URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Allan Middle Name: Morales Last Name: Bernados
Age: 77 Sex: M Status: Married Religion: Roman Catholic Hospital Unit No.
Address: Lawaan, Talisay
Student No. Occupation: Birth Date: June 12 1943
Birth Place: Cebu City Citizenship: Filipino Spouse:
Name of Mother: Deceased Name of Father: Deceased

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Tricia Bernados Relation: wife
Address: Lawaan Talisay
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) L sided weakness, slurring of speech
Vital Signs: BP: 160/100 HR: 89 RR: 38 Temp: 36.7 O2 Sat: 97% Weight:
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 8/13/20 Physician: Dr. Quijano
Department: IM Time Arrived:
Time Seen: 4:01 PM Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:
 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
8/13/20  Please admit to COVID Unit under the service of Dr. Quijano
4:01 PM  Secure signed consent to care
 Condition: Guarded
 TPR q 4 H
 NPO temporarily except meds
 Venoclysis: PNSS 1L at 20 gtts/min
 Diagnostics:
 COVID Antibody RTK
 VOVID RT-PCR c/o SHH
 CT Scan Brain Plain
 ECG 12 Leads
 CBC now then q 4H while on NPO
 CBC: S. crea, Na⁺, K⁺, SGPT, BUA, BUN, HBAIC
 FBS, Lipid Panel
 Urinalysis
 Protime, APT
 CXR PA
 ABG now
 Therapeutics:
1. Mannitol 200 cc IV bolusq 4H
2. Citicoline 1 gm IVTT q 8H
3. Atorvastatin 80 mg/tab, 1 tab OD per NGT
4. Pantoprazole 40 mg IVTT now then q 24H
5. Nicardipine drip: 10 mg + 90 cc PNSS at 20 cc/hr titrate c̅ BP, to maintain BP ≤ 140/90
≥ 90/60
 O₂ at 2-3 LPM via nasal prong
 MHBR
 Please insert NGT and FBC attach to urobag
 Monitor vital signs hourly to include neuro
 I & O q 4H in absolute figures
 Please attach to cardiac monitor
 Will inform Dr. Quijano
 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

DOCTOR’S ORDER SHEET

DATE DOCTOR’S ORDERS PROGESS
NOTES
 Rounds c̅ Dr. Quijano
 Continue Maintenance Meds
 DKA (Ketobest) ii tabs TID NGT
 Start Levetiracetam 500 mg/tab 1 tab BID NGT
 Please intubate patient and attach to MV
 c̅ the ff settings
 AC mode
 TV 400
 FIO₂ 100 %
 BUR 20
 PEEP 5
 PL 60
 PF 45
 Please refer to Dr. Barbosa for RSI

8/13/20  Give HRI 6 unitsSQ now

8:00 PM  Give 200 mg NaHCO₃with bows now
8/14/20  For 2D ECHO with doppler

7:00 AM  Please include Neurovital signs
7:30 AM  Give Paracetamol 500 mg IVTT PRN for fever
 Refer to Dr. Inting (Nephrologist) and Co- mngt Re: CKD (Hypertensive Nephrosclerosis
Vs U. Acid
 Please Facilitate swab Testing
 Repeat ABG now
6:19 AM  Blenderized Feeding 1500 kcal in 1000cc water in 6 divided feedings

8/14/20  Transfer to VSMMC

 Thank you for this referral
 History and PE reviewed
 Dr. Inting informed of this co-management through phone call with acknowledgement
 Facilitate Transfer
 Will see the patient
8/14/20
 IVF to 60cc/hr
 Give HRI 3 units SQ now

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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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
8/13/20 3-5 80 +30 NPO 110 60 60
5-6 80 +30 0 110 50 50
6-7 80 +30 0 110 50 50
7-8 80 +30 0 110 50 50
8-9 80 +30 0 110 50 50
9-10 80 +30 0 110 50 50
TOTAL: 600 TOTAL: 310
10-11 80 + 30 0 110 50 50
11-12 80 + 30 0 110 30 30
12-1 80 + 30 0 110 60 60
1-2 80 + 30 0 110 90 90
2-3 80 + 30 0 110 40 40
3-4 80 + 30 0 110 38 38
4-5 80 + 30 0 110 38 38
5-6 80 + 30 0 110 20 20
TOTAL: 880 TOTAL: 366
1, 530 676
8/14/20 6-7 80 - 30 110 30 30
7-8 80 50 30 160 40 40
8-9 80 - 30 110 55 55
9-10 80 - 30 110 45 45
10-11 80 - 30 110 50 50
11-12 80 260 30 370 30 30
12-1 80 30 30 140 60 60
1-2 80 - 30 110 30 30
TOTAL: 1,220 TOTAL: 340

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

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
8/14/20 2-3 80 Nicardipine 110 20 20
30
3-4 60 30 90 20 20
4-5 60 NGT 20 260 5 5
180
5-6 60 20 80 20 20

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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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)
DOH-SWUMed-NSD-F-013 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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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
+63 32 4188410 to 14

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