KARDEX

NAME: _Villamin, Alen Rei Legazpi___________________________ AGE:_38__ SEX:_Male___ HOSPITAL NO._0007492313_____

ADDRESS:_Padre Noval St., Sampaloc, Manila_______________________ CLASSIFICATION:Private Member WEIGHT:__59
kg__
ADMITTING PHYSICIAN:_Dr. Asanion___________________ DATE/TIME ADMITTED:12-14-2020 @ 10:15 am BLOOD TYPE:_O+_
ATTENDING PHYSCIAN:______________________________________________________________________________________
COMPLAINT:_dizziness, body weakness, tremors_________________________________________________________________
IMPRESSION DIAGNOSIS:_Diabetes Mellitus
T2___________________________________________________________________
SURGERY DONE:________________________________________________________ DATE/TIME OF SURGERY_______________

MENTAL STATUS: Activities: Diet: Tubes: Special Info:

___Conscious ___Ambulant __NPO _/_Foley Catheter ___Weigh Daily
_/_Drowsy ___Dangle and sit up ___DAT ___thoracic tube _/_BP q shift
___Stupor ___Bedrest with BRP ___Soft ___NGT ___Neuro V/S
___Unconscious _/_CBR w/o BRP ___Clear liquids ___CVP ___Abdominal girth
___Comatose Others:___________ ___ Gen. liquids Others:__________ Others:_repeat CBG
GCS: 12-13/15 (M:5, _________________ Others:_LSLF then NPO ________________ post-30 mins. then
V:4-5, E:3) post- TID pre-meals______
midnight________

Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND

ordered Ordered TIME
DISCONTINUE
D
12-14-2020 Regular Insulin 8 units SQ now 12-02-2020 PNSS 1L x 12H
Clonidine 75 mcg 1 tab SL now

Date Medical Treatment/ Date Done

Ordered Laboratories/Diagnostics
12-14-2020 CBC
UA
Na, K
SGOT, SGPT
FBS, LP
12 Lead ECG 12-14-2020
Chest PA
RAT for SARSCov2 12-14-2020
CBG now (385 mg/dl) 12-14-2020
 INTAKE & OUTPUT MONITORING SHEET

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

Tim INTAKE OUTPUT

Date Shift
e IVF Oral/NGT TOTAL Urine Drain TOTAL
 VITAL SIGNS MONITORING SHEET

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

Tim
Date Shift BP PR RR Temp. REMARKS
e
 CBG MONITORING SHEET

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL

NO.:_______________
GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

Date Time Shift CBG Result

12-14-2020 10:15 am 7-3 385 mg/dl
10:45 am 7-3 147 mg/dl
 GRAPHIC RECORD

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

DATE
No. of Days in
Hospital
R P 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7
T
R R 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5

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

BP URINE STOO BP URINE STOO BP URINE STOO BP URINE STOO

SHIFT L L L L
7-3
 3-11
11-7

IV FLUID SHEET

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

MAIN LINE
Time Time
Date Type of Solution Regulation Started Consumed
REMARKS
12-14- PNSS 1L 27-28 gtts/min 10:25 am started
2020

ANOTHER LINE / SIDE DRIP

Time Time
Date Type of Solution Regulation Started Consumed
REMARKS
 THERAPEUTIC SHEET

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL

NO.:_______________
GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

Name of Drug, Dosage, Route, & Date and Time Given

Frequency 12-02-2020

10:19 am
Regular Insulin 6 units SQ now (Sig.)

10:17 am
Clonidine 75 mcg 1 tab SL now (Sig.)
 PHYSICIAN’S ORDER/PROGRESS NOTES

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

TIME POSTED
Progress
Date Doctor’s Order C A R E D AND
Notes SIGNATURE
12/14/ 1 hour PTA Please admit patient to room of choice /
2020 Please secure consent for admission /
(+) dizziness Please secure consent for therapeutics /
(+) cold clammy /
VS q shift and record
10:15 skin
I&O q shift and record /
am (+) body malaise
(+) tremors Diet: LSLF temporarily, then NPO post-midnight /
Complete bedrest without bathroom privileges /

Dx:
Admitted at  CBC, UA / /
institution
 Na, K / /
 BUN Crea / /
 SGOT, SGPT / /
With hx of T2DM  FBS LP / /
– Poorly /
 12 Lead ECG
Controlled / /
 Chest PA
/ /
BP: 160/100  Rapid Antigen Test for SARSCov2
/
CR: 64  CBG now: 385 mg/dl
RR: 22
T: 36.6 °C Tx:
SpO2: 98% / 10:25 am (Sig.)
IVF PNSS 1L x 12 hours /
Regular insulin 8 units SQ now 10:19 am (Sig.)
/
Clonidine 75 mcg 1 tab SL now 10:17 am (Sig.)
Amlodipine 10 mg 1 tab OD in PM /
Metformin 500 mg 1 tab BID /
Atorvastatin 20 mg 1 tab OD HS /
/
Insert IFC and connect to urine bag aseptically
Repeat CBG after 30 minutes, then TID pre- /
meals
Refer accordingly

(Sig.)
D. Asanion
Lic. No. 01234
 (Sig.)
R. Cortez, RN
Lic. No. 04321

** Carried Administered Request Made Endorsed Discontinued

NURSE’S NOTES

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

Date-Shift FOCUS Data – Action – Response

12/02/2020

Admission D: admitted a 38 y/o male patient, accompanied by relatives with initial VS as

7-3 Assessment follows:
10:35 am
BP: 160/100 mmHg
CR: 64 bpm
RR: 22 cpm
T: 36.6 °C/axilla
SpO2: 98%
weak in appearance; with tremors, cold-clammy skin, dizziness, profuse
sweating, and generalized body weakness noted; with GCS of 12-13/15
(M:5, V:4-5, E:3) -------------------------------------------------------------------------------
(Sig.)

A: assisted on bed and positioned to moderate high back rest; side rails raised;
seen and examined by ER physician (Dr. Asanion) with orders made and
10:25 am carried out accordingly; consent to care and hospitalization secured; IVF of
10:15 am PNSS 1L inserted aseptically at left metacarpal vein with g.20 IV cannula @
and regulated to 27-28 gtts/min; CBG taken as ordered STAT @, result
10:19am/10:17am recorded accordingly; Regular insulin 8 units SQ now and Clonidine 75 mcg 1
tab SL now, given respectively as ordered @; consent for IFC secured from
10:29 am (Sig.) relative and attached to chart; IFC Fr. 18 aseptically inserted and connected
to urine bag @, draining to light-yellow-colored urine output; request for
laboratory and other diagnostic procedures made, forwarded, and available
results attached to chart; other standing orders carried out accordingly;
accompanied for Chest PA, facilitated and awaiting results; LSLF diet then
NPO post-midnight instructed to patient and watcher; ward nurse on duty
informed via telephone call regarding admission --------------------------------------
11:05 am ----------- (Sig.)

R: transferred to MMW via stretcher @, accompanied by ER NOD and

significant others; endorsed accordingly; no untoward events noted -------------
--------- (Sig)

(Sig.)
R. Cortez
Lic. No. 04321