By Dr.

Carlos Fernando Uc Ku Historia Clinica

HISTORIA CLINICA GERIATRICA

INTERROGATORIO:

1. FICHA DE IDENTIFICACIN
1.1. Nombre Completo:
Apellido paterno Apellido materno Nombre (s):
1.2. Gnero: M ( )F( )
1.3. Edad: _____ Aos
1.4. Fecha de nacimiento:
Da Mes Ao
1.5. Lugar de nacimiento:
Municipio Estado
1.6. Estado civil: Soltero ( ) Casado ( ) Viudo ( ) Unin Libre ( )
1.7. Lugar de residencia:
Municipio Estado
1.8. Domicilio:__________________________________________________________________________________
1.9. Telfono: _________________________________________________________________________________
1.10. Familiar con quien
vive: Apellido paterno Apellido materno Nombre (s):
1.11. Si vive solo:
Pariente ms cercano: Apellido paterno Apellido materno Nombre (s):

Direccin:_________________________________________________________________________________
Telfono: __________
1.12. Escolaridad: Primaria __ Secundaria __ Preparatoria/Bachillerato __ Licenciatura___ Otro_______________
1.13. Ocupacin: ____________________
1.14. Religin: _____________________
1.15. Hobbie (Pasatiempos): ____________________________________________________________________
1.16. Derechohabiente: IMSS:__ ISSTE:__ SEGURO POPULAR:__
1.17. Fecha y hora de estudio: ___:___
Hora Da Mes Ao
1.18. Nmero de expediente: ______________________

2. ANTECEDENTES HEREDO FAMILIARES:

a. Tuberculosis, Diabetes Mellitus, Hipertensin, Carcinomas, Cardiopatas, Hepatopatas, Nefropatas,
Enf.endocrinas, Enf. Mentales, Epilepsia, Asma, Enf. Hematolgicas, Sfilis
b. Investigar etiologa y edades de Morbimortalidad en abuelos, padres, hijos, conyuges, hermanos.
2.1. Abuelos:
Abuelo paterno: ____________________________________________________________________________
Abuela paterna: ____________________________________________________________________________
Abuelo materno: ___________________________________________________________________________
Abuela materna: ___________________________________________________________________________
2.2. Padres:
Padre:____________________________________________________________________________________
Madre: ___________________________________________________________________________________
2.3. Hermanos: (# de hermanos, lugar ocupado):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2.4. Cnyuge: _________________________________________________________________________________
2.5. Hijos:_____________________________________________________________________________________
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By Dr. Carlos Fernando Uc Ku Historia Clinica
2.6. Nietos:
___________________________________________________________________________________________
__________________________________________________________________________________________
2.7. Otros (tios, primos):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2.8. Antecedentes:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

3. ANTECEDENTES PERSONALES NO PATOLGICOS

3.1. Habitacin: Cuartos____ Piso:_______________ Techo:_______________ Ventanas:_______________
Servicios: :_______________ Personas con las que comparte la habitacin :_____
3.2. Convivencia:
Animales: :_______________, Cuantos:____ (Dentro) o (Fuera de la casa/habitacin

3.3. Alimentacin:
A. Desayuno:
_______________________________________________________________________________________
_________________________________________________________________________________
B. Almuerzo:
_______________________________________________________________________________________
_________________________________________________________________________________
C. Cena:
_______________________________________________________________________________________
_________________________________________________________________________________
D. Alimentacin (f/ tipo) _______res_____pollo______fruta_____ cerdo ______
3.4. Higiene:
Bao ___________defecacin ___________ lav. dientes ___________
3.5. Toxicomanas:
Tabaquismo (cig/da/aos) _______________________ Alcoholismo (beb/frec) ______________________
Toxicomanas (esp/da/aos)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
3.6. Inmunizaciones (Vacunas):
___________________________________________________________________________________________
___________________________________________________________________________________________

4. ANTECEDENTES PERSONALES PATOLGICOS:

4.1. Hereditarios:
___________________________________________________________________________________________
___________________________________________________________________________________________
4.2. EEAPI:
____________________________________________
A. Varicela: Si__ No__ Edad: ___aos,
B. Rubiola: Si__ No__ Edad: ___aos, ____________________________________________
C. Sarampin: Si__ No__ Edad: ___aos, ____________________________________________
D. Escarlatina: Si__ No__ Edad: ___aos, ____________________________________________
E. Exantema Sbito: Si__ No__ Edad: ___aos, ____________________________________________
F. Eritema Infeccioso: Si__ No__ Edad: ___aos,
4.3. Enfermedades (Padecidas hasta la fecha, Enfermedades Frecuentes) :
___________________________________________________________________________________________
___________________________________________________________________________________________
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By Dr. Carlos Fernando Uc Ku Historia Clinica
4.4. Antecedentes :
4.4.1. Quirrgicos:
1. Cx_____________________________________ Cundo?_____________ Cmo?____________________
Donde?_________________________ Por qu?_______________________________________________
2. Cx_____________________________________ Cundo?_____________ Cmo?____________________
Donde?_________________________ Por qu?_______________________________________________
3. Cx_____________________________________ Cundo?_____________ Cmo?____________________
Donde?_________________________ Por qu?_______________________________________________
4.4.2. Traumticos:
1. Tipo de traumatismo (accidentes):_____________________________ Magnitud: _________________
Fecha: ________Tx Recivido:________________
2. Tipo de traumatismo (accidentes):_____________________________ Magnitud: _________________
Fecha: ________Tx Recivido:________________
3. Tipo de traumatismo (accidentes):_____________________________ Magnitud: _________________
Fecha: ________Tx Recivido:________________
4.4.3. Transfusionales:
Sangre: ___ Suero:___ Plasma:___ Plaquetas:___
Motivo: ____________________________________
4.4.4. Grupo Sanguneo y Rh: _______________________________
4.4.4. Alrgicos:
Medicamentos:_______________________________________
Alimentos: __________________________________________
Ambientales: ________________________________________
Otros (Plasticos, latex, etc.)______________________________

5. ANTECEDENTES GINECOOBSTETRICOS
5.1. Menarca: ______aos
5.2. Ritmo (Cada cuantos das?)y periodicidad (Cuanto dura el sangrado?): _______________________
5.3. Inicio vida sexual activa: _______aos
5.4. Gesta: ______________ FUG: ______________
5.5. Para (Embarazos llevados a trmino): ______________ FUP: ______________
5.6. Abortos: ______________ FUA: ______________
5.7. Cesreas: ______________ FUC: ______________
5.8. Obitos(muerte fetal in tero antes de su viabilidad) ______________ FUO: ______________
5.9. FUM: ______________
5.10. Otros:
__________________________________________________________________________________________
__________________________________________________________________________________________

6. PADECIMIENTO ACTUAL
6.1. Qu, cmo, cundo, dnde:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6.2. Semiologa:
Antigedad (cundo comenz? Cunto dura? con qu frecuencia ocurre?)
Localizacion
Irradiacion
Calidad
Intencidad
Agravantes/Alivio
Circunstancias en las que ocurre: Factores ambientales, actividades personales, reacciones emocionales u otras situaciones que
pueden contribuir
Manifestaciones relacionadas
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By Dr. Carlos Fernando Uc Ku Historia Clinica
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6.2. Evolucin:
__________________________________________________________________________________________
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6.3. Estado actual: Cmo se siente en este momento?
__________________________________________________________________________________________
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__________________________________________________________________________________________
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6.4. Teraputica previa: (tratamientos anteriores)

7. INTERROGATORIO POR APARATOS Y SISTEMAS

Aparato digestivo. halitosis, boca seca, _________________________________________________________
masticacin, disfagia(odino), pirosis, nausea, _________________________________________________________
vomito, (hematemesis), dolor abd. meteorismo y _________________________________________________________
flatulencias, constipacin, diarrea, rectorragia,
_________________________________________________________
melenas, pujo y tenesmo, Ictericia coluria y
_________________________________________________________
acolia, prurito cutneo, hemorragias.
_________________________________________________________
Aparato cardiovascular. Disnea, tos (seca. _________________________________________________________
prod.), hemoptisis, dolor precordial, _________________________________________________________
palpitaciones, cianosis _________________________________________________________
edema y manifestaciones perifericas (acfenos, _________________________________________________________
fosfenos, sncope, lipotimia, cefalea, etc)
_________________________________________________________
_________________________________________________________

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By Dr. Carlos Fernando Uc Ku
Aparato respiratorio. Tos, disnea, dolor torcico,
hemoptisis, cianosis, vomica, alteraciones de la
voz.
Aparato Urinario. Alteraciones de la miccin
(poliuria, anuria, polaquiuria,oliguria, nicturia,
opsiuria, disuria, tenesmo vesical, urgencia,
chorro, enuresis, incontenincia) caracteres de la
orina (volumen, olor, color, aspecto) dolor
lumbar, edema renal, hipertensin arterial, datos
clnicos de anemia.
Aparato genital. Criptorquidia, fimosis, funcin
sexual. Sangrado genital, flujo o leucorrea, dolor
ginecolgico, prurito vulvar.
Aparato hematolgico. Datos clnicos de anemia
(palidez, astenia, adinamia y otros),
hemorragias, adenopatas, esplenomegalia.
Sistema endocrino. Bocio, letargia
bradipsiquia (lalia), intol. calor/frio,
nerviosismo,
hiperquinesis, carac. sexuales, galactorrea,
amenorrea, ginecomastia, obesidad,
ruborizacin.
Sistema osteomuscular. ganglios, xeroftalmia,
xerostomia, fotosensibilidad
artralgias/mialgias, Raynaud.
Sistema nervioso. cefalea, sncope,
convulsiones, deficit transitorio, vertigo,
confusion y obnub., vigilia/sueo, paralisis y M,
marcha y equilibrio, sensibilidad.
Sistema sensorial. visin, agudeza, borrosa
diplopia, fosgenos, dolor ocular, fotofobia,
xeroftalmia, amaurosis, otalgia, otorrea y
otorragia, hipoacusia, tinitus, olfaccin,
epistaxis, secrecin, Geusis, Garganta (dolor)
Fonacin.
Psicosomtico. Personalidad, ansiedad,
depresin, afectividad, emotividad, amnesia,
voluntad, pensamiento, atencin, ideacin
suicida, delirios.
Historia Clinica
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By Dr. Carlos Fernando Uc Ku Historia Clinica
II. Exploracin fsica

1. Signos vitales:
1.1. TA: __________ mmHg
1.2. FC: __________lpm
1.3. FR: __________Rpm
1.4. Temp.: _______C
1.5. Antropometra:
1.5.1. Peso: _______ kg.
1.5.2. Talla: _______ mts
1.5.3. IMC: _______ kg/m2

2. Impresin general:
2.1. Sexo: ______________________
2.2. Edad: ______________________
2.3. Fascies caracterstica: _________________________
2.4. Talla: ___________________
2.5. Constitucin: ___________________________________

2.6. Conformacin: ______________________________________

2.7. Integridad: _________________________________________
2.8. Posicin y actitud escogidas: ___________________________
2.9. Marcha: ___________________________________________________
2.10. Movimientos anormales: _____________________________________
2.11. Conciencia: _______________________________________________
2.12. Orientacin (Timepo, espacio, persona): _______________________________________________
2.13. Cooperacin: ______________________________________________
2.14. Nivel socioeconmico cultural: _______________________________

3. Cabeza:
3.1 Crneo:
Tamao: normocfalo, microcfalo, macrocfalo
Forma: braquicfalo, dolicocfalo, turricefalo Permetro craneano (en nios)
Cara: simetra, aumento de volumen, movimientos involuntarios, presencia de lesiones.
______________________________________________________________________________________________
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Frente: tamao, simetra de pliegues _______________________________________________________________

Arco periorbitario ______________________________________________________________________________
Cejas ________________________________________________________________________________________
Prpados: parpadeo, simetra _____________________________________________________________________
Pestaas_________________________________________________________________________________
Ojos:
Globo ocular. Tamao: exoftalmia, enoftalmia. Tensin
________________________________________________________________________________________
________________________________________________________________________________________
Conjuntiva ocular y palpebral:
________________________________________________________________________________________
________________________________________________________________________________________
Escleras (color): __________________________________________________________________________

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By Dr. Carlos Fernando Uc Ku Historia Clinica
Iris (color, simetra): _______________________________________________________________________
Pupila: __________________________________________________________________________________
Crnea, Reflejo fotomotor, movimientos oculares, agudeza visual.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Nariz:
Tamao________________________________________
Tabique nasal: posicin: ___________________________
Mucosa nasal: permeabilidad, olfato, aleteo nasal. Coriza:
______________________________________________________________________________________________
______________________________________________________________________________________________
Boca:
halitosis: _________________________________________________________________________________
Labios: __________________________________________________________________________________
Encas: ___________________________________________________________________________________
Dentadura: oclusin, masticacin: _____________________________________________________________
Higiene: __________________________________________________________________________________
Lengua y gusto: ___________________________________________________________________________
Paladar duro: ______________________________________________________________________________
Paladar blando: ____________________________________________________________________________
Glndulas salivares: salivacin: _______________________________________________________________
Amgdalas:________________________________________________________________________________
Faringe: __________________________________________________________________________________
Deglucin: _____________________________________________________________________________________
Odos: forma, tamao, posicin, simetra. Audicin:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Pabelln auricular: _______________________________________________________________________________
Conducto auditivo externo: higiene, secreciones: _______________________________________________________

4. Cuello:
Movilidad: _____________________________________________________________________________________
Tiroides: tamao__________________________________________________________________________
Trquea: ________________________________________________________________________________
Yugulares: pulso carotdeo, sensibilidad, aumentos de volumen, masa, rigidez.:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
5. Trax: Forma, simetra, uso musculatura accesoria, retraccin o abombamiento de espacios intercostales,
elasticidad, expansin, movilidad de la caja torcica, dolor, masas, percusin. Lesiones, cicatrices, cambios de
coloracin:
__________________________________________________________________________________________
__________________________________________________________________________________________
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Corazn: auscultacin ruidos cardiacos y arritmias:
______________________________________________________________________________________________
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Pulmones: auscultacin ruidos pulmonares:
______________________________________________________________________________________________
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By Dr. Carlos Fernando Uc Ku Historia Clinica
Mamas:
______________________________________________________________________________________________
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Axilas
Simetra, textura, aumento de volumen, presencia de masas, retraccin, secreciones, cambio de coloracin,
sensibilidad.
______________________________________________________________________________________________
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6. Abdomen:
Forma: plano, excavado, distendido, abombado, globuloso, en delantal: ____________________________________
Ombligo: aspecto:
______________________________________________________________________________________________
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Permetro abdominal: simetra, coloracin, cicatrices, lesiones, circulacin colateral, dolor, resistencia, masas, ruidos
hidroareos, matidez. Timpanismo, ascitis, organomegalias:
______________________________________________________________________________________________
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Zona gltea, intergltea y anal: hemorroides, edema lumbosacro:
______________________________________________________________________________________________
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7. Genitales: Grado (Etapa) de Taner, hemorragia, dolor, secreciones, inflamacin, masas, higiene:
__________________________________________________________________________________________
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Vello pubiano:
________________________________________________________________________________________
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o Genitales femeninos
Labios mayores:
___________________________________________________________________________
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Cltoris:
___________________________________________________________________________
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Meato urinario:
___________________________________________________________________________
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Labios menores:
___________________________________________________________________________
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Abertura vaginal (introito):
___________________________________________________________________________
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By Dr. Carlos Fernando Uc Ku Historia Clinica
Zona perineal:
___________________________________________________________________________
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o Genitales masculinos
Pene: color, secreciones:
___________________________________________________________________________
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Prepucio:
____________________________________________________________________
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Glande: esmegma:
____________________________________________________________________
____________________________________________________________________
Meato urinario:
____________________________________________________________________
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Testculos: tamao, consistencia:
___________________________________________________________________________
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8. Columna vertebral:
Movimientos, alineacin, deformidades, vicios, sensibilidad, curvatura:
______________________________________________________________________________________________
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Regin cervical: __________________________________________________________________________
Regin torcica: __________________________________________________________________________
Regin lumbar: ___________________________________________________________________________
Regin sacra: ____________________________________________________________________________
9. Extremidades:
Coloracin, pulsos, sensibilidad, higiene. Edema, varices:
______________________________________________________________________________________________
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Tono muscular: flaccidez, contracturas, atrofia, hipertrofia. Fuerza y resistencia. Movilidad: rango de
movimientos, limitaciones:
________________________________________________________________________________________
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Articulaciones: dolor, aumento de volumen, calor, rigidez, deformidad:
________________________________________________________________________________________
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Alineacin de extremidades: genu valgum (X), genu varum (0): ____________________________________
Brazos, manos y dedos:
________________________________________________________________________________________
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Pies y tobillos: pie valgo, pie varo. Dolor. Queratodermia, hallux valgus, dedo en martillo_
________________________________________________________________________________________
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10. Exploracin especial y/o armada:

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By Dr. Carlos Fernando Uc Ku Historia Clinica
11. Valoracin geritrica integral:
Actividades de la vida diaria:
________________________________________________________________________________________
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Actividades instrumentales de la vida diaria:
________________________________________________________________________________________
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Mini-mental state:
________________________________________________________________________________________
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Edo. Depresivo:
________________________________________________________________________________________
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I. Diagnsticos:
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II. Plan teraputico:
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III. Nombre y firma:
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