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:

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

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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: ________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

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: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

Abdomen: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tacto vaginal y rectal: ________________________________________________________________________________________

Extremidades: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Exploracion neurológica: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EXAMENES COMPLEMENTARIOS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DIAGNOSTICO PRESUNTIVO: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLAN TERAPÉUTICO: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NOMBRE, CEDULA Y FIRMA DEL MEDICO TRATANTE:_______________________________________________________________________________