URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14

EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Kaille Middle Name: Abad Last Name: Santos Age: 28 Sex: F Status: Married Religion: Roman Catholic
Hospital Unit No. Address: 96 F Llamas St. Cebu City
Student No. Occupation: Teacher Birth Date: May 16, 1992 Birth Place: Citizenship: Filipino Spouse:
Name of Mother: Name of Father:

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Mark Santos Relation: Husband Address: 96 F. Llamas St. Cebu City
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Watery Vaginal Discharge
Vital Signs: BP: 90/60 HR: 96 RR: 19 Temp: 36.5 O2 Sat: 98% Weight: 63 kg If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 4/13/20 Physician: Dr. Coja
Department: OB-Gyne Time Arrived: 1:29 PM
Time Seen: Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:

G₂P₁ (1101)
37 ²/₇ weeks AOG

S: 5 hours PTA, Patient noted sudden onset of watery vaginal discharges, clear associated with intermittent hypogastric pain, every
5-10 minutes thus consult.

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

4/03/20 ∙ Please admit under service

∙ Secure consent to care

∙ TPR q 4 Hours

∙ Diet as Tolerated
 ∙ IVF: D₅LR 1 L @ 30 gtts/min

∙ Labs:

⮚ CBC, Urinalysis, Serum Potassium, Creatinine, admitting CTG

∙ Medications:

1. Ampicillin(Apitrex) 2 grams IVTT q 6 hours ANST

∙ Refer to IM service for co-managment doctor

∙ Monitor FHT and uterine contraction q 15 minutes

∙ Monitor Vital Signs q 4 hours

∙ I and O q 4 hours

∙ Refer accordingly

4/03/20 ∙ Refer to IM for co-managment RE: Hypokalemia (IM-Nephro)

4:30 PM ∙ Refer Accordingly

4/3/20 ∙ Thank you for this referral for co-managment

6:10 PM ∙ History and PE reviewed

∙ Start KCL drip: D₅W 200 cc + 40 meq KCL 28 KCL drip for 12 hours

In cycle until delivery

∙ Start KCL tab, 1 tab PO 3x /day

∙ Start Vitamin B complex tab, 1 tab PO OD

∙ Include 1 banana/meal

∙ Decrease IVF rate to 20 gtts/min

∙ Repeat Urinalysis and Serum Potassium in AM and every

morning thereafter

∙ Give Anmum 3 servings/day

∙ For ECG 12 L

∙ Thank you

4/3/20 ∙ Insert Dinoprostone 0.5 mg intracervical gel now

9:15 PM ∙ For reassessment after 6 hours

∙ Attach for CTG now then intermittently

____________________________ _____________________________ 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

4/3/20 ∙ Monitor for tachysystole, uterine hypertonus, FHR changes and other

9:15 PM unsualities

∙ Refer Accordingly

4/4/20 ∙ IVFTF: D₅LR 1 L at 30 gtts/min

4:00 AM

4/4/20 ∙ IM MD

7:40 AM ∙ Continue KCL drip until further orders

∙ Please facilitate repeat Serum potassium now

∙ Please relay result to IMROD once in

∙ Thank you

∙ Dr. Coja updated

4/4/20 ∙ S/P NSVD

7:00 AM ∙ To RR temporary

∙ TPR q hourly

∙ DAT

∙ Infuse 20 ‘u’ oxytocin to present IVF, 200 cc MFD then regulated @ 30gtts/min

∙ IVFTF: c̅ D₅ LR 1 L + 20 ‘u’ oxytocin at 30 gtts/min, TC if no unusualities

∙ Meds:

1. Cefuroxime (Altoxime) 500 mg cap BID

2. MFA (Almefen) 500 mg cap q 6ᵒ

3. FeSO₄ + MV (OB-Care) cap OD

 4. Calcium + Vit. D (Osteo-D) tab BID

5. Mefen Ergometrine Maleate 1 IM now then

Ergonovine tab q 4 hours x6 doses

∙ Monitor VS q 15 x 2 hours, q 30 mins x 2 hours, q hourly until stable

∙ Refer if BP >140/100, <90/60, PR > 100, RR > 20, T≥ 38 ᵒC,

profuse vaginal bleeding, and any unusualities

∙ Catheterize especially if unable to void, p 4-6 hours

∙ Self purical ones BID

∙ Refer accordingly

_________________________ _____________________________ 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

4/4/20 ∙ May transfer to ward

8:36 AM ∙ Refer accordingly

4/4/20 ∙ KCL IV drip to consume then terminate

3:45 PM ∙ Reduce mainline IVF to follow to D₅NM 1 L + 40 mg

KCL incorporate x 12 gtts/min in cycle

∙ Continue oral KCL and Cefuroxime PO

∙ Repeat S. potassium and Urinalysis on Monday 4/6/20 AM

∙ Ordered KUB Ultrasound on Monday if available

4/5/20 ∙ IVF rate to KVO

 4/5/20 ∙ Continue Meds

7:30 AM ∙ Continue VS monitoring

∙ For PE tomorrow if c̅ no unusualities

4/5/20 ∙ Pelvic Exam done

12 NN ∙ May Go Home

∙ Please inform IM service

∙ Home Medications:

1. Cefuroxime (Altoxime) 500 mg /cap/ 1 cap BID x 5 days

2. Mefenamic Acid (Almefen) 500 mg/cap 1 cap q 6 hours, PRN for pain

3. Ferrous SO₄ + MV (OB-CARE) 1 cap OD x 2 months

4. Calcium + Vitamin D (OSTEO-D) 1 tab BID x 2 months

5. Vitamin C (Altocee) 1 cap OD x 2 months

∙ Follow up at RHU after one week

∙ Refer accordingly

4/5/20 ∙ Dr. Coja updated

12 NN ∙ Ok to discharge

∙ Home Meds:

1. Cefuroxime 500 mg/tab 1 tab BID to complete 14 days

2. Vitamin B Complex 1 tab OD for 2 months

3. Potasium citrate (Tascit) 12 meq/tab 1 tab OD with lunch for 2 weeks

∙ Follow up Dr. Coja at the clinic after 2 weeks

∙ Repeat Serum / CT and UA after 2 weeks

∙ For KUB Ultrasound OPD brings results upon follow up

_________________________ _____________________________ 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

4/3/20 1 120/80 86 20 35.3 98%

4 110/70 70 19 36.8 98%

8 110/70 82 20 36.7 98%

4/4/20 12 110/60 80 20 36.6 98%

4 120/80 72 20 36.3 98%

4/4/20 8 116/78 63 20 36.8 98%

12 130/80 79 21 36.1 98%

4 120/90 70 21 36.4 98%

8 110/70 74 20 36.4 98%

4/5/20 12 100/70 70 20 36.8 98%

4 100/70 75 20 36.5 98%

8 110/70 80 21 35.4 99%

12 110/80 72 21 35.6 98%

4/5/20 4 90/70 75 20 36.8 98%

8 110/70 78 21 35.6 99%

4//6/20 12 90/60 78 20 36.0 99%

4 110/70 75 20 36.4 98%

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

4/3/20 12:43-2 50 100 150 50 50

2-10 600 300 900 300 300

10-6 500 --- 500 400 400

Total: 1,550 Total: 750

4/4/20 6-9 300 ----- 300 0 0

9-2 480 1,200 120 KCL drip 1,800 300 300

2-10 960 2,500 192 3,652 1,200 1,200

10-6 672 300 972 580 580

Total: 6,724 Total: 2,080

4/5/20 6-2 320 1000 1,320 420 420

2-10 300 200 500 250 250

10-6 320 400 720 500 500

Total: 2,540 Total: 1,170

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: Date: Date: Date: Date:
Dosage, Route,
Time NOD NOD Time NOD NOD Time NOD NOD Time NOD NOD
Frequency 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

P.O.G.S. OBSTETRICS SHEET (1)

NAME: Kallie A. Santos AGE 28 CH S M W SEP. CASE NO. ADDRESS: 96 F Llamas St. Cebu City FINAL DIAGNOSIS:
Date/Time of Admission: 4/3/20 1:29 PM Reason for Admission: Watery Vaginal Discharge ADMITTING IMPRESSION: G₂P₁
(1101) PU 37 ²/₇ weeks AOG, Cephalic in LPL, PROM
Hypokalemia in pregnancy, R/O RTA

Blood Type: A RH: + VDRL: Non-reactive HbSAg: NA Antibiotics: - OBSTETRICAL HISTORY: G 2 P 1 (FT 1 PR 0 AB 0 LC 1)
Pregnancy Pregnancy YEAR Gestation Sex Birth Weight Complications/
Outcome Completed Present Status Abnormalities
2018 October
NSVD FT F 6 lbs. alive -------- Order
(I.B.T. SVD) (wks)
LSCS OR LCS

Desired Family Size: None Pills IUD Condom √ Others

Contraceptive History:
1 2 3 4 5 more

Educational Profile: None: Primary Secondary College √ Others Socio-Economic Profile: Dependent/Unemployed
Income: Below Min. Wage Employed/Self-Employed √ Minimum Wage
 Others Above Min. Wage √
Present Pregnancy: LMP July 08, 2019 EDC April 15, 2020 PMP June 8, 2019 AOG 37 ²/₇/ Utz
12, regular, 4-5 days, using 3-4 mod-soaked. Occ.dysmenorrhea
Menstrual Cycle: Date of Quickening: 12 ⁵/₇ weeks Ultrasound: Date
October 14, 2019 AOG
Antenatal Visits: None 1-2 2-5 5 √ 10x
Health Care Providers: MCH DOH GO MD OTHERS Immunizations: Tetanus Dates: TT₂ December 2019
Hepatitis Dates:
TB Dates:
Others Dates:
Medications: Vitamins Fe Ca Others ---
Total Weight Gain: 14 lbs. BP 110/60-80 HR 90 Urine Albumin - Sugar - ✔ ✔ ✔

DOH-SWUMed-NSD-F-058 Rev.1

URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14

P.O.G.S. OBSTETRICS SHEET (2)

NAME: _________________________________ AGE: ______ CH. ____S_____M_____W_____Sep._____ CASE NO. _________________

Antenatal Problems: Previous Cs / Surgery Age Status: Infertility

HbSag Infections IG __________ __________ __________ Others
Nutritional (2 __________ __________ __________ __________
dose/week) Fetal wastage IUGR __________

Physical Examination: Date __4/3/20__ Time __1 PM__________ Examination ____________________________________

Temp. _36.8___ RR ____19____ HR ____70____ BP __110/70____ Wt. ___158 lbs__ HT. __5’3_Ft__
General Status Level of Sensorium: ______√____ ______x____ Unconscious
Conscious ______√____ Coherent ___x_______ Anxious ____√______ Cooperative ___x_______
Others

HEENT: Chest _____Equal chest expansion____________ Heart __distinctive_________________________ Breast

________________________________________________ Lungs ___clear breath sounds________________ Abdomen: LSK
___________________________ EFU ____2, 790 g__________________ PHB ______140___________________ Fundal Ht. ____29
cm________________________ Position _____10+________________ Floating/Engaged _____________ Presentation
___________vx____________________________________________________________________________________

Pelvic Exam:
Ext. Genitalia: ______no lesions_________________________________________________________________

Vagina: _____ no lesions_________________________________________________________________

Cervix: Length: _________2____________(cm) Dilation ________2_____________ Effacement ________40%__________ Position:

_____________________ Anterior _____________ Midline _____________ Posterior ___ __√________

Presentation: Position ________________________ Membrane Intact Ruptured

√
Station _________________________ Amniotic Fluid Clear
Sutures ________________________ Meconium Stained
 Clinical Pelvimetry:

√
Contracted Inlet Borderline ____adequate_________ Midline Trial Labor Outlet

Remarks:
L1_Duncan_________________________________________________________________________________________________________________________________ L2 _L
laterally directed_____________________________________________________________________________________________________________________
L3__unengaged______________________________________________________________________________________________________________________________ L4
cephalic_prominence, R

DOH-SWUMed-NSD-F-059 Rev.1

URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14

P.O.G.S. OBSTETRICS SHEET (3)

NAME: ___Kallie A. Santos___4/3/20_____________________ AGE: ______ CH. ____S_____M_____W_____Sep._____ CASE NO.
_________________
Fetal Status: Normal
Distress
Bradycardia Tachycardia Fetal Monitor Late Deceleration Variable Late Decelaration
Auscultation
Delivery of Fetus: Date ______________4/4/20___________________ Time _____6:22 AM____ Attend: _____Dr. Coja____________
Manner: Vaginal Spontateous Assisted
Vaginal OS Spontaneous Forceps
Partial Complete Breech (Marvel / Breech to Head) ___________________________________________(Mins.)
With or Without Episiotomy Primary OS ( ) Low Transvers Vertical
Abdominal Laceration

( ) Classical ( ) W/T Ligation

Indication _______________________________________________________________________________________________
REPEAT OS ( ) Low Transverse Vertical
( ) Classical ( ) W/T Ligation
Indication
_______________________________________________________________________________________________ ( ) CS
Hysterectomy ( ) Sub-total
Indication
_______________________________________________________________________________________________ Delivery of Placenta:
Date __________4/4/20______________________ Time ___6:25 AM__________ By: _____Dr. Coja________
Manner: Spontaneous Mos Crede Manual Extraction Elective
√ Retained ( ) Incarcerated ( )
Brand Andrews Accrega
POSTPARTUM BLOOD PRESSURE: _____________________________mmHg
Blood Loss ______200___________(cc) Cause _______________ Atony _______________ Others _____________________
Replacement __________________________ Blood ____________________________(cc) Retained ____________________
 Placenta ____schultz mechanism___________________________________________________________________________________________________ IV Fluids
__D₅_LR 1 L+ 20 ‘u’oxytocin at 30 gtts/min_______________( cc) Laceration ________________________________________

ANALGESIA / ANESTHESIA:
None Regional √ Psycho-prophylaxis
Local Infiltration General

Spinal Sadle Others APGAR Score ___9, 10________

Epidural – Cauda Pudendal Birth Weight __2, 375 mgs__________ Sex
Penthotal or IV N20202 ___Male________________
Complications__________None_______________________________________________________________________________________
POSTPARTUM CONDITION Good Fair Poor
√
DOH-SWUMed-NSD-F-060 Rev.1

URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14

P.O.G.S. OBSTETRICS SHEET (4)

NAME: ____Kallie A. Santos_________ AGE: __28____ CH. ____S_____M_____W_____Sep._____ CASE NO. _________________

LABOR: ONSET: TIME ____4 AM___________ DATE ___4/4/20____ TOTAL DURATION 21 hours and 25 minutes(hrs.)
Full Dilation ____6 AM_______ First Stage _______21 hours____________________(hrs.)
Delivery ____6:22 AM_______ Second Stage ______22 minutes________________(hrs.)
Placenta ___6:25 AM________ Third Stage ______3minutes____________________(hrs.)

NORMAL LABOR CURVES: ACTIVE PHASE

Contraction
Induction Spontaneous Pit Augmentation

Membrane and Amiontic Fluid Ruptured Intact

√
Prom
 ________________(hrs.) √
Erom Amniotomy
Cord Prolapse Clear
Amnionitis Meconium Ileus
Thin
Thick

Progress of Labor Normal Abnormal Precipitate

Prolonged
Latent Phase
Dysfunctional
Arrest of Dilation
Protected Descent
DOH-SWUMed-NSD-F-061 Rev.1

URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
Partograph
Name Gravida Para. Hospital no. Date of admission Time of Admission Ruptured membranes hours

Fetal heart rate

180

Latent
Phase

1 2 3 4 5 6 7 8 9 10 1 12
1

170
160
150
140
130
120
110
100

Active
Phase

Liquor
Cervix (cm ) 5
slot x
Moulding 10 Descen
t of hed [plot 0]
9
8
7 Hours
6 43210
Time
5

Construction per 4321

10 mins
Oxytocin U/L Drops/min

Drugs
given
and
IV fluids
180
170
160
150
140
130
120
110
100

90
80
70

60
Temp 0C

protein
Urine acetone volume

Source: WHO. Used by permission

DOH-SWUMed-NSD-F-062 Rev.1

URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14

PUERPERIUM RECORD
NAME: __________________________________ AGE: ______ WARD/BED NO. _________________ CASE NO. ___________________
ATTENDING PHYSICIAN / RESIDENT: ________________________________ DELIVERY DATE: _________________________

A – POSTPARTUM OBSERVATION:
 enlarged Well contracted minimal (-) well
DATE BREAST UTERUS LOCHIA EPISIOTOMY BPT MEDICATIONS 1st
coaptated KCL drip KCL tab Vitamin B complex Cefuroxime Mefenamic Acid
2nd 3rd 4th 5th Fe SO₄ + MV
Calcium
B – COMPLICATION OF THE PUERPERIUM:

None

C – DISCHARGE PHYSICAL EXAMINATION DISCHARGE VAGINAL EXAMINATION:

1. Head and Neck ___________________________________ 2. Abdomen __________________________________________
Heart and Lungs _________________________________ 3. 1. Vulva No Lesions___________ 2. Perineum _No hematoma___
Thyroid Gland ____________________________________ 4. 3. Vagina ______no mass/lessions___ 4. Cervix _2 cm
Breasts ____________________________________________ 5. up_____________ 5. Uterus (+) mid introverted________
6. Vital signs: Temperature ______36.5______________________ Blood Pressure _________100/70_______________
Pulse/Heart Rate ___75_____________________ Respiratory Rate _____20______________________

D – ADVICE AND MEDICINE PRESCRIBED:

E – CONDITION ON DISCHARGED:
Good _________√_______ Poor_____________________
Fair ________________________Critical __________________
Died _______________________ Discharge on __________
_______________________________________ or transferred
to ______________________________________________________
on _____________________________________________________.
OB PGI / Senior Clerk :
______________________________________________________________________ Attending OB
Resident: __________________________________________________________(Signed)

DOH-SWUMed-NSD-F-063 Rev.1

URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14

LABORATORY RESULTS