CLINICA DE LA MUJER poniente

Tuxtla Gutirrez Chiapas

1.- ficha de identificacin
Nombre:
Nacionalidad

Edad

Sexo

Edo. Civil

Raza
Ocupacin

Lugar de origen

Lugar de residencia

Domicilio

Persona responsable

Religin

2.-Antecendetes
a) Heredo Familiares

Tuberculosis, Diabetes
Mellitus, Hipertensin,
Carcinomas,
Cardiopatas,
Hepatopatas,
Nefropatas,
Enf.endocrinas, Enf.
Mentales, Epilepsia,
*Investigar etiologa y edades de Morbimortalidad en abuelos, padres, hijos,
cnyuges, hermanos.

3 Antecedentes personales

Peso, talla al nacer,

permetro ceflico.
Antecedentes prenatales,
perinatales y postnatales.
Complicaciones, lugar de
nacimiento. Desarrollo fsico
y mental .Desarrollo psicomotor, edad del habla,
caminar, vacunacin:BCG,
SRP,DPT Pentavalente

b) personales patolgico
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Enf. Infecciosas
de la
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infancia, Tb , Enf. Venreas,
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Fiebre Tifoidea,
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Salmonelosis,
neumonas,
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Paludismo,
Parasitosis, Enf.
Alrgicas,________________________________________________________________________________________
Pad. Articulares,
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Intervenciones Quirrgicas,
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Hosp., Traumatismos
(acc),
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Perdida del
conocimiento,
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Intolerancia a
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medicamentos,
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Transfusiones.
c) Personales No patolgicos

Hbitos personales. Bao ___________ defecacin ___________ lav. Dientes

___________, habitacin (ctos, piso, techo, ven, hab, servicios)
___________________________________________Tabaquismo (cig/da/aos)
_________________________________, Alcoholismo (beb/frec) ______________________
Toxicomanas (esp/da/aos) __________________ Alimentacin (f/ tipo)
______________________________ Deportes (act. Fsica/f) _________________
Escolaridad _____________Hipersensibilidad / alergias
_______________________________ Trabajo/Desc
___________________________Pasatiempos ________________________________________
d) Gineco obsttricos Menarca _____________________ Desarrollo Sexual
________________ Ritmo Menstrual
(f/d/c)_________________________________________ FUM ________________
FPR______________ Vida sexual ____________FPP _______________ FUP
________________ Menp _______________ Clim _______________ Partos __________
Abortos ____________ Cesreas ____________ Mtodo Anticonceptivo __
c) Padecimiento Actual
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d)

sntomas generales

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1. Astenia 2.
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Adinamia 3.
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Anorexia 4. Fiebre 5.
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Prdida de peso
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e) Interrogatorio por aparatos y sistemas

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________________________________________________________________________________
Aparato
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urinario
Digestivo
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Caractersticas
de
Diarrea
________________________________________________________________________________
orina:
olor,
estreimiento,
________________________________________________________________________________
presencia
vomito, de
apetito,
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sangre,
dolor,frecuencia
trnsito
________________________________________________________________________________
de________________________________________________________________________________
miccin, dolor
intestinal,
lumbar
tolerancias de
________________________________________________________________________________
alimentos
________________________________________________________________________________
Aparato
genital.
________________________________________________________________________________
Aparato
________________________________________________________________________________
Dolor
cardiovascular.
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ginecolgico,
Disnea, tos (seca.
________________________________________________________________________________
Funcin
prod.),sexual,
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sangrado
genital
hemoptisis,
dolor
________________________________________________________________________________
precordial,
Sistema
________________________________________________________________________________
palpitaciones,
endocrino.
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cianosis edema y
Calor/frio,
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manifestaciones,
nerviosismo,
________________________________________________________________________________
etc.)Sexuales,
carac.
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galactorrea,
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Aparato
amenorrea,
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respiratorio. Tos,
ginecomastia,
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disnea, dolor
obesidad,
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torcico,
ruborizacin
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hemoptisis,
________________________________________________________________________________
cianosis,
Sistema
________________________________________________________________________________
alteraciones de la
osteomuscular.
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voz.
Ganglios,
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xeroftalmia,
Aparato
________________________________________________________________________________
xerostoma,
nervioso.foto
________________________________________________________________________________
sensibilidad
________________________________________________________________________________
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Psicosomtico.
________________________________________________________________________________
Personalidad,
________________________________________________________________________________
ansiedad,
________________________________________________________________________________
depresin,
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Diagnsticos previos

Tratamiento
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Exploracin fsica

1. Signos Vitales
1. FC:
4. Temperatura
5. Peso actual:

2. TA:

3. FR:
6. Peso anterior:

7. Peso ideal:
2. Exploracin general

3. Exploracin regional (inspeccin, palpacin, percusin, auscultacin, comb.)

Cabeza

Cuello

Trax

Abdomen

Miembros

Genitales

Comentario
Diagnostico
Pronostico
Tratamiento