Escolar Documentos
Profissional Documentos
Cultura Documentos
Nombre:
_________________________________________________
Afiliacin:
____________________________________
Edad:
aos
Sexo:
Femenino
Fecha de Ingreso:
Diagnstico de
Ingreso:
______________________________________________________
Cama:
______________
Servicio:
Ginecologa y Obstetricia
Mdico Tratante:
tomatetumedicina.wordpress.com
Nota Post-Parto
Ginecologa y Obstetricia
Fecha y Hora: ________________________________________________________
Nombre:
________________________________________________________
Afiliacin:
________________________________________________________
Edad
_________ aos
da hoy a tocociruga por presentar trabajo de parto con diagnstico de embarazo de _______ SDG con trabajo de
parto activo por lo que se le hidrata. Se mantiene con signos vitales normales, buen trabajo de parto. Pasa paciente a
sala de expulsin con dilatacin y borramiento completos, se coloca en posicin ginecolgica, se realiza asepsia y
antisepsia de regin perineal, se colocan campos estriles, se infiltra con Lidocaina simple al 2% en abanico, en regin
perineal, se realiza episiotoma mediolateral derecha, se protege perin con maniobra de Ritgen modificada. Se
obtiene recin nacido se pinza y corta cordn umbilical, se pasa al pediatra; se realiza alumbramiento dirigido,
protegiendo fondo uterino con maniobra de Brandt Andrews y se revisa la cavidad hasta dejarla virtualmente limpia, se
realiza episiorrafia por planos, iniciando con surjete continuo anclado en mucosa, y puntos invertidos en piel con
catgut crmico 1-0, se verifica hemostasia, se da por terminado acto quirrgico. Sale paciente de sala de expulsin en
buenas condiciones generales y hemodinmicamente estable.
Hallazgos:
Sexo: ______________________
Talla: _________________ cm
Dr. ____________________________
R1GO __________________________
MIP ___________________________
Historia Clinica
IMSS
Servicio Ginecobstetricia
Diseo: Luis Humberto Cruz Contreras
tomatetumedicina.wordpress.com
Ficha de identificacin
Nombre:
________________________________________________________________________
Afiliacin:
________________________________________________________________________
Edad:
Sexo:
________ aos
Femenino
Estado civil:
________________________________________________________________________
Ocupacin:
________________________________________________________________________
Origen:
________________________________________________________________________
Reside:
________________________________________________________________________
Religin
________________________________________________________________________
Interrogatorio: ________________________________________________________________________
Responsable:
________________________________________________________________________
Elaboracin:
Escolaridad:
________________________________________________________________________
Transfusionales: _____________________________________________________________________________________________
Antecedentes Ginecoobsttricos
Menarca: ___________ Menstruacin : ____________________ IVSA: _________________ Mtodo Ant.___________
tiempo de uso ____________ FURN: ___/ ________/ _____ FPP ___/_______/_____ Gestas _____ Para ______ Cesreas
____________Abortos ________, No parejas sexuales: __________, Mtodo ant. que desea ______________, Menopausia
____________________ ltima Citologa vaginal ______________________, Autoexploracin mamara
______________________, Mamografa ______________________
Padecimiento Actual
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Sntomas Generales
______________________________________________________________________________________________________
________________________________________________________________________________________
Exploracin Fsica
Signos Vitales
TA
Exploracin general
______________________________________________________________________________________________________
____________________________________________________________________________________________
Cabeza
______________________________________________________________________________________________________
___________________________________________________________________________________________
Cuello
______________________________________________________________________________________________________
____________________________________________________________________________________________
Trax
______________________________________________________________________________________________________
____________________________________________________________________________________________
Abdomen
______________________________________________________________________________________________________
____________________________________________________________________________________________
Extremidades
______________________________________________________________________________________________________
____________________________________________________________________________________________
Genitales
______________________________________________________________________________________________________
____________________________________________________________________________________________
Impresin Diagnstica:
_________________________________________________________________________________________________________
Mip _____________________________________
Notas de evolucin
Ginecologa y Obstetricia
cama _______
Fecha
___ /______ /_____
_______ hrs
________________________________________________________
_______________________________________________________
SV
Nota de Evolucin
TA _______/______
FR ___
FC _____ lpm
T _____ C
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________________________
SV
Nota de Evolucin
TA _______/______
FR ___
FC _____ lpm
T _____ C
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________________________
SV
Nota de Evolucin
TA _______/______
FR ___
FC _____ lpm
T _____ C
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________________________
Nota de Alta
Ginecologa y Obstetricia
Nombre
Cama:
Afiliacin
Edad:
SV: FC: _____ FR: ______ TA: _____ / ____ Temp. _____ C
Resumen Clnico:
Paciente femenina de _____ aos de edad,
con diagnstico antes mencionado. Se realiza procedimiento quirrgico sin incidentes ni complicaciones.
Hallazgos
A la exploracin fsica paciente conciente, orientada, con adecuado estado de hidratacin y coloracin de
tegumentos, cardiopulmonar si compromiso, abdomen con ligero dolor en hemiabdomen inferior,
extremidades sin edema.
Paciente que ha evolucionado satisfactoriamente y se decide su egreso por mejora.
Plan:
Alta a su domicilio
Cita abierta a urgencias ginecoobsttricas en caso de signos de alarma (dolor, sangrado o fiebre)
Recoger resultado de patologa
Cita a consulta externa de ginecologa en 1 mes
Dr. _______________________
R1GO __________________
MIP ___________________