HABITACION: ____OCUPACION: ____________________________________ FECHA 9/2 10 12 13 FECHA 9/2 10 12 12

ORIUNDO_____________ CC:________________ GRPO SANGUINEO______ LEUC 18 22 23 24 GOT 51 28 34

NOMBRE ____________________________________ EDAD: ____________ LINF 13 14 7.6 8 GPT 35 26 24
MC_____________________________________________________________
NEUT 74 73 81 79 FA 557
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EA:_____________________________________________________________ MON 6 5 3 4 BILR 8.7 4.4
_______________________________________________________________ EOSIN 3 1 6 7 DIR 6.7 3.4
_______________________________________________________________ BASO 1 1 1 1 INDIR 1.9 0.9
_______________________________________________________________ HB 9.4 8.6 6.7 6.5 NA+ 136 131 123
_______________________________________________________________ VMC 83 83 85 86 K+ 4.3 4.2 3.5
_______________________________________________________________ HCM 26 26 25 27 CL- 104 100 100
ANTECEDENTES:
PLAT 104 83 75 71 OSM
PATOLOGICOS:___________________________________________________
_______________________________________________________________ INR 1 1 1 1 GAP
_______________________________________________________________ PT 10 13 12 12 VIH
HEREDOFAMILIARES:______________________________________________ PTT 28 29 29 29 pH 7.4 7.36
_______________________________________________________________ CR 0.8 0.5 0.4 0.4 PO2 83 49
QUIRURGICOS___________________________________________________
CESAREA SI__ NO__ G___ P__ A__ C___ PORQUE ______________________ BUN 21 12 8 8 PCO2 29 32
ALERGICOS______________________________________________________ UREA 44 25 17 HCO3 21 18
_______________________________________________________________ DEPC-G D(A-a)
FARMACOLOGICOS_______________________________________________ GLICE 97 118 97 80 SO2 97 82
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HDL LACTA
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TOXICOS________________________________________________________ LDL P. TOL 4.1
EXAMEN FISICO COLES P. DIF
_______________________________________________________________ TRIG ALBU 3.0
_______________________________________________________________ CA++ 8 AMILA
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PO4-3 LIPASA
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_______________________________________________________________ VDRL L. PLE
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_______________________________________________________________ LDH 185 187 166 GLUC
_______________________________________________________________ VSG 25 PROTE
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PCR <6 6 LDH
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RETIC LEUCO
FERRI ADA
TRASF AMILA
Fe ++ COLES
EVOLUCION
HABITACION __ CC._____________FECHA DE INGRESO__________________
NOMBRE _________________________EDAD_________ G.S-Rh__________
ORIUNDO DE ________________OCUPACION_________________________
PACIENTE CON _________________ DIAS DE ESTANCIA HOSPITALARIA CON
DIAGNOSTICO DE:
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Objetivo: FC____ FR____ TA_____SAT______ GLUCOMETRIA _______
PESO_______ IMC___________ PAM_______ TEMPERATURA______
DIURESIS__________________________________________________
RXTORAX__________________________________________________
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EKG______________________________________________________
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PARCIAL DE ORINA__________________________________________
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OTRO PARACLINICO SI___ NO___ CUAL: ________________________
REPORTE:__________________________________________________
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TRATAMIENTO______________________________________________
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PENDIENTES_____________________________________________________
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ANALISIS________________________________________________________
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CAMBIOS_______________________________________________________
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