This form may be re

Series # ________

PLEASE FILL OUT APPROPRIATE FIELDS. WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form, together with other supporting documents, should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes in this form are necessary. Claim forms with incomplete information shall not be pro
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMIN
I. HEALTH CARE INSTITUTION (HCI) INFORMATION
1. Name of HCI 2. Accreditation Number
CAGAYAN VALLEY MEDICAL CENTER
3. Address of HCI
CARIG SUR, TUGUEGARAO CITY CAGAYAN
Bldg No. and Name/Lot/Block Street/Subdivision/Village Barangay/City/Municipality Province
II. PATIENT'S DATA
1. Name of Patient
NARAG MARK JUSTINE PONCE
Last Name First Name Middle Name

5. Chief Complaint
VOMITING
6. Admitting Diagnosis 7. Discharge Diagnosis

ACUTE GASTROENTERITIS WITH MODERATE DEHYDRATION, ACUTE GASTROENTERITIS WITH MODERATE DEHYDRATION,
TO CONSIDER NEPHROTIC SYNDROME NEPHROTIC SYNDROME

9. a. Date Admitted: 5/4/2019 9. b. Time Admitted:

10. a. Date Discharged: 5/7/2019 10.b. Time Discharged:

month/day/year
III. REASON FOR ADMISSION
1. History of Present Illness:

7 DAYS PTA, PT NOTED TO HAVE FACIAL SWELLING, SELF MEDICATED WITH FUROSEMIDE 20MG/TAB, DECREASING EDEMA
3 DAYS PTA, EXPERIENCED LOWER ABDOMINAL PAIN ASSOCIATED WITH LOOSE WATERY STOOLS FOR 10X, <1/4 CUP/BOUT WIT
INGESTED FOOD1/2 CUP PER BOUT. DICYCLVERINE TAB WAS GIVEN
2 DAYS PTA, STILL WITH LOOSE WATERY STOOL, NON BLOODY NON MUCOID
1 DAY PTA, 8X EPISODE OF VOMTIING HENCE CONSULT AT CVMC AND ADMISSION

2. a. Pertinent Past Medical History:

(+)NEPHROTIC SYNDROME-2015, CVMC
NO ALLERGIES TO FOOD/DRUG
2. b. OB/GYN History ✘
G P ( ) LMP: N/A

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

Altered mental sensorium Diarrhea Hematemesis

Abdominal cramp/pain Dizziness Hematuria
Anorexia Dysphagia Hemoptysis
Bleeding gums Dyspnea Irritability
Body weakness Dysuria Jaundice
Blurring of vision Epistaxis Lower extremity edema
✘
Chest pain/discomfort Fever Myalgia
Constipation Frequency of urination Orthopnea
Cough Headache Pain, (site)

✘
4. Referred from another health care institution (HCI) NO YES, Specify Reason:

Name of Originating HCI

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

✘
General Survey Awake and alert Altered sensorium
Vital Signs: BP: 110/70 HR: 110 RR 30
HEENT: Essentially normal Abnormal pupillary reaction Cervical lymphadenopathy
✘
Icteric scleraie Pale conjuctivai Sunken eyeballs
5. Physical Examination continued (Pertinent Finding per System)

✘
CHEST/LUNGS: Essentially normal Asymmetrical chest expansion Decreased breath sounds
Lump/s over breast(s) Rales/crackles/rhonchi Intercostal rib/clavicular retr
Others:
✘
CVS: Essentially normal Displaced apex beat Heaves and/or thrills
Irregular rhythm Muffled heart sounds Murmur
Others:
✘
ABDOMEN: Essentially normal Abdominal rigidity Abdomen tenderness
Palpable mass(es) Tympanitic/dull abdomen Uterine contraction
Others:
✘
GU (IE): Essentially normal Blood stained in exam finger Cervical dilatation
Others:
✘
SKIN/EXTREMITIES: Essentially normal Clubbing Cold clammy skin
Edema/swelling Decreased mobility Pale nailbeds
Rashes/petechiae Weak pulses
Others:
✘
NEURO-EXAM: Essentially normal Abnormal gait Abnormal position sense
Abnormal reflex(es) Poor/altered memory Poor muscle tone/strength
Others:

IV. COURSE IN THE WARD (Attach photocopy of laboratory/imaging results) Check box if ther is/are add

Date DOCTOR'S ORDER/ACTION

5/4/2019 ADMITTED
ADMITTED

D5LRS 1L AT 37-38 GTTS/MIN FOR 8HRS THEN AT 28-29 GTTS FOR 16 HRS

MEDS: AMPICILLIN, OMPERAZOLE, PARACETAMOL

5/5/2019 CONTINUE PRESENT MEDS AND MANAGEMENT

5/6/2019 NPO
FOR REPEAT CBC 4AM TOMORROW

CONTINUE MEDS, START PREDNISONE 30MG/TAB BID

5/7/2019 MAINTAIN
MGH CPAP

FF UP AT PEDIA OPD 8AM MAY 9, 2019 FOR REPEAT UA

SURGICAL PROCEDURE/RVS CODE (Attach photocopy of OR technique):

V. DRUGS/MEDICINES Check box if there is/are additional sheet(s).

Generic Name Quantity/Dosage/Route Total Cost Generic Name (cont) Quantity/Dosage/Route (co

PREDNISONE 30MG/TAB BID

AMOXICILLIN 500MG/CAP 1 CAP X 4 DAYS

MULTIVITAMINS 1 CAP OD

VI. OUTCOME OF TREATMENT

✘ IMPROVED HAMA EXPIRED ABSCONDED TRANSFERRED Specify reason:

VII. CERTIFICATION OF HEALTH CARE PROFESSIONAL

Certification of Attending Health Care Professional:
I certify that the above information given in this form, including all attachments, are true and correct

DR. AILEEN LIGSAY

Signature over Printed Name of Attending Health Care Professional
 This form may be reproduced and is NOT FOR SALE
CF4
(Claim Form 4)
Aug-18
Series # ________________________________

m date of discharge.
on shall not be processed.
AL, CIVIL OR ADMINISTRATIVE LIABILITIES.

H02001610

CAGAYAN 3500
Province Zip Code

2. PIN
3. Age 14
4. Sex
✘ Male Female

8. a. 1st Case Rate Code

EHYDRATION, 8. b. 2nd Case Rate Code

6 0
hour min AM ✘ PM

8 0

hour min ✘ AM PM

ECREASING EDEMA
0X, <1/4 CUP/BOUT WITH VOMITING 4X OF PREVIOUSLY
 Palpitations
Seizures
Skin rashes
Stool, bloody/black tarry/mucoid
Sweating
Urgency
✘
Vomiting
Weight Loss
Others

30 T 39.1
✘
mphadenopathy Dry mucous membrane
Sunken fontanelle
eased breath sounds Wheezes
costal rib/clavicular retraction

es and/or thrills Pericardial bulge

men tenderness Hyperactive bowel sound

ne contraction

cal dilatation Presence of abnormal dscharge

clammy skin Cyanosis/mottled skin

Poor skin turgor

rmal position sense Abnormal/decreased sensation

muscle tone/strength Poor coordination

k box if ther is/are additional sheet(s).

ON
nal sheet(s).
ntity/Dosage/Route (cont) Total Cost (cont)

ts, are true and correct.

5/7/2019
mm/day/year
Date Signed