Bachiller:________________________

UNIVERSIDAD DE CARABOBO
ASIGNATURA SEMIOLOGIA
HOSPITAL JOS MARIA CARABAO TOSTA
HISTORIA CLINICA

Fecha:
Hora:
Servicio:

I PARTE ANAMNESIS O INTERROGATORIO

Habitacin:

Ficha Patronmica
Nombre y Apellido:
Sexo:

Cama:

Edad:

Fecha de Nacimiento:

Lugar de Nacimiento:

Cdula de Identidad:

Grupo tnico:

Nacionalidad:

Telfono:

Direccin Actual:

Religin:

Estado Civil:

Ocupacin:

Avisar en caso de Emergencia a:

Telfono:

Direccin Actual:

Profesin:
Parentesco:

Motivo de Consulta
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Enfermedad Actual
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Diagnstico Sindromtico
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I. HISTORIA FAMILIAR
1. Estado de salud y/o causa de muerte
2. Antecedentes patolgicos familiares
2.1 Alcoholismo
2.2 Artritis
2.3 Asma
2.4 Cncer
2.5 Cardiovasculares
2.6 Enf. Metablicas
(Endocrinas)
2.7 T.B.C
2.8 Enf Digestivas
Enf. Renales
2.9 Enf. Alrgicas
2.10 Neuromentales
2.11 Sfilis
2.12 Discrasias Sanguneas
2.13 Otras

Padres:___________________________________________________________________________________________________
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Hermanos:_______________________________________________________________________________________________
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Hijos:_____________________________________________________________________________________________________
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Abuelos:__________________________________________________________________________________________________
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Pareja u otros:____________________________________________________________________________________________
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II. HISTORIA PERSONAL

4. Hbitos Psico-Biolgicos
4.1 Alimentacin
4.2 Apetito
4.3 Catarsis Intestinal
4.4 Diuresis
4.5 Sueo
4.6 Alcoholismo
4.7 Tabaquismo
4.8 Drogas
4.9 Medicamentos
4.10 Sexuales
4.11 Recreacin
4.12 Actividad Fsica
4.13 Aseo
4.14 Tipo de vivienda
4.15 Otros

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5. Inmunizaciones
5.1 Viruela
5.2 Toxoide Tetnica
5.3 Antiamarilica
5.4 BCG
5.5 Divalente
5.6 Hepatitis
5.7 Antipolio
5.8 Influenza
5.9 AH1N1
5.10 Otras

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6. Antecedentes Epidemiolgicos
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6.1 Lugares de Residencia: ___________________________________________________________________________________________________________
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6.2 Caractersticas de la Vivienda:
Piso _________________ Paredes _____________________ Techo _____________________ Nro de Hab ___
Disposicin de Excretas ______________________ Disposicin de Basura ____________________________ Aguas: Negras ____ Blancas ____
Nro de Baos _____ Nro de Personas _____ Tenencia de la vivienda: _________________________________________________________________
6.3 Animales: _________________________________________________________________________________________________________________________
6.4 Trabajos Desempeados: _________________________________________________________________________________________________________

7. Antecedentes Ginecolgicos y Obsttricos

7.1 Menarquia
7.2 Sexarquia
7.3 Menopausia
7.4 Partos
7.5 Abortos
7.6 Cesreas
7.7 Hijos Vivos
7.8 Menstruacin
7.9 Fecha de la ltima
menstruacin
7.10 Met. Anticonceptivos
7.11 Flujo Vaginal
7.12 Fecha de la ltima
citologa
7.13 Otros

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8. Antecedentes Quirrgicos y Traumticos

8.1 Operacin
8.2 Traumatismos
8.3 Fracturas
8.4 Prdida de conciencia

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9. Antecedentes Alrgicos
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9.1 Inhalatorias
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9.2 Alimentarias
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9.3 Cutneas
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9.4 Medicamentos
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Antecedentes Patolgicos
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10. Enfermedades de la
Infancia
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10.1 Sarampin
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10.2 Tos Ferina
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10.3 Rubeola
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10.4 Lechina
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10.5 Parotiditis
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10.6 Amigdalitis
10.7 Malaria
10.8 Sfilis
10.9 Parasitosis
10.10 Conjuntivitis
10.11 Otitis
10.12 Enf. De Piel
10.13 Otras

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11. Enfermedades Mdicas
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11.1 Difteria
11.2 Gripe
11.3 Influenza
11.4 Chancros
11.5 Sfilis
11.6 Micosis
11.7 Conjuntivitis
11.8 Sinusitis
11.9 Otitis

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11.10 Asma
11.11 Amigdalitis
11.12 Cardiopatas
11.13 Gastropatas
11.14 Fiebres prolongadas
11.14 Convulsiones
11.15 Hepatitis
11.16 Mononucleosis
11.17 Otros

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Hospitalizaciones: ____________________________________________________________________________________________________________________
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Transfusiones: ________________________________________________________________________________________________________________________
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III. INTERROGATORIO POR APARATOS Y SISTEMAS

12. Piel, Pelo y Uas
12.1 Erupcin
12.2 Prurito
12.3
Cambio
de
Pigmentacin
12.4
Aparicin
de
tumoraciones y lunares
12.5
Cambios
de
apariencia en lunares
12.6 Cambios en textura
de piel y uas
12.7 Cada o fragilidad en
cabello
12.8 Cianosis
12.9 Edemas
12.10 Otros

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13. Cabeza
13.1 Cefalea
13.2 Mareos
13.3 Vrtigo
13.4 Sncope
13.5 Otros

14. Ojos
14.1 Agudeza Visual
14.2 Diplopa
14.3 Secreciones
14.4 Lentes
14.5 Otros

15. Odo
15.1 Agudeza Auditiva
15.2 Dolor
15.3 Secreciones
15.4 Otros

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16. Nariz
16.1 Anosmia
16.2 Hiposmia
16.3 Sinusitis
16.4 Epistaxis
16.5 Rinorrea
16.6 Obstruccin nasal
16.7 Otros

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17. Boca y Garganta ___________________________________________________________________________________________________________
17.1 Mucosa
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17.2 Condicin de dientes ___________________________________________________________________________________________________________
17.3 Halitosis
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17.4 Glosodinia
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17.5 Odinofagia
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17.6 Disfagia
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17.7 Ronquera
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17.8 Dolor
17.9 Otros
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18. Cuello
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18.1
Dolor
a
la ___________________________________________________________________________________________________________
movilizacin
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18.2 Inflamacin
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18.3 Adenomegalias
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18.4 Otro
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19. Respiratorio
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19.1 Disnea
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19.2 Tos
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19.3 Dolor
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19.4 Esputos
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19.5 Hemoptisis
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19.6 Otros
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20. Cardiovascular
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.20.1 Palpitaciones
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20.2 Dolor Torcico
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20.3 Desmayo
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20.4 Disnea
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20.5
Aumento
de
volumen o frialdad en los ___________________________________________________________________________________________________________
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miembros inferiores
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20.6 Otras
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21. Gastrointestinal ___________________________________________________________________________________________________________
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21.1 Apetito
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21.2 Dolor Abdominal
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21.3 Nauseas y Vmitos
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21.4 Rectorragia
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21.5 Pirosis
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21.6 Flatulencias
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21.7 Eructos
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21.8 Melena
21.9 Hemorroides
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21.10 Ulceras
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21.11 Hemorroides
21.12 Dolor Rectal
21.13 Esteatorrea
21.14 Acolia
21.15 Tenesmo
21.16 Otros

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22. Genitourinario
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22.1 Disuria

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22.2 Nocturia
22.3 Hematuria
22.4 Incontinencia
22.5 Miccin
22.6 Secreciones
22.7 Prostatismo
22.8 Otros

23. Neurolgico
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23.1 Nerviosismo
23.2 Perdida de memoria
23.3 Desorientacin
23.4 Marcha
23.5 Personalidad
23.6 Parlisis
23.7 Convulsiones
23.8 Sueo-Vigilia
23.9 Otros

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24. seo-muscular
.24.1 Debilidad
24.2 Dolor
24.3 Fracturas
24.4
Dolor
articulaciones
24.5 Deformaciones
articulaciones
24.6 Otros

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II PARTE EXAMEN FSICO

Presin Arterial:
Sistlica:

Frecuencia Respiratoria:

Temperatura:

Diastlica:

Pulso:

Caractersticas de Pulso y Arterias:

Talla:

Peso:

IMC:

Circunferencia abdominal:

Circunferencia braquial:

Aspecto General (Facie)

Tipo Constitucional:

Actitud: