Hoja Clínica Quirúrgica

HOJA CLINICA QUIRÙRGICA.

FECHA: _____________________   FICHA Nº:__________________

ANAMESIS

¿Que le pasa?

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¿Desde cuando?

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Exploración clínica:

Actitud general:                        alerta___              deprimido__                         postrado___               

Estado general:                        normal__              delgado___                         caquéctico        ___       obeso___

Grado de hidratación:   normal__            semideshidratado__              deshidratado___

Mucosas:                     normal__             pálidas___                            congestivas____                      ictericias__

Constantes: Tª ____ (ºc)                            Pulso: __________                          FREC. Resp: __________

FREC. Card: ____________

Auscultación:                           Pulmón: _____________________         corazón: ___________________

Palpación Abdominal: ________________________

Sintomatología: ____________________________

Ecg ________   Rx _________   BHC _______  ECO________  Citología___________  AP___________

Antibioograma _________      Endoscopia_______________           Otros___________________

Resultados__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diagnostico______________________________________________________________________________________

Pronostico_______________________________________________________________________________________

Tratamiento______________________________________________________________________________________

Doy mi consentimiento para que el animal referido, sea sometido a anestesia e intervención quirúrgica, pruebas complementarias y cuantas actuaciones clínicas se estimen conveniente tras haber sido informado (a) de los riesgos que ello comporta.

Firma______________________________                                 Número cedula______/__________/___________

Nombres y Apellidos:________________/_________________/_________________/____________________

HOJA ANESTESICA

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Fecha: _____________________

Anestesista: _________________

VALORACIÒN   PREOPERATORIA.

Peso: ___________ (Kg.)

Carácter:         tranquilo: ______           nervioso______         violento__________           excitable_________

Tª _______ (ºC) Pulso:__________      FREC. Resp________          FREC. Card__________      

ANESTESIA

TIPO	DROGAS O DOSIS	EFECTO (+  ++  +++)

INTERVENCIÓN QUIRÚRGICA / ANESTESIA

POSICIÓN:____________________________________________________________________________________________________________________________________________________________________________________

TIEMPO	PULSO	FREC.CARD	FREC. RESP.

RECUPERACIÓN.

TIEMPO DE RECUPERACION: ____________________________________________________________________

OBSERVACIONES:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PROTOCOLO QUIRURGICO

RESPONSIBLE: _________________________________________________________________________________

INSTRUMENTISTA: ______________________________________________________________________________

AYUDANTE: ____________________________________________________________________________________

TIPO DE INTERVENCION:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

TRATAMIENTO POS- TOPERATORIO

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