HISTORIA CLINICA

ANAMNESIS
Nombre ________________________________________ Edad ____ Sexo ______
Estado Civil _____ Ocupación _________ Procedencia __________ Raza ________
Religión __________ Lugar de Nacimiento ____________________________________
Domicilio_______________________________________________________________
Fecha, hora y persona que elabora la Historia Clínica ____________________________
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MOTIVO DE CONSULTA
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ANTECEDENTES

ANTECEDENTES FAMILIARES
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ANTECEDENTES GINECO-OBSTÉTRICOS
Menarca: _____________ Fecha de última menstruación (FUM)____________
Aspectos de la menstruación
Frecuencia: _______ Ritmo: ________ Cantidad:__________ Duración: __________
Inicio vida sexual activa: _____________________ No. parejas ___________________
Aspectos de embarazos
No. de gestaciones (G):_________ N.o de partos (P): _______ N.o de Cesarías________
N.o abortos (A): _____________ Fecha de ultimo parto (FUP): __________________
Método de planificación: _________________

ANTECEDENTES PERSONALES PATOLÓGICOS

Enfermedades:__________________________________________________________
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Hospitalización: _________________________________________________________
Intervenciones Quirúrgicas: ________________________________________________
Transfusiones sanguíneas: ________________________________________________
Consumo de Tabaco: _____________________________________________________
Consumo de drogas: ___________________________________________________
Alergia a medicamentos: __________________________________________________

CURSO: SEMIOLOGÍA
EXPLORACION FISICA

Estado general: ABEG AREG AMEG LOTEP

Funciones Vitales: PA: _______ mmhg P:______por min T: __________ºC
R:________por min Peso:________Kg Talla:_______Mt

Cabeza y cara ___________________________________________________________

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Ojos __________________________________________________________________
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Nariz y senos faciales _____________________________________________________
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Boca __________________________________________________________________
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Faringe y laringe _________________________________________________________
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Oídos _________________________________________________________________
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Cuello _________________________________________________________________
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Tórax y pulmones ________________________________________________________
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CURSO: SEMIOLOGÍA
Glándula mamaria _______________________________________________________
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Abdomen ______________________________________________________________
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Neurológico ____________________________________________________________
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Extremidades superiores __________________________________________________
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Extremidades inferiores ___________________________________________________
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Genitales ______________________________________________________________
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Tacto rectal _____________________________________________________________
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CURSO: SEMIOLOGÍA
EXÁMENES AUXILIARES
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DIAGNOSTICO DIFERENCIAL
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DIAGNOSTICO DEFINITIVO
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TRATAMIENTO
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CURSO: SEMIOLOGÍA
EVOLUCIÓN
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EPICRISIS
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CURSO: SEMIOLOGÍA