UNIVERSIDAD AUTNOMA DE NUEVO LEN

FACULTAD DE MEDICINA
DEPARTAMENTO DE INTRODUCCIN A LA CLNICA
FORMATO DE HISTORIA CLNICA
Datos preliminares y de Identificacin
Nombre del
Paciente:______________________________________________________________
Edad:________________ Sexo:________________ Estado
Civil:__________________________
Lugar y Fecha de
Nacimiento:________________________________________________________
Ocupacin
Actual:_________________________________________________________________
Domicilio:________________________________________________________________
________
Telfono(s):_____________________________________ email:___________________________
Tipo Interrogatorio:_____________ Informante:_______________
Confiabilidad:_____________
Departamento:_____________________________ Sala:_________________
Cama:__________
Fecha y Hora de
Ingreso:____________________________________________________________
Fecha en la que se elabor la
historia:_________________________________________________
Datos de quien(es) elabora(n) la
historia:_______________________________________________

Antecedentes Heredofamiliares
Ascendientes
Abuelo:__________________________________________________________________
________
Abuela:__________________________________________________________________
________
Padre:__________________________________________________________________
_________
Madre:__________________________________________________________________
________
Colaterales
Hermano(s):______________________________________________________________
________
Hermana(s):______________________________________________________________
________
Descendentes
Hijo(s):__________________________________________________________________
________
Hija(s):__________________________________________________________________
________
CECM

Antecedentes Personales No Patolgicos

Tabaquismo:________ Fecha de inicio:___________ Cantidad
ingerida:_____________________
Alcoholismo:________ Fecha de inicio:___________ Cantidad
ingerida:_____________________
Toxicomanas:_______ Fecha de inicio:___________ Cantidad
ingerida:_____________________
Tatuajes:_______
Caracteristicas:___________________________________________________
Caractersticas de la
Vivienda:________________________________________________________
________________________________________________________________________
________
Educacin:_________________________ ___
Escolaridad:______________________________
Estado Econmico:_______________________________
Religin:_________________________
Entretenimientos:__________________________________________________________
_______
Actividad
Fisica:___________________________________________________________________
Consumo de medicamentos sin prescripcin
medica:_____________________________________
Transfusiones
Sanguineas:___________________________________________________________

Actividad Sexual:________ Preferencia Sexual:___________ Compaeros

Sexuales:___________
Relaciones
Interpersonales:__________________________________________________________
Actitud ante la vida y su
enfermedad:__________________________________________________

Dieta
Desayuno:___________________________________________________# de
caloras:__________
Comida:_____________________________________________________# de
caloras:__________
Cena:_______________________________________________________# de
caloras:__________
Cantidad de calorias totales cosumidas al da:____________________
Peso:_____________ Estatura:_____________ Complexin:______________
Grado de actividad: sedentaria
moderada
buena
IMC:______________
Interpretacin:________________________________________________

Perfil del paciente

CECM

________________________________________________________________________
________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________

Antecedentes Personales Patolgicos

Enfermedades peditricas (fecha, tratamiento y
secuelas):__________________________________________________________
________________________________________________________________________
________Enfermedades anteriores (fecha, tratamiento y
secuelas):_________________________________
________________________________________________________________________
________
Enfermedades actuales (fecha, tratamiento y
complicaciones):_____________________________
________________________________________________________________________
________
Hospitalizaciones Previas (fecha, evolucin y
secuelas):___________________________________
________________________________________________________________________
________
Antecedentes Quirrgicos (fecha, evolucin y
secuelas):___________________________________
________________________________________________________________________
________
Antecedentes Traumticos (fecha, evolucin y
secuelas):__________________________________
________________________________________________________________________
________
Antecedentes Alrgicos (fecha, tratamiento, # de episodios y
secuelas):______________________
________________________________________________________________________
________
Inmunizaciones:___________________________________________________________
________

Antecedentes Ginecoobstetricos
Menarquia:__________________ FUM:_______________________
Ritmo y
Regularidad:______________________________________________________________
_
CECM

Menstruaciones
Anormales:_________________________________________________________
Fecha de Menopausia:________________ Enf. De Transmisin
Sexual:______________________
Leucorrea:______________ Sangrado
Postcoito:________________________________________
Disminirrea:______________________________________________________________
________
Tumores
Ginecolgicos:____________________________________________________________
_
DOC:__________ Fecha:___________
Resultado:_______________________________________
Mamografa:____________ Fecha:____________
Resultado:______________________________
Metodos de Planificacin
Familiar:____________________________________________________
Gestas(G):_________ Partos(P):_________ Cesreas(C):_________
Abortos(A):__________
Hijos Vivos:_________ Complicaciones en el
embarazo:__________________________________
Problemas de
Fertilidad:____________________________________________________________

Interpretacin de los apartados anteriores

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________

Motivo de Consulta:
__________________________________________________________________
_______
__________________________________________________________________
_______
__________________________________________________________________
_______
__________________________________________________________________
_______
__________________________________________________________________
__________________________________________________________________
______________
Principio, Evolucin y Estado Actual (PEEA)
Sintoma:_________________________________________________________________
________________________________________________________________________
________________
CECM

Area:___________________________________________________________________
_________
Acompaantes:___________________________________________________________
________________________________________________________________________
________________
Agravantes:______________________________________________________________
________________________________________________________________________
________________
Atenuantes:______________________________________________________________
________________________________________________________________________
________________
Cantidad:________________________________________________________________
________
Calidad:_________________________________________________________________
_________
Cronologa:______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________
Sintoma:_________________________________________________________________
________________________________________________________________________
________________
Area:___________________________________________________________________
_________
Acompaantes:___________________________________________________________
________________________________________________________________________
________________
Agravantes:______________________________________________________________
________________________________________________________________________
________________
Atenuantes:______________________________________________________________
________________________________________________________________________
________________
Cantidad:________________________________________________________________
________
CECM

Calidad:_________________________________________________________________
_________
Cronologa:______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________
Sintoma:_________________________________________________________________
________________________________________________________________________
________________
Area:___________________________________________________________________
_________
Acompaantes:___________________________________________________________
________________________________________________________________________
________________
Agravantes:______________________________________________________________
________________________________________________________________________
________________
Atenuantes:______________________________________________________________
________________________________________________________________________
________________
Cantidad:________________________________________________________________
________
Calidad:_________________________________________________________________
_________
Cronologa:______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________

CECM

Sintoma:_________________________________________________________________
________________________________________________________________________
________________
Area:___________________________________________________________________
_________
Acompaantes:___________________________________________________________
________________________________________________________________________
________________
Agravantes:______________________________________________________________
________________________________________________________________________
________________
Atenuantes:______________________________________________________________
________________________________________________________________________
________________
Cantidad:________________________________________________________________
________
Calidad:_________________________________________________________________
_________
Cronologa:______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________
Sintoma:_________________________________________________________________
________________________________________________________________________
________________
Area:___________________________________________________________________
_________
Acompaantes:___________________________________________________________
________________________________________________________________________
________________
Agravantes:______________________________________________________________
________________________________________________________________________
________________

CECM

Atenuantes:______________________________________________________________
________________________________________________________________________
________________
Cantidad:________________________________________________________________
________
Calidad:_________________________________________________________________
_________
Cronologa:______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________

Datos Relevates (negativos y positivos que tengan relacin con la

enfermedad actual):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________

Inspeccin General (Habitus

Exterior):_____________________________________________
________________________________________________________________________
________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________

Exploracin de Cuello y
Trax:_____________________________________________________
________________________________________________________________________
________
________________________________________________________________________
________________________________________________________________________
CECM

________________________________________________________________________
________________________

Interrogatorio por aparatos y sistemas:

Sx
Generales:_______________________________________________________________
______
Ap.
Respiratorio:______________________________________________________________
____
Sist.
Cardiovascular:___________________________________________________________
_____
Ap.
Gastrointestinal:___________________________________________________________
____
Ap.
Genitourinario:____________________________________________________________
____
Sist.
Endocrino:_______________________________________________________________
_____
Sist.
Nervioso:________________________________________________________________
_____
Ojo y
Visin:__________________________________________________________________
____
Ojo, Nariz y
Garganta:______________________________________________________________
Ap. Genital
Femenino:______________________________________________________________
Piel y
Anexos:_________________________________________________________________
____
Sist.
Musculoesqueletico:_______________________________________________________
____
Sx de
Alergias:_________________________________________________________________
___
Sx. Mentales y de
Conducta:_________________________________________________________

Somatometra y Signos Vitales:

Peso:_______
Talla:_________ IMC:_________ I. Cintura/Cadera:__________
TA:___________ FC:_________ FR:_________ Pulso:_______ _
Temperatura:_________
CECM

Enunciado:
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Exmenes de laboratorio y gabinete:
Biometra Hematica
Resultado

Valores Normales
4.04 - 6.13 /UL
12.2 18.1 g/dL
37.7 53.7%
80 97 fL
27 31.2 pg
31.8 35.4 g/dL
11.6 14.8 %
4 11 k/UL
2 6.9 k/UL
0.6 3.4 k/UL
0 0.9 k/UL
0 0.7 k/UL
0 0.2 k/UL
142 424 k/UL
0 99.9 fL

Resultado

Valores Normales
70 105 mg/dL
7- 20 mg/dL
0.7 1.3 mg/dL
2.3-6.1
130 - 220

RBC
HGB
HCT
MCV
MCH
MCHC
RDW
WBC
NEU
LYM
MONO
EOS
BASO
PTL
MPV
Qumica Sangunea
Glucosa
BUN
Creatinina
Acido Urico
Colesterol
CECM

Prot. C reactiva
Latex. Artritis Reumatoide
Antiestreptolisimas

0 200 UI/L

Electrolitos Sricos
Resultado

Valor Normal
101 111 mmol/L
136 145 mmol/L
3.6 5.1 mmol/L

Resultado

Valor Normal
140 200 mg/dL
6.1 7.9 g/dL
3.5 4.8 g/dL
10 42 UI/L
10 42 UI/L
38 126 UI/L
0.2 1.0 mg/dL
0.0 0.2 ng/dL

Resultado

Valor Normal

Cl
Na
K
Perfil Hepatico
Colesterol
Proteinas Totales
Albumina
Trans.Glut. Oxala.
Trans.Glut. Piruv.
Fosfatasa alcalina
Bulirrubina Total
Bilirrubina Directa
Valores Calculados
Globulina
Cociente A/G
Bilirrubina Indirecta
EGO
Fisico
Color
Aspecto
Quimico
Densidad
Colesterol
Proteinas Totales
Albumina
Trans.Glut. Oxala.
Trans.Glut. Piruv.
Fosfatasa Alcalina
Bilirrubina Total
Bilirrubina Directa
Bilirrubina Indirecta
Globulina
Cociente A/G

CECM

140 200 mg/dL

6.1 7.9 g/dL
3.5 4.8 g/dL
10 42 UI/L
10 42 UI/L
38 126 UI/L
0.2 1.0 mg/dL
0.0 0.2 mg/dL
Valor Calculado
Valor Calculado
Valor Calculado