Historia clínica

Ficha de identificación
Nombre: ___________________________________________ Edad: ______ Fecha y hora: __________________

Sexo: ( ) M ( ) F No. Expedientes: ______________________ Estado civil: _____________

Ocupación: ___________________ Lugar de nacimiento: ____________________________

Residencia: ___________________ Domicilio: _____________________________________

Religión: _____________________ Teléfono: ______________________________________

Email: _________________________________________

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Motivo de consulta
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Padecimiento actual

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Fecha de inicio, principales síntomas, evolución,
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cuadro inicial.
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Cronológico, descripción, análisis y evolución de los
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síntomas. No omitir nunca: disnea, dolor precordial,
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fenómenos concomitantes, palpitaciones, edema,
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manifestaciones de insuficiencia respiratoria, de
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insuficiencia arterial y venosa. Lipotimias, vértigos.
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Antecedentes personales patológicos
Padecimientos de la infancia (sarampión, tos ferina,
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varicela, parotiditis, asma bronquial, IRA, diarreas)
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adolescencia, adulto, quirúrgicos, traumatológicos,
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alergias, cardiópatas, paludismo, tifoidea,
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tuberculosis, ictericia, padecimientos mentales y
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neurológicos, enfermedades hemorrágicas,
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hipertensión arterial, diabetes mellitus, exposición a
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radiaciones, inhalación de insecticidas,
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transfusionales, malformaciones, dependencia a
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drogas y medicamentos, artropatías, enfermedades
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venéreas, parasitosis intestinal, enfermedades
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vasculares, fiebre reumática, VIH
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 Antecedentes personales no patológicos

Escolaridad, salimentación (leche, huevos, pescado (perca,

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lenguado, bacalao), crustáceos (cangrejos, langostas,
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camarones), frutos secos, maní/cacahuate, trigo, soya,
etc.),
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vivienda, servicio de la vivienda, uso de letrinas,
ingreso,
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empleo, higiene personas, inmunizaciones:
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poliomielitis (SABIN), DPT-HIb-Hb (tetanos, difteria,
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tosferina, hemophilus influenzae, hepatitis B), BCG
(tuberculosis),
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zoonosis, deportes, integración familiar
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Gineco-obstétricos: menarca, ritmo, IVSA, N° parejas
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sexuales, FUR, gesta, abortos, partos, Papanicolau,
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mastografía, densitometría ósea, colposcopia, método de
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planificación familiar
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Antecedentes heredofamiliares
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(Padres, abuelos, hermanos, cónyuges, hijos, colaterales,
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conviviente, causa de muertes, edades y estado de salud)
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alcoholismo, toxicomanías, diabetes mellitus,
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hipertensión arterial, neoplasias, cardiopatías, sífilis,
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tuberculosis, alergias, ictericia, obesidad, padecimientos
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mentales y neurológicos, artropatías, litiasis biliar y renal,
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malformaciones congénitas, padecimientos
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hemorrágicos, VIH, enfermedad de Alzhéimer
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Aparatos y sistemas
Aparato respiratorio
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Preguntas antecedentes de: rinorrea, epistaxis, tos,
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expectoración, hemoptisis, vómica, seudovomica, dolor
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torácico, disnea, sibilancias audibles, estertores a
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distancia, estornudos, prurito nasal, obstrucción nasal.
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Identifica: rinolalia, disfonía.
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Aparato digestivo
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Preguntas antecedentes de: hambre, apetito, alteraciones
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en la salivación, disfagia, odinofagia, hemorragia gingival,
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problemas en lengua, halitosis, dolor retroesternal o en la
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espalda, nausea, vomito, rumiación, regurgitación,
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aerofagia, eructos, dolor epigástrico a la ingestión,
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meteorismo, distensión, dolor, flatulencia, ictericia,
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hematemesis
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Características físicas de las heces, diarrea, constipación,
acolia, melena, rectorragia, parasitosis, lientería, _______________________________________________
esteatorrea, obstrucción intestinal, tumor, hernias, pujo, _______________________________________________
tenesmo rectal, prurito anal, incontinencia rectal, _______________________________________________
intervenciones quirúrgicas previas. _______________________________________________
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Piel y anexos _______________________________________________
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Preguntas antecedentes: coloración y pigmentación de _______________________________________________
la piel, características del vello y uñas. _______________________________________________
Lesiones primarias: mancha, pápula, nódulo, vesícula, _______________________________________________
ampolla, pústula, nudosidad, roncha. _______________________________________________
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Lesiones secundarias: costra, escama, atrofia, _______________________________________________
ulceración, escara, esclerosis, cicatriz, liquenificación, _______________________________________________
vegetación y verrugosidades, neoformaciones. _______________________________________________
Síntomas acompañantes: prurito, hiperhidrosis. _______________________________________________
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De estas lesiones busque: topografía, simetría, _______________________________________________
expuestas, partes salientes o entrantes, morfología. _______________________________________________
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Somatometría

FC: ______ FR: ______ TA: ______ Temp: ______ Peso: ______ Talla: ______ Glucemia: ______ SPO2: ______

Inspección general

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Regiones
ss
Cabeza y cuello

Tronco

Pelvis

Extremidades superiores
Extremidad superior e inferior

Diagnostico sindromático

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Diagnostico presuntivo

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Estudios complementarios

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Tratamiento

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