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HISTORIA CLNICA

IDENTIFICACIN

Nombre: _______________________________________________ HCL N:_______________

Sexo: __________ Edad: ___________ Fecha de nacimieno:_______________________

L!"ar de nacimieno: ________________________ L!"ar de #rocedencia:________________

L!"ar de re$idencia: _______________________ E$co%aridad:

________________________Oc!#aci&n: ____________________ 'i%i(a #roecore$ _________ Reirado #oren)ermedad ___

Re%i"i&n: _____________ E$ado ci*i%: ___________ Direcci&n de re$idencia:_________________

Te%+)ono: ______________________ Ce%!%ar:____________________________

Fecha in"re$o a !r"encia$: ______________ Fecha ra$%ado a medicina

inerna: ______________

Enidad a$e"!radora: ___________________ F!ene in)ormaci&n:________________________

Ca%idad de in)ormaci&n: _____________________ Fecha e%aboraci&n HCL:___________________

Nombre$ enre*i$adore$:__________________________________________________________

,OTI-O DE CONS'LTA

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ENFER,EDAD ACT'AL ./rea0 comien(o0 d!raci&n0 e$ c1c%ico0 e$ado ac!a%0 i#o do%or0inen$idad0 acom#a2amieno$0 a!mena o di$min!3e con0 en*ironmen4

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ANTECEDENTES

56 7ATOL8ICOS .Dx0 dro"a0 Cr%e$0 cri$i$0 ac!a%idad40 a%er"ia$0

inm!ni(acione$

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9 'IR;R8ICOS

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8 _____ 7 _____ A _____ C _____ , _____ E _____ - _____ Fecha B%imo 7aro____________

9 ACTI-IDAD SE'AL .Inicio0 )rec0 i#o #area0 Bnica0 o mB%i#%e$0#roecci&n4

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9 FAR,ACOL8ICOS .Do$i$0 )rec!encia0 adherencia4

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9 TRANSF'SIONALES .@Tran$)!$ione$0 i#o $an"re0 reacci&n0)echa0 *o%!men4

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ANTECEDENTES

9 TOICOL8ICOS: .Comien(o0 na%0 Frec: 7a?!ee$CTD

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9 S'EKO .Hora inicio0 conci%iaci&n $!e2o0 #ro)!ndidad0 De$#erar0inerr!#cione$0 #romedio4

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9 -IAES

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9 SOCIOECON,ICOS .,aeria% *i*ienda0 $er*icio$0 $aniario$0 cocina con %e2a0@#er$ona$0 o$edor cr&nico4

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G6 FA,ILIARES .7adre$0 hermano$0 hio$4

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FA,ILIO8RA,A

RE-ISIN 7OR SISTE,AS

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8ENERAL .7e$o0 a$enia0 adinamia0 ebre0 dioa)ore$i$0 e$ca%o)r1o4________________________________________________________________________________________________________________________________________________________________

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7ie%_____________________________________________________________________________

Cabe(a__________________________________________________________________________

Oo$____________________________________________________________________________

Nari(____________________________________________________________________________

O1do$___________________________________________________________________________

Oro)arin"e_______________________________________________________________________C!e%%o___________________________________________________________________________Re$#iraorio______________________________________________________________________Cardio*a$c!%ar____________________________________________________________________

T8I_____________________________________________________________________________'ro%&"ico________________________________________________________________________

Si$re#rod!______________________________________________________________________

,!$c!%oe$?!e%+ico_______________________________________________________________Ne!ro%&"ico______________________________________________________________________

Endocrino________________________________________________________________________

Hemao_________________________________________________________________________

7$i?!iMrico______________________________________________________________________

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EXPLORACIN FSICA

A$#eco "enera%:

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Ta%%a _________________ 7e$o ________________ I,C ."

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F!er(a__________________________________________________________________________

Cerebe%o

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9 Orienaci&n: .9 54 _________

Tem#ora%: Fecha.54___ me$ .54___ d1a $emana.54____ a2o .54___ C%ima.54___

E$#acia%: L!"ar .54___ #i$o .54 ___ ci!dad .54 ___ De#arameno .54___7a1$ .54__

9 Re#eici&n inmediaa: .9P4 ____

QLe *o3 a nombrar P #a%abra$6 !iero ?!e %a$ re#ia de$#!+$ de m16Trae de memori(ar%a$0 #!e$ $e %a$ *o3 a #re"!nar en 5 min!o mM$6/R=OL ,ESA 7ERRO

9 Aenci&n 3 cM%c!%o: .94 _____

Seria% : .5 meno$ 4 UP9 VW9 U9 G9 W .hacer chec en cadare$#!e$a correca4

De%erear ,'NDO a% re*+$: O __ D __ N __ ' __ ,__ .XAnoar e% meor#!nae4

9 ,emoria .9P4 ____

7edir ?!e re#ia %a$ P #a%abra$ #re*ia$0 dar 5 #!no #or cadare$#!e$a correca6

9 Len"!ae .9 54

,o$rar !n LA7ICERO __ 3 !n RELO ___ .e% #aciene debe nombrar%o$4Y .9G4 ____

Re#eir !na )ra$e QEn %a ca$a ha3 #erro$Y .954 ____

Z!+ $on !n #erro 3 !n "ao[ .954 _____________________________________

Orden: QTome e$e #a#e% con $! mano derecha0 d&b%e%o #or %a miadcon amba$ mano$0 3 d+e%o $obre %a cama Y .9P4 ____

Leer 3 obedecer: Qcierre %o$ oo$ Y .954 ____

E$cribir !na )ra$e .con $!eo0 *erbo0 #redicado4 Y .954 ____

Co#iar %o$ #enM"ono$ Y .954 ____

7!nae oa%: ____

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CIERRE LOS OOS

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