Evaluacion abdomen agudo ( 03 sept oficial) by Stanley Olivares

HOSPITAL NACIONAL ZACAMIL

EMERGENCIA MEDICO-QUIRURGICA

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

 PM

CARACTERISTICAS DEL DOLOR TIEMPO EVOLUCION: ______ Hrs.

INTENSIDAD INICIAL

TIPO

 LEVE  MOD  SEVERA

INICIAL ____________________ ACTUAL _________________ FORMA DE INICIO

LOCALIZACION

 LEVE  MOD  SEVERA

INTENSIDAD ACTUAL

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  COLICO CONTINUO  INTERMITENTE  EXACERBACIONES  COLICO INTERMITENTE  EN CINTURON  OPRESIVO RELACIONES

IRRADIACION:  NO  SI DONDE_____________________________________ POSICIONES : SI  NO EPISODIOS

ANTALGICAS

REFERIDO  NO

SI 

  

PRIMERA VEZ SEGUNDA VEZ MULTIPLES

UNIDAD/SALUD

 SUBITO  PROGRESIVO  LENTO

 CON COMIDAS  CON MOVIMIENTOS REPIRATORIOS  CON MOVIMIENTOS  CON MICCION  CON MOV. DE MIEMBROS INFERIORES

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

MEDICO PRIVADO

________________________________

 HOSPITAL

SINTOMATOLOGIA AGREGADA  SI  ANTECEDE AL DOLOR FIEBRE  NO EVOLUCION ______

NAUSEAS

ICTERICIA

VOMITOS

 SI  NO

 SI  NO  SI  NO

ESCALOFIOS

 CONTINUO TIPO :  INTERMITENTE  REMITENTE

URINARIA :  DISURIA

 INICIO  A MEDIADOS  AL FINAL  SI  NO

CUANTIFICADA:________ªc

PERDIDA PESO

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

 SECO  GASTRICO  ANTECEDE AL DOLOR TIPO : BILIAR  PRECOZ FRECUENCIA :_____ INCOERCIBLES  FECALOIDE  TARDIO

ESTREÑIMIENTO

 LEVE INTENSIDAD:  MOD  FUERTE

 NO ASOCIADO A FIEBRE  SI  SI  NO

 OCULAR _____/ 4 CRUCES  GENERALIZADA

 NO DIARREA  SI EVOLUCION ______ TENESMO SI  NO 

 INICIO  A MEDIADOS  AL FINAL

COLURIA  NO  SI ACOLIA  NO  SI

 SI  NO

 BLANCA /GRUMOS 

 URGENCIA  HEMATURIA  POIAQUIURIA

 TOTAL  PARCIAL

 NINGUNA RELACION/DOLOR  AUMENTA DISMINUYE

 ABUNDANTE LIQUIDA CANTIDAD :________ FRECUENCIA : ______ V/D CARACTERISTICA  PASTOSA

LEUCORREA

 NO  SI _____lbs PERIODO______MES

 SANGUINOLENTA  MOCO

FETIDA  SI  NO

 DIFICULTAD A LA MICCION

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

ANTECEDENTES PERSONALES CUADROS SIMILARES PREVIOS :  NO  SI ESTUDIOS PREVIOS :_________________________________________________________________________ ALERGIAS :___________ _________________________________________________________ ENFERMEDADES MEDICAS :  NO  SI _____________________________________________________________________________ CIRUGIAS PREVIAS:  NO  SI ____________________________________________________________________________________ USO DE MEDICAMENTOS HABITUALES :  NO  SI ________________________________________________________________

 SI

 CUADROS DE STRESS

FACTORES PSICOLOGICOS  NO  DEPRESION ESTRENIMIENTO CRONICO :  SI  NO

PATRON DEFECATORIA

 DIARIO  CADA 3 DIAS  CADA 2 DIAS  MAYOR DE 3 DIAS

ANTECEDENTE GINECOLOGICO F U R : _______________

 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

ESOU

HOSPITAL NACIONAL ZACAMIL EXAMEN FISICO :

APARIENCIA

T A : _________

F C :________

 AGUDAMENTE ENFERMO  CRONICAMENTE ENFERMO  APARENTEMENTE SANO

POSICION :  INMOVIL

ORIENTADO EN

EMERGENCIA MEDICO-QUIRURGICA

F R : ________ T º : ____________  TIEMPO  LUGAR  PERSONA

ACTITUD

 MAHOMETANA  FLEXION DEL MUSLO SOBRE EL ABDOMEN

 TRANQUILO  SOMNOLIENTO  ANSIOSO  INQUIETO  AGRESIVO  ATENUA CON LOS MOVIMIENTOS  GENERALIZADA  OCULAR

MANIFESTACIONES GENERALES:  PALIDEZ DIAFORETICO  CIANOTICO  ROBICUNDO  ICTERICO

_____/ 4 CRUCES

POR SISTEMAS : _________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________

ABDOMEN : INSPECCION

PERISTALSIS

 PLANO  GLOBOSO  EXCAVADO  AUSENTE  PRESENTE

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

 BLANDO/DEPRESIBLE RESISTENCIA  MUSCULAR VOLUNTARIA  MUSCULAR INVOLUNTARIA

DOLOR

 SUPERFICIAL  PROFUNDA

LOCALIZACION

 BORBORIGMOS  METEORISMO

PALPACION

CICATRICEZ

PERCUSION  TIMPANISMO  MATIDEZ

 DEPRESIBLE  EMPASTAMIENTO

 GENERALIZADA  LOCALIZADA

 NO  SI DONDE ____________________________________________ NORMAL  ANORMAL ___________________________________________  NORMAL  ANORMAL __________________________________________

DONDE:_________________________________________________________

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___________________________________________________________________________________________________________________________________________________________

DIAGNOSTICO: _____________________________________________________________________________ ______________________________________________ PLAN:

*____________________________________________ *____________________________________________ *____________________________________________ *____________________________________________

ANALISIS ________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ___________ ________________________________________________________________________________________________________________________________ ________ ________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________FIRMA________________________

EVALUACION INMEDIATO SUPERIOR : R 2 

R3 

JR 

OTROS 

_____________________________________________________________________________________________________________________________ ___________ ________________________________________________________________________________________________________________________ ________________ _____________________________________________________________________________________________________________________________ ___________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________ FIRMA__________________________

OPINION DE STAFF ________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ___________ ________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________ ________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ___________

PLAN DEFINITIVO _____________________________________________________________________________________________________________________________ ___________ ________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ___________ ________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ___________ ________________________________________________________________________________________________________________________________________

FIRMA ESOU

______________________

HOSPITAL NACIONAL ZACAMIL

EMERGENCIA MEDICO-QUIRURGICA

HOJA DE EVALUACION SUBSECUENTE DEL ABDOMEN AGUDO NOMBRE: ____________________________________________ REGISTRO: _______________FECHA: _____/_______/_______ 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:______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________

DIAGNOSTICO: _____________________________________________________________________________ ______________________________________________ PLAN:

*____________________________________________ *____________________________________________ *____________________________________________ *____________________________________________

ANALISIS _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ________ _____________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________FIRMA_________________________

EVALUACION INMEDIATO SUPERIOR : R 2 

R3 

JR OTROS 

FIRMA ______________________ ESOU