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CF4
(Claim Form 4)
February 2020

IMPORTANT REMINDERS: Series #

PLEASE FILL OUT APPROPRIATE FIELDS. WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form, together with other supporting documents, should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
I. HEALTHCARE INSTITUTION INFORMATION (HCI)
1. Name of HCI 2. Accreditation Number
SCHISTOSOMIASIS HOSPITAL H08020879

3. Address of HCI
. SALVACION PALO LEYTE 6501

Bldg No. and Name/Lot/Block Street/Subdivision/Village Barangay/City/Municipality Province Zip Code

II. PATIENT'S DATA

1. Name of Patient 2. PIN
030252616256
NACO ROGELIO PELICANO
3. Age
Last Name FirstName Middle Name 50 year(s) old

5. Chief Complaint 4. Sex  Male Female

Hematemesis
6. Admitting Diagnosis: 7. Discharge Diagnosis: 8.a. 1st Case rate
UGIB PROB. FROM POSTAL HYPERTENSIVE GASTROPATHY ANEMIA SEVERE D64.9
FROM HEPATIC SCHISTO: COVID19 SUSPECT
8.b. 2nd Case rate

9.a. Date Admitted: 1 1 1 1 2 0 2 1 9.b. Time Admitted: 1 0 : 2 5 AM  PM

month day year hour min
10.a. Date Discharged: 10.b. Time Discharged:
1 2 0 2 2 0 2 1 0 2 : 2 6 AM  PM
month day year hour min

III. REASON FOR ADMISSION

1. History of Patient Illness:
PATIENT IS 1 50/M WHO CAME IN DUE TO EPISODES OF HEMATEMESIS FEW MONTHS PTA. THIS WAS ALSO ASSOCIATED WITH ABDOMINAL ENLARGEMENT AND
BIPEDAL EDEMA. NO OTHER YSPMTOMS NOTED SUCH AS COUGH, FEVER OR DYSPNEA. PERSISTENCE OF HEMATEMESIS PROMPTED CONSULT.
2.a. Pertinent Past Medical History:
Non-hypertensive
Non-diabetic
No history of PTB
2019 - had hematemsis
2.b. OB/GYN History
G P ( Full Term: Pre-Term: Abortions: Live Birth: ) LMP:  NA

3. Pertinent Signs and Symptoms on Admission (tick applicable box/es):

Altered mental sensorium Diarrhea  Hematemesis Palpitations

 Abdominal cramp/pain Dizziness Hematuria Seizures

Anorexia Dysphagia Hemoptysis Skin rashes
Bleeding gums Dyspnea Irritability Stool, bloody/black tarry/mucoid
Body weakness Dysuria Jaundice Sweating
Blurring of vision Epistaxis Lower extremity edema Urgency
Chest pain/discomfort Fever Myalgia Vomiting
Constipation Frequency of urination Orthopnea Weight loss
Cough Headache
Pain Site

Others

4. Referred from another health care institution (HCI):  No Yes

Name of Originating HCI:

Specify reason:

5. Physical Examination on Admission (Pertinent Findings per System) Height: 168 (cm)
General Survey  Awake and Alert Weight: 74 (kg)
Altered sensorium:

Vital Signs: BP 100/60 mmHg HR: 105/min RR: 25/min Temp: 37.5 °C

HEENT:  Essentially normal Abnormal pupillary reaction Cervical lymphadenopathy Dry mucous membrane

Icteric sclerae Pale conjunctivae Sunken eyeballs Sunken fontanelle

Others:

CHEST/LUNGS:  Essentially normal Asymmetrical chest expansion Decreased breath sounds Wheezes

Lump/s over breast(s) Rales/crackles/rhonchi Intercostal rib/clavicular retraction

Others:
NACO, ROGELIO PELICANO
CVS:  Essentially normal Displaced apex beat Heaves and/or thrills Pericardial bulge

Irregular rhythm Muffled heart sounds Murmur

Others:

ABDOMEN: Essentially normal Abdominal rigidity Abdomen tenderness Hyperactive bowel sounds

Palpable mass(es) Tympanitic/dull abdomen Uterine contraction

Others: ENLARGED ABDOMEN.

GU (IE):  Essentially normal Blood stained in exam finger Cervical dilatation Presence of abnormal discharge
Others:

SKIN/EXTREMITIES: Essentially normal Clubbing Cold clammy skin Cyanosis/mottled skin

 Edema/swelling Decreased mobility Pale nailbeds Poor skin turgor

Rashes/petechiae Weak pulses

Others:

NEURO-EXAM:  Essentially normal Abnormal gait Abnormal position sense Abnormal/decreased sensation

Abnormal reflex(es) Poor/altered memory Poor muscle tone/strength Poor coordination

Others:

IV. COURSE IN THE WARD (Attach photocopy of laboratory/imaging results) Check box if there is/are additional sheet(s).

Date DOCTOR’S ORDER/ACTION

11-11-2021 PATIENT IS 1 50/M WHO CAME IN DUE TO EPISODES OF HEMATEMESIS FEW MONTHS PTA. THIS WAS ALSO ASSOCIATED WITH ABDOMINAL ENLARGEMENT
AND BIPEDAL EDEMA. NO OTHER YSPMTOMS NOTED SUCH AS COUGH, FEVER OR DYSPNEA. PERSISTENCE OF HEMATEMESIS PROMPTED CONSULT.

11-12-2021 ON HIS PATIENT IS NOW ON HIS SECOND SARI DAY. NO EPISODE OF HEMATEMESIS NOTED. PATIENT CLAIMED TO HAVE PREVIOUS HISTORY OF
HEMATOCHEZIA. ON PHYSICAL EXAMINATION, PATIENT NOTED WITH GLOBULAR ABDOMN FROM MASSIVE ASCITES AND EDEMA. NO COUGH NOTED.

11-13-2021

-INCREASE FUROSEMIDE IV TO 40MG IV 2 12 HRS

-CONTINUE MEDICATIONS
-FOR BLOOD TYPING
-CONTINUE MEDICATIONS
-REFER

11-14-2021
-CONTINUE MEDICATIONS
-REFER

11-15-2021
-CONTINUE MEDICATIONS
-REFER

11-16-2021
-STILL SECURING BLOOD - FACILITATE TRANSFUSION ONCE W/ AVAILABLE UNIT
-FOR RPT CBC POST TRANFUSION
-REFER

11-17-2021
-STILL FOR BT
-FOR FF UP BLOOD TYPING RESULT
-CONTINUE MEDICATIONS
-REFER

11-18-2021
-DISCONTINUE CEFTRIAZIONE IV
-STILL FOR SECURE BLOOD, PROPERLY SCREENED AND CROSS-MATCHED ACCORDING TO PATIENT'S BLOOD TYPE
-CONTINUE MEDCIATIONS
-REFER

11-19-2021
-TRANFUSE AVAILABLE BLOOD AFTER PROPER TYPING @ CROSSMATCHING
-CONTINUE MEDICATIONS
-REFER

11-20-2021
-CONTINUE MEDICATIONS
-REFER

11-21-2021
-CONTINUE MEDICATIONS
-REFER

11-22-2021
-FACILITATE S/E FOR KK
-FACILITATE BLOOD TRANFUSION OF 2ND UNIT OF BLOOD

11-23-2021
-STILL FOR S/E KK
-STILL FOR SECURING BLOOD
-CONTINUE MEDICATIONS
-REFER

11-24-2021
-STILL SECURING BLOOD FOR TRANFUSION
-CONTINUE MEDICATIONS
-REFER

11-25-2021
-STILL FOR SECURE BLOOD FOR TRANSFUSION
-CONTINUE MEDICATIONS
-REFER
NACO, ROGELIO PELICANO
IV. COURSE IN THE WARD (Attach photocopy of laboratory/imaging results) Check box if there is/are additional sheet(s).

Date DOCTOR’S ORDER/ACTION

11-26-2021
-STILL SECURING BLOOD
-CONTINUE MEDICATIONS
-REFER

11-27-2021
-ATTACH HL
-SECURING BLOOD
-CONTINUE MEDICATIONS
-REFER

11-28-2021
-CONTINUE MEDICATIONS
-STILL SECURING BLOOD
-REFER

11-29-2021
-REINSERT IV ONCE W/ BLOOD AVAILABLE FOR TRANSFUSION
-CONTINUE MEDICATIONS
-REFER

11-30-2021
-CONTINUE MEDICATIONS
-REFER

12-01-2021
-CONTINUE MEDICATIONS
-REFER

12-02-2021
-PATIENT WAS IMPROVED AND DISCHARGED WITH HOME MEDS

SURGICAL PROCEDURE/RVS CODE (Attach photocopy of OR technique):

V. DRUGS/MEDICINES Check box if there is/are additional sheet(s).

Generic Name Quantity/Dosage/Route/Frequency Total Cost

Spironolactone 4 tablet, 1 TABLET (S) 25 mg Tablet(s), Oral, every 12 hours P 53.20

Furosemide 2 ampule, 1 AMPUL 20 mg/2ml AMPUL, Intravenous, once a day P 18.36

Omeprazole 2 vial, 1 vial 40 mg vial, Injection, once a day P 72.32

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Ceftriaxone 4 vial, 2 vial 1 g vial, Injection, once a day P 133.80

Lactulose Syrup 1 bottle, 1 BOTTLE 3.35 mg/5 ml syrup, Oral, once a day P 119.00

Propranolol 4 tablet, 1 TABLET (IMMED./COMP. RELEASE) COATED 10 mg Tablet(s), Oral, P 33.04

every 12 hours

Furosemide 2 ampule, 2 AMPUL/VIAL 20 mg/2ml AMPUL, Intravenous, every 12 hours P 18.36

Plain NSS 2 bottle, 2 BOTTLE 1 liter BOTTLE, Injection, once a day P 104.52

Propranolol 2 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Spironolactone 2 tablet, 2 TABLET (S) 25 mg Tablet(s), Oral, once a day P 26.60

Furosemide 6 ampule, 8 AMPUL 20 mg/2ml AMPUL, Intravenous, once a day P 55.08

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Ceftriaxone 2 vial, 2 vial 1 g vial, Injection, once a day P 66.90

Propranolol 2 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Spironolactone 2 tablet, 2 TABLET (S) 25 mg Tablet(s), Oral, every hour P 26.60

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Ceftriaxone 2 vial, 2 vial 1 g vial, Injection, once a day P 66.90

Plain NSS 2 bottle, 2 BOTTLE 1 liter BOTTLE, Injection, once a day P 104.52

Propranolol 2 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Spironolactone 2 tablet, 2 TABLET (S) 50 mg Tablet(s), Oral, once a day P 28.00

Furosemide 4 tablet, 4 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Ceftriaxone 2 vial, 2 vial 1 g vial, Injection, once a day P 66.90

Spironolactone 1 tablet, 1 TABLET (S) 25 mg Tablet(s), Oral, once a day P 13.30

Furosemide 2 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 4.76

Propranolol 2 tablet, 1 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Spironolactone 2 tablet, 1 TABLET (S) 50 mg Tablet(s), Oral, once a day P 28.00

Furosemide 4 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Ceftriaxone 2 vial, 2 vial 1 g vial, Injection, once a day P 66.90

Lactulose Syrup 1 bottle, 1 BOTTLE 3.35 mg/5 ml syrup, Oral, once a day P 181.25

Plain NSS 1 bottle, 1 BOTTLE 1 liter BOTTLE, Injection, once a day P 52.26

Propranolol 2 tablet, 1 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Spironolactone 2 tablet, 1 TABLET (S) 50 mg Tablet(s), Oral, once a day P 28.00

Furosemide 4 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

NACO, ROGELIO PELICANO
V. DRUGS/MEDICINES Check box if there is/are additional sheet(s).

Generic Name Quantity/Dosage/Route/Frequency Total Cost

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Ceftriaxone 2 vial, 2 vial 1 g vial, Injection, once a day P 66.90

Plain NSS 1 bottle, 1 BOTTLE 1 liter BOTTLE, Injection, once a day P 52.26

Propranolol 2 tablet, 1 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Spironolactone 2 tablet, 1 TABLET (S) 50 mg Tablet(s), Oral, once a day P 28.00

Furosemide 4 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Propranolol 2 tablet, 1 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Spironolactone 2 tablet, 1 TABLET (S) 50 mg Tablet(s), Oral, once a day P 28.00

Furosemide 4 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Furosemide 4 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Propranolol 2 tablet, 1 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Dextrose 5% In Water 2 bottle, 1 BOTTLE 500 mL BOTTLE, Intravenous, once a day P 75.26

DOPAMINE 4 injection, 1 AMPUL 200 mg/5 ml AMPUL, Injection, once a day P 336.00

Dextrose 5% In Water 2 bottle, 1 BOTTLE 500 mL BOTTLE, Intravenous, once a day P 75.26

Iron Sucrose 1 ampule, 1 AMPUL 20 mg/ml AMPUL, Intravenous, once a day P 167.92

Propranolol 2 tablet, 1 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Furosemide 4 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Furosemide 4 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Propranolol 2 tablet, 1 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

DOPAMINE 2 injection, 1 AMPUL 200 mg/5 ml AMPUL, Injection, once a day P 168.00

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Propranolol 2 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Furosemide 4 tablet, 4 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Furosemide 2 tablet, 2 TABLET (S) 40 mg Tablet(s), Oral, every hour P 4.76

Propranolol 2 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Furosemide 4 tablet, 4 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Furosemide 2 ampule, 2 AMPUL 20 mg/2ml AMPUL, Intravenous, every hour P 18.36

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Furosemide 4 tablet, 4 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Propranolol 2 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Propranolol 1 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 8.26

Furosemide 4 tablet, 4 TABLET (S) 40 mg Tablet(s), Oral, once a day P 9.52

Propranolol 2 tablet, 2 TABLET (S) 10 mg Tablet(s), Oral, once a day P 16.52

Omeprazole 1 vial, 1 vial 40 mg vial, Injection, once a day P 36.16

Praziquantel 4 tablet, 4 TABLET (S) 150 mg Tablet(s), Oral, once a day P 4.00

VI. OUTCOME OF TREATMENT

 IMPROVED RECOVERED HAMA/DAMA EXPIRED ABSCONDED TRANSFERRED

Specify reason:

VII. CERTIFICATION OF HEALTH CARE PROFESSIONAL

Certification of Attending Health Care Professional:
I certify that the above information given in this form, including all attachments, are true and correct.

AL R. NAVALES, MD 03 03 2022
Signature over Printed Name of Attending Health Care Professional month day year
Date Signed