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valoraciones de urgencias
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valoraciones de urgencias
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NOMBRE: PALOMINO CALTE JAZMINNSS: 71008316606F1997ORD
16.06.2023 09:45HRS
P. JAZMIN 25 AÑOS DE EDAD, ACUDE DE MANERA ESPOTNANEA A VALORACIÓN CURSANDO EMBARAZO DEL PRIMER TRIMESTRE
MOTIVO DE CONSULTA: DOLOR ABDOMINAL AYER Y MANCHADO HEMATICO TRANSAVGINAL HOY POR LA MAÑANA
APP: HEMOTIPO:
AGO: MENARCA A LOS FUR: FPP: MPF: CITOLOGÍA PAP:
CONTROL PRENATAL:
GESTA
S. PA:
SIGNOS VITALES: TA 115/81 mmHg, FC 85 LPM, FR 20 RPM, TEMP 36.9 °C, SPO2 98%
O. A LA EXPLORACIÓN FISICA, PACIENTE ORIENTADO EN SUS TRES ESFERAS, ALERTA, COOPERADOR, ADECUADA COLORACION DE PIEL Y
TEGUMENTOS, NORMOCÉFALO, SIN MEGALIAS NI OTRAS ALTERACIONES, TORAX CON ADECUADA ENTRADA Y SALIDA DE AIRE, PRECORDIO
RITMICO SIN AGREGADOS, ABDOMEN PLANO, DEPRESIBLE, RASTREO CON USG ENDOVAGINAL UTERO OCUPADO CON EMBARAZO
INTRAUTERINO, SACO GESTACIONAL NORMOIMPLANTADO, ADECUADA REACCION CORIODECIDUAL, SIN HEMATOMAS O
DESPRENDIMIENTOS, LCC 10.9MM= 7.1 SDG, FCF 165 LPM, CERVIX SIN MODIFICACIONES.
USG:
A. PACIENTE DE LA TERCERA DECADA DE LA VIDA QUE CURSA EMBARAZO DEL PRIMER TRIMESTRE AL MOMENTO SIN URGENCIA
OBSTETRICA, SE COMENTA LA POSIBILIDAD DE SANGRADO DE IMPLANTACIÓN SE SUGIERE USO DEPROGESTERONA COMPLEMENTARIA A
VITAMINAS.
IDX: GESTA 2 PARTO 1 EMBARZO DE 7.1 SDG POR LCC
PLAN:
ALTA DEL SERVICIO POR MEDIOS PROPIOS..
CITA CON SU MÉDICO FAMILIAR.
CITA ABIERTA A URGENCIAS EN CASO DE DATOS DE ALARMA, SE EXPLICAN.
DRA. LUZ DEL CARMEN GARCÍA MIRANDA
GINECOLOGÍA Y OBSTETRICIA MATRÍCULA 98389636
MIP CAÑA AVALOS
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