RESUMEN DE EGRESO SERVICIO DE NEUROCIRUGIA

Nombres y Apellidos:_________________________________________________________ Edad________ C.I:___________________

N Hist:___________________

FECHA INGRESO:_________________________ FECHA EGRESO:__________________________

Motivo Ingreso: ( ) Enfermedad Comn ( ) Accidente Comn

( ) Otros (especifique)__________________________________

Causa Ingreso:_______________________________________________________________________________________________
Ex. Fsico de ingreso: Glasgow______/15 puntos (AO ____ RV____ RM____), pupilas _______________, __________reactivas a la
luz, reflejo corneal (
(____/++++),

FM

), consensual (

), fotomotor (

MsSs izq (____/V),

FM

), tusgeno (

MsSs der

), apnea a los 2 min. (

(____/V),

FM

), ROT MsSs (____/++++), ROT MsIs

MsIs izq (____/V),

FM

MsIs der

(____/V);

___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
________________________.
Impresin Diagnostica de Ingreso:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_______________________________________________________________________________________________

Intervencin(es). (Fecha y Procedimiento efectuado) __________________________________________________________________

___________________________________________________________________________________________________________________
_______________________________________________________________________________________________________

Ex. Fsico de egreso: Glasgow______/15 puntos (AO ____ RV____ RM____), pupilas _______________, __________reactivas a la luz,
reflejo corneal (
(____/++++),

FM

), consensual (

), fotomotor (

MsSs izq (____/V),

FM

), tusgeno (
MsSs der

), apnea a los 2 min. (

(____/V),

FM

), ROT MsSs (____/++++), ROT MsIs

MsIs izq (____/V),

FM

MsIs der

(____/V);

___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
________________________.

Diagnsticos de Egreso:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
______________________________________________________________________________________________________________

Mdico