HISTORIA CLINICA

MEDICO EXTERNO:_____________________________________________________
CARNE:_______________________________________________________________

HISTORIA CLINICA

1. DATOS GENERALES:

NOMBRE:________________________________________________EDAD:___________SEXO:______________
ESTADO CIVIL:____________________PROC./RESIDENCIA:_______________________FECHA HOY:___________
OCUPACION______________________________RELIGION______________________GRUPO ETNICO_________

2. MOTIVO DE CONSULTA:_______________________________________________________________________
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3. HISTORIA DE LA ENFERMEDAD ACTUAL: __________________________________________________________

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4. REVISION POR SISTEMAS:

Sistema Respiratorio: _________________________________________________________________________
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Sistema Cardiovascular: _______________________________________________________________________
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Sistema Gastrointestinal: ______________________________________________________________________
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Sistema Genito-Urinario: ______________________________________________________________________
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Sistema Osteo-muscular: ______________________________________________________________________
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Sistema Endócrino: ___________________________________________________________________________

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Sistema Nervioso Psiquiátrico: __________________________________________________________________
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Sistema Linfático: ____________________________________________________________________________
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Sistema Hematológico: ________________________________________________________________________
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Sistema O:R:L: _______________________________________________________________________________
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Sistema Ocular: ______________________________________________________________________________
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5. ANTECEDENTES:
PERSONALES PATOLOGICOS
A) QUIRURGICOS:____________________________________________________________________________
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B) TRAUMATICOS:___________________________________________________________________________
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C) MANIAS Y VICIOS: ________________________________________________________________________
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D) ALERGICOS:______________________________________________________________________________
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E) GINECO-OBSTETRICOS:_____________________________________________________________________
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F) PERSONALES NO PATOLOGICOS:
GESTAS:________________PARTOS:______________ABORTOS________
FECHA DE ULTIMA REGLA:_________________ FECHA DE PENULTIMA REGLA:_________________________
HIJOS VIVOS:____________________HIJOS MUERTOS:__________MENARQUIA:______________________
G) OTROS:__________________________________________________________________________________

6. EXAMEN FISICO:
SIGNOS VITALES: P/A:________________TALLA:__________________PESO:________________________
FRECUENCIA CARDÍACA:____________________FRECUENCIA RESPIRATORIA:____________________________
PULSO:______________________TEMPERATURA:______________________________.

APARIENCIA GENERAL: ________________________________________________________________________

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PIEL Y FANERAS: _____________________________________________________________________________
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 GANGLIOS:__________________________________________________________________________________
CABEZA:____________________________________________________________________________________
OJOS:______________________________________________________________________________________
OIDOS._____________________________________________________________________________________
NARIZ:______________________________________________________________________________________
OROFARINGE:________________________________________________________________________________
CUELLO:____________________________________________________________________________________
TORAX:_____________________________________________________________________________________
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CORAZON:__________________________________________________________________________________
MAMAS:____________________________________________________________________________________
PULMONES:_________________________________________________________________________________
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ABDOMEN:__________________________________________________________________________________
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GENITALES EXTERNOS _________________________________________________________________________
TACTO RECTAL:_______________________________________________________________________________
EXTREMIDADES:______________________________________________________________________________

EXAMEN NEUROLOGICO:

A) PARES CRANEALES:__________________________________________________________________
B) REFLEJOS OSTEO-TENDINOSOS:________________________________________________________
C) SENSIBILIDAD:______________________________________________________________________
D) EQUILIBRIO________________________________________________________________________
E) REFLEJOS PATOLOGICOS:_____________________________________________________________
F) FONDO DE OJO:____________________________________________________________________

METODO DE WEED

No. Fecha de Problema Activo Fecha de Progresión de Fecha de

inicio ++ Activo Problema Pasivo Resuelto.

LISTADO INICIAL O TEMPORAL DE PROBLEMAS:

a)_____________________________________
b)_____________________________________
c)_____________________________________
d)_____________________________________
e)_____________________________________
f)_____________________________________
g)_____________________________________
h)_____________________________________
i)______________________________________

7. SECUENCIA DE EVENTOS
a)________________________________________b)____________________________c)___________________
d)______________________________________e)________________________f)_______________________

Análisis:
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8. LISTADO PERMANENTE DE PROBLEMAS:

a)______________________________________________

b)________________________________________________

c)_________________________________________________

d) ________________________________________________

e)_________________________________________________

f)__________________________________________________

9. DESARROLLO DE PROBLEMAS:
Datos subjetivos:_____________________________________________________________________________
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Datos Objetivos: _____________________________________________________________________________
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PLAN DE DIAGNOSTICO:
DIAGNOSTICOS DIFERENCIALES:
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METODOS DE DIAGNOSTICO:
a)___________________________________
b)___________________________________
c)___________________________________
d)__________________________________
e)__________________________________

ANALISIS EN EL DESARROLLO DE PROBLEMAS

CONCLUSIÓN DIAGNÓSTICA:____________________________________________________________________
Plan de Tratamiento: _________________________________________________________________________
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Plan educacional: _____________________________________________________________________________
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10. NOTAS DE EVOLUCION:
DATOS SUBJETIVOS: __________________________________________________________________________
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DATOS OBJETIVOS: ___________________________________________________________________________

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ANALISIS DE LA EVOLUCION: ___________________________________________________________________

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DATOS NUEVOS
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PLAN DE DIAGNOSTICO PENDIENTE

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PLAN DE TRATAMIENTO PENDIENTE

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PLAN EDUCACIONAL PENDIENTE

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11. HOJAS DE FLUJO Y GRAFICAS.