MODELO DE HISTORIA CLNICA

Ctedra de Medicina I (Semiologa) UHMI N 1

Hospital Nacional de Clnicas

Fecha: / / . Mdico: ________________________________.

DATOS PERSONALES
Apellido y Nombre: _________________________________________________________________________.
Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupacin: _______________.
Domicilio: _____________________________________________________________. TE: ______________.
Residencia: _______________________________________________________________________________ .

MOTIVO DE CONSULTA

ANTECEDENTES DE LA ENFERMEDAD ACTUAL

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1- Sntomas Generales: fiebre,
perdida de peso, astenia, fatiga,
otros.
2 - Piel y faneras: prurito, lesiones _____________________________________________________________
primarias y secundarias,
alteraciones de uas y cabellos,
otros.
3 - TCS: edema, tumoraciones,
otros.
4 - SOMA: dolor, tumefaccin,
fuerza muscular, limitacin del
movimiento, otros.
5 - Ap. Cardiovascular: disnea,
palpitaciones, dolor precordial,
sncope, claudicacin intermitente, _____________________________________________________________
otros.
6 - Ap.Respiratorio: epistaxis, tos, _____________________________________________________________
expectoracin, hemptisis, dolor
torcico, cianosis, otros.
7 - Ap. Digestivo: halitosis,
disfagia, regurgitacin, acidez,
pirosis, nauseas y vmitos,
hematemesis, alteraciones del
hbito intestinal, otros.
8 - Ap. Genitourinario: disuria,
polaquiuria, nicturia, hematuria,
incontinencia, dolor, alteraciones
ciclo menstrual, alteraciones
sexuales, otros
9 - Sistema Nervioso: cefalea,
mareos, vrtigo, sensibilidad,
motricidad, temblor, alteraciones
de la visin, audicin, otros.
ANAMNESIS SISTEMICA
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1-Fisiolgicos : menarca, ciclo
menstrual, fecha ltima
menstruacin, embarazos, partos,
alimentacin, actividad fsica,
sueo, diuresis y catarsis, actividad
sexual, otros.
2- Inmunizaciones.
3- Vivienda y medio ambiente.
4- Socioeconmicos.
5- Patolgicos: mdicos, alrgicos, _____________________________________________________________
quirrgicos, traumticos.
6-Txico-Medicamentosos: tabaco, _____________________________________________________________
alcohol, sustancias de uso
indebido, medicamentos, otros.
7-Epidemiolgicos: Chagas,
HIV/Sida, Brucelosis,
Toxoplasmosis, transfusiones,
residencias anteriores, otros.
8-Heredo-Familiares.
9- Estudios preventivos.
10- Otros.
ANTECEDENTES PERSONALES
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1-Inspeccin General
2-Mediciones y Controles
3-Piel y faneras: color, turgor,
elasticidad, humedad,
temperatura, lesiones primarias,
lesiones secundarias, pelos y uas.
4-TCS: cantidad, distribucin,
vrices, circulacin colateral,
edema, adenopatas, otros.
5-SOMA: huesos (conformacin y
sensibilidad), msculos,
articulaciones.
1-Cabeza y cuello: crneo, odos,
ojos, nariz, boca. Tiroides,
cartidas, PVC, otros.
2-Ap. Respiratorio: inspeccin,
expansin de V y B, vibraciones
vocales, claro pulmonar, murmullo
vesicular, auscultacin de la voz,
ruidos patolgicos, otros.
3-Mamas.
4-Ap. Cardiovascular: precordio
(inspeccin, zona mximo
impulso, latidos patolgicos,
ruidos cardacos normales y
patolgicos), pulsos perifricos,
auscultacin arterial, otros.
5-Abdomen: inspeccin,
auscultacin, palpacin superficial
y profunda, puntos dolorosos,
orificios herniarios, percusin,
otros.
6-Ap. Genitourinario: puo
percusin, puntos reno-ureterales,
examen genital, tacto rectal, otros.
7-Sistema Nervioso: pares
craneales. Motricidad (tono,
trofismo, motricidad voluntaria y
fuerza muscular). Reflejos
superficiales y profundos.
Sensibilidad (superficial y
profunda).
Funcin cerebelosa.
EXAMEN FISICO
Examen General
Estado de conciencia: __________________________________________.
Actitud: _____________________________________________________.
Decbito: ____________________________________________________.
Marcha: _____________________________________________________.
Facie: _______________________________________________________.
FC: _____________ TA: _____________ FR: __________ T: _______.
Peso: ___________ Altura: ___________ IMC: ___________________.
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Examen Segmentario
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 LISTADO DE PROBLEMAS

LISTADO DE DIAGNOSTICOS

METODOS COMPLEMENTARIOS SOLICITADOS

TRATAMIENTO INICIAL

EVOLUCIONES

EPICRISIS

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