REPBLICA BOLIVARIANA DE VENEZUELA

UNIVERSIDAD DEL ZULIA

FACULTAD DE MEDICINA
ESCUELA DE MEDICINA
UNIDAD DOCENTE HOSPITAL CHIQUINQUIR
CTEDRA DE GINECOLOGA Y OBSTETRICIA II
HISTORIA CLNICA
A.-DATOS DE IDENTIFICACIN
Nombre Completo: ___________________________ Edo. Civil: _________ Edad: _____
Lugar y Fecha de Nacimiento ______________________ Procedencia: ______________
Profesin: ______________ Ocupacin: _____________ Fecha de Ingreso: ___________
Direccin Actual: __________________________________________________________
Telfono (s):__________________________________ Raza: ______________________
B.- MOTIVO (S) DE CONSULTA
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C.- ENFERMEDAD ACTUAL
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EJBJ/2000

D. ANTECEDENTES FAMILIARES
TBC: ___________________________________________________________________
SFILIS: _________________________________________________________________
DIABETES: ______________________________________________________________
CARDIOVASCULAR: ______________________________________________________
NEUROLGICOS: ________________________________________________________
CNCER: _______________________________________________________________
ASMA BRONQUIAL: _______________________________________________________
EMBARAZOS MLTIPLES: _________________________________________________
OTROS PROCESOS: ______________________________________________________
E.- ANTECEDENTES PERSONALES
Mdicos:_________________________________________________________________
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___Eruptivas
___ Diabetes

___ Enfermedad de

___ Enf. Vasculares

Transmisin Sexual

Perifricas

___ Parsitos
___ Alergias

___ Fracturas

___ Cardiopatas

___ Tiroides

___ Drogas

___ Enf. Articular y

___ T.B.C.P.

___ Hemorroides

___ Exp. Ambiental

___ Tabaquismo

___ Inf. Urinarias

___Otros

de Colgeno

GINECOLGICOS:________________________________________________________
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QUIRRGICOS:__________________________________________________________
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ANTECENDENTES GINECO-OBSTTRICOS
Menarquia a los ___________ aos. Caracteres_________________________________
tipo: ___________________ Primeras Relaciones Sexuales a los _______________ aos
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Ao

Tipo de

Tipo de

Embarazo

Parto

Tiempo
de

Hemorragia

Trabajo

Lesin
Perineal

HTA
Inducida

Puerperio

Peso del

Vivo (v)

Nio

Muerto (m)

Embarazo

Sexo

CONTROL PRENATAL
Amenorrea desde______________ Parto Probable______________ Paridad: _________
Donde hizo Prenatal: ______________________________________________________
No. De Consultas hechas: __________________________________________________
En el ______________________________________ No. De Historia ________________
OBSERVACIONES:
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PACIENTE

CNYUGUE

Grupo Sanguneo
RH
VDRL- FTA

FECHA

ULTRASONIDOS
RESULTADOS

MUESTRA
HEMATOLGICA

FECHA DE HALLAZGO

Hemoglobina
Hematocrito
Cuenta Blanca
Frmula
Glicemia
Examen de Orina
Citologa
HIV
Toxotest
Otros

F.- EXAMEN FSICO

PESO PREVIO

PESO ACTUAL

TALLA

TEMPERATURA

PULSO

RESPIRACIN

T.A.

ASPECTO GENERAL

GINECOLGICO
Vulva y Perin:

PIEL:
CABEZA:
CUELLO:
TRAX:
MAMAS:

Vagina:
Cuello Uterino:
tero:
F. de Saco:

APARATO CARDIOVASCULAR:
EXTREMIDADES:
ABDOMEN:

VARICES:
APARATO LOCOMOTOR:

APARATO DIGESTIVO:

EDEMA:

APARATO URINARIO:

NEUROLGICO:

EXAMEN OBSTTRICO:
OTROS:

DIAGNSTICO(S) DE INGRESO:
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G.- PARTO
PERIODO DE BORRAMIENTO Y DILATACIN
Primeros dolores el da ________________a las _______ horas, ______ minutos _____m
Dilatacin Completa el da ______________ a las _______ horas, _____ minutos _____m
Variedad de Posicin: ___________________________
Ruptura de las Membranas a las ________ horas, _____ minutos ____m
Espontnea _____
Precoz
____
Artificial _____
Tempestiva ____
Tarda
____
Prematura
____

Caracteres del Lquido Amnitico: ____________________________________________

Duracin del periodo: ______________________________ Hora: _____ Minutos: _____
TACTOS
DA Y HORA

CUELLO,
CONSISTENCIA Y
LONGITUD

DILACIN

SEGMENTO
INFERIOR

PRESENTACIN:
POSICIN Y
PLANO

FOCO FETAL

FUNCIN
CONTRACTIL

MEMBRANAS

TEMPERATURA

OBSERVADOR

OBSERVACIONES:

MEDICACIN:

MONITOREO CLNICO DE LA PACIENTE PRE-PARTO

SIGNO VITAL
DE PACIENTE
(HORA)

EXPLORACIN
TERO
ABDOMINAL
(AU- FCF)

TACTO VAGINAL
MEMBRANAS
CUELLO
OTROS

CONTRACCIONE
S UTERINAS EN
10 MIN.

MEDICACIN

PERIODO DE EXPULSIN
DA

MES

CONDUCTA
(Parto, Cesrea
y Causa)
Lesin Perineal

RECIN NACIDO
SEX
O

AO

Nacimiento: __________

PESO

Hora: ____, ____ m

CONDICIONES:
Variedad de
posicin
durante el
desprendimiento

Duracin del
periodo expulsivo

PRODUCTO
(Sexo, Peso y
APGAR)

Duracin del
trabajo de parto

LONGITU
D

Desgarros Perineales (Grados)

Vagina

Cuello

Episiotoma: Tipo, Tcnica y Material de Sutura

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PERIODO DE ALUBRAMIENTO
A los ___ minutos de expulsin
Espontnea _____
Artificial _____

Medicamentos
_____
Maniobras externas _____
Extraccin Manual _____

Indicacin:_______________________________________________________________
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Cantidad de Sangre Perdida: ______________________________ c.c. aproximadamente
Observaciones:___________________________________________________________
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EXAMENES DE LOS ANEXOS
Placenta: Forma __________, Peso _____ grs., Insercin ________, Particularidades ___
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Membranas: Medidas__________________________________________________ cms.
Particularidades___________________________________________________________
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Cordn Umbilical: Longitud ____________________ cms. Volumen _________________
Particularidades___________________________________________________________
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MEDICAMENTOS

CANTIDAD

DURACIN

VALOR

VA

FECHA

HORA

ANALGESIA
ANESTESIA

MEDICACIN POST-PARTO
DROGA

DOSIS

Observaciones: ___________________________________________________________
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Intervencin, Medicacin y Observaciones: _____________________________________
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Indicacin: _______________________________________________________________
Anestesia: _________________ Dosis: _______________ Anestesilogo: ____________
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Dx Post Operatorio: _______________________________________________________
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Hallazgos Exploratorios ____________________________________________________
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Resumen de Ingreso _______________________________________________________

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PUERPERIO
SNTOMAS
Das Post-Parto
Dieta
Evacuaciones
Senos Condicin
Pezones
tero: Altura
Loquios
Perin
Observaciones

Secrecin
Condicin:

TRATAMIENTO

Firma

Firma
SNTOMAS

Das Post-Parto
Dieta
Evacuaciones
Senos Condicin
Pezones
tero: Altura
Loquios
Perin
Observaciones

TRATAMIENTO

Secrecin
Condicin:

Firma

Firma
SNTOMAS

Das Post-Parto
Dieta
Evacuaciones
Senos Condicin
Pezones
tero: Altura
Loquios
Perin
Observaciones

Firma

TRATAMIENTO

Secrecin
Condicin:

Firma