Ministerio del Poder Popular para el Nombre: ___________________________

Trabajo y Seguridad Social Instituto

Venezolano de los Seguros Sociales Edad: _____________________________
Hospital Dr. José María Carabaño Tosta. # Historia: _________________________
Servicio de Ginecología y Obstetricia.

Fecha: ______/______/___________
Hora: __________________ RESUMEN DE INGRESO

Motivo de consulta: ________________________________________________________________________

Enfermedad Actual: ________________________________________________________________________
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ANTECEDENTES FAMILIARES
Padres: ___________________________________________________________________________________
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Hermanos: ________________________________________________________________________________
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ANTECEDENTES PERSONALES
Antecedentes patológicos de importancia: ______________________________________________________
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Alergias: __________________________________________________________________________________
Quirúrgicos: ______________________________________________________________________________
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Transfusiones: _____________________________________________________________________________

ANTECEDENTES GINECOLOGICOS
Menarquia: _____ años, ciclos menstruales: _____________, duración: ___________cantidad: __________
Dolor: ______________ Sexarquia _____ años, N° de parejas: ________________, Método de planificación
familiar: _____________________________________________________________, Ultima citología______
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Enfermedades de transmisión sexual: __________________________________________________________

ANTEDECENTES OBSTETRICOS
Embarazos anteriores: ______________________________________________________________________
Complicaciones: ____________________________________________________________________________
Peso máximo fetal: __________________________, Peso mínimo fetal: _______________________________

EMBARAZO ACTUAL
N° de controles: ____________________________________________________________________________
Infección del tracto urinario: _________________________________________________________________
Infección vaginal: __________________________________________________________________________
Inductores de maduración pulmonar: __________________________________________________________
Otras complicaciones: _______________________________________________________________________
 EXAMEN FISICO
PESO: __________TALLA: ________ PA: _______/_________ mmHg Frc: _______ lpm, FrR______ rpm
Estado general: ____________________________________________________________________________
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Mamas: __________________________________________________________________________________
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Cardiopulmonar: __________________________________________________________________________
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Abdomen: ________________________________________________________________________________
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Genitales externos: _________________________________________________________________________
Especulo: _________________________________________________________________________________
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Tacto: ____________________________________________________________________________________
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Extremidades: _____________________________________________________________________________
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Neurológico: ______________________________________________________________________________
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FECHA Hemoglobina FECHA HIV

HCT VDRL
Leucocitos Tipeaje
Neutrófilos Toxoplasmosis
Linfocitos Uroanalisis
Plaquetas
PT
PTT
CORRELACIÓN ECOGRAFICA
Fecha de ecografía Semana de gestación Para la fecha actual

Comentario: ______________________________________________________________________________
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IDX de Admisión: __________________________________________________________________________

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