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

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INTERROGATORIO POR APARATOS Y SISTEMAS

Aparato respiratorio:

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Aparato digestivo:

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Aparato cardiovascular:

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Aparato renal y urinario:

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Aparato genital:

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Sistema endocrino:

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Sistema hematopoyético y linfático:

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Piel y anexos:

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Musculo esquelético:

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Sistema nervioso:

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Órganos de los sentidos:

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Síntomas generales:

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EXPLORACIÓN FÍSICA:

Impresión General: _______________________________________________________________________

Signos Vitales: FC__________TA:_________FR: _______PULSO:____________ TEMPERATURA: _________

Peso actual: ________Talla: __________BMI:___________

Inspección general:

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Cabeza:

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Cuello:

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Tórax:

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Abdomen:

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Tacto vaginal y rectal:

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Extremidades:

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Exploracion neurológica:

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EXAMENES COMPLEMENTARIOS:

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DIAGNOSTICO PRESUNTIVO:

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PLAN TERAPÉUTICO:

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NOMBRE, CEDULA Y FIRMA DEL MEDICO

TRATANTE:_______________________________________________________________________________