Case 7

URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
EMERGENCY ROOM RECORD
PATIENT DATA:
First name: Rachel Middle Name: Chiong Last Name: Mendez
Age: 28 Sex: F Status: Single Religion: Roman Catholic Hospital Unit No.
Address: 51 Mendez Compound Labangon Street Cebu City
Student No. Occupation: Birth Date: February 23, 1992
Birth Place: Cebu City Citizenship: Filipino Spouse:
Name of Mother: Name of Father:
PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Rosie Mendez Relation: Mother
Address: 51 Mendez Compound Labangon Cebu City
Contact Details:
PATIENT’S PROBLEM:
Complaints(s) Watery Vaginal Discharge
Vital Signs: BP: 120/80 HR: 83 RR: 20 Temp: 36.4 O2 Sat: 98% Weight: 109 lbs
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 2/22/20 Physician: Dr. Jumao-as
Department: OB-Gyne Time Arrived: 12:15 PM
Time Seen: Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:
DDR – Direct to Delivery Room

+63 32 4188410 to 14
DOCTOR’S ORDER SHEET

PATIENT’S NAME :___________________________________ AGE:_________ ROOM:_________CASE NUMBER:______________
DATE DOCTOR’S ORDERS PROGESS NOTES

2/22/20 POST PARTUM ORDERS
12:15 PM  Direct to deliver Room
 Secure Consent
 To RR temporarily
 TPR q 4 hours, I & O q shift
 Full Diabetic Diet
 IVF: D₅LR 1 L + 20 units oxytocin , run 200 cc as MFD
then regulate at 30 gtts/min
 Terminate IVF if there is no profuse vaginal bleeding
 Labs:
 CBC
 U/A
 HBA1C
 Meds:
1. Cefuroxime (Altoxime) 500 mg 1 tab BID P.O.
2. Tramadol + Paracetamol ( Altotram) 1 tab q 8 hours
or as needed for pain
3. Multivitamins + Iron ( OB CARE) 1 cap OD x 3 months
4. Calcium (Osteo- D) 1 tab OD x 3 months
5. Methylergometrine Maleate 200 mg 1 amp IM now
6. Methylergometrine Maleate 125 mcg 1 tab q 4 hours x 6 doses
 V/S q 15 x 2 hours, q30 mins x 2 hours, q hourly until stable
 Refer if BP ≥ 140/90, HR > 100, RR > 30, T ≥ 38ᵒ C, profuse vaginal
Bleeding and other unusualities
 Refer to IM ( Dr. Chua) for Co-management RE: Diffuse Toxic Goiter
 Perineal Care BID
 Encourage exclusive breastfeeding
 Refer Accordingly
 Due to void after 4 hours
___________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE
DOH-SWUMed-NSD-F-005 Rev.2
+63 32 4188410 to 14
DOCTOR’S ORDER SHEET

DATE DOCTOR’S ORDERS PROGESS NOTES
2/22/20  May transfer to ward
1:00 PM  Refer accordingly
2/22/20  Thank you for this referral

2:50 PM  Dr. Chua was informed of this referral through phone call
 Will see patient
2/22/20  Rounds with Dr. Chua

6:00 PM  Case and plans discussed
 Resume Methimazole 5 mg 2 tabs P.O. now, then 1 tab P.O. BID
2/23/20  Continue Meds

6:20 AM  For P.E. tomorrow if no unusualities
2/23/20  Rounds with Dr. Chua

10:15 AM  Case and Plans discussed
 Please set FT 4, TSH on next blood extraction
 Follow up with Dr. Chua, 1-2 months
2/23/20  Continue methimazole 5 mg 1 tab BID
2/24/20  P.E. done

6:30 AM  MGH
 Meds:
1. Cefuroxime (Altoxime) 500 mg 1 tab BID x 6 days
2. Multivitamins + Iron (OB CARE) 1 cap OD x 3 months
3. Calcium (Osteo-D) 1 tab OD x 3 months
4. Tramadol + Paracetamol ( Alto-Tram) 1 tab, TID PRN for pain
 Please inform I.M. regarding this plan
 Follow up at RHU on March 3, 2020
_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE
+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
2/22/20 12:00 AT OR
4:00 110/80 82 20 36.8 99%
8:00 110/80 80 20 36.5 99%
12:00 120/70 90 20 36.5 99%
4:00 120/70 88 20 36.6 99%
2/23/20 8:00 120/80 89 18 36.5 99%
12:00 110/70 85 20 36.3 99%
4:00 110/70 88 18 36.0 98%
8:00 100/70 85 20 36.1 98%
12:00 110/70 87 20 36.4 99%
4:00 120/80 83 19 36.3 98%
8:00 120/80 85 19 36.4 98%
12:00 110/80 81 18 36.4 99%
+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
2/22/20 11-2 400 --- 400 100 EBL 200 300
2-6 260 200 460 ---- ---
6-10 300 210 510 210 210
10-6 c̅ HL 410 410 200 200
Total: 1, 780 Total: 710
2/23/20 6-2 c̅ HL 800 800 700 700

2-6 c̅ HL 600 600 500 500
6-10 c̅ HL 400 400 200 200
10-6 c̅ HL 500 500 350 350
Total: 2, 300 Total: 1,750
2/24/20 6-2 c̅ HL 450 450 680 680
6-2 = 6-2 =
2-10 = 2-10 =
10-6_ __=______________ 10-6 =_________________
24H Total = 24H Total =
Fluid Balance = _____________________________
+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)
+63 32 4188410 to 14
LABORATORY RESULTS

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URGELLO STREET, CEBU CITY, PHILIPPINES 6000

DDR – Direct to Delivery Room

DOCTOR’S ORDER SHEET

DATE DOCTOR’S ORDERS PROGESS NOTES

DOCTOR’S ORDER SHEET

2/22/20  Thank you for this referral

2/22/20  Rounds with Dr. Chua

2/23/20  Continue Meds

2/23/20  Rounds with Dr. Chua

2/23/20  Continue methimazole 5 mg 1 tab BID

2/24/20  P.E. done

Date Time BP PR RR Temp. Mental Status Remarks Signature

FLUID INTAKE & OUTPUT MONITORING RECORD

DATE TIME INTAKE TOTAL OUTPUT TOTAL

2/23/20 6-2 c̅ HL 800 800 700 700

2/24/20 6-2 c̅ HL 450 450 680 680

MEDICATION ADMINISTRATION RECORD (MAR)

MEDICATION: Dosage, Date: Date: Date: Date:

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