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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:mif="urn:hl7-org:v3/mif" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
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<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
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<id extension="c266" root="2.16.840.1.113883.19.4"/>
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<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
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<title>Nota de episodio</title>
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<effectiveTime value="202512042041"/>
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<confidentialityCode code="V" codeSystem="2.16.840.1.113883.5.25"/>
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<recordTarget>
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<patientRole>
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<id assigningAuthorityName="Cédula ciudadanía" extension="55162001" root="2.16.840.1.113883.19.6.1.1"/>
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<id extension="2" root="2.16.840.1.113883.19.6.2.2"/>
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<id extension="2" root="2.16.840.1.113883.19.6.3.2"/>
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<id extension="1111" root="2.16.840.1.113883.19.6.4"/>
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<addr use="HP">
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<country>CO</country>
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<state>41</state>
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<city>41551</city>
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<postalCode>41551</postalCode>
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<streetAddressLine>VERIDA EL TUNAL</streetAddressLine>
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</addr>
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<telecom use="HP" value="88362500"/>
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<patient>
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<name>
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<given>SARA </given>
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<given>MILENA</given>
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<family>OSORIO</family>
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<family>LOPEZ</family>
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</name>
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<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
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<birthTime value="19741211"/>
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</patient>
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</patientRole>
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</recordTarget>
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<author>
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<time value="202512042041"/>
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<assignedAuthor>
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<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
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<assignedPerson>
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<name>
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<given>JUAN</given>
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<given>SEBASTIAN</given>
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<family>TOLEDO</family>
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<family>VAQUIRO</family>
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<suffix>MD.</suffix>
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</name>
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</assignedPerson>
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<representedOrganization>
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<id extension="Codigo ministerio" root="2.16.840.1.113883.19.5.4"/>
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</representedOrganization>
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</assignedAuthor>
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</author>
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<custodian>
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<assignedCustodian>
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<representedCustodianOrganization>
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<id root="2.16.840.1.113883.19.5.5"/>
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<name>HOSPITAL SAN ANTONIO DE PITALITO</name>
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<telecom/>
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<addr use="WP">
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<country>CO</country>
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<state>41</state>
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<city>41551</city>
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<postalCode>41551</postalCode>
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<streetAddressLine>Calle 3 Sur N° 1B 45</streetAddressLine>
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</addr>
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</representedCustodianOrganization>
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</assignedCustodian>
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</custodian>
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<componentOf>
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<encompassingEncounter>
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<id extension="8817" root="2.16.840.1.113883.2.17"/>
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<code code="R" codeSystem="2.16.840.1.113883.2.17" codeSystemName="CUPS" displayName="OTRAS ECOGRAFÍAS"/>
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<effectiveTime>
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<low value="20251203"/>
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<high value="20251204"/>
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</effectiveTime>
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<dischargeDispositionCode code="01" codeSystem="2.16.840.1.113883.12.112" codeSystemName="HL7 Discharge Disposition" displayName="Routine Discharge1 Vivo (a)"/>
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<location>
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<healthCareFacility>
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<id root="2.16.540.1.113883.19.2"/>
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<location>
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<name>Urgencia</name>
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</location>
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</healthCareFacility>
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</location>
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</encompassingEncounter>
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</componentOf>
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<component>
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<structuredBody>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="30525-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Age"/>
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<title>Edad</title>
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<text>50 Año</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="76437-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Primary insurance"/>
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<title>EPS</title>
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<text>Asociación Mutual La Esperanza ASMET SALUD</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="45410-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admitted from"/>
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<title>SERVICIO DE INGRESO</title>
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<text>1 Urgencias</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="29299-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for visit Narrative"/>
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<title>MOTIVO DE LA SOLICITUD DEL SERVICIO PERCEPCIÓN DEL USUARIO</title>
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<text>Paciente femenina de procedencia rural consulta por dolor abdominal agudo, de aparición súbita e intensidad progresiva, que motiva atención en urgencias</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="67800-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EMS injury incident description Narrative NEMSIS"/>
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<title>CAUSA EXTERNA</title>
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<text>13 Enfermedad general</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="42347-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admission diagnosis "/>
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<title>ESTADO GENERAL AL INGRESO</title>
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<text>Paciente en regular estado general, consciente, orientada, con facies de dolor, signos vitales dentro de parámetros iniciales.</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="81267-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Setting of exposure to illness"/>
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<title>ENFERMEDAD ACTUAL</title>
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<text>Paciente sin antecedentes de enfermedad conocidos.</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of family member diseases Narrative"/>
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<title>ANTECEDENTES FAMILIARES</title>
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<text>Paciente sin antecedentes</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past illness Narrative"/>
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<title>ANTECEDENTES PERSONALES</title>
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<text>Por favor llene los espacios de antecedentes que apliquen para el paciente.
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Antecedentes quirúrgicos
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Antecedentes Transfusionales
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Antecedentes Tóxicos
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Antecedentes inmunológicos
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Antecedentes alérgicos
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Antecedentes traumáticos
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Antecedentes psiquiátricos
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Antecedentes ginecobstétrico
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Antecedentes farmacológicos
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Antecedentes familiares
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Antecedentes psicológicos
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Antecedentes otros
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Antecedentes medicamento_contraindicado</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="8687-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Review of systems - Reported"/>
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<title>REVISIÓN POR SISTEMAS</title>
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<text>Ojos
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Oídos
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Nariz, boca y garganta
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Cardiovascular
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Respiratorio
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Gastrointestinal
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Genitourinarios
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Musculoesqueletico
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Linfatico
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Tegumentario
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Neurologíco
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Endocrino
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Inmunologíco
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Psiquiatrico</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings Narrative"/>
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<title>HALLAZGOS EXAMEN FÍSICO</title>
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<text>Mucosas hidratadas. Abdomen blando, doloroso a la palpación en región (epigastrio / mesogastrio / hipogastrio), sin signos de irritación peritoneal. Ruidos intestinales presentes. Extremidades sin edema. Piel sin alteraciones visibles.</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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| 208 |
<title>DIAGNOSTICO PRESUNTIVO INGRESO</title>
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<text>A011 Fiebre paratifoidea A</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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<title>DIAGNOSTICO RELACIONADO INGRESO</title>
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<text>A011 Fiebre paratifoidea A</text>
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</section>
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</component>
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<component>
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<section>
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<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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<title>DIAGNOSTICO CONFIRMADO INGRESO</title>
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<text>A011 Fiebre paratifoidea A</text>
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</section>
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</component>
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<component>
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<section>
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| 230 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="86922-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Therapeutic goals panel"/>
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<title>CONDUCTA: MANEJO TERAPÉUTICO</title>
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<text>Se indica manejo del dolor, hidratación oral según tolerancia, vigilancia de signos vitales y observación clínica. Se orienta sobre signos de alarma y seguimiento en APS.</text>
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</section>
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</component>
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<component>
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<section>
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| 238 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="11506-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Progress note"/>
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<title>NOTA DE PROGRESO</title>
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<text>Durante la estancia en urgencias, la paciente presenta mejoría progresiva del dolor abdominal tras manejo analgésico inicial. No se evidencian signos de complicación, no hay eventos adversos ni cambios desfavorables en su estado clínico. Debido a la evolución favorable y estabilidad hemodinámica, se modifica la conducta hacia egreso, con formulación de tratamiento ambulatorio y recomendaciones</text>
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| 242 |
</section>
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</component>
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<component>
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<section>
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| 246 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 247 |
<code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure Narrative"/>
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<title>RESULTADO DE PROCEDIMIENTOS</title>
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<text>la paciente presenta mejoría progresiva del dolor abdominal tras manejo analgésico inicial</text>
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| 250 |
</section>
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| 251 |
</component>
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<component>
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| 253 |
<section>
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| 254 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 255 |
<code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure indications"/>
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| 256 |
<title>INDICACIONES TERAPÉUTICAS</title>
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| 257 |
<text/>
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| 258 |
</section>
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| 259 |
</component>
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| 260 |
<component>
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| 261 |
<section>
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| 262 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 263 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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| 264 |
<title>DIAGNOSTICO PRESUNTIVO EGRESO</title>
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| 265 |
<text>A000 Colera debido a Vibrio cholerae 01, biotipo cholerae</text>
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| 266 |
</section>
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| 267 |
</component>
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| 268 |
<component>
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| 269 |
<section>
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| 270 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 271 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
|
| 272 |
<title>DIAGNOSTICO RELACIONADO EGRESO</title>
|
| 273 |
<text>A000 Colera debido a Vibrio cholerae 01, biotipo cholerae</text>
|
| 274 |
</section>
|
| 275 |
</component>
|
| 276 |
<component>
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| 277 |
<section>
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| 278 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 279 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
|
| 280 |
<title>DIAGNOSTICO CONFIRMADO EGRESO</title>
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| 281 |
<text>A000 Colera debido a Vibrio cholerae 01, biotipo cholerae</text>
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| 282 |
</section>
|
| 283 |
</component>
|
| 284 |
<component>
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| 285 |
<section>
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| 286 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 287 |
<code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge summary"/>
|
| 288 |
<title>PLAN DE MANEJO AMBULATORIO</title>
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| 289 |
<text>Analgesia y antiespasmódicos según fórmula. Hidratación y dieta blanda. Reposo relativo. Control por APS en 2–3 días. Acudir a urgencias por signos de alarma (dolor intenso, fiebre, vómito persistente, deshidratación, sangrado)</text>
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| 290 |
</section>
|
| 291 |
</component>
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| 292 |
</structuredBody>
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| 293 |
</component>
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| 294 |
</ClinicalDocument>
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