Todo caso que prese!e e"a!e#a #$cu%o p$pu%o &es'cu%ar que e&o%uc'oa a cos!ra (co po%'#or)'s#o re*'oa%+, de prese!ac' c.)a%o cauda%, #u/ prur'*'osa, co o s' )'e0re1 /, que ade#$s prese!a cua%qu'era de %as s'*u'e!es #a')es!ac'oes2 so0re')ecc'oes de p'e% / par!es 0%adas ('#p.!'*o, ce%u%'!'s, a0sceso, )asc'!'s ecro!'3a!e, pa'cu%'!'s, o!ras+1 euro%*'cas (cere0e%'!'s, ece)a%'!'s, #e'*'!'s, #'e%'!'s, s4dro#e de Gu'%%a' 5arr.+1 resp'ra!or'a (eu#o'!'s, (eu#o'!'s, eu#o4as+1 6e#a!o%*'cas (s4dro#e 6e#orr$*'co+1 &'scera% o d'se#'ada d'se#'ada (#'ocard'!'s, per'card'!'s, 6epa!'!'s, e)r'!'s+1 u o!ras co#p%'cac'oes, o que por e% co#pro#'so de% es!ado *eera%, requ'era 6osp'!a%'3ac'7 CODIGO DE REGISTRO N8
Fec6a de 6osp'!a%'3ac'
Fec6a de I&es!'*ac' (&'s'!a do#'c'%'ar'a+
Fec6a o!')'cac' EESS a Red9M'crorred
Fec6a o!')'cac' Red9M'crorred a D'recc' de Sa%ud
Fec6a de o!')'cac' de D'recc' de Sa%ud a CDC
::::9:::::9::::: ::::9:::::9:::::
::::9:::::9::::: ::::9:::::9:::::
SEMANA ;< ;< - <=>?
::::9:::::9::::: ::::9:::::9:::::
::::9:::::9::::: ::::9:::::9:::::
DISA9 DIRESA9 GERESA ::::::::::::::::::: ::::::::::::::::::: RED :::::::::::::::::::::: :::::::::::::::::::::: No#0re de% EESS ::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::: Cap!ac' de% caso2 V'*'%ac'a pas'&a ( + V'*'%ac'a ac!'&a ( + Ape%%'do pa!ero::::::::::::: pa!ero::::::::::::::::: :::: Ape%%'do #a!ero2 #a!ero2 :::::::::::::::::::: :::::::::::::::::::: No#0res 2 ::::::::::::::::: ::::::::::::::::: DNI::::::::::::::::: DNI::::::::::::::::: Fec6a de ac'#'e!o2 ::::9:::::9::::: ::::9:::::9::::: Edad ::::::A@os 9 Meses Se"o M B F B No#0re de %a #adre9!u!or2 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Te%)9Ce%u%ar7:::::::::::::::::::::::::
Depar!a#e!o Pro&'c'a D's!r'!o Loca%'dad
No#0re de 3oa T'po de &4a (A&7 r7 Ca%%e Ps7 O!ro+ No#0re de &4a N#ero9#79M37
Depar!a#e!o2 ::::::::::::::::::::::: :::::::::::::::::::::::::::::::: ::::::::: Pro&'c'a2 ::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::: :::::::::::::: D's!r'!o2 ::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::: ::::::::::::::: ::: Loca%'dad2 :::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::: ::::::::::::
No#0re de 3oa 2 ::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::: ::::::::::::::: ::: T'po de &4a (A&7 r7 Ca%%e Ps7 O!ro+2:::::::::::::::::::::::::: No#0re de &4a2 :::::::::::::::::::::: :::::::::::::::::::::::::::::::::: :::::::::::::::::::: :::::::: N#ero9#79M372:::::::::::::::::: N#ero9#79M372:::::::::::::::::::::::::::::: ::::::::::::::::::::::: :::::::::::
E %as %!'#a %!'#ass < a se#a se#aas as es!u&o es!u&o e co!ac co!ac!o !o co o!ro o!ro caso caso de &ar'ce &ar'ce%a %aJJ (S'+ (S'+
Casa
( +
N'do9*uarder4a
( +
Co%e*'o
( +
'&ers'dad9Is!'!u!o
( +
Ce!ro de !ra0ao
( +
Es!a0%ec'#'e!o de sa%ud
( +
O!ros (espec')'car+
( +
(No+ (No+
('*or ('*orado ado++
Es!e caso !u&o co!ac!o co!ac!o co *es!a!e (SI+ (NO+ e qu. qu. )ec6a2 :::9::::9:::: :::9::::9:::: Se#aas de *es!ac' e que suced' e% co!ac!o B
Fec6a ''c'o erupc' de %es'oes d.r#'cas2 ::::9::::9:::: T'po de %es' d.r#'ca2 #$cu%a ( + p$pu%a ( + &es4cu%a ( + cos!ra ( +
Fec6a ''c'o de )'e0re2 ::::9::::9:::: ::::9::::9:::: N8 d4as durac'2 ( Te#pera!ura2 :::: 8C
+
(S'+ (No+ So0re')ecc' de p'e% / par!es 0%adas
(
+
Neuro%*'cas
(
+
Resp'ra!or'as
(
+
He#orr$*'cas
(
+
Ma%)or#ac' co*.'!a
(
+
(S'+
(No+
I#uosupres'
(
+
Desordees #e!a0%'cos
(
+
As#a
(
+
E)er#edades reu#a!o%*'cas
(
+
C$cer
(
+
E)er#edades card4acas
(
+
Ges!a!e2 NK se#aas de *es!ac'
(
+
O!ras (espec')'car+
(
+
A%!a #.d'ca (
+
B
A%!a &o%u!ar'a (
+
Re)er'do (
+
Fa%%ec'do (
+
Fec6a2
Re)er'do a2 Causa de #uer!e2
So%o cos'derar dos's de &acua co co#poe!e a!'&ar'ce%a2 N#ero de dos's rec'0'da2 :::::::::
-
-
Fec6a de %!'#a dos's2
Fue!e de &er')'cac'2 ::::::::::::::::::::::::::
No es!$ 'd'cado %a o0!ec' de #ues!ra ru!'ar'a para d'a*s!'co de &ar'ce%a, dado que .s!a es e#'e!e#e!e c%4'co7 Las #ues!ras de %a0ora!or'o se 'd'ca e casos co#p%'cados *ra&es e %os que o se !e*a cer!e3a de% d'a*s!'co c%4'co7
T'po de #ues!ra
Fec6a de o0!ec' de >8 #ues!ra
Fec6a e&4o EE SS, Red 9 M'crorred
Fec6a e&4o Red 9 M'crorred a LRR
Fec6a e&4o LRR a INS
Fec6a e#'s' resu%!ado INS
Resu%!ado
O0ser&ac'oes
Suero H'sopado de &es4cu%a
No#0re de %a persoa que '&es!'*a e% caso2 ::::::::::::::::::::::::::::::::::::::::: Te%.)oo::::::::::::::::::::::::::: Car*o :::::::::::::::::::::::::::::::::::::: e#a'% ::::::::::::::::::::::::::::::::::::::::::::::::::::::::: F'r#a ::::::::::::::::::::::::::::
Centro Nacional de Epidemiología, Prevención y Control de Enfermedades – Ministerio de Salud Correo electrónico:
[email protected] - Telefax 01 – 631 – 4500, Calle aniel !laec"ea 1##, $e%&% 'ar(a - )i*a 11 INFS!"#$ %&%%'(%&)& Es una línea gratuita de notificación desde cual*uier tel+fono fio o p-.lico de /elefónica
