URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Celeste Middle Name: Empuerto Last Name: Maraguinot
Age: 21 Sex: F Status: Married Religion: Roman Catholic Hospital Unit No.
Address: Canduman, Mandaue City
Student No. Occupation: teacher Birth Date: May 16, 1999
Birth Place: Cebu City Citizenship: Filipino Spouse: Frederick Maraguinot
Name of Mother: Victoria Empuerto Name of Father: Feliciano Empuerto

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Frederick Maraguinot Relation: Husband
Address: Canduman, Mandaue City
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Headache 2 days
Vital Signs: BP: 150/90 HR: 94 RR: 24 Temp: 37.1 O2 Sat: 98% Weight: 66.5 kg
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 2/18/20 Physician: Dr. Seboa
Department: OB-Gyne Time Arrived: 7:15 PM
Time Seen: 7:20 PM Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:

LMP: 6/5/19 I: 28-30 days, regular

EDC: 3/8/20 D: 4-5 days
AOG: 36 ³/₇ A: moderate
M: 15 years S: none

S: 2 days PTA patient felt mild headache, dizzy and light headed, she did not check her blood pressure. No medication taken,
condition tolerated, duration only in minutes.
1-day PTA patient was at work (elementary teacher) when she suddenly felt light headed, dizzy, with headache, now more
intense, she took her blood pressure and it was 140/90. Patient went home and had rest.

3H PTA sought consult with a private doctor, BP:150/90 and was advised for admission.

O: awake, alert, pink palpebral conjunctiva, clear breath sounds, equal chest expansion, dynamic precordium, no murmur,
gravida linea nigra, no contractions, FH: 33 cm, FHT 128 BPM

A: G₁P₀ PU 36 ⁶/₇ weeks AOG, LMP, Mild Preeclampsia

 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

2/18/20  Please admit under service
9:40 PM  Secure consent to care
 TPR q 4 hours
 I & O q shift
 Diet: DAT
 IVF: D₅ LR 1L at 20 gtts/min
 Labs:
 CBC, U/A, BUA, Admitting CTG, LDH, HBsAg, S. Creatinine, SGPT,
 Monitor UC & FHT q 15 mins
 Monitor progress of labor
 Dr. Seboa informed of this admission
 Refer accordingly
 Seizure precaution

2/19/20  Dinoprostone 0.5 intracervical gel intra-cervically now

12:00 AM  Attach to CTG now then intermittently
 Monitor for tachysystole, uterine hypertonus, FHR changes or
other unusualities
 Refer accordingly

2/19/20  IVFTF: D₅ LR 1L at 20 gtts/min

12 PM

2/19/20  Incorporate 8 units oxytocin to ongoing IVF, starting at 8 gtts/min,

3 PM titrate according to uterine contractions

2/19/20  Hold Oxytocin drip and shift to D₅ LR 1L at 30 gtts/min

10:45 PM

2/20/20  IVFTF: D₅ LR 1L at 30 gtts/min

6:00 AM

___________________________ _____________________________
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
2/20/20  Hold D₅ LR
8:43 AM  Resume oxytocin drip at 10 gtts/min titrate according to uterine contraction

2/20/20  O₂ inhalation at 10 LPM via facemask

10:30 AM

2/20/20  Hold oxytocin drip

 Run D₅ LR 200 cc as MFD then regulate at 30 gtts/min
 Give Ampicillin (Ampitrex) 2 grams IVTT ANST q 6 ᵒ 1st dose at 8 PM

2/20/20 POST PARTUM ORDERS

 S/P NSVD
 To RR temporarily
 TPR q 4 hours
 Infuse 20 units units to present IVF run 200 MFD then regulate at 30 gtts/min
 IVFTF: D₅ LR remaining 500 cc + 10 units oxytocin at 30 gtts/min
 Terminate once consumed if there is no unusualities
 Meds:
1. Cefuroxime (Altoxime) 500 mg BID
2. Mefenamic Acid (Almefen) 500 mg q 6 hours
3. Ferrous Sulfate (Beniforte) 1 cap OD
4. Calcium (Osteo-D) 1 tab BID
 Monitor V/S q 15 min for 2 hours, q 30 min for 2 hours then q hourly until stable
 Refer BP if > 140/100; < 90/60; HR > 100 BPM; RR > 20 ; T > 38 ᵒC; profuse vaginal
bleeding , headache or any unusualities
 Apply ice pack on hypogastric area and perineum
 Encourage Breastfeeding
 Self-perineal care BID; use gynepro feminine wash
 Catheterize aseptically if unable to void after 6 hours
 Refer Accordingly
 Thank you
 Methylergometrine Maleate 200 mcg 1 amp IM now

_________________________ _____________________________
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 PROGRESS
NOTES
2/20/20  Please give hydrazaline 5 mg slow IVTT now
8:28 PM  MgSO ₄ 4 grams diluted in 100 ml of PNSS at 15-20 minutes

2/20/20  Please give 1 gram MgSO₄ 1 gram diluted in 100 PNSS to run in 1 hour for 4 hours
9:03 PM  Monitor RR, DTR, urine output every 4 hours then inform ROD
 Insert FBC FR. 16 attached to urobag
 I & O q hourly
 Refer accordingly

2/20/20  May transport patient to the ward

9:20 PM

2/20/20  Defer Mefenamic Acid

9:30 PM  Give tramadol + Paracetamol 1 capsule q 8 hours

2/21/20  D/C Magnesium Sulfate Drip by 7:00 PM tonight

7:00 AM  Remove FBC once magnesium sulfate drip is completed or discontinued by 7:00 PM
 Due to void 4-6 hours
 For P.E. tomorrow if there is no unusualities
 Give Nifedipine 30 mg 1 tab OD

2/22/20  For P.E. today

6:00 AM  Full body bath prior to P.E.
 Refer accordingly

2/22/20  MGH
10:20 AM  Seen and examined
 Take home medication
1. Cefuroxime (Altoxime) 500/tab 1 tab BID P.O. x 6 days more
2. Mefenamic Acid 500 mg/tab 1 tab q 6 hrs x 6 days more
3. MV +Iron (Beniforte)/cap take 1 cap BID P.O. x 3 months
4. Ca + Vit. D (Osteo-D) 1 tab BID P.O. x 3 months
5. Nifedipine (Adalat Gits) 30 mg/tab 1 tab OD P.O. x 1 week
 Follow up at SWU-RH on 2/28/2020
 Terminate Heplock
 Refer Accordingly
 BP Monitoring BID c/o Local Health Center

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+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
2/18/20 9:40 130/90 73 20 36.3 99%
2/19/20 12 120/90 75 20 36.5 99%
4 110/70 70 19 36.6 99%
2/19/20 8 120/90 70 19 36.3 99%
12 120/90 76 19 36.4 99%
4 120/80 72 22 36.7 99%
8 120/80 77 19 36.8 99%
2/20/21 12 120/90 80 20 36.8 98%
4 130/90 76 24 36.3 98%
8 120/90 81 18 36.0 98%
12 130/90 79 19 36.8 98%
4 130/80 69 20 36.7 99%
8 160/80 86 20 37.6 99%
2/21/20 12 130/90 90 20 37.4 97%
1 120/90 86 20 37.2 97%
2 130/80 81 19 37.0 98%
3 130/90 79 20 36.8 98%
4 120/80 84 20 35.9 97%
5 120/80 81 20 36.1 98%
6 120/80 86 20 36.5 98%
8 120/80 98 21 36.3 99%
12 120/80 81 20 35.8 99%
4 120/80 82 19 36.7 97%
8 130/90 80 20 36.5 98%

DOH-SWUMed-NSD-F-073 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+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 12 120/90 76 20 36.6 97%
4 120/80 74 20 36.5 97%
8 120/80 72 19 36.5 98%
12 120/80 74 20 36.3 99%

DOH-SWUMed-NSD-F-073 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
2/18/20 10:30-6 500 300 800 340 340
Total: 800 Total: 340

2/19/20 6-2 700 300 1, 000 300 300

2-10 200 200 400 600 600
10-6 1, 030 0 1, 030 500 500
Total: 2, 430 Total: 1, 400

2/20/20 6-2 550 500 1, 050 670 670

2/20/20 2-10 500 0 MgSO₄ drip104 604 1, 300 EBL- 200 1, 500
2/20/20 10-11 50 0 MgSO₄ drip104 154 700 700
Total: 1, 808 Total: 2, 870

11-12 100 100 200 150 150

2/21/20 12-1 100 100 MgSO₄ drip104 200 100 100
1-2 100 100 MgSO₄ drip104 200 100 100
2-3 100 --- 100 50 50
3-4 100 --- 100 70 70
4-5 -- 30 30 50 50
5-6 -- 50 50 50 50
Total: 880 Total: 570

2/21/20 6-7 102 60 162 30 30

7-8 102 --- 102 30 30
8-9 102 120 222 30 30
9-10 102 60 162 30 30
10-11 102 --- 102 50 50

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
11-12 102 200 302 50 50
12-1 102 80 182 50 50
1-2 102 120 222 50 50
Total: 1, 456

2/21/20 2-3 102 110 212 100 100

3-4 102 100 202 80 80
4-5 102 80 182 25 25
5-6 102 100 202 28 28
6-7 102 210 312 75 75
7-8 102 210 312 150 150
8-9 102 110 212 200 200
9-10 102 --- 102 180 180
Total: 1, 736 Total: 838

2/22/20 10-6 c̅ HL 840 840 700 700

6-2 c̅ HL 700 700 300 300

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

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
+63 32 4188410 to 14
LABORATORY RESULTS