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INSTITUCIÓN: ____________________________________

INGRESO DEL PACIENTE

1. Fecha y hora de ingreso:


2. Servicio de ingreso:
3. Número de historia clínica:
4. Nombre del registrador:

HISTORIA CLINICA
I. ANAMNESIS:
A. DATOS DE FILIACION
1. Nombres:
2. Apellidos:
3. Tipo y Numero de identificación:
4. Edad:
5. Grupo étnico o raza:
6. Sexo:

B. DATOS PERSONALES

1. Escolaridad: 8. Estado civil:

2. Ocupación: 9. Religión:

3. Lugar procedencia: 10. Fuente de información:

4. Lugar de nacimiento: 11. Credibilidad

5. Dirección de residencia: 12. Régimen de seguridad social:

6. Barrio: 13. Entidad a la cual pertenece:

7. Estrato: 14. Iniciativa de consulta:


15. Nombre de acompañante: ___________________________
Parentesco: ____________Tel: ____________
16. Nombre de responsable: _______________________, Parentesco:
__________ Tel: ___________
II. MOTIVO DE CONSULTA:

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III. EVOLUCION DE LA ENFERMEDAD ACTUAL:

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Estado actual del paciente: ____________________________


IV. ANTECEDENTES
1. ANTECEDENTES PATOLOGICOS:
a. PERINATALES
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b. POSNATALES
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c. INFANCIA:
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d. ADULTO:
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e. QUIRURGICOS:
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HOSPITALARIO:
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f. TRAUMATICO:
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g. TRANSFUSIONALES:
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h. FARMACOLOGICOS:
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i. ALÉRGICOS:
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_______________________________________________.
2. ANTECEDENTES NO PATOLOGICOS:
a. INMUNIZACIÓN:
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_______________________________________________.
b. PSICOSOCIALES:
 Hábitos

 Alimenticios:
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 Cigarrillo:
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 Alcohol:
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 Drogas:
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 Café:
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 Estilo de vida:
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 Condiciones de la vivienda:
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 Índice de hacinamiento
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 Historia laboral
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c. HEMATOLÓGICOS
a. Grupo Sanguíneo_________________
b. RH _____________________
3. ANTECEDENTES FAMILIARES:
 Madre:
 Padre:
V. REVISION POR SISTEMAS
1. SISTEMA NEUROSENSORIAL
a. OJO:
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b. OIDO:
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c. NARIZ:
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d. BOCA:
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2. SISTEMA CARDIACO:
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3. SISTEMA VASCULAR PERIFERICO:


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4. SISTEMA RESPIRATORIO:
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5. SISTEMA GASTROINTESTINAL:
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6. SISTEMA MUSCULO-ESQUELETICO:
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7. SISTEMA URINARIO:
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8. GENITALES: MASCULINO:
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9. SISTEMA ENDOCRINO:
a. HIPÓFISIS, SUPRARRENALES:
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b. TIROIDES:
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c. PARATIROIDES:
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d. PÁNCREAS:
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10. SISTEMA HEMATOPOYÉTICO:
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11. PIEL Y ANEXOS


a. CAMBIOS EN LAS CARACTERÍSTICAS DE LA PIEL:
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b. LESIONES EN LA PIEL:
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c. OTRAS
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d. CABELLO/PELO:
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e. UÑAS
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f.
12. SISTEMA LINFORETICULAR:
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13. SISTEMA NERVIOSO CENTRAL:


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VI. EXAMEN FÍSICO

1. DESCRIPCIÓN GENERAL

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2. SIGNOS VITALES

 Presión arterial:  Temperatura:

 Frecuencia cardiaca:  Talla:

 Frecuencia  Peso:
respiratoria:
 IMC:
 Pulso:
 Glasgow
3. REGIONES DEL CUERPO HUMANO
 CABEZA Y CUELLO
Inspección
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Palpación
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Percusión
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Auscultación
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 TORAX
Inspección
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Palpación
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Percusión
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Auscultación
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 ABDOMEN
Inspección
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Palpación
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Percusión
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Auscultación
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 EXTREMIDADES SUPERIORES
Inspección
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Palpación
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 EXTREMIDADES INFERIORES
Inspección
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Palpación
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 GENITOUINARIO
Inspección
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Palpación
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Percusión
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Auscultación
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 PIEL Y FANELAS
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 SISTEMA NERVISO CENTRAL


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VII. DIAGNOSTICO
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VIII. PLAN DE MANEJO O TRATAMIENTO


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IX. EXAMENES DE LABORATORIO Y GABINETE
EVOLUCIÓN MEDICA

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DIAGNÓSTICOS

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5.

ANTECEDENTES

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3.

SUBJETIVO

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EXAMEN FÍSICO

SIGNOS VITALES

TA: ________ mmHg , FR________ Resp x´, SPO2 ______ %


FC:______ Lat x´ PULSO _____ Puls x´ Glasgow________
Glucosa _____ mg/dl

PIEL _______________________________________________
CABEZA____________________________________________
CARA ______________________________________________
OJOS _______________________________________________
NARIZ _______________________________________________
BOCA________________________________________________
CUELLO______________________________________________
CARDIO-PULMONAR
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ABDOMEN
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GENITUURINARIO
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EXTREMIDADES
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SNC
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ANÁLISIS
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PLAN A SEGUIR

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