University of Northern Philippines

Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986
CLINICAL FACE SHEET
______2000168986______
Case Number
Name: Patient X Age: Date of Place of Birth: Magsingal Category of

90 Birth:12/27/31 Patient: IM
Home Address: Panay, Magsingal Sex: Civil Status: Religion: Nationality:

Female Married Catholic Filipino
Next of Kin: Relationship: Address: Contact No.:
Date Admitted: November Time: Date of Discharge: Time: No. of Hospital Days:
24, 2020 7:30 A.M. ________ A.M.
________ P.M.
Ward: Attending Physician: Dr. Almeda Admitting Nurse: Nurse Labini
ADMITTING DIAGNOSIS:
CVD BLEED
FINAL DIAGNOSIS: ICD 10 Code:
Condition on Discharge: Disposition:
[ ] recovered [ ] died [ ] discharged [ ] absconded

[ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD
[ ] unimproved [ ] not autopsied [ ] home against for follow up advice
COMPLICATIONS:
OPERATION/PROCEDURE DONE:
Review for completeness:
___________________________________________ __________________________________________
Signature over Printed Name Signature over Printed Name
of Attending Physician (Record Officer)
VITAL SIGNS MONITORING SHEET

____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12
Date Time Shift BP PR RR Temp REMARKS

11/24/2020 7:30 7:30-5:30 180/120 78 18 36 HIGH BP
11/24/2020 8:00 7:30-5:30 160/120 80 20 36.5 HIGH BP
11/24/2020 9:00 7:30-5:30 140/100 90 21 36.8 HIGH BP
11/24/2020 10:00 7:30-5:30 140/100 100 25 37 HIGH BP, HIGH RR
11/24/2020 11:30 7:30-5:30 140/100 90 20 37.6 HIGH BP, FEBRILE
11/24/2020 12:00 7:30-5:30 140/100 98 19 37.9 HIGH BP, FEBRILE
11/24/2020 1:00 7:30-5:30 140/100 100 25 38 HIGH BP, HIGH RR, FEBRILE
11/24/2020 2:00 7:30-5:30 150/110 98 30 38.6 HIGH BP, HIGH RR, FEBRILE
11/24/2020 4:00 7:30-5:30 150/110 110 40 39 HIGH BP, HIGH PR, HIGH RR,
FEBRILE
FEBRILE
11/25/2020 8:00 7:30-5:30 160/110 113 43 38.7 HIGH BP, HIGH PR, HIGH RR,
FEBRILE
FEBRILE
FEBRILE
FEBRILE
FEBRILE
11/25/2020 1:00 7:30-5:30 140/90 100 39 38 HIGH BP, HIGH RR, FEBRILE
11/25/2020 3:00 7:30-5:30 130/90 95 36 37 HIGH BP, HIGH RR,
11/25/2020 4:00 7:30-5:30 130/90 96 35 37.4 HIGH BP, HIGH RR,
INTAKE & OUTPUT MONITORING SHEET

____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
INTAKE OUTPUT
Date Time Shift IVF Oral/NGT TOTAL Urine Drain TOTAL
11/24/20 5:30 7:30- 637 cc 637 cc 100 cc 100 cc
5:30
11/25/20 5:30 7:30- 1,571 cc 466 cc 2,037 cc 300 cc 10 cc 310 cc
5:30
CONSENT TO CARE
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
I hereby authorize Dr. ______________________________ and the staff of Ilocos Sur Cooperative
Medical Mission Group and Hospital to perform these treatments and procedures deemed necessary for my
care.
I also give authorization for the hospital to supply information from my medical record to my
insurance carrier and/or my attorney.
____________________________ ____________________________
Signature of Witness Signature of Patient
This authorization must be signed by the relative or by the kin of a minor or where the patient is
physically and mentally incompetent.
Patient is minor of _______ years.

Patient is unable to sign because of _____________________________________________.
I, ________________________________, being the next kin of

_______________________________, hereby authorize Dr. ________________________________ and
the said hospital to perform the necessary treatment.
___________________________ ____________________________
Signature of Witness Signature of Relative
___________________________ ____________________________
Date Relationship
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
CLINICAL HISTORY
PATIENT’S DATA
1. Name of Patient: 2. PIN
PATIENT X
Last Name First Name Middle Name 3. Age
5. Chief Complaint 90
LOSS OF CONSCIOUSNESS
4. Sex
Male Female
st
6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1 Case Rate Code
CVD BLEED
8. b. 2nd Case Rate Code
9. a. Date Admitted: 9. b. Time Admitted:

l1l1l ¯ l2l4l ¯ l2l0l2l0l l0l7l ¯ l3l0l AM PM
month day year hour min
10. a. Date Discharged: 10. b. Time Discharged:
l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM
month day year hour min
REASON FOR ADMISSION
1. History of Present Illness:
Few hours PTA patient noted sudden onset of decrease sensorium with loss of consciousness, unarousable hence
brought for admission
2. a. Pertinent Past Medical History:
2. b. OB/GYN History:
G_____ P_____ (_____-_____-_____-_____) LMP:_________________ NA
3. Pertinent Signs and Symptoms on Admission (Check applicable box/es):
 Altered Mental Sensorium  Diarrhea  Hematemesis  Palpitations

 Abdominal cramp/pain  Dizziness  Hematuria  Seizures
 Anorexia  Dysphagia  Hemoptysis  Skin rashes
 Dyspnea  Irritability  Stool, bloody/black tarry/mucoid
 Bleeding gums
 Dysuria  Jaundice  Sweating
 Body weakness
 Epistaxis  Lower extremity edema  Urgency
 Blurring of vision  Fever  Myalgia  Vomiting
 Chest pain/discomfort  Frequent urination  Orthopnea  Weight loss
 Constipation  Headache  Pain, ____________ (site)  Others: _________________________
 Cough
4. Referred from another Health Care Institution (HCI): No Yes, Specify Reason _____________________________________________________
Name of Originating HCI ____________________________________________
5. Physical Examination on Admission (Pertinent Findings per System)
General Survey:  Awake and alert  Altered sensorium,with loss of consciousness
Vital Signs: BP: 180/120 HR: 78 RR: 18 Temp.; 36 Wt.:_______________ (pedia patients)
HEENT:  Essentially normal  Abnormal pupillary reaction  Cervical lymphadenopathy  Dry mucous membrane
 Icteric sclerae  Pale Conjunctiva  Sunken eyeballs  Sunken fontanelle
Others: Mild dilated pupils
PHARMACY CHARGE SLIP
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986

Admission Date: 11/24/2020 Admitting Physician: DR. ALMEDA
□ ER fee
□ Hospital kit
□ CB-Plaster
□ VG 24
□ VG 22
□ VG 20
□ VG 18
□ Macro set
□ Micro set
□ Pillow
□ Pillow case
□ Bed sheet
□ Linen
□ CBG/HGT
□ ECG
□ Neb kit
□ Nasal cannula
□ Face mask
□ E-gloves
□ OR cap
□ 10 cc
□ 5 cc
□ 3 cc
□ TBS
Medications
 Omeprazole 40 mg
 Ampicillin + Sulbactam 1.5 g
 Tramadol 50 mg
 Paracetamol 300 mg
 Manitol 100cc
 Furosemide 10 mg
 KCL drip 40 meqs
 1 L PLRS
 Salbutamol nebulization 1 neb
LABORATORY REPORTS
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
DATE: 11/24/2020
DXTCS:
ECG: Atrial premature complex; minimal ST depression; short PR interval
CHEST X-RAY: Atheromatous aorta
WBC: 12X10 (12,000) elevated
PLATELET: 310 (normal 100-300) has infection
RBC + HEMOGLOBIN: Normal
DATE: 11/25/2020
DXTCS:
Low Serum Na: 133.2 (135-148 mmol/L)
Low Serum Potassium: 2.37 (3.5-5.3 mmol/L)
Rapid Test:
IgM: NEGATIVE
Ig6: NEGATIVE
High Glucose: 172.1 mg/dl (70-115 mg/dl)
High Total Cholesterol: 1660 mg/dl (0-200 mg/dl)
Triglycerides: 104 mg/dl (0-200 mg/dl)
LABORATORY REPORTS
Rationale:
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
Low Serum Sodium: A low sodium level has many causes, including consumption of too many fluids,
kidney failure, heart failure, cirrhosis and uses of diuretics. Symptoms result from brain dysfunction. Patient
was diagnosed with cardiovascular disease; most likely it is the causes of having a low serum sodium level.
Low Serum Potassium: Potassium helps carry electrical signals to cells in your body. It is critical to the
proper functioning of nerve and muscles cells, particularly heart muscle cells. Normally, your blood
potassium level is 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than
2.5 mmol/L) can be life-threatening and requires urgent medical attention.
Rapid Test Negative: A negative test result with this test means that SARS-COV2 specific antibodies were
not present in the specimen above the limit of detection. However, a negative result does not rule out
COVID19 and should not be used as the sole basis for treatment, patient management decisions or to rule
out active infection.
High Glucose Level: Higher glucose levels and having these high glucose symptoms mean that you need to
see your doctor and have a A1C test. High glucose is urine does not necessarily indicate high blood glucose:
you may have low renal threshold for glucose, which means that some sugar gets into your urine even when
the blood sugar is still normal. Low renal threshold is not a diabetes herald.
High Total Cholesterol: Cholesterol travels through the bloodstream attached to carrier molecules made of
fat and protein -- called lipoproteins. LDL stands for low-density lipoprotein, which is one of those carrier
molecules. The other is HDL, or high-density lipoprotein. The total serum cholesterol consists of high-
density lipoprotein, or HDL cholesterol; low-density lipoprotein, or LDL cholesterol; and triglycerides.
Levels are reported in milligrams per deciliter of blood, or mg/dL. The American Heart Association
defines normal total cholesterol as less than 200 mg/dL. Total serum cholesterol above 200 is "borderline
high" and raises your risk of heart disease. Total serum cholesterol above 240 is considered high. A person
with total cholesterol that high has double the risk of developing heart disease compared to someone
whose total cholesterol is below 200.
GRAPHIC RECORD
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
DATE
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
No. of Days in
Hospital
R
PR T
R
42
41
160 40
150 39
140 38
130 37
120 36
110 35
100
90
50 80
40 70
30 60
20 50
10
7-3
URINE 3-11
11-7
7-3
STOO 3-11
L 11-7
BP
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
IV FLUID SHEET
MAIN LINE
Time Time
Date IV Fluids Regulation REMARKS
Started Consumed
11/24/20 PNSS 16 gtts/min 7:30 AM 11:30 PM CONSUMED
11/25/2 PNSS 16 gtts/min 11:30 PM STARTED
0
ANOTHER LINE / SIDE DRIP

Time Time
Date IV Fluids Regulation Started Consumed
REMARKS
11/2420 Nicardipine drip 10 mg + 90 15 mgtts/min 7:30 8:30 HOLD
cc PNSS
Nicardipine drip 10 mg + 90 20 mgtts/min 8:30 10:00 HOLD
cc PNSS
11/25/2 KCL drip 40 meqs in 1L 21 gtts/min 7:30 STARTED
0 PLRS x 12 hours for 2
cycles
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
DOCTOR’S ORDER
Date Progress Notes Doctor’s Order

ER ORDERS: Admit patient; Please secure consent for
11/24/2020 @
7:30 AM admission and management.
Diet: NPO
Dx: CBC; U/A; NA, K, BUN, CREA; AST ALT; FBS;12
lead ECG; Chest PA; Rapid antigen for SARCOV19;
Plain Cranial CT Scan; CBG.
Tx: IVF PNSS 1L x 16hrs; Nicardipine drip 10 mg + 90
cc PNSS start at 15 mgtts/min then uptitrate by 20
mgtts/min/hr until achievable BP of 120/80; inert NGT
and IFC aseptically; Monitor VS q1 and record; monitor
I and O q shift; Refer accordingly.
11/24/2020 @
10:00 AM
TX: Omeprazole 40 mg IV now then OD, hold
Nicardipine, Ampicillin + Sulbactam 1.5 g IV q 8hrs
ANST; Tramadol 50 mg IV q8; Paracetamol 300 mg IV
q4 PRN for temp 38.5˚C and above.
11/25/2020 @ TX: May start OF of 1400 kcal in six divided doses,

7:30 AM
Manitol 100cc IV q6 hours, Furosemide 10 mg IV now
then BID, KCL drip 40 meqs in 1 L PLRS x 12 hrs for 2
cycles as sidedrip, Salbutamol nebulization 1 neb q6
hrs, IVF to follow: PNSS 1LX 16 hours, continue I and
O monitoring, continue VS monitoring, refer
accordingly.
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
THERAPEUTIC SHEET
Name of Drug, Dosage, Date and Time Given:

Route, & Frequency
IVF PNSS 1L x 16 hrs 11/24/2020 @ 11/24/2020 @

7:30 AM 7:30 AM
CONSUMED
Nicardipine drip 10 mg 11/24/2020 @ 11/24/2020 @

+ 90 cc PNSS at 15 7:30 AM 10:00 AM
mggts/min then HOLD
uptitrate by 20
mgtts/min/hr
Nicardipine drip 10 mg 11/24/2020 @ 11/24/2020 @

+ 90 cc PNSS at 20 8:30 AM 10:00 AM
mggts/min HOLD
11/24/2020 @ 11/25/2020 @
Omeprazole 40 mg IV 10:00 AM 10:00 AM
now then OD
11/24/2020 @ 11/24/2020 @ 11/25/2020 @ 11/25/2020 @

Ampicillin + 10:00 AM 6:00 PM 2:00 AM 10:00 AM
Sulbacyan 1.5 g IV q 8
hrs ANST
Tramadol 50 mg IV q8 11/24/2020 @ 11/24/2020 @ 11/25/2020 @ 11/25/2020 @

10:00 AM 6:00 PM 2:00 AM 10:00 AM
Mannitol 100 cc IV q6 11/25/2020 @

hrs 7:30 AM
____________________________________________________________________________________________________________________
ISCMMGH®
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
Furosemide 10 mg IV 11/25/2020 @
NOW then BID 7:30 AM
Salbutamol 11/25/2020 @
nebulization 1 neb q6 7:30 AM
hrs
KCL drip 40 meqs in 11/25/2020 @

1L PLRS x 12hrs for 2 7:30 AM
cycles as sidedrip
____________________________________________________________________________________________________________________
ISCMMGH®

University of Northern Philippines

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UNIVERSITY OF NORTHERN PHILIPPINES

CLINICAL FACE SHEET

Name: Patient X Age: Date of Place of Birth: Magsingal Category of

Home Address: Panay, Magsingal Sex: Civil Status: Religion: Nationality:

Next of Kin: Relationship: Address: Contact No.:

Ward: Attending Physician: Dr. Almeda Admitting Nurse: Nurse Labini

FINAL DIAGNOSIS: ICD 10 Code:

Condition on Discharge: Disposition:

[ ] recovered [ ] died [ ] discharged [ ] absconded

Review for completeness:

VITAL SIGNS MONITORING SHEET

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

Date Time Shift BP PR RR Temp REMARKS

INTAKE & OUTPUT MONITORING SHEET

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

Patient is minor of _______ years.

I, ________________________________, being the next kin of

8. b. 2nd Case Rate Code

9. a. Date Admitted: 9. b. Time Admitted:

2. a. Pertinent Past Medical History:

 Altered Mental Sensorium  Diarrhea  Hematemesis  Palpitations

General Survey:  Awake and alert  Altered sensorium,with loss of consciousness

Others: Mild dilated pupils

PHARMACY CHARGE SLIP

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

CHEST X-RAY: Atheromatous aorta

WBC: 12X10 (12,000) elevated

PLATELET: 310 (normal 100-300) has infection

RBC + HEMOGLOBIN: Normal

Low Serum Potassium: 2.37 (3.5-5.3 mmol/L)

High Glucose: 172.1 mg/dl (70-115 mg/dl)

High Total Cholesterol: 1660 mg/dl (0-200 mg/dl)

Triglycerides: 104 mg/dl (0-200 mg/dl)

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

ANOTHER LINE / SIDE DRIP

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

Date Progress Notes Doctor’s Order

11/25/2020 @ TX: May start OF of 1400 kcal in six divided doses,

Name: PATIENT X Age/Sex/CS: 90/F/MARRIED Ward/Room: Ward 12

Name of Drug, Dosage, Date and Time Given:

IVF PNSS 1L x 16 hrs 11/24/2020 @ 11/24/2020 @

Nicardipine drip 10 mg 11/24/2020 @ 11/24/2020 @

Nicardipine drip 10 mg 11/24/2020 @ 11/24/2020 @

11/24/2020 @ 11/24/2020 @ 11/25/2020 @ 11/25/2020 @

Tramadol 50 mg IV q8 11/24/2020 @ 11/24/2020 @ 11/25/2020 @ 11/25/2020 @

Mannitol 100 cc IV q6 11/25/2020 @

KCL drip 40 meqs in 11/25/2020 @

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