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HISTORIA CLINICA

DATOS FILIATORIOS:
Apellido y Nombre:__________________________________________________________________________________
Edad:______________

Sexo:________

Fecha de Nacimiento:____________________

Ocupacin:________________________________________
Estado Civil:________________

Nacionalidad:_________________

Residencia Actual:___________________________________________________________________________________
Grado de Instruccin:_____________________ Religin:______________________________________

MOTIVO DE CONSULTA:
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ANTECEDENTES DE ENFERMEDAD ACTUAL:
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ANTECEDENTES HEREDOFAMILIARES:
Padres: ____________

Vivos: __

Fallecidos: ____
Causas:_________________________________________________________

Hermanos:__________ Vivos:__

Fallecidos:____
Causas:_________________________________________________________

Hijos:______________

Vivos:__

Fallecidos:____
Causas:_________________________________________________________

DBT

SI__
NO__
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HTA

SI__
NO__
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TBC

SI__
NO__
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Gemelar SI__
NO__
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Otras (especificar) SI__

NO__ ______________________________________________________________________

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ANTECEDENTES PERSONALES:
1) Hbitos Txicos:
Alcohol:____________________________________________________________________________________________
Tabaco:____________________________________________________________________________________________
Drogas:____________________________________________________________________________________________
Infusiones__________________________________________________________________________________________
2) Fisiolgicos:
Alimentacin:_______________________________________________________________________________________
Dipsia:_____________________________________________________________________________________________
Diuresis:___________________________________________________________________________________________
Catarsis: ___________________________________________________________________________________________
Somnia: ___________________________________________________________________________________________
Otros: _____________________________________________________________________________________________
3) Patolgicos:
Infancia:___________________________________________________________________________________________
Adulto:____________________________________________________________________________________________
DBT

SI__

NO__ _____________________________________________________________________________

HTA

SI__

NO__ _____________________________________________________________________________

TBC

SI__

NO__ _____________________________________________________________________________

Gemelar SI__

NO__ _____________________________________________________________________________

Otras (especificar) SI__

NO__ ______________________________________________________________________

Quirrgicos: ________________________________________________________________________________________
Traumatolgicos: ___________________________________________________________________________________
Alrgicos: __________________________________________________________________________________________
Otros: _____________________________________________________________________________________________

4) Gineco-obsttricos:
FUM: /
/

FPP: /

Menarca:___________

RM (Rit. Menstr)__/___ IRS________

Gestas:______

EDAD GESTACIONAL:______________ semanas.

Partos:_______

N de parejas______

Cesreas:_______

Anticonceptivos: SI___ NO___ Tipo_______________________

Flujo genital___________
Abortos:________

Tiempo____________________________________
ltima toma________________________________

Cirugas ginecolgicas (especificar)_____________________________________________________________________


Otros:_____________________________________________________________________________________________

EXAMEN FISICO:
Impresin General:___________________________________________________________________________________
__________________________________________________________________________________________________
Signos Vitales: FC:________
T Axilar:________

TA:________

FR:________

PULSO:________

T Rectal:________

Peso Habitual: __________ Peso actual:__________ Talla:__________

BMI__________

INSPECCION GENERAL:
Hbito Constitucional:__________________________

Marcha:______________________________________

Ubicacin:___________________________________

Actitud:_______________________________________

PIEL, FANERAS Y TEJIDO CELULAR SUBCUTANEO:


Aspecto:_____________________________________

Distribucin pilosa:______________________________

Lesiones:____________________________________

Faneras:_______________________________________

Tejido Celular Subcutneo:____________________________________________________________________________


CABEZA:
Crneo y cara:______________________________________________________________________________________
Cuero cabelludo:____________________________________________________________________________________
Regin frontal:______________________________________________________________________________________

Regin orbitonasal:__________________________________________________________________________________
Regin orofarngea:__________________________________________________________________________________
CUELLO:
Inspeccin:_________________________________

Palpacin:_________________________________________

Percusin:__________________________________

Auscultacin:______________________________________

TORAX:
Piel:_______________________________________________________________________________________________
Forma:____________________________________________________________________________________________
Mamas:
Forma:______________

Tamao:____________

Pezones:__________________________

Simetra:____________

reolas:____________

Maniobras de los pectorales:_____________________________________

APARATO RESPIRATORIO:
Tipo de Respiracin:_________________________________________________________________________________
Tiraje:_____________________________________________________________________________________________
Uso de msculos accesorios:___________________________________________________________________________
APARATO CARDIOVASCULAR:
Latidos:______________________________

Choque de punta:___________________________________

R1:_________________________________

R2:______________________________________________

R3:_________________________________

R4:______________________________________________

Soplos:______________________________

Chasquidos:_______________________________________

ABDOMEN Y PELVIS: EXMEN OBSTTRICO:


Inspeccin:_________________________________________________________________________________________
_
Palpacin:

AU:____________

DU:____________

LCF:____________

MFA:____________

Maniobras de Leopold:_______________________________________________________________________________
Especuloscopa:_____________________________________________________________________________________
Maniobra de Tarnier:_________________________________________________________________________________
Tacto Vaginal:_______________________________________________________________________________________
Score de Bishop: P_____ R_____ E_____ L_____ D_____
Membranas ovulares: ________________________________

Presentacin ______________________________

Plano_____________________________________ Variedad de posicin _______________________________________


Pelvimetra interna___________________________________________________________________________________
APARATO GENITOURINARIO:
Puopercusin Lumbar: ________________

Derecha____________ Izquierda:____________

Tacto Vaginal:_______________________________________________________________________________________
Vulva:_____________________________________________________________________________________________
Flujo:______________________________________________________________________________________________
Sensibilidad:________________________________________________________________________________________
Fondo de saco vaginal________________________________________________________________________________
Cuello Uterino:______________________________________________________________________________________
SISTEMA NERVIOSO:
Estado de conciencia:________________________________________________________________________________
Glasgow: Ocular:_____________________ Motor:_______________________ Verbal:_______________________
Conducta:__________________________________________________________________________________________
Lenguaje:________________________________

Pares craneales:_____________________________

Reflejos: Fotomotor: ______________________

Acomodacin:______________________________

Reflejos osteotendinosos:_____________________________________________________________________________
Motricidad:_____________________________

Babinski:__________________________________

Sensibilidad: ____________________________

Temblor:__________________________________

Romberg:_______________________________

Taxia:_____________________________________

Dismetra:_______________________________

Rigidez de nuca:_____________________________

Fondo de ojo:_______________________________________________________________________________________
OSTEOMIOARTICULAR:
Columna Vertebral:__________________________________________________________________________________
Ejes seos:______________________________

Articulaciones:______________________________

Miembros:_______________________________

Trofismo muscular:__________________________

EXAMENES COMPLEMENTARIOS:
LABORATORIO:
Hto:____________
Leucocitos____________

Cayados____________

Eosinfilos____________

Linfocitos____________

Segmentados____________

Monocitos____________

VCM_______ Plaquetas_________________________________________________________________
Glucemia_____

Urea______ Creatinina_____

GOT______ GPT______
PH_____

CO2______

FAL______

HCO3_____

Sodio_____

Potasio_____

Bilirrubina Total______ Directa_____

PO2_____

Sat_____

GAP_____

Cloro________

Coagulograma__________

A-a_____

FIO2:___________

Orina______________________________________________________________________________________________
Hemocultivo: SI___ NO___

Urocultivo: SI___ NO___ Otros:____________________________________

ELECTROCARDIOGRAMA:
Ritmo_____________________________________ FC__________ Eje QRS_____________________________________
Onda P____________________________________

QRS______________________________________________

Onda T____________________________________

ST_______________________________________________

PR__________ QTc__________ Conclusin_______________________________________________________________


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RADIOGRAFIA DE TORAX:
Partes Blandas:______________________________________________________________________________________
Partes seas:_______________________________________________________________________________________
Campos Pulmonares:_________________________________________________________________________________
Silueta cardiovascular:________________________________________________________________________________
ndice cardiotorxico:________________________________________________________________________________
Conclusiones:_______________________________________________________________________________________
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OTROS ESTUDIOS:
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DIAGNOSTICO PRESUNTIVO:
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DIAGNOSTICOS DIFERENCIALES:
1)_________________________________________________________________________________________________
2) ________________________________________________________________________________________________
3) ________________________________________________________________________________________________
4) ________________________________________________________________________________________________
5) ________________________________________________________________________________________________

PLAN TERAPUTICO:
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EVOLUCIN
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