Historia Clnica

Alumno: __________________________________________________________________________
Fecha:

/ 2014

Hora: _____________

Anamnesis: _________________

Confiabilidad: ________________

Nombre: __________________________________________________________________________
Sexo: a) Femenino

b) Masculino

Fecha de nacimiento y Edad:

aos

Lugar de procedencia: ______________________________________________________________________

Domicilio: ________________________________________________________________________________
Ocupacin________________________________________________________________________________
Persona responsable: ______________________________________________________________________
Grado de Instruccin: a) Inicial b) Primaria c) Secundaria d) Estudios Superiores e) ____________________
Estado Civil: a) Soltero b) Casado Civil c) Casado Religioso d) Viudo e) _______________________________
Religin: a) Catlica b) Cristiana c) Evanglica d) Testigo de Jehov e) ________________________________

Datos Biogrficos: (tipo de parto, infancia, estudios, relaciones sociales, oficios, profesiones, domicilios)
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Modo de vida actual: (Composicin familiar, vivienda, situacin econmica, recreacin)

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Antecedentes Personales:
1) Hbitos txicos
Alcohol: ___________________________________________________________________________
Tabaco: ___________________________________________________________________________
a) Sin riesgo (menos de 10)
b) Riesgo moderado (10 20)
c) Riesgo intenso (21 40)
d) Alto riesgo (41 a ms)
Drogas: ___________________________________________________________________________
Cafena: ___________________________________________________________________________
2) Patolgicos:
Vacunas: __________________________________________________________________________
Enfermedades de la infancia: __________________________________________________________
Enf. Infectocontagiosas: ______________________________________________________________
Enf. Crnicas: ______________________________________________________________________
Intervenciones quirrgicas: ___________________________________________________________
Alergia a frmacos: __________________________________________________________________
Medicacin de uso habitual: __________________________________________________________
Hospitalizaciones anteriores: _________________________________________________________
Relaciones sexuales: a) Heterosexual b) Homosexual c) Bisexual
Nmero de parejas sexuales: ____________
Infecciones sexuales: _______________________________________________________________
Accidentes: _______________________________________________________________________
3) Gineco-obsttricos
Fecha de ltima menstruacin:
/
/
Fecha del primer parto:
/
/
Edad gestacional: _____________________________________
Menarca: ___________________________________________
Ritmo menstrual:
/
/
Partos: _____________________________________________
Cesreas: ___________________________________________
Abortos: ____________________________________________
Anticonceptivos: a) Si b) No Tipo: _______________________
ltima toma de anticonceptivos: ________________________
Cirugas ginecolgicas: ________________________________
ltimo Papanicolaou: _________________________________
4) Antecedentes Heredofamiliares:
Padre:

a) Enfermedades: _____________________________________________________________
b) Causa de muerte: ___________________________________________________________

Madre:

a) Enfermedades: _____________________________________________________________
b) Causa de muerte: ___________________________________________________________

Hermanos: _______

a) Enfermedades: ________________________________________________
b) Causa de muerte: ______________________________________________

Hijos: ____________

a) Enfermedades: ________________________________________________
b) Causa de muerte: ______________________________________________

Fecha de ingreso:

Motivo de Consulta / Sntomas principales:

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Enfermedad Actual Tiempo de enfermedad: _______________

Forma de comienzo: a) Brusco b) Progresivo c) Insidioso
Curso: a) Progresivo b) Fijo c) Retrgrado
Relato Cronolgico:
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Funciones Biolgicas
Apetito: a) Anorexia b) Hiporexia c) Conservado d) Polifagia
Diuresis: a) Anuria (< 100 mL) b) Oliguria (< 400 mL) c) Normal (500 a 2500 mL) d) Poliuria (ms de 3 L)
Caractersticas de la miccin: a) Polaquiurea b) Disuria c) Tenesmo d) Normal e) Nicturia f) Otros
Caractersticas de la orina: __________________________________________________________________________
Por su peso debera orinar:__________________________________________________________________________
Sed: a) Hipodipsia b) Conservada c) Polidipsia
Deposiciones: a) Diarrea (> 3 veces/da) b) Conservada (3-21 veces/Semana) c) Estreimiento (< 3 v/s)
Caractersticas de las heces: _________________________________________________________________________
Caractersticas del sueo: a) Insomnio de inicio b) Insomnio de mitad c) Hipersomnia d) Inversin e) Conservado
Horas de Sueo: a) < 4 horas diarias b) 4 a 8 horas d. c) de 8 a 15 horas d. d) de 16 a 18 horas d.
Variacin de peso:_________________________________________________________________________________

Revisin por aparatos y sistemas

Cabeza: Cefalea, traumatismos.
Ojos: Visin, lentes, diplopa, escotomas, dolor, enrojecimiento, inflamacin, lagrimeo.
Odos: Audicin, zumbidos, dolor, secreciones.
Respiratorio: Tos, hemoptisis, disnea, cianosis, TBC, asma, neumona, exposicin ocupacional.
Cardiovascular: Angina, disnea, ortopnea, edema, palpitaciones, soplos, insuficiencia cardiaca, infarto.
Gastrointestinal: Disfagia, odinofagia, regurgitaciones, pesadez, ardor epigstrico, nuseas, vmitos, melena, diarrea,
ictericia, hernias, hemorroides, prurito anal, sangrado rectal.
Urinario: Dolor lumbar, disuria, hematuria, incontinencia, clculos, infeccin, tenesmo.
Ginecolgico: Papanicolaou realizado, metrorragia, secreciones, enfermedades venreas.
Msculo-esqueltico: calambres, debilidad, luxaciones, fracturas, artralgias, dolor de espalda.
Sistema Nervioso: Sncope, convulsiones, mareo, parlisis, temblor, sensibilidad, memoria.
Emocional: Ansiedad, sueo, depresin, pensamientos suicidas.

Examen General
Examen fsico:
Signos vitales: FC: ____________ PA: _______________ FR: __________________ Pulso: ______________
T Axilar _______________ Permetro Abdominal: ____________________ Peso: ___________
Talla: ____________ IMC: ______________ Superficie Corporal: _________________
a)
b)
c)
d)
e)
f)
g)
h)

Caquexia (< 16)

Delgadez moderada (16 17)
Delgadez leve (17 18.5)
Normal (18.5 25)
Sobrepeso (25 30)
Obesidad 1 (30 35)
Obesidad 2 (35 40)
Obesidad mrbida (> 40)

Aspecto General: (Facies, hidratacin, nutricin, conciencia)

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Piel: (Temperatura, elasticidad, humedad, color, erupciones, petequias, cicatrices, estras, nevos, ictericia)
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Uas: (Implantacin, color, forma, consistencia, estras, tiempo de recoloracin capilar)

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Sistema Piloso: (Color, sequedad, fragilidad, distribucin, tumoraciones)
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Linfticos: (Crecimiento, nmero, consistencia, movilidad, sensibilidad)
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Examen Regional
Crneo: __________________________________________________________________________________
Esclertica: _______________________________________________________________________________
Prpados: ________________________________________________________________________________
Pupilas: __________________________________________________________________________________
Odos: ___________________________________________________________________________________
CAE: ____________________________________________________________________________________
Boca: ___________________________________________________________________________________
Lengua: __________________________________________________________________________________
Dientes: _________________________________________________________________________________
Cuello: __________________________________________________________________________________
Tiroides: _________________________________________________________________________________
Trax y pulmones:
-

Inspeccin: ________________________________________________________________________
Palpacin: _________________________________________________________________________
Percusin: _________________________________________________________________________
Auscultacin: ______________________________________________________________________

Cardiovascular:
-

Inspeccin: ________________________________________________________________________
Palpacin: ________________________________________________________________________
Percusin: ________________________________________________________________________
Auscultacin: ______________________________________________________________________

Abdomen:
-

Inspeccin: ________________________________________________________________________
Auscultacin: ______________________________________________________________________
Percusin: _________________________________________________________________________
Palpacin: _________________________________________________________________________

Sistema msculo-esqueltico:
-

Huesos: __________________________________________________________________________
Msculos: _________________________________________________________________________
Articulaciones: _____________________________________________________________________

Sistema Nervioso:
-

Estado de consciencia: _______________________________________________________________

Actitud y bipedestacin: ______________________________________________________________
Reflejos: __________________________________________________________________________
Sensibilidad tctil: __________________________________________________________________
Signos menngeos: __________________________________________________________________
Coordinacin dinmica: ______________________________________________________________

Datos Bsicos
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Problema de Salud 1:
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Plan Diagnstico:
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Plan Teraputico:
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Problema de Salud 2:
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Plan Diagnstico:
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Plan Teraputico:
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Problema de Salud 3:
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Plan Diagnstico:
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Plan Teraputico:
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Problema de Salud 4:
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Plan Diagnstico:
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Plan Teraputico:
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Problema de Salud 5:
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Plan Diagnstico:
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Plan Teraputico:
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Plan Educacional
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