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PRESENTADO POR:_________________________________________ FECHA:_____________UNIVERSIDAD SANTIAGO DE CALIPROGRAMA TERAPIA R...
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GINECOOBSTRETICOSG ___________ P _______ C _________ A__________ FUM ___________CITOLOGIAS _______________________________...
OIDOS_____________________________________________________________________________________________________________________...
EXAMEN FISICO DEL SISTEMA RESPIRATORIOINSPECCIONRITMO DE LA RESPIRACIÓN___________________________________________________...
ESTERNON (maniobra de Pittres)________________________________________________________________________________COSTILLAS___...
AUSCULTACIONRUIDOS RESPIRATORIOS NORMALES_________________________________________________________________________________...
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Historia clinica adulto 1 terapeuta respiratorio

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Historia clinica adulto 1 terapeuta respiratorio

  1. 1. PRESENTADO POR:_________________________________________ FECHA:_____________UNIVERSIDAD SANTIAGO DE CALIPROGRAMA TERAPIA RESPIRATORIAHISTORIA CLINICA ADULTODATOS DE IDENTIFICACIONNOMBRE Y APELLIDOS _________________________________________________________No. HC___________________________ FECHA DE INGRESO ______________EDAD ______________ SERVICIO DE INGRESO___________No. IDENTIFICACION_____________________ SERVICIO ACTUAL __________GENERO F______ M _______ CAMA No. ________________RAZA ___________________ EPS ____________________________SISBEN___________________ OTROS__________________________ESTADO CIVIL ______________________ ESTRATO SOC.___________________PROCEDENCIA ______________________ CIUDAD _________________________NIVEL DE ESCOLARIDAD _________________ BARRIO ________________________OCUPACION ACTUAL __________________ INFORMANTE __________________GRUPO SANGUINEO ________________ RH _______________MOTIVO DE CONSULTA_______________________________________________________________________________________________________________________________________________________________ENFERMEDAD ACTUAL________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  2. 2. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ANTECEDENTES PERSONALESPATOLOGICOS__________________________________________________________________________________________________________________________________________________OCUPACIONALES _______________________________________________________________________________________________________________________________________________FARMACOLOGICOS______________________________________________________________________________________________________________________________________________HOSPITALARIOS_________________________________________________________________________________________________________________________________________________QUIRURGICOS___________________________________________________________________________________________________________________________________________________TRAUMATICOS__________________________________________________________________________________________________________________________________________________ALERGICOS_____________________________________________________________________TOXICOLOGICOS________________________________________________________________________________________________________________________________________________AMBIENTALES _________________________________________________________________________________________________________________________________________________EPIDEMIOLOGICOS______________________________________________________________________________________________________________________________________________SOCIOECONOMICOS___________________________________________________________________________________________________________________________________________VENEREOS______________________________________________________________________TRANSFUNSIONALES____________________________________________________________PSICOLOGICOS Y/O PIQUIATRICOS _______________________________________________
  3. 3. GINECOOBSTRETICOSG ___________ P _______ C _________ A__________ FUM ___________CITOLOGIAS __________________________________________________________________MAMOGRAFIA _________________________________________________________________ANTECEDENTES FAMILIARES________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________REVISION POR SISTEMAS Y EXAMEN FISICOCABEZA________________________________________________________________________________________________________________________________________________________________OJOS________________________________________________________________________________________________________________________________________________________________NARIZ Y SENOS PARANASALES________________________________________________________________________________________________________________________________________________________________BOCA Y GARGANTA________________________________________________________________________________________________________________________________________________________________
  4. 4. OIDOS________________________________________________________________________________________________________________________________________________________________CUELLO________________________________________________________________________________________________________________________________________________________________MAMAS________________________________________________________________________________ABDOMEN________________________________________________________________________________________________________________________________________________________________EXTREMIDADES________________________________________________________________________________________________________________________________________________________________GENITOURINARIO________________________________________________________________________________________________________________________________________________________________PIEL________________________________________________________________________________________________________________________________________________________________SIGNOS VITALESFR ________ To _________ FC _________ PULSO _________ T/A _____________
  5. 5. EXAMEN FISICO DEL SISTEMA RESPIRATORIOINSPECCIONRITMO DE LA RESPIRACIÓN________________________________________________________________________________AMPLITUD________________________________________________________________________________TIPO DE TORAX_______________________________________________________________________________PATRON RESPIRATORIO________________________________________________________________________________SIMETRIA TORACICA________________________________________________________________________________SIGNOS DE DIFICULTAD RESPIRATORIA________________________________________________________________________________OTROS HALLAZGOS________________________________________________________________________________________________________________________________________________________________PALPACIONCOLUMNA VERTEBRAL________________________________________________________________________________CLAVICULAS________________________________________________________________________________
  6. 6. ESTERNON (maniobra de Pittres)________________________________________________________________________________COSTILLAS________________________________________________________________________________ESCAPULAS________________________________________________________________________________DISTENSIBILIDAD TORACICA O EXPANSIBILIDAD________________________________________________________________________________ELASTICIDAD TORACICA________________________________________________________________________________FREMITO VOCAL TACTIL________________________________________________________________________________FREMITO BRONQUICO________________________________________________________________________________PERCUSIONCARA ANTERIOR________________________________________________________________________________________________________________________________________________________________CARA POSTERIOR________________________________________________________________________________________________________________________________________________________________CARA LATERAL________________________________________________________________________________________________________________________________________________________________
  7. 7. AUSCULTACIONRUIDOS RESPIRATORIOS NORMALES________________________________________________________________________________________________________________________________________________________________RUIDOS SOBREAGREGADOS________________________________________________________________________________________________________________________________________________________________AUSCULTACION DE LA VOZ________________________________________________________________________________________________________________________________________________________________IMPRESIÓN DIAGNOSTICA________________________________________________________________________________________________________________________________________________________________PARACLINICOS________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DIAGNOSTICO DEFINITIVO________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________TRATAMIENTO MEDICO________________________________________________________________________________________________________________________________________________________________
  8. 8. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________.TRATAMIENTO DE TERAPIA RESPIRATORIA1._______________________________________________________________________________2._______________________________________________________________________________3._______________________________________________________________________________4._______________________________________________________________________________5._______________________________________________________________________________6._______________________________________________________________________________7._______________________________________________________________________________EVOLUCION________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________OBSERVACIONES________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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