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Formato de Historia Clinica

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Programa de Enseñanza Clínica Complementaria

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Formato de Historia Clinica

  1. 1. Programa de Enseñanza Clínica Complementaria HISTORIA CLINICA FICHA DE IDENTIFICACION: Nombre:____________________________________________________Edad:___________Sexo:________ Ocupación:________________Estado Civil:_____________Nacionalidad:____________________________ Residencia_____________________Escolaridad:________________________Religión:_________________ Servicio:________________________Cama:________ No. Expediente:______________________________ ANTECEDENTES HEREDOFAMILIARES: Padres: ........................Vivos: ................................Fallecidos:.............................................................................. ………………………… ……Causas:.................................................................................. Hermanos:....................Vivos:................................Fallecidos:.............................................................................. ………………………… …… Causas:.................................................................................. Hijos:............................Vivos:..................................Fallecidos:............................................................................ Causas:……............................................................................ Diabetes Mellitus tipo 2 SI ⃝ NO ⃝ __________________________________________________________ Hipertensión Arterial SI ⃝ NO ⃝ __________________________________________________________ Tuberculosis SI ⃝ NO ⃝ __________________________________________________________ Cáncer SI ⃝ NO ⃝ __________________________________________________________ Otras (especificar) SI ⃝ NO ⃝ __________________________________________________________ ANTECEDENTES PERSONALES NO PATOLOGICOS: 1) Hábitos Tóxicos: Alcohol: __________________________Tabaco:_________________________Drogas:_________________ 2) Fisiológicos: Alimentación:____________________________________________________________________________ Dipsia:__________________________________________________________________________________ Diuresis: ________________________________________________________________________________ Catarsis:_________________________________________________________________________________ Somnia:_________________________________________________________________________________ Otros:__________________________________________________________________________________ ANTECEDENTES PERSONALES PATOLOGICOS:
  2. 2. Infancia:_________________________________________________________________________________ Adulto:__________________________________________________________________________________ Diabetes Mellitus tipo 2 SI ⃝ NO ⃝ __________________________________________________________ Hipertensión Arterial SI ⃝ NO ⃝ __________________________________________________________ Tuberculosis SI ⃝ NO ⃝ __________________________________________________________ Cáncer SI ⃝ NO ⃝ __________________________________________________________ Otras (especificar) SI ⃝ NO ⃝ __________________________________________________________ Quirúrgicos:______________________________________________________________________________ Traumatológicos:_________________________________________________________________________ Alérgicos: _______________________________________________________________________________ Otros: __________________________________________________________________________________ GINECO-OBSTÉTRICOS: FUM: / / FPP: / / EDAD GESTACIONAL: semanas. Menarca:_______RM (Rit. Menstr)____/___ IRS____Nº de parejas____Flujo genital____________________ Gestas:.............Partos:.............Cesáreas:...............Abortos: ____________ Anticonceptivos: SI ⃝ NO ⃝ Tipo: ______________________ Tiempo: __________Última toma: ________________________________ Cirugías ginecológicas (especificar)___________________________________________________________ Otros: __________________________________________________________________________________ PADECIMIENTO ACTUAL ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
  3. 3. INTERROGATORIO POR APARATOS Y SISTEMAS Aparato respiratorio: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Aparato digestivo: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Aparato cardiovascular: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Aparato renal y urinario: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Aparato genital: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Sistema endocrino: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Sistema hematopoyético y linfático: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Piel y anexos: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Musculo esquelético: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Sistema nervioso: ________________________________________________________________________________________
  4. 4. ________________________________________________________________________________________ ________________________________________________________________________________________ Órganos de los sentidos: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Síntomas generales: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ EXPLORACIÓN FÍSICA: Impresión General: _______________________________________________________________________ Signos Vitales: FC__________TA:_________FR: _______PULSO:____________ TEMPERATURA: _________ Peso actual: ________Talla: __________BMI:___________ Inspección general: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Cabeza: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Cuello: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Tórax: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
  5. 5. ________________________________________________________________________________________ ________________________________________________________________________________________ Abdomen: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Tacto vaginal y rectal: ________________________________________________________________________________________ Extremidades: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Exploracion neurológica: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ EXAMENES COMPLEMENTARIOS: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ DIAGNOSTICO PRESUNTIVO: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ PLAN TERAPÉUTICO: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ NOMBRE, CEDULA Y FIRMA DEL MEDICO TRATANTE:_______________________________________________________________________________

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