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programadeenseanzaclnicacomplementaria222-131118134330-phpapp02
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Transcript of programadeenseanzaclnicacomplementaria222-131118134330-phpapp02
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Programa de Enseñanza Clínica Complementaria
HISTORIA CLINICA
FICHA DE IDENTIFICACION:
Nombre:____________________________________________________Edad:___________Sexo:________Ocupación:________________Estado Civil:_____________Nacionalidad:____________________________ Residencia_____________________Escolaridad:________________________Religión:_________________Servicio:________________________Cama:________ No. Expediente:______________________________
ANTECEDENTES HEREDOFAMILIARES:
Padres: ........................Vivos: ................................Fallecidos:.............................................................................. ………………………… ……Causas:..................................................................................
Hermanos:....................Vivos:................................Fallecidos:.............................................................................. ………………………… …… Causas:..................................................................................
Hijos:............................Vivos:..................................Fallecidos:............................................................................
Causas:……............................................................................
Diabetes Mellitus tipo 2 SI ⃝ NO ⃝__________________________________________________________
Hipertensión Arterial SI ⃝ NO ⃝__________________________________________________________
Tuberculosis SI ⃝ NO ⃝__________________________________________________________
Cáncer SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar) SI ⃝ NO ⃝__________________________________________________________
ANTECEDENTES PERSONALES NO PATOLOGICOS:
1) Hábitos Tóxicos:
Alcohol: __________________________Tabaco:_________________________Drogas:_________________
2) Fisiológicos: Alimentación:____________________________________________________________________________Dipsia:__________________________________________________________________________________Diuresis: ________________________________________________________________________________ Catarsis:_________________________________________________________________________________Somnia:_________________________________________________________________________________Otros:__________________________________________________________________________________
ANTECEDENTES PERSONALES PATOLOGICOS:
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Infancia:_________________________________________________________________________________Adulto:__________________________________________________________________________________Diabetes Mellitus tipo 2 SI ⃝ NO ⃝__________________________________________________________
Hipertensión Arterial SI ⃝ NO ⃝__________________________________________________________
Tuberculosis SI ⃝ NO ⃝__________________________________________________________
Cáncer SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar) SI ⃝ NO ⃝__________________________________________________________
Quirúrgicos:______________________________________________________________________________Traumatológicos:_________________________________________________________________________ Alérgicos: _______________________________________________________________________________ Otros: __________________________________________________________________________________
GINECO-OBSTÉTRICOS:
FUM: / / FPP: / / EDAD GESTACIONAL: semanas.
Menarca:_______RM (Rit. Menstr)____/___ IRS____Nº de parejas____Flujo genital____________________
Gestas:.............Partos:.............Cesáreas:...............Abortos: ____________ Anticonceptivos: SI ⃝ NO ⃝
Tipo: ______________________ Tiempo: __________Última toma: ________________________________
Cirugías ginecológicas (especificar)___________________________________________________________
Otros: __________________________________________________________________________________
PADECIMIENTO ACTUAL
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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INTERROGATORIO POR APARATOS Y SISTEMAS
Aparato respiratorio: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Aparato digestivo: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Aparato cardiovascular: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Aparato renal y urinario: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Aparato genital: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sistema endocrino: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sistema hematopoyético y linfático: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Piel y anexos: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Musculo esquelético: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sistema nervioso: ________________________________________________________________________________________
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________________________________________________________________________________________________________________________________________________________________________________
Órganos de los sentidos: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Síntomas generales: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXPLORACIÓN FÍSICA:
Impresión General: _______________________________________________________________________
Signos Vitales: FC__________TA:_________FR: _______PULSO:____________ TEMPERATURA: _________
Peso actual: ________Talla: __________BMI:___________
Inspección general: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Cabeza: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Cuello: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Tórax: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________________________________________________________________
Abdomen: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tacto vaginal y rectal: ________________________________________________________________________________________
Extremidades: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Exploracion neurológica: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXAMENES COMPLEMENTARIOS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DIAGNOSTICO PRESUNTIVO: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PLAN TERAPÉUTICO: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
NOMBRE, CEDULA Y FIRMA DEL MEDICO TRATANTE:_______________________________________________________________________________