REPUBLICA BOLIVARIANA DE VENEZUELA

UNIVERSIDAD NACIONAL EXPERIMENTAL ROMULO GALLEGOS

CATEDRA: INGLES INSTRUMENTAL
PRIMER AO DE MEDICINA SECCION 5
PROFESORA: DRA. CARMEN MONTAEZ

HISTORIA MEDICA

BACHILLER:
TORO, SHARON
C.I.-21.310.420

SAN JUAN DE LOS MORROS, NOVIEMBRE 2012.

HISTORIA MDICA
La historia clnica, tambin llamada expediente clnico, es un documento
legal que surge del contacto entre el profesional de la salud (mdico, psiclogo,
enfermero, kinesilogo, odontlogo) y el paciente donde se recoge la informacin
necesaria para la correcta atencin de los pacientes. La historia clnica es un
documento vlido desde el punto de vista clnico y legal, que recoge informacin de
tipo asistencial, preventivo y social.

La ficha clnica tiene por propsito fichar al paciente.

La historia clnica tiene por propsito un diagnstico y planificacin del
tratamiento. La historia clnica es parte del preoperatorio.

Antecedentes personales
Objetivos especficos: identificar a nuestro enfermo, clasificndolo de
acuerdo al grupo erario, raza (nacionalidad), ocupacin, etc.
Anamnesis
Es el relato que hace el paciente, a travs de un interrogatorio dirigido, de
los sntomas por los que consulta y del estado de salud general.
Objetivos especficos:
Precisar el motivo de la consulta.
Lograr informacin a travs de sus antecedentes familiares, de afecciones
infectas contagiosas y patologas hereditarias que puedan afectar al
paciente para tomar las medidas apropiadas, ya sean teraputicas o
precautorias.
Informarse sobre enfermedades generales, pasadas o presentes que tengan
implicancia en el diagnstico y tratamiento del enfermo.
Motivo de la consulta
No se puede decir que la exodoncia (que es un tratamiento) o la caries (que
es un diagnstico) sean motivo de consulta. Puede ser molestias, problemas de
esttica.
Se puede definir como un signo un sntoma por el que consulta el paciente.
Debe ser lo ms simple y lo ms general. Por ejemplo, dolor facial derecho o
aumento de volumen en la regin submental. Puede ser simplemente dentadura en
mal estado. El paciente puede relatar halitosis.
Si el paciente viene con indicacin de ortodoncia, para extraer premolares
sanos, se trata de una derivacin. Tambin puede ser derivado de prtesis.
Examen fsico general
Objetivos:
- Identificar alteraciones fsicas de tipo general (deambulacin)
- Constatar alteraciones del estado de conciencia.
- Evaluar signos vitales.

- Identificar alteraciones extraorales de la regin de la cara y cuello.

(El grado de hidratacin o deshidratacin se puede medir a nivel de la piel; el
paciente debe mostrar lesiones que tenga en otras partes del cuerpo).
Examen fsico segmentario
Estados de asimetra: se compara un segmento izquierdo con uno derecho.
Generalmente los problemas bilaterales son sistmicos. A veces es necesario,
para apreciar cambios de asimetra, mirar desde arriba.
Palpacin: procesos inflamatorios, lesiones, ganglios, etc. Se hace siempre
comparando, con el pulpejo de los dedos. Tambin se pueden usar las palmas
de las manos completas. Se percibe calor, consistencia, movilidad, fluctuacin
(presencia de lquidos que fluctua de un lado a otro), retinencia (como un
quiste, va y vuelve), grado de intensidad (edema, etc). Un edema blando sugiere
un edema traumtico.
Percusin: seno maxilar (sinusitis)
Auscultacin (ATM)
EJEMPLO DE HISTORIA MEDICA:

MODELO DE HISTORIA MDICA

Fecha:

Mdico:________________________________.
DATOS PERSONALES

Apellido y Nombre: _________________________________________________________________________.

Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupacin: _______________.
Domicilio: _____________________________________________________________.
Telefono: ______________.
Residencia: _______________________________________________________________________
MOTIVO DE CONSULTA

ANTECEDENTES DE LA ENFERMEDAD ACTUAL

ANAMNESIS SISTEMICA
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1- Sntomas Generales: fiebre,
__________________________________________________________________________________
perdida de peso, astenia, fatiga,
__________________________________________________________________________________
otros.
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2 - Piel y faneras: prurito,
lesiones primarias y secundarias, __________________________________________________________________________________
alteraciones de uas y cabellos, __________________________________________________________________________________
__________________________________________________________________________________
otros.
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3 - TCS: edema, tumoraciones,
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otros.
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4 - SOMA: dolor, tumefaccin,
__________________________________________________________________________________
fuerza muscular, limitacin del
__________________________________________________________________________________
movimiento, otros.
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5 - Ap. Cardiovascular: disnea,
________________________________________________________
palpitaciones, dolor precordial,
__________________________________________________________________________________
sncope, claudicacin
__________________________________________________________________________________
intermitente, otros.
__________________________________________________________________________________
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6 - Ap.Respiratorio: epistaxis,
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tos, expectoracin, hemptisis,
__________________________________________________________________________________
dolor torcico, cianosis, otros.
__________________________
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7 - Ap. Digestivo: halitosis,
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disfagia, regurgitacin, acidez,
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pirosis, nauseas y vmitos,
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hematemesis, alteraciones del
__________________________________________________________________________________
hbito intestinal, otros.
_____________________________________________________________________________
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8 - Ap. Genitourinario: disuria,
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polaquiuria, nicturia, hematuria,
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incontinencia, dolor, alteraciones
__________________________________________________________________________________
ciclo menstrual, alteraciones
__________________________________________________________________________________
sexuales, otros
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9 - Sistema Nervioso: cefalea,
__________________________________________________________________________________
mareos, vrtigo, sensibilidad,
__________________________________________________________________________________
motricidad, temblor,
________
alteraciones de la visin,
audicin, otros.

ANTECEDENTES PERSONALES
1-Fisiolgicos : menarca, ciclo
menstrual, fecha ltima
menstruacin, embarazos,
partos, alimentacin, actividad
fsica, sueo, diuresis y catarsis,
actividad sexual, otros.
2- Inmunizaciones.
3- Vivienda y medio ambiente.
4- Socioeconmicos.
5- Patolgicos: mdicos,
alrgicos, quirrgicos,
traumticos.
6-Txico-Medicamentosos:
tabaco, alcohol, sustancias de
uso indebido, medicamentos,
otros.
7-Epidemiolgicos: Chagas,
HIV/Sida, Brucelosis,
Toxoplasmosis, transfusiones,
residencias anteriores, otros.
8-Heredo-Familiares.

_____________________________________
9- Estudios preventivos.

_____________________________________
10- Otros.

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1-Inspeccin General

EXAMEN FISICO
Examen General
Estado de conciencia: __________________________________________.
Actitud: _____________________________________________________.
Decbito: ____________________________________________________.
Marcha: _____________________________________________________.
Facie: _______________________________________________________.

2-Mediciones y Controles

FC: _____________ TA: _____________ FR: __________ T: _______.

Peso: ___________ Altura: ___________ IMC: ___________________.

3-Piel y faneras: color, turgor,

elasticidad, humedad,
temperatura, lesiones primarias,
lesiones secundarias, pelos y
uas.
4-TCS: cantidad, distribucin,
vrices, circulacin colateral,
edema, adenopatas, otros.

__________________________________________________________________________________
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__________________________________________________________________________________
______________________________________________________.
__________________________________________________________________________________
__________________________________________________________________________________
________________.

5-SOMA: huesos (conformacin y __________________________________________________________________________________

sensibilidad), msculos,
__________________________________________________________________________________
articulaciones.
________________.
Examen Segmentario
1-Cabeza y cuello: crneo, odos, __________________________________________________________________________________
ojos, nariz, boca. Tiroides,
__________________________________________________________________________________
cartidas, PVC, otros.
________________
2-Ap. Respiratorio: inspeccin,
__________________________________________________________________________________
expansin de V y B, vibraciones
__________________________________________________________________________________
vocales, claro pulmonar,
__________________________________________________________________________________
murmullo vesicular, auscultacin ______________________________________________________
de la voz, ruidos patolgicos,
otros.
3-Mamas.
____________________________________________________________
4-Ap. Cardiovascular: precordio __________________________________________________________________________________
(inspeccin, zona mximo
__________________________________________________________________________________
impulso, latidos patolgicos,
__________________________________________________________________________________
ruidos cardacos normales y
__________________________________________________________________________________
patolgicos), pulsos perifricos, ________________________________
auscultacin arterial, otros.
5-Abdomen: inspeccin,
__________________________________________________________________________________
auscultacin, palpacin
__________________________________________________________________________________
superficial y profunda, puntos
__________________________________________________________________________________
dolorosos, orificios herniarios,
_____________________________________________________
percusin, otros.
6-Ap. Genitourinario: puo
__________________________________________________________________________________
percusin, puntos reno__________________________________________________________________________________
ureterales, examen genital, tacto ________________
rectal, otros.
7-Sistema Nervioso: pares
__________________________________________________________________________________
craneales. Motricidad (tono,
__________________________________________________________________________________
trofismo, motricidad voluntaria y __________________________________________________________________________________
fuerza muscular). Reflejos
__________________________________________________________________________________
superficiales y profundos.
__________________________________________________________________________________
Sensibilidad (superficial y
__________________________________________________________________________________
profunda).
__________________________________________________________________________________
Funcin cerebelosa.
__________________________.

LISTADO DE PROBLEMAS

LISTADO DE DIAGNOSTICOS

METODOS COMPLEMENTARIOS SOLICITADOS

TRATAMIENTO INICIAL

EVOLUCIONES

EPICRISIS

MODEL HISTORY
Date:

Physician.: ________________________________.
PROFILE

First and last name:

_________________________________________________________________________.
Sex: _______. Date : _________. Status: ___________. Ocupation: _______________.
Adress: _____________________________________________________________. Telephone:
__________.
Location:
_______________________________________________________________________________ .

REASON FOR CONSULTATION

HISTORY OF PRESENT ILLNESS

1-General Symptoms: fever,

weight loss, weakness, fatigue,
other.
2 - Skin and appendages: pruritus,
primary and secondary lesions,
hair and nail disorders, other.

3 - TCS: edema, tumors, other.

4 - SOMA: pain, swelling, muscle

strength, limitation of movement,
other.

5 - Rev. Cardiovascular: dyspnea,

palpitations, chest pain, syncope,
intermittent claudication, other.
6 - Ap.Respiratorio: epistaxis,
cough, expectoration, hemoptysis,
chest pain, cyanosis, other.

7 - Rev. Digestive: halitosis,

dysphagia, regurgitation,
heartburn, heartburn, nausea and
vomiting, hematemesis, altered
bowel habit, others.
___________________________
8 - Rev. Genitourinary: dysuria,
frequency, nocturia, hematuria,
incontinence, pain, menstrual
disorders, sexual dysfunction,
other
____________________________
9 - Nervous System: headache,
dizziness, vertigo, sensitivity,
mobility, tremors, changes in
vision, hearing, other.

SYSTEMIC ANAMNESIS
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PERSONAL HISTORY
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2 - Immunizations.
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3 - Housing and environment.
_____________________________________________________________
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4 - Socioeconomic.
_____________________________________________________________
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5 - Pathological doctors, allergies, _____________________________________________________________
___________________________________________________
surgical, traumatic.
_____________________________________________________________
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6-Toxic-Medicated: snuff, alcohol, _____________________________________________________________
_____________________________________________________________
substance abuse, drugs, other.
_____________________________________________________________
7-Epidemiological: Chagas, HIV / _____________________________________________________________
AIDS, Brucellosis, Toxoplasmosis, _____________________________________________________________
_____________________________________________________________
transfusions, previous residences,
_____________________________________________________________
other.
___________________________________________________
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8-Heredo-Family.
_____________________________________________________________
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9 - preventive studies.
_____________________________________________________________
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10 - Other.
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1-Physiological: menarche,
menstrual cycle, date last
menstruation, pregnancy,
childbirth, nutrition, physical
activity, sleep, diuresis and
catharsis, sexual activity, other.

1- General Inspection

PHYSICAL EXAMINATION
General Examination
Consciousness: __________________________________________.
Attitude: ____________________________________________________.
Decubitus: ___________________________________________________.
March: _____________________________________________________.
Facie: _______________________________________________________.

2- Measurements and Controls

FC: _____________ TA: _____________ FR: __________ T: _______.

Weight: ___________ Height: ___________ BMI: ___________________.

3- Skin and appendages: color,

turgor, elasticity, moisture,
temperature, primary lesions,
secondary lesions, hair and nails..

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________.

4- TCS: quantity, distribution,

varicose veins, collateral
circulation, edema,
lymphadenopathy, other.
5- SOMA: bones (conformation
and sensitivity), muscles, joints.

____________________________________________________________
____________________________________________________________
____________________________________________________________.

1- Head and Neck: skull, ears,

eyes, nose, mouth. Thyroid,
carotid, PVC, other.
2- Ap. Respiratory: inspection,
expansion of V and B, vocal
vibrations, clear lung breath
sounds, auscultation of voice,
noise pathological other.
3- Mamas.
4- AP. Cardiovascular: precordium
(inspection, maximum thrust zone,
beats pathological, normal and
abnormal heart sounds), peripheral
pulses, auscultation blood, other.
5- Abdomen: inspection,
auscultation, palpation and deep,
painful spots hernial orifices,
percussion, other.
6- Rev. Genitourinary: fist
percussion, reno-ureteral points,
genital examination, digital rectal
examination, other.
7- Nervous system: cranial nerves.
Motricity (tone, tropism, voluntary
motor skills and muscle strength).
Superficial and deep reflexes.
Sensitivity (superficial and deep).

Cerebellar function.

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Segmental Review
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LIST OF PROBLEMS

LIST OF DIAGNOSTIC

Complementary methods REQUESTED

INITIAL TREATMENT

DEVELOPMENTS

EPICRISIS