Republica Bolivariana de Venezuela

Republica Bolivariana de VenezuelaMinisterio del Poder Popular para la Educacin Superior

Universidad del Zulia

Facultad de Medicina

Escuela de Medicina

Catedra de Semiologia-Patologia Medica

HUM-HCHistoria Clnica Integral

Fecha:___/___/___A. Datos de Identificacin:

Nombres y Apellidos:____________________________________________________

Edad:___________ Sexo:________________Grupo tnico:_____________________ Religin:___________________ Raza:______________Grupo Sanguneo:________ Estado Civil:______________ Lugar y Fecha de nacimiento:___________________ ______________________________________________________________________

Nacionalidad:___________________ Profesin u Ocupacin___________________Direccin Actual:_______________________________________________________ ______________________________________________________________________Grado de Instruccin:_______________ Fecha de Ingreso:_____________________Numero de Habitacin:____________ Telfonos:_____________________________

Informacin Suministrada por:__________________ Parentesco:_______________ Confiabilidad:_________________ B. Motivo de Consulta:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.C. Enfermedad Actual:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.D. Antecedentes

D.1 Antecedentes Personales y Patolgicos:

Hbitos:

a.Dieteticos/Alimenticios:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

b.Alcoholicos:_____________________________________________________________________________________________________________________________________________________________________________________________.

c.Cafeicos:________________________________________________________________________________________________________________________________________________________________________________________________.

d.Tabaquismo:____________________________________________________________________________________________________________________________________________________________________________________________.

e.Drogas:_________________________________________________________________________________________________________________________________________________________________________________________________. f.Sexuales:_____________________________________________________________________________________________________________________________. g.Sueo:__________________________________________________________________________________________________________________________________________________________________________________________________.h.Ejercicios/recreacion:_____________________________________________________________________________________________________________________________________________________________________________________.

i.Condiciones Higinicas:

_________________________________________________________________________________________________________________________________________________________________________________________________________.

Enfermedades y Medicamentos: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Alergias:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Hospitalizaciones y Operaciones:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Accidentes:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Transfusiones y Transplantes:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Trabajos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Vivienda:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Vacunas:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

D.2 Antecedentes Familiares:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

E. Revisin de Sistemas:

a. Enfermedades Infecto-contagiosas y ETS: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

b.Psiquico:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.c.Cabeza:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

d.Ojos:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

e.Oidos:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.f. Nariz y Senos paranasales: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.g. Boca y Garganta: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.h.Cuello:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.i. Aparato Respiratorio:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.j. Aparato Cardiovascular:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.k. Aparato Digestivo:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.l. Aparato Genitourinario:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.m. Antecedentes Ginecolgicos y Obsttricos:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.n. Neuromuscular, Articulaciones y Huesos:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

. Piel y Anexos:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

o. Endocrino, nutricional y hematopoytico:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.F. Examen Fsico

Signos Vitales:

-Presin Arterial:____________________________________________________.

-Pulso:_____________________________________________________________.

-Respiracion:_________________________________________________________________________________________________________________________________________________________________________________________________________.

-Temperatura:___________________________________________________________________.

-Peso y Talla:___________________________________________________________________.

Condicin General del paciente: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Cabeza:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Cuello:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Torax:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Abdomen:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Miembros:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Neurologico:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

G. Hallazgos Positivos:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.H. Diagnsticos:Diagnstico Sindromatico:____________________________________________.

Diagnstico Anatmico:______________________________________________.

Diagnstico Funcional: _______________________________________________.

Diagnstico Etiolgico: _______________________________________________.

Diagnstico Principal:________________________________________________. Diagnsticos Diferenciales:______________________________________________________________________________________________________________________________________.I. Evolucin Intrahospitalaria: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Realizado por:

Br:____________________________C.I:_________________Firma:_____________

Br:____________________________C.I:_________________Firma:_____________

Br:____________________________C.I:_________________Firma:_____________