HISTORIA CLNICA

HOSPITAL:
SERVICIO: Medicina
I. ECTOSCOPA:
1.1.- Estado de Gravedad: __________________________________________________________
1.2.- Edad Aparente: _____________________________________________________________
1.3.- Facies o signos destacados:
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II. ANAMNESIS:
2.1.- Filiacin:
a) Nombre: __________________________________________________________________________
b) Edad: _______________________
c) Fecha de nacimiento: ______________________________________
d) Sexo: _______________________
e) Raza: _________________________
f) Ocupacin: _________________________________
g) Estado Civil: ___________________________________
h) Grado de Instruccin: ____________________________
i) Religin: _______________________
j) Idioma: _____________________________
k) Lugar de Nacimiento: ___________________________
l) Lugar de Procedencia: ____________________________
m) Tiempo en el Lugar de Procedencia: ______________________________
n) Domicilio: __________________________________________________
o) Persona Responsable: __________________________________________
p) Fecha de Ingreso: __________________________________ Hora de ingreso: _______________
q) Forma de ingreso: ___________________________________________
r) Fecha de Historia Clnica: _______________________ Hora de Historia Clnica: ______________
t) N de historia clnica: _____________________________
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2.2.- Enfermedad Actual:

a) Sntomas Principales:

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b) Tiempo de Enfermedad: _____________________________
c) Forma de Inicio: _____________________________
d) Curso de la Enfermedad: _____________________________
e) Relato Cronolgico:

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III.-FUNCIONES BIOLGICAS:

ACTUAL
- Apetito
- Sed:
- Orina:
- Deposiciones:
- Sueo:

IV. ANTECEDENTES:
a) Personales:
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- Vivienda: __________________________________________________________________________
-N de personas: ______________________________________________________________________
-Crianza de animales: _________________________________________________________________
- Luz: ______________________________________________________________________________
- Agua: _____________________________________________________________________________
- Desage: __________________________________________________________________________
- Hbitos Nocivos: ____________________________________________________________________
a. ASPECTO GENERAL:

Facies:_______________________________________________________________________
Tipo constitucional:____________________________________________________________
Actitud: _____________________________________________________________________
Estado de gravedad: ___________________________________________________________
Estado de nutricin:____________________________________________________________
Estado de hidratacin:__________________________________________________________
Estado mental y grado de colaboracin:_____________________________________________
C. REVISIN POR APARATOS Y SISTEMAS
a. Estado de la Piel:
-Color:______________________________________________________________________
-Humedad:___________________________________________________________________
-Turgencia:___________________________________________________________________
b. T.C.S.C:_______________________________________________________________________

c. Vasos Linfticos:________________________________________________________________
d. Ojos:__________________________________________________________________________
e. Boca: _________________________________________________________________________
f.

Nariz: _________________________________________________________________________

g. Odos: _________________________________________________________________________
h. Gusto: ________________________________________________________________________
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i.

Garganta: _____________________________________________________________________

j.

Cuello: ________________________________________________________________________

k. Mamas: _______________________________________________________________________
l.

Trax: ________________________________________________________________________

m. Cardiovascular: ________________________________________________________________
n. Abdomen: _____________________________________________________________________
o. Genitourinario: _________________________________________________________________
p. Endocrino: _____________________________________________________________________
q. Neurologa: ____________________________________________________________________
r.

Muscular: _____________________________________________________________________

s. Osteoarticular: _________________________________________________________________
VI. PLANTEAMIENTO PRELIMINAR
DIAGNSTICO SINDRMICO:

1.________________________________________________________________________
2.________________________________________________________________________
3.________________________________________________________________________
4.________________________________________________________________________
5.________________________________________________________________________
IMPRESIN DIAGNSTICA CLNICA:

1.________________________________________________________________________
2.________________________________________________________________________
3.________________________________________________________________________
4.________________________________________________________________________