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Modelo de Historia Clínica

Modelo de Historia Clínica

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MODELO DE HISTORIA CLÍNICA

Fecha: / / . Médico: ________________________________.
DATOS PERSONALES
Apellido y Nombre:
_________________________________________________________________________.
Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. c!paci"n:
_______________.
#omicilio: _____________________________________________________________. $E: ______________.
%esidencia: _______________________________________________________________________________
.
MOTIVO DE CONSULTA
ANTECEDENTES DE LA ENFERMEDAD ACTUAL
ANAMNESIS SISTEMICA
1
&' S(ntomas )enerales: *iebre+
perdida de peso+ astenia+ *ati,a+
otros.
- ' .iel y *aneras: pr!rito+ lesiones
primarias y sec!ndarias+
alteraciones de !/as y cabellos+
otros.
0 ' $CS: edema+ t!moraciones+
otros.
1 ' SMA: dolor+ t!me*acci"n+
*!er2a m!sc!lar+ limitaci"n del
movimiento+ otros.
3 ' Ap. Cardiovasc!lar: disnea+
palpitaciones+ dolor precordial+
s(ncope+ cla!dicaci"n intermitente+
otros.
4 ' Ap.%espiratorio: epistaxis+ tos+
expectoraci"n+ hem"ptisis+ dolor
tor5cico+ cianosis+ otros.
6 ' Ap. #i,estivo: halitosis+
dis*a,ia+ re,!r,itaci"n+ acide2+
pirosis+ na!seas y v"mitos+
hematemesis+ alteraciones del
h5bito intestinal+ otros.
7 ' Ap. )enito!rinario: dis!ria+
pola8!i!ria+ nict!ria+ hemat!ria+
incontinencia+ dolor+ alteraciones
ciclo menstr!al+ alteraciones
sex!ales+ otros
9 ' Sistema Nervioso: ce*alea+
mareos+ vérti,o+ sensibilidad+
motricidad+ temblor+ alteraciones
de la visi"n+ a!dici"n+ otros.
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2
ANTECEDENTES PERSONALES
&'Fisiol",icos : menarca+ ciclo
menstr!al+ *echa :ltima
menstr!aci"n+ embara2os+ partos+
alimentaci"n+ actividad *(sica+
s!e/o+ di!resis y catarsis+ actividad
sex!al+ otros.
-' ;nm!ni2aciones.
0' <ivienda y medio ambiente.
1' Socioecon"micos.
3' .atol",icos: médicos+ alér,icos+
8!ir:r,icos+ tra!m5ticos.
4'$"xico'Medicamentosos: tabaco+
alcohol+ s!stancias de !so
indebido+ medicamentos+ otros.
6'Epidemiol",icos: Cha,as+
=;</Sida+ >r!celosis+
$oxoplasmosis+ trans*!siones+
residencias anteriores+ otros.
7'=eredo'Familiares.
9' Est!dios preventivos.
&?' tros.
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EXAMEN FISICO
3
Examen General
&';nspecci"n )eneral Estado de conciencia: __________________________________________.
Actit!d: _____________________________________________________.
#ec:bito: ____________________________________________________.
Marcha: _____________________________________________________.
Facie: _______________________________________________________.
-'Mediciones y Controles FC: _____________ $A: _____________ F%: __________ $@: _______.
.eso: ___________ Alt!ra: ___________ ;MC: ___________________.

0'.iel y *aneras: color+ t!r,or+
elasticidad+ h!medad+
temperat!ra+ lesiones primarias+
lesiones sec!ndarias+ pelos y !/as.
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1'$CS: cantidad+ distrib!ci"n+
v5rices+ circ!laci"n colateral+
edema+ adenopat(as+ otros.
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__________________________________________________________.
3'SMA: h!esos Acon*ormaci"n y
sensibilidadB+ m:sc!los+
artic!laciones.
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Examen Semen!ar"#
&'Cabe2a y c!ello: cr5neo+ o(dos+
oCos+ nari2+ boca. $iroides+
car"tidas+ .<C+ otros.
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-'Ap. %espiratorio: inspecci"n+
expansi"n de < y >+ vibraciones
vocales+ claro p!lmonar+ m!rm!llo
vesic!lar+ a!sc!ltaci"n de la vo2+
r!idos patol",icos+ otros.
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0'Mamas. ____________________________________________________________
1'Ap. Cardiovasc!lar: precordio
Ainspecci"n+ 2ona m5ximo
imp!lso+ latidos patol",icos+
r!idos card(acos normales y
patol",icosB+ p!lsos peri*éricos+
a!sc!ltaci"n arterial+ otros.
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3'Abdomen: inspecci"n+
a!sc!ltaci"n+ palpaci"n s!per*icial
y pro*!nda+ p!ntos dolorosos+
ori*icios herniarios+ perc!si"n+
otros.
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4'Ap. )enito!rinario: p!/o
perc!si"n+ p!ntos reno'!reterales+
examen ,enital+ tacto rectal+ otros.
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6'Sistema Nervioso: pares
craneales. Motricidad Atono+
tro*ismo+ motricidad vol!ntaria y
*!er2a m!sc!larB. %e*leCos
s!per*iciales y pro*!ndos.
Sensibilidad As!per*icial y
pro*!ndaB.
F!nci"n cerebelosa.
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LISTADO DE PRO$LEMAS
%

LISTADO DE DIAGNOSTICOS
METODOS COMPLEMENTARIOS SOLICITADOS
TRATAMIENTO INICIAL
EVOLUCIONES
EPICRISIS
&

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