UNIVERSIDAD TÉCNICA DE MACHALA ESCUELA DE MEDICINA

HISTORIA CLÍNICA

DATOS DE FILIACIÓN:Nombres: ________________________________________________________________________Edad: _____________________________Sexo: ______________________________Etnia: ______________________________Religión: ___________________________Estado civil: _________________________Instrucción: _________________________

Ocupación: _____________________________Lugar de nacimiento: _____________________Lugar de vivienda: ________________________N° de cama: _____________________________Fecha de ingreso: ________________________Fecha de realización HC: ___________________

MOTIVO(S) DE INGRESO O CONSULTA_____________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ______________________________________

ENFERMEDAD ACTUAL____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REAS______________________________________________________________________________________________________________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLÓGICOS______________________________________________________________________________________________________________________________________________________________________

ANTECEDENTES PERSONALES PATOLÓGICOS____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ANTECEDENTES PATOLÓGICOS FAMILIARES_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HÁBITOS:NO TÓXICOS______________________________________________________________________________________________________________________________________________________________________

TÓXICOS_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SEXUALES___________________________________________________________________________________

CONDICIÓN SOCIO-ECONÓMICA______________________________________________________________________________________________________________________________________________________________________

FUENTE DE INFORMACION:____________________________________________________________COMENTARIO:__________________________________________________________________________________________________________________________________________________________

EXAMEN FÍSICOSIGNOS VITALES F.C________ lpm T.A _______ mmHg T º _______ º C F.R _______ rpm Sat. O2 ____ % FiO ____ %

IMC_______ kg/m2

- PESO:________- TALLA:_______

ICC_________ cm2

- CINTURA_________- CADERA__________

EXAMEN SOMÁTICO GENERALApariencia general: ______________________________________Facie:_________________________________________________Biotipo:________________________________________________Estado nutricional:_______________________________________Actitud:________________________________________________Deambula:______________________________________________Actividad psicomotriz:____________________________________

PIEL Y FANERASPiel:__________________________________________________________________________________________________________________________________________________________________Uñas:_________________________________________________________________________________________________________________________________________________________________Pelo:__________________________________________________________________________________________________________________________________________________________________

EXAMEN FÍSICO REGIONALCabeza:_______________________________________________________________________________________________________________________________________________________________Oído:_________________________________________________________________________________________________________________________________________________________________Ojos:__________________________________________________________________________________________________________________________________________________________________Nariz:_________________________________________________________________________________________________________________________________________________________________Boca:_________________________________________________________________________________________________________________________________________________________________Cuello:________________________________________________________________________________________________________________________________________________________________

RESPIRATORIOINSPECCION_________________________________________________________________________PALPACION____________________________________________________________________________________________________________________________________________________________PERCUSION____________________________________________________________________________________________________________________________________________________________AUSCULTACION_________________________________________________________________________________________________________________________________________________________

CARDÍACOINSPECCION_________________________________________________________________________PALPACION_________________________________________________________________________PERCUSION_________________________________________________________________________AUSCULTACION_________________________________________________________________________________________________________________________________________________________

DIGESTIVOINSPECCION____________________________________________________________________________________________________________________________________________________________AUSCULTACION_________________________________________________________________________________________________________________________________________________________PERCUSION____________________________________________________________________________________________________________________________________________________________PALPACION____________________________________________________________________________________________________________________________________________________________

GENITO URINARIOINSPECCION_________________________________________________________________________PALPACION_________________________________________________________________________PERCUSION_________________________________________________________________________AUSCULTACION______________________________________________________________________TACTO RECTAL:______________________________________________________________________

SOMAINSPECCION:___________________________________________________________________________________________________________________________________________________________PALPACION:____________________________________________________________________________________________________________________________________________________________

NEUROLÓGICOEXAMEN MENTAL: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EXAMEN MOTOR:FUERZA MUSCULAR_____________________________________________________________________________________________________________________________________________________REFLEJOS:- BICIPITAL_______________________- _______________________________- TRICIPITAL______________________- _______________________________- ROTULIANO_____________________- _______________________________- CUTÁNEOPLANTAR_______________- _______________________________

TAXIA______________________________________________________________________________PRAXIA_____________________________________________________________________________

PARES CRANEALESOLFATORIO:_________________________________________________________________________OPTICO:_______________________________________________________________________________________________________________________________________________________________MOC:_________________________________________________________________________________________________________________________________________________________________TROCLEAR:__________________________________________________________________________MOE:______________________________________________________________________________TRIGÉMINO:___________________________________________________________________________________________________________________________________________________________FACIAL:________________________________________________________________________________________________________________________________________________________________AUDITIVO:_____________________________________________________________________________________________________________________________________________________________GLOSOFARINGEO:____________________________________________________________________NEUMOGASTRICO:___________________________________________________________________ESPINAL:___________________________________________________________________________HIPOGLOSO MAYOR:_________________________________________________________________

EXAMEN SENSITIVO:SENSIBILIDAD SUPERFICIAL

- TÁCTIL_______________________________________________________________________- DOLOROSA Y TÉRMICA__________________________________________________________

SENSIBILIDAD PROFUNDA- PALESTESIA__________________________________________________________- BATIESTESIA_________________________________________________________- BAROGNOSIA________________________________________________________

DIAGNÓSTICOS PRESUNTIVOS: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

REALIZADO POR:__________________________________________________________________________