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FI 11.4.23
Natural: Bucaramanga
Procedente: Bogota
Residente: Bogota
Vive con: Esposo e hijo (Julian Guzman)
Ocupación: Pensionada (empleada bancaria)
Lateralidad
Religión
MC
EA
Paciente en aceptables condiciones generales
- C/C: normcefalo, pupilas isocóricas, reactivas, escleras anictéricas, conjuntivas normocrómicas, cavidad oral humeda, sin lesiones, cuello, moviles y sin adenopatías
- TÓRAX: simétrico, expansibilidad conservada, RsCs rítmicos sin soplos, RsRs conservados, sin sobreagregados
- ABDOMEN: a la inspección sin lesiones, RsIs presentes, blando, depresible, doloroso a la palpacion profunda en hipogastrio y fosa iliaca derecha, sin signos de irritación peritoneal
- EXTREMIDADES: eutróficas, moviles, pulsos presentes y simétricos
- SNC/SNP: alerta, consciente y orientado, nomina, comprende y repite, sin deficit ni focalización aparente en el momento
Laboratorios:
11.4.23 ph 7.47 pco2 19 po2 90 hc03 13.9 be -7.0 sat 90.8 leu 8.85 neu 7.22 linf 0.93 gran inm 0.06 mon 0.60 eo 0.01 ba 0.03 hb 12 hcto 35.9 vcm 87.1 hbcm 29.1 plt 287 bun 68 cr 3.95 parcial de orina color amarillo claro aspecto lig turbio densidad 1030 ph 6.0 proteínas trazas glucosa, cetonas, bilirrubinas, nitritos, leucocitos negativos, sedimento urinario leucocitos 0-5xc clls altas escasas leucocitos 0-5xc bacterias escasas Gram de orina no se observan.
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