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***RESPUESTA INTERCONSULTA MEDICINA INTERNA****
MC: "Tengo fiebre"
MI: "ITU parcialmente tratada"
-NATURAL: Bogotá
-PROCEDENTE: Bogotá
-RESIDENTE: Bogotá
-RELIGION: Católica
-ESCOLARIDAD: Técnico en criminalística
-OCUPACIÓN: Secretaria administrativa
-ESTADO CIVIL: Unión libre
-LATERALIDAD: diestra
-VIVE CON: Pareja e hija de 9 años
-FAMILIAR: Alex forero
CALIDAD DE INFO: buena
EA:
ANTECEDENTES:
-PATOLOGICOS: niega
-FARMACOLOGICO : niega
-QX: Niega
-ALERGICOS: Niega
-TÓXICOS: Niega
- FAMILIARES: ca de mama (abuela)
-HOSPITALIZACIONES: Marzo 2023 por IVU la cual fue tratado con Amoxa/clavulonato 15 días
-ETS: Niega
-GINECOLOGICOS: G1P1E0C0A0M0 FUP 14/02/2007 FUR 28/03/2023 MENARQUIA: 14 años ANTICINCEPTIVOS: Yadel IVS: 15 años NPS: 4
-INMUNOLÓGICOS: 2 dosis para COVID SINOVAC
EF:
-C/C: normocéfalo, simetría facial, conjuntivas anictéricas, mucosa oral semiseca sin lesiones orofaringe sin lesiones o escurrimiento posterior, cuello simétrico, movilidad conservado sin adenomegalias, sin masas sin ingurgitación yugular
- tórax: simétrico, sin retracciones, normoexpansible, RsRs presentes sin agregados RsCs rítmicos y sin soplos
-Abdomen: RsIs presentes no solos, blando, levemente doloroso en flanco izquierdo, sin signos de irritación peritoneal, puñopercusión positiva
- Extremidades: simétricas, móviles, sin edema
-Neurológico: paciente alerta, orientada en 3 esferas, sin signos aparentes de focalización
RESULTADOS:
LABORATORIOS:
*09/04/2023: uroanalisis: contaminado, gram sin germen// b hcg: negativa // BUN: 6.53// creatinina: //hemograma: leucos: 16420 linfo 1270 neu 14070 hb 13.9 HTO 39.8 VCM 90.2 PLQ 308000
*11-03/2023: urocultivo extrainsttucional: E. coli amikacina sensible, ampi/sulbactam sensible, BLEE negativo cefazolina sensible, cefepime sensible, ceftriaxona sesible ertapenem sensible, gentamicina resistente, nitrofurantonia sensible trimetropim/ sulfa resistente
IMAGENES:
*09/04/2023: eco vías urinarias: sin alteraciones
ANALISIS:
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