 Start venoclysis with D5LR 1 Liter @ 30 gtts/min
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

 Labs: CBC, Urinalysis, HbAg
 Monitor FHT and uterine contraction q 15 minutes
 Monitor progress of Labor
 Pedia: Dr. Villar
 Refer Accordingly

5/14/20  No IE until bloody show

11:50  Pain score of 9/10

5/14/20  Incorporate 9 units oxytocin to ongoing IVF

1:00PM  Start at 10 gtts/min, titrate according to uterine contractions

5/14/20  O₂ Inhalation at 10 LPM via face mask

1:015 PM

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev.2
DATE DOCTOR’S ORDERS PROGESS NOTES
5/14/20  S/P NSVD and ME repair
3:15 PM  To RR temporarily
 V/S every 4 hours, I &O q shift
 DAT
 IVF: Incorporate 11 units oxytocin to ongoing IVF
100 cc as med, then regulate at 15 gtts/min
 Terminate IVF once consumed
 Meds:
A. Cefalexin (Canelin)500 mg1 cap TID P.O. x 7 days
B. Celecoxib (Coxto) 200 mg 1 cap BID P.O.
C. Moringa (Feralac) 1 cap OD P.O.
D. Senna (Senokot Forte) 1 cap OD HS
E. MV + Iron (Foralivit) 1 cap OD P.O.
 V/S q 15 mins x 2 hours q 30 minutes x 2 hours
q hourly until stable
 Refer if BP ≥ 140/90, HR > 100, RR > 30, T ≥ 38 ᵒC,
Profuse vaginal bleeding & other unusualities
 Due to void 4-6 hours postpartum
 Encourage exclusive breastfeeeding
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

 Daily perineal care BID
 Refer accordingly

5/14/20 May transport Pt. to Room

5:00 PM
5/15/20  May Go Home
11:33 AM  Meds to Continue:
A. Cefalexin (Canelin)500 mg1 cap TID P.O. x 6 days
B. Celecoxib (Coxto) 200 mg 1 cap BID P.O.
C. Senna (Senokot Forte) 1 cap OD HS
D. Moringa (Feralac) 1 cap BID P.O.
E. MV + Iron (Foralivit) 1 cap OD P.O.
 Folloew up after 1 week

_________________________ _____________________________
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
5/14/20 10:00 100/70 104 21 36.2 98%
12:00 120/90 85 19 36.4 98%
1:00 110/80 86 20 36.5 98%
3:15 112/70 79 20 37.2 98%
3:30 125/79 80 19 37.1 99%
3:45 124/77 79 20 36.9 98%
4:00 130/77 74 20 36.9 99%
4:15 126/74 78 21 37.5 98%
4:30 128/69 76 20 37.3 97%
4:45 129/78 78 20 37.0 98%
5:00 125/69 79 20 37.1 98%
5:15 128/70 78 20 37.0 99%
5/14/20 6:00 120/70 75 20 37.3 98%
8:00 120/70 100 20 38.0 99%
5/15/20 12:00 120/70 85 20 37.1 98%
4:00 120/70 91 20 36.2 97%
5/15/20 8:00 100/70 100 20 37.0 97%
12:00 100/70 100 20 36.8 98%
5/15/20 4:00 110/70 75 20 36.6 98%
8:00 110/80 82 20 36.4 98%
5/16/20 12:00 110/70 65 20 36.5 98%
4:00 120/70 77 20 36.7 98%
5/16/20 8:00 120/70 113 20 36.0 98%

DOH-SWUMed-NSD-F-073 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

TEMPERATURE PULSE AND RESPIRATION RATE CHART

Patient Name: __________________________________________ Attending Physician: ________________________________________
Age: _______ Sex: _______ Room No. /Bed No. ___________ Hospital Unit No. ____________________________________________
Day of
Hospitalization
Post-Operative Day
No.
Date
RR PR Temp 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12

150 41
140 40
130 39
120 38

37
110

36
100
35

90

80

70 70

60 60

50 50

40 40

30 30

20

10

BLOOD PRESSEURE
6-2
2-10
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

STOOL 10-6
TOTAL
6-2
URINE 2-10
10-6
TOTAL

DOH-SWUMeD-NSD-F-007 Rev. 2
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
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOH-SWUMed-NSD-F-004 Rev. 2
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
5/14/20 11-12:30 100 - 100 - -
12:30-2 50 - 50 100 100
5/14/20 2-5 250 - 250 100 100
5-6 60 150 210 100 100
6-10 240 200 440 250 250
5/14/20 10-6 150 1,000 1,150 600 600
c̅ Total: 2200 Total: 1,150
HL

5/15/20 6-2 c̅ HL 1,000 1,000 900 900

2-10 c̅ 600 600 500 500
HL

10-6 c̅ 800 800 600 600

HL

Total: 2,400 Total: 1,500

5/16/20 6-2 c̅ 300 300 250 200
HL
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

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

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
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

Signature Specimens:
(Provide signature beside full name in print)
DOH-SWUMed-NSD-F-013 Rev.2

P.O.G.S. OBSTETRICS SHEET (1)

Order
(I.B.T. SVD) (wks)
LSCS OR LCS
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOH-SWUMed-NSD-F-058 Rev.1

P.O.G.S. OBSTETRICS SHEET (2)

NAME: _________________________________ AGE: ______ CH. ____S_____M_____W_____Sep._____ CASE NO. _________________

Antenatal Problems: HbSag __________ Fetal wastage __________
Previous Cs / Surgery __________ IUGR __________
Infections IG __________ Infertility __________
Nutritional (2 dose/week) __________ Others __________

Age Status:
Physical Examination: Date __5/14/20________ Time __11:40 AM___ Examination __________________________
Temp. __36.2__ RR __21_____ HR __104__ BP ___100/70____ Wt. __________ HT. __________

General Status Level of Sensorium: ____✔_____ Conscious __________ Anxious

_____✔____ Coherent ____✔____ CooperativeECE
__________ Unconscious __________ Others
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

HEENT: Chest _______ECE________________________________________ Heart ______Distant Heart Sounds, (-) mur_____________________

Breast ____No masses__________________________________ Lungs _______CBS______________________________________
Abdomen: LSK ___________________________ EFU ____26.35 grams________ PHB ____130________________________
Fundal Ht. ______28_____________________ Position ___LOT_______________ Floating/Engaged ________________
Presentation _______Cephalic____________________________________________________________________________________

Pelvic Exam:
Ext. Genitalia: ___________non gaping, no lesions____________________________________________________________

Vagina: ____(-) Lesions__________________________________________________________________________________________

Cervix: Length: _____________________(cm) Dilation ______6 Cm__________ Effacement ______90% __________

Position: _____________________ Anterior _____________ Midline _____________ Posterior _____________

Presentation: Position ________LOT_____________ Membrane ✔ Intact Ruptured

Station _________________________ Amniotic Fluid Clear
Sutures ________________________ Meconium Stained

Clinical Pelvimetry:

Contracted Inlet Borderline _________________________

Midline Trial Labor Outlet

Remarks: ________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
DOH-SWUMed-NSD-F-059 Rev.1

LABORATORY RESULTS
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14