INSTITUTO VENEZOLANO DE LOS SEGUROS SOCIALES

HOSPITAL UNIVERSITARIO “DR. RAFAEL CALLES SIERRA”

SERVICIO DE GINECO OBSTETRICIA
PUNTO FIJO – ESTADO FALCÓN

RESUMEN DE INGRESO
NOMBRE Y APELLIDO: __________________________ NRO. HISTORIA:
FECHA: HORA:
MC: ____________________________________________________________________________________
EA: ____________________________________________________________________________________
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DATOS SOCIECONÓMICOS
Grado de instrucción: ______________________ Cónyuge: _________________
Ocupación: ________________ Cónyuge: _____________ Remunerado: ________
Casa propia: _____ Techo: ________________ Paredes: ______________ Luz: ____
Piso: ___________ Aseo: _________ Agua potable: __________ Cloacas: ______

ANTECEDENTES FAMILIARES:
Abuelo: Materno: _________________________ Paterno: ________________________________
Abuela: Materna: _________________________ Paterna: ________________________________
Madre: ____________________________ Padre: _____________________________________________
Hermanos: __________________________________ Hijos: __________________________________

ANTECEDENTES PERSONALES
DM: _____________ HTA: ________________ Asma: ____________ Alergias: ____________________
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Tipiaje: _____________________
Transfusiones:___________________________________________________________________________
Interv. Quirúrgicas: _______________________________________________________________________

ANTECEDENTES GINECO OBSTETRICOS

Menarquia: _____________Ciclos: _____________ FUR: ____________ FPP: ___________________
PRS: _______________ PS: ______________________ Gestas: __________ Abortos: ____________
Partos: ___________ Cesáreas: _________ Ectópicos: ____________ EQx: ___________________
Uso de DIU: _____________________________________________________________________________
Uso de ACOs: ___________________________________________________________________________
FU Parto/Cesárea: ___________ Peso Max.: ________ Peso Min.:________ FU citología: __________
Reporte: ________________________________________________________________________________
Emb. Actual planificado: _______ Aceptado: _______ Controlado: ________ Nro. Controles: ______
Lugar: _________________________________________________________________________________
Complicaciones:_________________________________________________________________________
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 EXAMEN FISICO
TA: ____________ FC: ________ FR: ________ Peso: __________ Talla: ________
ORL: ___________________________________________________________________________________
CUELLO: _______________________________________________________________________________
CARDIOPULMONAR: _____________________________________________________________________
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MAMAS: ________________________________________________________________________________
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ABDOMEN: AU: ______________ FETO: ___________________ SITUACION: ___________________
DORSO: ____________________ PRESENTACIÓN: _________________ FCF: ____________________
DU: ____________________________________ MF: ____________________________________________
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GENITALES EXTERNOS: _________________________________________________________________
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ESPECULOSCOPIA: ______________________________________________________________________
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TACTO VAGINAL: ________________________________________________________________________
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TACTO BIMANUAL: ______________________________________________________________________
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TACTO RECTAL Y/O RECTOVAGINAL: ______________________________________________________
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EXTREMIDADES: ________________________________________________________________________
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NEUROLÓGICO: _________________________________________________________________________
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DIAGNÓSTICO: _________________________________________________________________________
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COMENTARIO DE INGRESO: ______________________________________________________________
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DR(A) .___________________________