Post on 21-May-2015
Datos personales:
Nombre: _____________________________________________________________
Genero: __________________
Edad: ____________________
Fecha de nacimiento: ___________________________________________________
Ocupación:_______________________________________________
Estado civil: ______________________________________________
Religión:_________________________________________________
Dirección:_______________________________________________________________
Nivel de escolaridad: ____________________________________________________
Nombre del servicio: _____________________________________________________
Numero de cama: _______________________________________________________
Numero de expediente: _________________________________________________
Fecha y hora de ingreso: ________________________________________________
Fecha y hora de historia: _________________________________________________
Datos otorgados por: ____________________________________________________
Confiabilidad de los datos: _______________________________________________
Consulta por:____________________________________________________________
Presente enfermedad
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Antecedentes patológicos
• Enfermedades de la infancia: ______________________________________________________________________________________________________________________________________
• Enfermedades de la adolescencia: ______________________________________________________________________________________________________________________________________
• Enfermedades de la edad adulta: ______________________________________________________________________________________________________________________________________
• Hospitalizaciones: ______________________________________________________________________________________________________________________________________
Intervenciones quirúrgicas: ______________________________________________________________________________________________________________________________________
• Exámenes especiales ______________________________________________________________________________________________________________________________________
• Alergias:______________________________________________________________________________________________________________________________________
• Transfusiones: ______________________________________________________________________________________________________________________________________
Antecedentes no patológicos
• Cafeísmo: ____________________________________________________
• Etilismo: _____________________________________________________
• Tabaquismo:_________________________________________________
• Drogas: ______________________________________________________
• Patrón de sueño: ______________________________________________
• Patrón de micción: ____________________________________________
• Patrón de defecación: __________________________________________
• Alimentación: ________________________________________________
• Hidratación: __________________________________________________
• Inmunizaciones: ______________________________________________
• Antecedentes familiares: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
• Ecológico-social: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
EXAMEN FÍSICO
Apariencia general: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signos vitales:
- Presión arterial:
______________
- Pulso: ______________________
- Frecuencia cardíaca:
____________
- Frecuencia respiratoria:
_________
- Temperatura:
_________________
- Peso: ________________________
- Talla: _______________________
- IMC: ____________________
- PIEL__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- CABEZA___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- OJOS__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- OÍDOS___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- NARIZ Y SENOS PARANASALES___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- BOCA Y GARGANTA________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- CUELLO__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- TORAX
- PULMONARINSPECCION:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PALPACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PERCUSIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
AUSCULTACIÓN:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
- CARDÍACOINSPECCION:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PALPACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PERCUSIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
AUSCULTACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- ABDOMEN
INSPECCIÓN:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
AUSCULTACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PERCUSION:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PALPACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ARTICULACIONES: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ÓSEO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MÚSCULAR: __________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
- EXTREMIDADES
MIEMBRO SUPERIOR: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MIEMBRO INFERIOR: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- NEUROLÓGICO
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PARES CRANEALES:
I. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II. ______________________________________________________________________________________________________________________________________
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III. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
IV. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
V. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VI. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VII. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VIII. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
IX. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
X. ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
XI. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
XII. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Fuerza Tono Sensibilidad ROT
REFLEJOS ESPECIALES:
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DIAGNOSTICO:
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COMENTARIO DEL CASO:
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UNIVERSIDAD AUTÓNOMA DE SANTA ANAUNASAESCUELA DE MEDICINA
HISTORIA CLINICA
ALUMNO: _________________________________________________________
CÁTEDRA: ________________________________________________________
CATEDRÁTICO: ___________________________________________________
CICLO: ____________
FECHA: _______________________________________