HISTORIA CLNICA

Rodrigo Gonzalo Valdivia Ugarte

1. ANAMNESIS O INTERROGATORIO:
I.

Filiacin:
Nombre: _________________________________________.
Edad: ____________________________________________.
Sexo: ____________________________________________.
Ocupacin: ________________________________________.
Lugar de nacimiento: ________________________________.
Lugar de procedencia: _______________________________.
Domicilio: ________________________________________.
Numero de ficha: ___________________________________.
Fecha: ___________________________________________.

II.

Enfermedad actual:

Qu le ocurre o cual es su molestia?

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Desde cundo le ocurre?

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A que le atribuye?
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Dnde le duele y en qu momentos le duele?

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El dolor le genera alguna incapacidad?

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A molestia que tiene fue provocada o apareci

espontneamente?
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Existe sangrado en el rea de la molestia y si el sangrado es

espontaneo o provocado?
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III.

Antecedentes personales y familiares:

Antecedentes personales:

Alguna ingreso hospitalario:

Alguna enfermedad grave o tratamiento quirrgico:

Algn Consumo de medicamentos

Alergias:

Hemorragias con necesidad de tratamientos:

Afecciones de tipo metablicas o infectocontagiosas o

degenerativas

Hbitos:

Posiblemente se encuentre embarazada:

Antecedentes familiares

Alguna enfermedad de importancia que posea su padre

madre hermanos abuelos:

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IV.

Posible causa de su muerte:

Exploracin clnica:
o Inspeccin:
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o Palpacin:
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o Percucion:
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o Olfaccion:
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o Auscultacin:
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2. EXAMEN FSICO:
General:

Signos vitales:
Presin

pulso

temperatura

F. respiratoria

arterial

Estado general del paciente:

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Piel:
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Cabeza:
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Cara:
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Ojos:
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Odos:
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Nariz:
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Atm:
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Cuello:

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Torax:
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Abdomen:
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Exploracin neurolgica:
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Aparato locomotor:
o Extremidades superiores:
o Extremidades inferiores:

Regional:
Labios:
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Vestbulo:
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Carrillo:
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Paladar duro:
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Velo de paladar:
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Pilares palatinos y amgdalas:

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Lengua:
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Piso de boca:
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Oclusin:
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Grado de higiene:
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Encia:
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3. EXMENES AUXILIARES:
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4. DIAGNOSTICO DEFINITIVO:
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5. PLAN DE TRATAMIENTO:
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