BASILAN STATE COLLEGE NURSING LAB

Sumagdang, Isabela City, Basilan 7300

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 PATIENT’S CHART

CONSENT FOR ADMISSION / TREATMENT

I voluntarily consent to the procedures and services that may be performed for me on an
inpatient or outpatient basis under the general and special instructions of my physician, and/or
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
his/her assistant or designee. I understand that these procedures and services may include but are
not limited to emergency treatment or services, laboratory procedures, imaging services, medical or
surgical treatment or procedures, anesthesia, or hospital services. I understand that other conditions
may be diagnosed which may require additional treatment. I authorize and consent to use of
recordings, films, or other images of me (i.e., any photographic, video, electronic or audio media) for
purposes of identification, diagnosis or treatment in connection with the care provided to me.

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 I have read the above document and understand its contents. I acknowledge that I am the
patient, or I am the patient’s legally authorized representative, and/or guarantor and consent to the
above items and make the acknowledgments hereby made.

Name of Patient/Guardian: Randall A. Echavez

Relationship to Patient: Friend
Signature of Patient/Guardian: r.echavez
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Name of NOD: Fhatima Keana M. Kadil, RN
Signature: f.kadil
Date & Time: July 14, 2021

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 PATIENT’S PROFILE

PATIENT’S NAME (LAST) (GIVEN) (MIDDLE) WARD SERVICE :

Center

Montero Michael P.

PATIENT’S ADDRESS CONTACT SEX CIVIL STATUS

NO. ( ) FEMALE ( ) CHILD ( ) SEPARATED
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Tetuan Fabian Street, Zamboanga 09555424853 ( ✓ ) MALE ( ✓ ) SINGLE ( ) WIDOWED
City ( ) MARRIED

BIRTHDATE AGE BIRTHPLACE RELIGION OCCUPATION

June 20, 1986 34 Tetuan Catholic Plumber

EMPLOYER (TYPE OF BUSINESS) ADDRESS CONTACT NO.

FATHER’S NAME ADDRESS

Brook R. Montero
Tetuan, Fabian Street, Zamboanga City
MOTHER’S NAME ADDRESS
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 Baliwasan Grande, Zamboanga City
Melissa P. Tuazon
ADMISSION DISCHARGE TOTAL NO. OF DAYS ATTENDING PHYSICIAN
DATE: July 14, 2021 DATE: July 17, 2021 5 days Dr. Khleign Margaux F.
TIME: 8:00 am TIME: 3:00 pm Stanford

TYPE OF ADMISSION REFERRED BY:

( ✓ ) NEW ( ) OLD ( ) FORMED ( ) OPD

DATA FURNISHED BY: ADDRESS OF INFORMANT: RELATIONSHIP TO PATIENT:

ADMISSION DIAGNOSIS
Schizophrenia
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
PRINCIPAL DIAGNOSIS
Schizophrenia

OTHER DIAGNOSIS
N/A

PRINCIPAL OPERATION/PROCEDURE: N/A

OTHER OPERATION PROCEDURES
ACCIDEND/INJURIES/POISONING (CODE)
PLACE OF OCCURENCE
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 _____________________
ATTENDING PHYSICIAN
NOD

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

PATIENT’S CHART

Name: Michael P. Montero Age/Sex: 34/Male Ward: Center

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Address: Tetuan, Fabian Street, Zamboanga City

HISTORY
Chief Complaint: Schizophrenia

History of Present Illness:

Past Medical History

( ) Asthma ( ) Hypertension ( ) Previous Hospitalization
( ) Previous Surgery ( ) Allergies ( ) Diabetes
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
( ) Heart Disease

Family History:
( ) Hypertension ( ) Cancer ( ) Asthma ( ) Diabetes
( ) Hearth Disease ( ) Others

Personal Social History

( ) Smoking ( ) Alcohol Drinking

OB-GYN History:

LMP: OB Score:

REVIEW OF SYSTEMS

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
General:
( ✓ ) Weight Loss ( ) Weight Gain ( ) Fever

Nervous:
( ) Seizure ( ) Headache ( ) Dizziness ( ) Diplopia

EENT
( ) Blurring of Vision ( ) Hearing Loss ( ) Tinnitus ( ) Ear Discharge
( ) Anosmia ( ) Nasal Discharge ( ) Dysphagia ( ) Hoarseness

Respiration:
( ) Cough ( ) Dyspnea ( ) Hemoptysis ( ) Cyanosis

Cardiovascular:
( ) Chest pain ( ) Orthopnea ( ) Palpitation ( ) Varicose

Digestive:
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
( ) LBM ( ) Constipation ( ) Vomiting ( ) Black stool
( ) Mass ( ) Hemorrhoids ( ) Abdominal Pain ( ) Decrease caliber stool
( ) Melena ( ) Hematochezia ( ) Changes in Bowel Movement

Genito-Urinary:
( ) Frequency ( ) Urgency ( ) Dysuria ( ) Hematuria

Reproductive:
( ) Vaginal Bleeding ( ) Amenorrhea ( ) Dyspareunia ( ) Metrorrhagia

Endocrine:
( ) Polydipsia ( ) Polyphagia ( ) Polyuria ( ) Palpitations
( ) Tremors ( ) Heat Intolerance ( ) Cold Intolerance
Musculoskeletal:

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

PATIENT’S CHART

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Name: Michael P. Montero Age/Sex: 34/Male Ward: Center

Address: Tetuan, Fabian Street, Zamboanga City

PHYSICAL EXAMINATION
( ) Pain ( ) Back pain ( ✓ ) Muscle Weakness ( ) Atrophy
Integumentary:
( ) Rashes/Lesions ( ) Discolorations ( ) Change in Moles ( ) Itchiness
( ) Pallor ( ) Jaundice
Hematologic:
( ) Easy Bruising ( ) Bleeding
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Extremities:
( ) Edema ( ) Deformities ( ) Cyanosis

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
General Survey:

BP: 105/60 mmHg temp: 36.8°C PR:116 bpm RR: 20 bpm O2SAT: 96% RA Weight: 4545 kg
Height: 5'5

SKIN:

HEENT: No abnormalities. Head is round without injuries. No present of nodule or masses

in the scalp. Hair is smooth, and thick. Color of eyes is black. Conjunctiva is transparent.
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Iris is visible and the extra occular movement is normal. Pinna of the ears are aligned to
the outer canthus of the eyes. Nose is symmetrical in size, no presence of lesion and
discharge.

HEART: No abnormalities found

CHEST and LUNGS:: Symmetrical in size and shape and normal breath sounds.

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
ABDOMEN: No abnormalities found

GENITALIA: No abnormalities found

NEURO-EXAM: No abnormalities found

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
IMPRESSION: N/A

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

KARDEX

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Name: Michael P. Montero Age/Sex: 34/Male Ward: Center

Address: Tetuan, Fabian Street, Zamboanga City

DIET ORDERED BY DATE/TIME ORDERED NOD WITH

SIGNATURE

-------------------------- -------------------------------- -------------------------------- ----------------------------

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
-- ---- ---- ----

ALLERGIES (USED RED INK):

IVF & DATE/TIME ORDERED D/T ORDERD REFUSES IV

DROPS (CONSUMED) BY (Discontinued) BY D/T
0.9% NacI July 14, 2021 Dr. Stanford --------------------- ---------------- -------------------
1L 8:00 AM --- --- ----
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
(15gtts/min)
July 15, 2021 Dr. Scott
D5LR 1L 10:00 AM --------------------- ---------------- -------------------
(20gtts/min) --- --- ----

July 16, 2021 Dr. Stanford

O.45% NacI 3:00 PM
(20gtts/min) --------------------- ---------------- -------------------
--- --- ----

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
SIDE DRIPS DATE/TIME ORDERED D/T ORDERED REFUSED IV
& DROPS (CONSUMED) BY (Discontinued) BY D/T

------------------ ------------------- ------------------ --------------------- ---------------- ------------------

--- --- -- -- --- ---

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

VITAL SIGNS SHEETS

Name: Michael P. Montero Age/Sex: 34/Male
Ward: Center
Address: Tetuan, Fabian Street, Zamboanga City

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
DATE July 14, 2021 July 15, 2021 July 16, 2021
HOSPITAL 1 2 3
DAY
POST OP DAY
HOUR 2400 0400 0600 1200 1600 2000 2400 0400 0600 1200 1600 2000 2400 0400 0600 1200 1600 2000

BP
TEMPARATUR
E

40

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
39

38

37.5 37.5 37.5°C 37.5°C

°C °C
37.4 37.2 37.2 37.2 37.4° 37.4° 37.4°C 37.2°C 37.4°C
37 °C °C °C °C C C
36.8 36.7 36.7
°C °C °C
36.6 36.5
°C °C

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 36

PULSE 116 85 88 80 80 80 81 82 82 83 80 80 81 84 80 80 81 82
bpm bpm bpm bpm bpm
bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm
RESPIRATION 20 20 19 18 18 17 17 16 19 18 17 18 18 16 17 18 16 18
bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm bpm
WEIGHT 45 ------ ------ ------ ------ ------ 50 ------ ------ ------ -------- ------ -------- 52 kg -------- ------- --------- --------
kg - - - -- -- kg -- -- -- - -- - -
DR. VISIT Dr.
Stanfor
Dr.
Scott
d
INTAKE ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ -------- ------ -------- ------- ------- ------- ------- -------
- - -- -- -- -- -- -- -- -- -- -
ORAL ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- -------

0.9%
IV NacI
------- ------- ------- ------- ------- D5LR ------- ------- ------- ------- ------- 0.45%
NacI
------- ------- ------- ------- -------

TUBE ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- -------
FEEDING
PPN/TPN/LIPI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
DS
IV MEDS -------

CHEMOTHERAPY 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL INTAKE
OUTPUT 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
URINE 0 0 0 1 2 0 0 0 2 0 1 0 0 0 0 0
1 1
GI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
EMESIS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
DRAINS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL OUTPUT 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0
FECES

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

PATIENT’S CHART

Name: Michael P. Montero Age/Sex: 34/Male Ward:

Center
Address: Tetuan, Fabian Street, Zamboanga City

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 DOCTORS ORDER/NURSE COMPLIANCE SHEET
C-Carried A- Administered R- Request Made E- Endorsed D- Discontinued

Date/Time ORDERS Date/Time

Remarks C A R E D Signature of
NOD
JULY 14, 2021 Risperidone 5 mg ✓

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
JULY 15, 2021 Olanzapine 5 mg ✓

JULY 16, 2021 Benztropine 2 mg ✓

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

MEDICATION AND TREATMENT RECORD

Name: Michael P. Montero Age/Sex: 34/Male Ward:

Center
Address: Tetuan, Fabian Street, Zamboanga City
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 Date/ Time

Date Ordered Medications 1st Dose

07/14/2021 Risperidone 5 mg

07/15/2021 Olanzaline 5 mg

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
07/16/2021 Benztropine 2 mg

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

NEUROVITAL SIGNS SHEET

Name: Michael P. Montero Age/Sex: 34/Male Ward: Center

Address: Tetuan, Fabian Street, Zamboanga City
STIMULUS RESPONSE DATE

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 EYES OPENING SCORE Night AM PM Night AM PM

a. Approach to bedside Spontaneous 4 2 3 3 5 2 4

b. Verbal Command Open eyes to name or command 3 3 3 2 1 3 5

c. Pain (Nail bed pressure) Open eyes to pain 2 1 4 2 2 4 1

d. Pain (Nail bed pressure) No response 1 4 5 3 1 1 4

VERBAL

a. Conversation Converses, oriented to time, place, person 1 2 1 1 2 3 4

b. Conversation Converses, but disoriented to one or more 1 1 1 2 3 2 2

areas

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
c. Conversation No sustained conversation; non- 3 2 4 3 1 3 3
recognizable word

d. Conversation Conversation not sustained; words 2 2 2 1 2 2 4

disorganized

e. Pain No sound made 1 1 3 2 4 3 3

MOTOR

a. Verbal command Obeys command 6 5 2 3 2 1 2

b. Pain Located pain and attempts to remove 5 4 2 1 1 3 5

c. Pain Flexes arm in response to pain 4 2 3 2 2 2 3

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
d. Pain Flexes arm at elbow and pronates 3 2 2 1 3 3 4

e. Pain Flexes arm at elbow and pronates 2 4 3 4 1 4 3

f. Pain No Response 1 1 2 2 2 2 3

TOTAL SCORE 39 40 31 32 39 50

CAPILLARY ASSESSMENT:

Equal size & reactive to light (constrict actively & equally) 5 4 3 2 1 3 4

Unequal size & reactive to light 4 1 3 2 4 5 2

Unequal size & non-reactive to light 3 4 3 2 1 4 3

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Bilateral dilation & fi 2 1 3 2 3 4 3

Others 1 2 4 3 1 3 2

Initial NAME Signature Initial NAME Signature

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

REFERRAL SHEET

Name: Age/Sex: Ward:

Address

Referring Health Care Institution

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Date of Referral: July 14, 2021 Time of Referral: 8:00 AM

Name of Health Care Institution (HCI): CIUDAD MEDICAL ZAMBOANGA

Philhealth Accreditation No. of HCI: H030007456

Address of HCI: Zamboanga, Peninsula

Name of Attending/Referring Physician: Dr. Khleign Margaux F. Stanford M.D

Signature of Attending/Referring Physician: f.kadil

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Patient Information

Name of Patient: Michael P. Montero

Date of Birth: June 20,1986 Age: 34 Gender: Male

Diagnosis/es: Schizophrenia

Reason for Referral/ Transfer: Patient's Choice

Referral health Care institution

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Date of Receipt: 07/14/2021 Time of Receipt: 1:30 pm

Name of Health Care Institution (HCI):CIUDAD MEDICAL ZAMBOANGA

Philhealth Accreditation No. of HCI: H030007456

Address of HCI: Zamboanga, Peninsula

Name of Receiving Physician: Dr. Khleign Margaux F. Stanford

Signature of Receiving Physician: stanford.margaux

Name of Nurse on Duty: Fhatima Keana M. Kadil, RN

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Signature of Nurse on Duty: f.kadil

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

DISCHARGE SUMMARY

Name: Michael P. Montero Age/Sex: 34/Male Ward: Center

Address: Tetuan, Fabian Street, Zamboanga City
Date Admitted: 07/14/2021 Date of Discharge: 07/17/2021

Attending Physician: Dr. Khleign Margaux F. Stanford

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Admitting Diagnosis: Schizophrenia

Final Diagnosis: Schizophrenia

Brief Clinical History and Pertinent P.E.: N/A

Laboratory Findings: Including ECG, X-Ray, and Other Diagnostic Procedures

N/A

Course in the Ward: (Including Medications)

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
N/A

Disposition: (Include home medication, special instruction, and follow-up)

N/A

Date Accomplished

07/17/2021
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
Resident In-Charge

Dr. Khleign Margaux F. Stanford

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 BASILAN STATE COLLEGE NURSING LAB
Sumagdang, Isabela City, Basilan 7300

NURSE’S NOTES
Name: Michael P. Montero Age/Sex: 34/Male Ward: Center
Address: Tetuan, Fabian Street, Zamboanga City

Date Focus Progress Notes

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
07/16/2021 Data: (S)received patient on a delusional state, responsive but
distracted by the appearance of nurse
8:30 AM Dehydration
"Natatakot akong uminom at kumain kase feeling ko lalasunin nila
ako"as verbalized by the patient.

Data:(O) V/S

Bp::105/60mmhg

Pr:116bpm

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 Rr:20bpm

T: 36.8°c

Sp02: 96%

Action:

(Independent)

-administer D5lr dextrose and 0.9% Back

-Encourage to increase fluid intake and food absorption

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
 -keep patient comfortable and safe

(Dependent)

-dependent rounds done by the physician.

3:00 PM R: says that he doesn't experience any fluid loss and eating habits are
back to normal"as verbalized by the patient.

BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com
BaSC Main Campus, College of Information Communication and Trade Technology Bldg. Isabela City, Basilan (+63) 997-5540-331 Basilanstate_college@yahoo.com