Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Historia Clinica Formato Large
Historia Clinica Formato Large
Historia Clinica Formato Large
Interrogatorio
1.
Ficha de Identificacin
2. Antecedentes
a)
Heredo Familiares
Tuberculosis
Diabetes Mellitus
Hipertensin
Carcinomas
Cardiopatas
Hepatopatas
Nefropatas
Enf.endocrinas
Enf. Mentales
Epilepsia
Asma
Enf. Hematolgicas
Sfilis
Personales No patolgicos
Hbitos personales. bao ___________defecacin ___________ lav. dientes ___________ habitacin (ctos, piso, techo,
ven, hab, servicios) _____________________________________________________________________
Tabaquismo (cig/da/aos) _______________________
Gineco obsttricos
3.
4. Sntomas Generales
1. Astenia
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2. Adinamia
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3. anorexia
4. fiebre
5. perdida de peso
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5.
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Psicosomtico. Personalidad,
ansiedad, depresin, afectividad,
emotividad, amnesia, voluntad,
pensamiento, atencin, ideacin suicida,
delirios.
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6. Diagnsticos anteriores
7.
Exploracin Fsica
1.
Signos Vitales
1. FC:
2. TA:
3. FR:
4. Temperatura
5. Peso actual:
6. Peso anterior:
7. Peso ideal:
2. Exploracin general
2. cuello
3. trax
4. abdomen
5. miembros
6. genitales
7. otros
4.
5.
Comentario
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Diagnostico
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(especificar )
Pronostico
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Tratamiento
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