META CLINIC INVESTMENTS S.A.

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CLINICAL HISTORY
Emergency Department
Type of HC: HCURGE
INCOME DATA
Income: 21889 01/17/2021 10:43:59 PM Bed
No. Folio: 17 Folio Date: 01/17/2021 10:50:26 PM Service Area: EMERGENCIES CM - CONSULTATIONS
External Cause: General_Disease Not Applicable
PATIENT DATA
Doc type. Citizenship ID 1121883229 Names: VELASQUEZ SUAREZ YARENS PAOLA
F. Nac. 02/12/1991 12:00:00 a.m. Age of HC 29 Years, 1 Month, 15 Days Female
Married Telephone: Occupation:
Address: CARRERA 18A No 6 - 33 ARIGUANI II Origin: URBAN
AFFILIATION DATA
Entity: Sanitas Health Promotion Entity EPS Plan: CONTRIBUTORY HEALTH INSURANCE EPS
S.A.S.
Level/Stratum: QUOTE TO A Regimen CONTRIBUTORY
Date and time of start of service: Sunday, January 17, 2021 10:50 PM
Treating Specialty:
REASON FOR THE CONSULTATION
I am leaking fluid
CURRENT ILLNESS
29-year-old patient, G2C1V1, with a pregnancy of 38.2 weeks according to the first trimester ultrasound, reports a clinical picture of 4 hours of fluid discharge.
THROUGH THE VAGINA ASSOCIATED WITH PAIN IN THE LOWER ABDOMEN "CONTRACTION TYPE" A FEW MINUTES AGO. DENIES PREMONITORY SIGNS OF
PREECLAMPSIA, VAGINAL BLEEDING OR DISCHARGE OF LIQUID THROUGH THE VAGINA, EMESIS, FEVER, AND DYSMURIA. POSITIVE FETAL MOVEMENTS.
BACKGROUND
TYPE DATE OBSERVATIONS
Doctors 17/01/2021 PATHOLOGICAL: MIGRAINE: WILL CEASE DUE TO DYSTOCIA OF PRESENTATION, NASAL SEPTUM DRUGS:
NIEGAALERGIAS: NIEGAG/O: G2C1V1 FUP 30/08/2013, FUM: 30/04/2020. ETS: NIEGACPN: SI, TRASTORNO
Pregnancy hypertension, have ruled out preeclampsia or positive HIV and syphilis.
15/12/2021
Uterine and fetal arteries within normal ranges, with cerebroplacental index in
PERCENTILE 10 THAT RAISES SUSPICION OF UNDERLYING LATE-ONSET PLACENTAL INSUFFICIENCY WITHOUT
SIGNS OF ASPHYXIA AT THE MOMENT

REVISION BY SYSTEMS
Head and Senses:
Thorax/Cardio/Pulmonary :
Digestive System :
Genito - Urinary:
Musculoskeletal
Neurological:
Skin and Appendages:
PHYSICAL EXAM
Vital Signs
TAS: 120.0000 TAD: 70.0000 mm Hg TAM:86.6667 mm Hg FC: 73.0000 x MIN. 16.0000 x MIN.

Temperature 36.4000 °C 98.0000 Perfusion: <2 Seg. State of Consciousness: Alert

:
Ocular Response: Spontaneous 4 Verbal Response: Guidance 5 Motor Response: Follows Commands 6 Glasgow: 15.0000

Peso 79.0000 Kgs Size: 162,000 cms 30.1000

0

General State: PHYSICAL EXAM: PREGNANT WOMAN IN ACCEPTABLE GENERAL CONDITION, ALERT, AFEBRILE, HYDRATED, WITHOUT SIGNS OF
RESPIRATORY DIFFICULTY. C/C: NON-JAUNDICED SCLERAE, NORMOCHROMIC CONJUNCTIVAE, MOIST ORAL MUCOSA,
MOBILE NECK WITHOUT MASSES OR LYMPHADENOPATHIES. C/P: SYMMETRICAL THORAX, NORMALLY EXPANDABLE, RHYTHMIC HEART SOUNDS,
NO BREATH SOUNDS, VESICULAR MURMUR PRESENT, NO AGGREGATES. ABDOMEN: GLOBULAR DUE TO PREGNANT UTERUS, FHR: 143
LPM, FETUS IN LONGITUDINAL POSITION, LEFT BACK, CEPHALIC PRESENTATION, INTESTINAL SOUNDS
PRESENT, SOFT, DEPRESSIBLE, NOT PAINFUL A THE PALPATION, WITHOUT SIGNS OF IRRITATION
[Link]: EXTERNAL GENITALS NORMOCONFIGURED, WITHOUT LESIONS, NORMOTHERMIC VAGINA,
NORMOELASTIC, UTERUS IN AVF, POSTERIOR CERVIX LONG AND SOFT, CLEAR AMNIORRHEA, NO VAGINAL BLEEDING.
EXTRE: EUTROPHIC, SYMMETRICAL, WITHOUT EDEMA, PRESENT PULSES, CAPILLARY FILLING LESS THAN TWO SECONDS. NEURO:
ALERT, ORIENTED, NORMOREACTIVE ISOCORIA, INTACT CRANIAL NERVES, NO MOTOR OR SENSORY DEFICIT
GLASGOW 15/15.

Print Date: Monday, January 18, 2021 User: 1121912092

LICENSED TO: [INVERSIONES CLINICA META S.A.] NIT [892000401-7]

 META CLINIC INVESTMENTS S.A. Page 2/2

CLINICAL HISTORY
Emergency Department
Type of HC: HCURGE
INCOME DATA
Income: 21889 01/17/2021 10:43:59 PM Bed:
No. Folio: 17 Folio Date: 01/17/2021 10:50:26 PM Service Area: EMERGENCY CM - CONSULTATIONS
External Cause: General Disease Not Applicable
PATIENT DATA
Doc type. Citizenship ID 1121883229 Names: VELASQUEZ SUAREZ YARENS PAOLA
F. Nac. 02/12/1991 12:00:00 a.m. Age of HC 29 Years 1 Month 15 Days Female
Married Telephone: Occupation:
Address: CARRERA 18A No 6 - 33 ARIGUANI II Origin: URBAN
AFFILIATION DATA
Entity: SANITAS EPS Health Promotion Entity Plan: CONTRIBUTORY EPS SANITAS
S.A.S.
Level/Stratum: QUOTE TO Regimen: CONTRIBUTIVE
Head and Senses :
Neck :
Cardio-Pulmonary-Vascular :
Abdomen:
Genitourinary
Members:
Musculoskeletal:
Neurological:
Skin and Appendages
ANALYSIS: 29-YEAR-OLD PATIENT WITH TERM PREGNANCY, IN PRELABOR, WITH SOFT CERVIX AND CLEAR AMNIORRHEA, GIVEN THE
THE ANTECEDENT IS DISCUSSED WITH THE ON-CALL GYNECOLOGIST, HOSPITALIZATION IN THE DELIVERY ROOM IS INDICATED. EXPLANATION IS GIVEN.
Clearly the patient refers to understanding and accepting.
THERAPEUTIC PLAN: OBSERVATION DELIVERY ROOM LACTATED RINGER AT 100 CC/HOUR IV SS.// VX GYNECOLOGY SS:// VIG AND SYPHILIS,
FETAL MONITORING UTERINE ACTIVITY CONTROL VITAL SIGNS CONTROL
DIAGNOSTIC IMPRESSION ICD-10 CODE
CODE NAME DESCRIPTION DX PRINCIPAL TYPE
O479 FALSE LABOR WITHOUT OTHER SPECIFICATION Presumptive
IN-HOSPITAL TREATMENT PLAN
QUANTITY NAME VIA ADM OBSERVATION
1 PERIPHERAL IV CATHETER SAFETY 18G X1.16 INCH None ,
1 BURETROL TEAM 150ML None ,
1 PUMP EQUIPMENT WITH KEY 5000/XL None ,
1 Ringer's Lactate Injectable Solution 1,000ML Intravenous 100 CC/ HOUR
5 HYPODERMIC SYRINGE WITH NEEDLE 10ML 21G*1/2 None .
1 NON-STERILE LONG SLEEVE SURGICAL GOWN None ,
REQUESTED EXAMS
Name HUMAN IMMUNODEFICIENCY VIRUS HIV 1 AND 2 ANTIBODIES F. Request January 17, 2021 11:07 PM
Observation
Name TREponema pallidum Antibodies (Treponemal Test) Manual F. Application 17/01/2021
(RAPID TEST)
Observation
Name Fetal Monitoring Antepartum F. Request 17/01/2021
Observation
MEDICAL INDICATIONS
NAME OBSERVATIONS
Emergency Observation
REFERRED SPECIALTIES
NAME REASON
341 - GYNECOLOGY AND OBSTETRICS PRELABOR - MEMBRANE RUPTURE

Print Date: Monday, January 18, 2021 User: 1121912092

LICENSED TO: [INVERSIONES CLINICA META S.A.] NIT [892000401-7]

GUERRERO PRADA MAIRA ALEXANDRA Professional: WARRIOR PRADA MAIRA ALEXANDRA
GENERAL MEDICINE R . M .: 1121915588
GENERAL MEDICINE

Print Date: Monday, January 18, 2021 User: 1121912092

LICENSED TO: [INVESTMENT CLINIC META S.A.] NIT [892000401-7]