Evaluacion abdomen agudo(3 sept) by Stanley Olivares

•EVALUACION DEL ABDOMEN AGUDO

•EVALUACION SUBSECUENTE Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

HOJA DE EVALUACION DE ABDOMEN AGUDO NOMBRE : ______________________________________________ REGISTRO : _____________FECHA: ____/____/____ EDAD : ______________ SEXO : M  F OCUPACION : ________________________ HORA: _______  AM CONSULTA POR____________________

CARACTERISTICAS DEL DOLOR

 PM

 SUBITO  PROGRESIVO ACTUAL _________________ FORMA DE INICIO  LENTO INICIAL ____________________

TIEMPO EVOLUCION: ______ Hrs.

INTENSIDAD INICIAL

 LEVE  MOD  SEVERA

LOCALIZACION

INTENSIDAD ACTUAL

 LEVE  MOD  SEVERA

ESCALA DOLOR INICIAL

1 2 3 4 5 6 7 8 9 10

ESCALA DOLOR ACTUAL

1 2 3 4 5 6 7 8 9 10

 CONTINÚO  ARDOROSO 0 QUEMANTE TIPO  COLICO CONTINUO  INTERMITENTE  EXACERBACIONES  CON COMIDAS  COLICO INTERMITENTE  EN CINTURON  CON MOVIMIENTOS REPIRATORIOS  OPRESIVO RELACIONES CON MOVIMIENTOS  CON MICCION IRRADIACION:  NO SI DONDE_____________________________________  CON MOV. DE MIEMBROS INFERIORES POSICIONES : SI  NO ANTALGICAS

REFERIDO  NO SI 

 EPISODIOS   UNIDAD/SALUD

PRIMERA VEZ SEGUNDA VEZ MULTIPLES

MEDICACION SI  AUTO  MEJORO CUAL________________ NO  MEDICO IGUAL _______________________

MEDICO PRIVADO

________________________________

 HOSPITAL

Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

SINTOMATOLOGIA AGREGADA  SI  ANTECEDE AL DOLOR  INICIO  CONTINUO  LEVE FIEBRE  NO EVOLUCION ______  A MEDIADOS TIPO :  INTERMITENTE INTENSIDAD:  MOD  AL FINAL  REMITENTE  FUERTE  SI NAUSEAS  NO ESCALOFIOS  NO ASOCIADO A FIEBRE  SI  SI  NO

ICTERICIA

 SI  NO

 SI VOMITOS  NO

 OCULAR _____/ 4 CRUCES  GENERALIZADA

RELACION CON CUADRO ACTUAL: SI  NO TIEMPO EVOLUCION ________

CUANTIFICADA:________ªc

PERDIDA PESO

 NO  SI _____lbs PERIODO______MES

COLURIA  NO  SI ACOLIA  NO  SI  TOTAL  PARCIAL

 SECO  GASTRICO  ANTECEDE AL DOLOR  NINGUNA TIPO : BILIAR  PRECOZ FRECUENCIA :_____ INCOERCIBLES RELACION/DOLOR  AUMENTA  FECALOIDE  TARDIO DISMINUYE

 NO  INICIO  ABUNDANTE LIQUIDA  SANGUINOLENTA DIARREA  SI EVOLUCION ______  A MEDIADOS CANTIDAD :________ FRECUENCIA : ______ V/D CARACTERISTICA  PASTOSA  MOCO  AL FINAL TENESMO SI  NO 

ESTREÑIMIENTO

 SI  NO

LEUCORREA

 SI  NO

URINARIA :  DISURIA  URGENCIA  HEMATURIA  POIAQUIURIA

 BLANCA /GRUMOS FETIDA  SI  AMARILLA  NO  DIFICULTAD A LA MICCION

ANOREXIA :  INTOLERANCIA ALIMENTARIA  HAMBRE DOLOROSA  DISPEPSIA  ASOCIADA A HALITOSIS Y ERUCTOS EXAMENES PREHOSPITALARIOS: _________________________________________________________________________________________________________________________________________ OTROS: __________________________________________________________________________________________________________________________________________________________________

Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

ANTECEDENTES PERSONALES CUADROS SIMILARES PREVIOS :  NO  SI ESTUDIOS PREVIOS :_________________________________________________________________________ ALERGIAS :___________ _________________________________________________________ ENFERMEDADES MEDICAS :  NO  SI ___________________________________________________________________ CIRUGIAS PREVIAS:  NO  SI ___________________________________________________________________________ USO DE MEDICAMENTOS HABITUALES :  NO  SI _____________________________________________________ FACTORES PSICOLOGICOS:  SI  CUADROS DE STRESS

 NO  DEPRESION ESTRENIMIENTO CRONICO :  SI  NO

ANTECEDENTE GINECOLOGICO F U R : _______________

 DIARIO  CADA 3 DIAS PATRON DEFECATORIA:  CADA 2 DIAS  MAYOR DE 3 DIAS



REGULAR CICLO MENSTRUAL :  IRREGULAR

DURACION ___________

G__P___P___A___V___

DISMENORREA :  SI

 NO INCAPACITANTE AMENORREA  SI CUANTO: _______________  NO  INCAPACITANTE  NO PLANIFICACION  ACO  MENSUAL  BIMENSUAL  TRIMESTRAL  OTROS FAMILIAR Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

EXAMEN FISICO : T A : _________ F C :________ F R : ________ T º : ____________  AGUDAMENTE ENFERMO  TIEMPO  TRANQUILO  SOMNOLIENTO APARIENCIA  CRONICAMENTE ENFERMO ORIENTADO EN  LUGAR ACTITUD  ANSIOSO  INQUIETO  APARENTEMENTE SANO  PERSONA  AGRESIVO POSICION :  INMOVIL  MAHOMETANA  FLEXION DEL MUSLO SOBRE EL ABDOMEN  ATENUA CON LOS MOVIMIENTOS  GENERALIZADA MANIFESTACIONES GENERALES:  PALIDEZ DIAFORETICO  CIANOTICO  ROBICUNDO  ICTERICO  OCULAR _____/ 4 CRUCES

POR SISTEMAS : _________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________ Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

ABDOMEN :  PLANO INSPECCION  GLOBOSO  EXCAVADO  AUSENTE PERISTALSIS  PRESENTE

 ESCASO PANICULO ADIPOSO  ABUNDANTE  NORMAL  AUMENTADA  DISMINUIDA

 BLANDO/DEPRESIBLE RESISTENCIA  MUSCULAR VOLUNTARIA  MUSCULAR INVOLUNTARIA

DOLOR

 BORBORIGMOS  METEORISMO

 NO CICATRICEZ  SI DONDE ____________________________________________ PERCUSION  TIMPANISMO  MATIDEZ

 DEPRESIBLE PALPACION  EMPASTAMIENTO

NORMAL  ANORMAL ___________________________________________  NORMAL  ANORMAL __________________________________________

DONDE:_________________________________________________________

 SUPERFICIAL  GENERALIZADA  PROFUNDA LOCALIZACION  LOCALIZADA UBICACIÓN _______________________________________________________________________

SIGNOS: APENDICULARES  NEGATIVO  POSITIVO / CUALES: ______________________________________________________________________________________________________________  MURPHY  NEG  POS  JOBERT  NEG  POS OTROS / DEFINA _________________________________________________________________________  REBOTE  NEG  POS  SUPERIORES  NEG  POS SIGNOS URINARIOS : PUNTOS URETERALES  MEDIOS  NEG  POS PUÑO PERCUSION RENAL  DERECHA  NEG  POS  INFERIORES  NEG  POS  IZQUIERDA  NEG  POS TACTO :  VAGINAL ____________________________________________________________________________________________________________________________________________________________  RECTAL ___________________________________________________________________________________________________________________________________________________________

DEFECTOS HERNIARIOS_____________________________________________________________________________________________________________________________________________________ MASAS: ________________________________________________________________________________________________________________________________________________________________________ REGION INGUINAL___________________________________________________________________________________________________________________________________________________________ Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

HOSPITAL NACIONAL ZACAMIL

EMERGENCIA MEDICO-QUIRURGICA

DIAGNOSTICO: _____________________________________________________________________________ ______________________________________________ PLAN:

*____________________________________________ *____________________________________________ *____________________________________________ *____________________________________________

ANALISIS _____________________________________________________________________________________________________________________________ ____ _____________________________________________________________________________________________________________________________ ____ _____________________________________________________________________________________________________________________________ ____ ______________________________________________________________________________________________________ ___________________________ _____________________________________________________________________________________________________FIRMA___________________

EVALUACION INMEDIATO SUPERIOR :

R2 

R3 

JR 

OTROS 

_________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ____ _________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ____ _________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ____ ______________________________________________________________________________________________ FIRMA__________________________

OPINION DE STAFF ____________________________________________________________________________________________________________ _____________________ _____________________________________________________________________________________________________________________________ ____ __________________________________________________________________________________________________________ _______________________ _____________________________________________________________________________________________________________________________ ____ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________

PLAN DEFINITIVO _________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ____ _________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________ _____________________________________________________________________________________________________________________________ ____ ___________________________________________________________________________________________ ______________________________________

FIRMA ______________________

Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

HOSPITAL NACIONAL ZACAMIL

EMERGENCIA MEDICO-QUIRURGICA

HOJA DE EVALUACION SUBSECUENTE DEL ABDOMEN AGUDO REGISTRO: _______________FECHA: _____/_______/_______

NOMBRE: ____________________________________________ HORA

: ______

 AM

 PM

NUMERO DE EVALUACION

 SEGUNDA  TERCERA

EVOLUCION DEL DOLOR TIEMPO DE EVOLUCION AL MOMENTO: ____________Hrs. CAMBIOS

TIEMPO DE ESTANCIA EN OBSERVACION

 MAS  MENOR DE  3 A 6 HORAS  7 A 12 HORAS

 13 A 24 Hrs  MAYOR 24 Hrs

 IGUAL _____________________________________________________________________________________________________________________________ ________________________  MEJORIA_____________________________________________________________________________________________________________________________ __________________________  PEOR ______________________________________________________________________________________________________________________________________________________

LOCALIZACION:

INTENSIDAD

IRRADIACION:  SI DONDE___________________________________________  NO

ACTUAL ________________________________________

 LEVE  MOD  SEVERA

ESCALA

POSICIONES ANTALGICAS

 SI  NO

EXAMEN FISICO : TA : ______________ FC : _____________ FR :____________ Tº ___________ ______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _________ ______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _________ __________________________________________________________________________________________________________________________________ ____ __________________________________________________________________________________________________________________ ____________________ EXAMENES LABORATORIO: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

ESTUDIOS COMPLEMENTARIOS:

Rx_____________________________________________________________________________________________________________________________ ______ _____________________________________________________________________________________________________________________________ __________ _____________________________________________________________________________________________________________________________________ USG:________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ OTROS:_______________________________________________________________________________________________ _______________________________ ______________________________________________________________________________________________________________________________________

Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil

HOSPITAL NACIONAL ZACAMIL

EMERGENCIA MEDICO-QUIRURGICA

DIAGNOSTICO: _____________________________________________________________________________ ______________________________________________ PLAN:

*____________________________________________ *____________________________________________ *____________________________________________ *____________________________________________

EVALUACION INMEDIATO SUPERIOR :

R2 

R3 

JR 

OTROS 

FIRMA ______________________

Dr. Stanley Olivares jefe de Emergencia Hospital Nacional Zacamil