Universidad Autnoma del Estado de Hidalgo

Escuela Superior de Tepeji

Historia Clnica
Ficha de identificacin
Nombre: ________________________________________________________________________
Edad:__________ Sexo:_____________________ Ocupacin: _____________________________
Fecha de nacimiento:________________________ Nacionalidad:__________________________
Estado civil: ___________________ Lugar de nacimiento:_________________________________
Domicilio:________________________________________________________________________
___________________________________Religin:______________________________________

Antecedentes Heredofamiliares
Padre:___________________________________________________________________________
Madre:__________________________________________________________________________
Hermanos:_______________________________________________________________________
Hijos:____________________________________________________________________________

Diabetes Hipertensin Obesidad Otro

Padre
Madre
Hermanos
Hijos

Antecedentes Personales No Patolgicos

Lugar de nacimiento: _______________________________________________________________

Residencia actual: _________________________________________________________________
Otra residencia: ___________________________________________________________________
Casa rentada o propia: _______________ No. De habitantes: ______________________________
Parentesco: ______________________________________________________________________
Agua: _____ Luz:_____ Drenaje:_____ Telfono:_____ Internet:_____ Cable:____
No. de habitaciones:_____ No. de baos:_____
Casa (material):______________ Piso (Material):_____________ Techo (material):_____________
Grado de estudios:_________________________________________________________________
Ocupacin:_______________________________________________________________________
Ingreso econmico:________________________________________________________________
Tiempo libre:_____________________________________________________________________
Deportes:_______________________________ Frecuencia:_______________________________
No. de comidas:_____ Horarios de comida:_____________________________________________
Carne:_____ Pollo:_____ Frutas:______ Verduras:_____ Legumbres:_____ (veces a la semana)
Litros de agua al da:______
Baos:_________________________________ Cambio de ropa:____________________________
Cepillado de dientes:______ Lavado de manos:__________________________________________

Carla Elena Murguia Gonzalez

 Universidad Autnoma del Estado de Hidalgo
Escuela Superior de Tepeji

Aseo de la casa:___________________________________________________________________
Higiene de alimentos:______________________________________________________________
Mascotas:________________________________________________________________________
Vida sexual:__________________ No. de parejas sexuales:________________________________
Mtodos anticonceptivos utilizados:___________________________________________________
Drogas:__________________________________________________________________________
Alcohol:__________________________________________________________________________
Tabaquismo:______________________________________________________________________
Tatuajes:_________________________________________________________________________

Antecedentes Patolgicos Personales

Enfermedades:____________________________________________________________________
Medicamentos:___________________________________________________________________
Hospitalizaciones:_________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Alergias:_________________________________________________________________________
Vacunas:_________________________________________________________________________

Padecimiento actual

Motivo de consulta:
________________________________________________________________________________
________________________________________________________________________________

Antecedentes de padecimiento actual:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Signos vitales
Frecuencia cardiaca Frecuencia respiratoria Tensin arterial Temperatura axilar

Somatometra
Talla Peso IMC Permetro abdominal

Carla Elena Murguia Gonzalez

 Universidad Autnoma del Estado de Hidalgo
Escuela Superior de Tepeji

Habitus exterior
Condicin:_______________________________________________________________________
Edad:______ Sexo:____________
Constitucin:_____________________________________________________________________
Conformacin:____________________________________________________________________
Fascies:__________________________________________________________________________
Actitud:__________________________________________________________________________
Movimientos anormales:____________________________________________________________
Marcha:_________________________________________________________________________
Estado de conciencia:_______________________________________________________________

INTERROGATORIO POR APARATOS Y SISTEMA

Aparato digestivo
ANOREXIA, HIPOREXIA, HIPEROREXIA:_________________________________________________
POLIDIPSIA: ______________________________________________________________________
NUSEAS: _______________________________________________________________________
VMITOS: _______________________________________________________________________
DISPEPSIA:_______________________________________________________________________
ODINOFAGIA: ____________________________________________________________________
RECTORRAGIA: ___________________________________________________________________
MELENAS: _______________________________________________________________________
ABDOMINALGIA: __________________________________________________________________
PIROSIS: _________________________________________________________________________
HEMATEMESIS: ___________________________________________________________________
ACOLIA: _________________________________________________________________________
METEORISMO: ____________________________________________________________________
TENESMO:_______________________________________________________________________

Aparato respiratorio
TOS:____________________________________________________________________________
DOLOR TORCICO: ________________________________________________________________
DISNEA: _________________________________________________________________________
HEMOPTISIS: _____________________________________________________________________
EPSTAXIS:________________________________________________________________________
CIANOSIS:________________________________________________________________________

Carla Elena Murguia Gonzalez

 Universidad Autnoma del Estado de Hidalgo
Escuela Superior de Tepeji

Aparato cardiovascular
DOLOR TORCICO:_________________________________________________________________
EDEMAS: ________________________________________________________________________
DISNEA: _________________________________________________________________________
DISNEA PAROXSTICA NOCTURNA: ____________________________________________________
ORTOPNEA: ______________________________________________________________________
PALPITACIONES: __________________________________________________________________
SNCOPE, PRESNCOPE:_____________________________________________________________

Aparato urinario
DISURIA:_________________________________________________________________________
POLAQUIURIA: ___________________________________________________________________
INCONTINENCIA: __________________________________________________________________
POLIURIA, OLIGURIA, ANURIA: _______________________________________________________
NICTURIA: _______________________________________________________________________
HEMATURIA: _____________________________________________________________________
PROSTATISMO: ___________________________________________________________________
TENESMO: _______________________________________________________________________

Aparato genital
MENARQUIA: ____________________________________________________________________
RITMO MENSTRUAL: _______________________________________________________________
HIPERMENORREA, HIPOMENORREA: _________________________________________________
AMENORREA: ____________________________________________________________________
METRORRAGIA: ___________________________________________________________________
LEUCORREA: _____________________________________________________________________
DISMENORREA: __________________________________________________________________
DISPAREUNIA: ____________________________________________________________________
IMPOTENCIA: ____________________________________________________________________
LBIDO: __________________________________________________________________________

Sistema nervioso
CEFALEA: ________________________________________________________________________
CONVULSIONES: __________________________________________________________________
DFICIT TRANSITORIO: _____________________________________________________________
CONFUSIN: _____________________________________________________________________
OBNUBILACIN: __________________________________________________________________
MARCHA: ________________________________________________________________________
EQUILIBRIO: _____________________________________________________________________
LENGUAJE: ______________________________________________________________________
SUEO-VIGILIA: ___________________________________________________________________

Carla Elena Murguia Gonzalez

 Universidad Autnoma del Estado de Hidalgo
Escuela Superior de Tepeji

Sistema hematolgico
ASTENIA: ________________________________________________________________________
PALIDEZ: ________________________________________________________________________
HEMORRAGIAS: ___________________________________________________________________
ADENOPATAS: ___________________________________________________________________

Exploracin por aparatos y sistemas

PIEL, FANERAS Y TEJIDO CELULAR SUBCUTANEO

Aspecto:__________________________ Distribucin pilosa:_______________________________

Lesiones:__________________________ Faneras:_______________________________________
Tejido Celular Subcutneo:__________________________________________________________

CABEZA

Crneo y cara: ____________________________________________________________________

Cuero cabelludo:__________________________________________________________________
Regin frontal:____________________________________________________________________
Regin orbitonasal: ________________________________________________________________
Regin orofarngea: ________________________________________________________________

CUELLO

Inspeccin:_______________________________ Palpacin:_______________________________
Percusin:_______________________________ Auscultacin:_____________________________

TORAX

Piel:_____________________________________________________________________________
Forma:__________________________________________________________________________

Mamas:
Forma:____________ Tamao:______________ Simetra:______________ Arolas:____________
Pezones:___________________ Maniobras de los pectorales:______________________________
Piel: Retraccin Elevacin De naranja lcera Observaciones

Observaciones:____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

APARATO RESPIRATORIO

Tipo de Respiracin:________________________________________________________________
Tiraje:___________________________________________________________________________

Carla Elena Murguia Gonzalez

 Universidad Autnoma del Estado de Hidalgo
Escuela Superior de Tepeji

Uso de msculos accesorios:_________________________________________________________

Semiologa Hemitrax derecho Hemitrax izquierdo

Excursin de bases
Excursin de vrtices
Vibraciones vocales
Sonoridad
Murmullo vesicular
Rales crepitantes hmedos
Roncus
Sibilancias
Soplo tubario
Frote pleural
Otros

APARATO CARDIOVASCULAR

Latidos:_____________________________ Choque de punta:______________________________

R1:_____________________________________ R2:_____________________________________
R3:_____________________________________ R4:_____________________________________
Soplos:__________________________________ Chasquidos:______________________________

Pulsos Derecho Izquierdo

Carotideo
Humeral
Radial
Femoral
Poplteo
Tibial posterior
Pedio

ABDOMEN Y PELVIS: EXMEN OBSTTRICO

Inspeccin:_______________________________________________________________________
Palpacin: AU:_____________ DU:______________ LCF:______________ MFA:_______________
Maniobras de Leopold:
________________________________________________________________________________
________________________________________________________________________________
Especuloscopa:___________________________________________________________________
Maniobra de Tarnier:_______________________________________________________________
Tacto Vaginal: ____________________________________________________________________
Score de Bishop: P ____ R ____ E ____ L ____ D ____
Membranas ovulares: __________________________ Presentacin: ________________________
Plano:_______________ Variedad de posicin: __________________________________________
Pelvimetra interna:________________________________________________________________

Carla Elena Murguia Gonzalez

 Universidad Autnoma del Estado de Hidalgo
Escuela Superior de Tepeji

APARATO GENITOURINARIO

Puopercusin Lumbar: ______________ Derecha____________ Izquierda:__________________

Tacto Vaginal: ____________________________________________________________________
Vulva: ___________________________________________________________________________
Flujo:____________________________________________________________________________
Sensibilidad:______________________________________________________________________
Fondo de saco vaginal:______________________________________________________________
Cuello Uterino:____________________________________________________________________

SISTEMA NERVIOSO

Estado de conciencia:_______________________________________________________________
Glasgow: Ocular:_________________Motor:__________________Verbal:____________________
Conducta:________________________________________________________________________
Lenguaje:_______________________ Pares craneales:____________________________________
Reflejos: Fotomotor: __________________ Acomodacin:_________________________________
Reflejos osteotendinosos:___________________________________________________________
Motricidad:___________________________ Babinski:____________________________________
Sensibilidad: __________________________ Temblor:____________________________________
Romberg:_____________________________ Taxia:______________________________________
Dismetra:___________________________ Rigidez de nuca:_______________________________
Fondo de ojo:_____________________________________________________________________

OSTEOMIOARTICULAR

Columna Vertebral:________________________________________________________________
Ejes seos:__________________________ Articulaciones:________________________________
Miembros:__________________________ Trofismo muscular:_____________________________

Carla Elena Murguia Gonzalez