Documente Academic
Documente Profesional
Documente Cultură
ESCUELA DE MEDICINA
HISTORIA CLINICA
DATOS DE IDENTIFICACION
MOTIVO(S) DE CONSULTA
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________________________________________________
ENFERMEDAD ACTUAL
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Dr. E. Concho/BR.J.Hidalgo/2010
ANTECEDENTES FAMILIARES:
Cardiovasculares:___________________________________________________________
Diabetes:__________________________________________________________________
Sifilis:_____________________________________________________________________
TBC:______________________________________________________________________
Neurologicos:______________________________________________________________
Cancer:___________________________________________________________________
Embarazos multiples:________________________________________________________
Asma bronquial:____________________________________________________________
Otros:____________________________________________________________________
ANTECEDENTES PERSONALES:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________________________________________________
QUIRURGICOS:__________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
GINECOLOGICOS:_______________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Menarquia a los___ años de edad. Carácter: _______ Tipo:_________ Sexarquia a los _____ años
de edad. FUR: ____________
Año Tipo Tipo Tipo Hemorragia Trast. Lesion Puerperio Peso Vo Sexo
de de de hip. perineal de RN M
emb. parto trab. del
emb.
CONTROL PRENATAL
Amenorrea desde:_______ Fecha probable de parto:_____________ Paridad:________Centro
asistencial:___________________ Nº DE CONSULTAS REALIZADAS:________
Obsetrvaciones:________________________________________________________________________________________
____________________________________________________________________________________________________________
EXAMEN FISICO
Piel:_________________________________ Vagina:_______________________________
_____________________________________ _____________________________________
________________________ ________________________
Examen/fecha
( ) Prematura
Espontanea ( ) ( ) Precoz
Artificial ( ) ( ) Tempestiva
( ) Tardía
Dia Cuello Dilatación Presentación, Segmento MEMBRANAS Función FCF TA Temp. Obser
y consistencia variedad de inferior contráctil
hora y longitud posición y
plano
Observaciones:_________________________________ Medicamentos:_________________________________
____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________
PERIODO DE EXPULSION RECIEN NACIDO
Episiotomía: ___________________________________________________________
PERIODO DE ALUMBRAMIENTO
AVagina
los _______minutos
( )
Expulsión
Cuello ( )
_Episiotomia:___________________________________________________________Indicación:
( ) Espontanea Maniobras externas ( )
____________________________________________________________________________
_______________________________________
_______________
( ) Provocada Extracción manual ( ) _______________________________________
Medicación ( ) Observaciones:
_______________________________________
Cantidad de sangre perdida____________ mi. Aprox. _______________________________________
_______________________________________
EXAMEN DE LOS ANEXOS
____
Placenta: Forma: _____________ Peso: ____________grs Inserción: ___________ Particularidades:
___________________________________________________________ Membranas: Medidas: ___________ cm
Particularidades:__________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________
Indicacion:______________________________________________________________________________________________
_________________________________________________________
Diagnostico post-operatorio:
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Observaciones:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
RESUMEN DE INGRESO:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PUERPERIO
SINTOMAS TRATAMIENTO
Temp: TA: PULSO: FR:
Mamas: Condicion: Secrecion:
Pezones:
Utero: Altura: Condicion:
Loquios:
Perine:
Evacuaciones: Flatos:
Diuresis:
Observaciones:
Fecha:
Firma: Firma:
SINTOMAS TRATAMIENTO
Temp: TA: PULSO: FR:
Mamas: Condicion: Secrecion:
Pezones:
Utero: Altura: Condicion:
Loquios:
Perine:
Evacuaciones: Flatos:
Diuresis:
Observaciones:
Fecha:
Firma: Firma:
SINTOMAS TRATAMIENTO
Temp: TA: PULSO: FR:
Mamas: Condicion: Secrecion:
Pezones:
Utero: Altura: Condicion:
Loquios:
Perine:
Evacuaciones: Flatos:
Diuresis:
Observaciones:
Fecha:
Firma: Firma:
EVOLUCION INTRAHOSPITALARIA
ORDENES MÉDICAS
RESUMEN DE EGRESO
Intervenciones practicadas:
Diagnóstico de egreso:
Diagnostico Anatomopatologico:
Tratamiento: