Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Historia Clinica UNAM Formato
Historia Clinica UNAM Formato
4.A
Propedutica Medico Quirrgica
Historia Clnica#
l. INTERROGATORIO:
Directo: ( ) Indirecto ( )
Nombre y parentesco del informante (en caso de no ser el paciente)
_______________________________________
FICHA DE IDENTIFICACIN
Nombre del paciente:
Nombre(s)
Apellido
paterno
Gnero: M a s c u l i n o ( ) F e m e n i n o
Apellido materno
( )
Edad_____________
Lugar y fecha de nacimiento:
_____________________________________________________________________________
Da/mes/ao
Domicilio:
______________________________________________________________________________________________
____________________________________________________________________________________
______________
Calle , Nmero Y Colonia
______________________________________________________________________________________________
______________________________________________________________________________________________
______
Delegacin poltica
Municipio
Entidad federativa
__________________________________________________________________
__________________________________________________________________
Cdigo
postal
Telfono
Estado civil:
Soltero[a]: ( ) Casado[a]: ( ) Unin libre: ( ) Divorciado[a]: ( ) Viudo[a]: ( )
Escolaridad:______________________________________________________
Profesin u
ocupacin:________________________________________________________
Religin:__________________________________________________________
Nacionalidad:______________________________________________________
Ocupacin:
Empleado ( ) Pensionado ( ) Desempleado ( ) Jubilado ( )
Persona responsable del paciente:
______________________________________________________________________________________________
___
Nombre
completo
Direccin completa
Telfono particular ______________________________
Telfono donde laboral___________________________
ANTECEDENTES PERSONALES
Antecedentes heredo-familiares:
(abuelos, padres, tos, cnyuge, hijos, primos). Investigar: diabetes
mellitus,enfermedades tiroideas, hipertensin arterial, cardiopatas, nefropatas, enfermedades
broncopulmonares, neurolgicasmentales, enfermedades infectocontagiosas,
reumticas y neoplsicas.
______________________________________________________________________________________________
______________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________________________________________
______________________________________________________________________________________________
______________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________________________________________
Antecedentes personales no patolgicos:
_______________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________
Uso de tiempo libre (horario de descanso y recreacin, deportes y pasatiempos,
vacaciones).
______________________________________________________________________________________________
_______________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________
Inmunizaciones. Vacunas y nmero de dosis (Sabin, DPT, pentavalente, BCG,
etctera). Biolgicos (suero antirrbico,antialacrn, anticrotlico, gammaglobulina,
anti-Rh).
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_______________________
Conciencia de enfermedad:
______________________________________________________________________________________________
___________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________________________
Antecedentes gneco-obsttricos:
Menarca, ciclo menstrual (frecuencia, duracin, cantidad, dismenorrea); inicio
devida sexual activa (VSA), nmero de parejas, nmero de embarazos, nmero de
partos, abortos, cesreas, mtodo anticonceptivo, fecha de ltima menstruacin,
enfermedades de transmisin sexual, menopausia, climaterio, Papanicolaou y
lactancia materna.
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________
Antecedentes androlgicos:
Circunscisin, criptorquidia, poluciones nocturnas, inicio de VSA, nmero de
parejas,enfermedad de transmisin sexual, trastornos de la ereccin y
andropausia.
______________________________________________________________________________________________
___________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________________________________________
Antecedentes personales patolgicos:
Infectocontagiosos, enfermedades exantemticas, enfermedades crnicodegenerativas y parasitarios, alrgicos, quirrgicos, traumticos, transfusionales,
convulsivos, adicciones (tabaquismo,alcoholismo, drogas) y hospitalizaciones
previas.
______________________________________________________________________________________________
___________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________________________________________
PADECIMIENTO ACTUAL
Motivo y circunstancia de la consulta.
______________________________________________________________________________________________
_____________________________
______________________________________________________________________________________________
___________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
______________________________________________________________________________________________
_____
Teraputica empleada. Resultados:
______________________________________________________________________________________________
__________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________
______________________________________________________________________________________________
___________________________________________________________________
______________________________________________________________________________________________
_________
_________________________________________________
______________________________________________________________________________________________
___
Aparato cardiovascular:
palpitaciones, dolor precordial, disnea de esfuerzo, disnea paroxstica, apnea,
cianosis,acfenos, fosfenos, tinnitus, sncope, lipotimias y edema.
______________________________________________________________________________________________
_____
______________________________________________________________________________________________
_____
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Musculoesqueltico:
Mialgias, dolor seo, artralgias, alteraciones en la marcha, hipotona, disminucin
del volumen muscular, limitacin de movimientos y deformidades.
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Sistema nervioso:
Cefalea, paresias, plegias, parlisis, parestesias, movimientos anormales
(temblores, tics, corea),alteraciones de la marcha, vrtigo y mareos.
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
rganos de los sentidos:
Alteraciones de la visin, de la audicin, del olfato, del gusto y del tacto (hipo,
hiper odisfuncin). Mareo y sensacin de lquido en el odo.
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Esfera psquica:
Tristeza, euforia, alteraciones del sueo (insomnio, hipersomnia, disomnia),
terrores nocturnos, ideaciones (alucinatorias, delirantes, obsesivas, suicidas),
miedo exagerado a situaciones comunes, irritabilidad, apata. Relaciones
personales.
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Sntomas generales:
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Cabeza
Crneo: inspeccin, palpacin, percusin y, si es necesario, auscultacin.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________ Cara: inspeccin, palpacin percusin y, si es
necesario, auscultacin.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____ Ojos:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
___ Odos:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____ Nariz:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____ Boca:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Cuello:
inspeccin, palpacin percusin y, si es necesario, auscultacin.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Trax:
inspeccin, palpacin, percusin, auscultacin y exploracin instrumental. _Regin
precordial: Glndulas mamarias:
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
_________
Abdomen:
inspeccin,
auscultacin
, palpacin, percusin y, en caso necesario, medicin.
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
_________
Regin inguino-crural:
inspeccin,
auscultacin
, palpacin y percusin.
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
_________
Genitales externos:
inspeccin, palpacin (tacto) y exploracin instrumental.
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
_________
Tacto vaginal
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
_________
Tacto rectal
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
_________
Extremidades:
torcicas y plvicas. Inspeccin, palpacin, percusin, auscultacin y, en caso
necesario, medicin.
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
______________________________
Columna vertebral:
inspeccin, palpacin, percusin.
_____________________________________________________________________________________
___________
______________________________________________________________________________________________
_________________________________
Exploracin neurolgica:
Pronsticos
: Para la vida, el rgano, la funcin, la calidad de vida, la esttica.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
__ ________________________________________________________________
______________________________________________________________________________________________
_________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Criterios de referencia:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
__
Nombre del alumno
________________________________________________________________________
__________________________________________________________________________
Grupo _______________________________________________________________
_____________________ ______________________________________________
V o . B o .
T u t o r - c l n i c o
Referencias consultadas (tres):
______________________________________________________________________________________________
____
______________________________________________________________________________________________
____
______________________________________________________________________________________________
_____