Republica Bolivariana de Venezuela

Ministerio del Poder Popular para la Educacin Superior

Universidad del Zulia
Facultad de Medicina
Escuela de Medicina
Catedra de Semiologia-Patologia Medica
HUM-HC
Historia Clnica Integral
Fecha:___/___/___
A. Datos de Identificacin:
Nombres y Apellidos:____________________________________________________
Edad:___________ Sexo:________________Grupo tnico:_____________________
Religin:___________________ Estado Civil:______________
Lugar y Fecha de nacimiento:________________________________________
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Nacionalidad:___________________ Profesin u Ocupacin___________________
Direccin Actual:_______________________________________________________
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Grado de Instruccin:_______________ Fecha de Ingreso:_____________________
Cama:____________
Informacin Suministrada por:__________________ Parentesco:_______________
Confiabilidad:_________________
B. Motivo de Consulta:_______________________________________________
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C. Enfermedad Actual:_______________________________________________
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D. Antecedentes
D.1 Antecedentes Personales y Patolgicos:
Hbitos:
a.Dieteticos/Alimenticios:______________________________________________
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b.Alcoholicos:_______________________________________________________
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c.Cafeicos:__________________________________________________________
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d.Tabaquismo:______________________________________________________
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e.Drogas:___________________________________________________________
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f.Sexuales:__________________________________________________________
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g.Sueo:____________________________________________________________
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h.Ejercicios/recreacion:_______________________________________________
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i.Condiciones Higinicas:
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Enfermedades y Medicamentos:
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Alergias:____________________________________________________________
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Hospitalizaciones y Operaciones:
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Accidentes:_________________________________________________________
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Transfusiones y Transplantes:
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Trabajos:___________________________________________________________
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Vivienda:___________________________________________________________
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Vacunas:___________________________________________________________
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D.2 Antecedentes Familiares:

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E. Revisin de Sistemas:
a. Enfermedades Infecto-contagiosas y ETS:
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b.Psiquico:__________________________________________________________
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c. Piel y Anexos:
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d.Cabeza:___________________________________________________________
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e.Ojos:_____________________________________________________________
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f.Odos:_____________________________________________________________
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g.Nariz y Senos paranasales:
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h. Boca y Garganta:
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i.Cuello:____________________________________________________________
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j. Aparato Respiratorio:
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k. Aparato Cardiovascular:
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F. Examen Fsico
Signos Vitales:
-Presin Arterial:____________________________________________________.
-Pulso:_____________________________________________________________.
-Respiracin:
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-Temperatura:
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-Peso y Talla:
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Condiciones Generales del paciente:
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Piel y Anexos:
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Cabeza:____________________________________________________________
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Ojos:_______________________________________________________________
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Odos:______________________________________________________________
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Nariz:______________________________________________________________
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Boca y Faringe:
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Cuello:_____________________________________________________________
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Trax:_____________________________________________________________
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Pulmones:__________________________________________________________
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Corazn:___________________________________________________________
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Abdomen:__________________________________________________________
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Miembros:__________________________________________________________
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Neurologico:________________________________________________________
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G. Hallazgos Positivos:
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H. Diagnsticos:
Diagnstico Sindromatico:____________________________________________.
Diagnstico Anatmico:______________________________________________.
Diagnstico Funcional: _______________________________________________.
Diagnstico Etiolgico: _______________________________________________.
Diagnstico Principal:________________________________________________.
Diagnsticos Diferenciales:
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I. Evolucin Intrahospitalaria:
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Realizado por:
Br:____________________________C.I:_________________Firma:_____________
Br:____________________________C.I:_________________Firma:_____________
Br:____________________________C.I:_________________Firma:_____________