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HISTORIA CLNICA SEMIOLOGA

HISTORIA CLNICA N_______________


NOMBRE: _______________________________________________________ SEXO:

F M

EDAD: _______ DOCUMENTO DE IDENTIDAD: ______________________________________


TELFONO: ____________________ OCUPACIN: __________________________________
NACIDO EN: ______________________ PROCEDENCIA: ______________________________
PERSONA RESPONSABLE: ___________________________________PARENTESCO_________
MOTIVO DE CONSULTA:
HISTORIA DE LA ENFERMEDAD ACTUAL: cuando comenz, como comenz, donde comenz, que
tratamiento se ha hecho, y como se encuentra ahora
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ANTECEDENTES FAMILIARES:
ABUELO PATERNO: HTA____ infarto_____ hemofilia_____ albinismo____ enf. Transmisin sexual:
sfilis, gonorrea, VIH,
Fumador activo____ alergias_________
cncer ____________
artritis__________ hepatitis______
diabetes ___ Parkinson______
otra?cual?
________________________________________________________________________________________descripcio
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ABUELA PATERNA HTA____ infarto_____ hemofilia_____ albinismo____ enf. Transmisin sexual:
sfilis, gonorrea, VIH,
Fumador activo____ alergias_________
cncer ____________
artritis__________ hepatitis______
diabetes ___ Parkinson______
otra?cual?
________________________________________________________________________________________descripcio
n________________________________________________________________________________________________
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ABUELO MATERNO: HTA____ infarto_____ hemofilia_____ albinismo____ enf. Transmisin sexual:


sfilis, gonorrea, VIH,
Fumador activo____ alergias_________
cncer ____________
artritis__________ hepatitis______
diabetes ___ Parkinson______
otra?cual?
________________________________________________________________________________________descripcio
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ABUELA MATERNA: HTA____ infarto_____ hemofilia_____ albinismo____ enf. Transmisin sexual:
sfilis, gonorrea, VIH,
Fumador activo____ alergias_________
cncer ____________
artritis__________ hepatitis______
diabetes ___ Parkinson______
otra?cual?
________________________________________________________________________________________descripcio
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___________________________________________________________________________________________PADR
ES: HTA____ infarto_____ hemofilia_____ albinismo____ enf. Transmisin sexual: sfilis, gonorrea,
VIH,
Fumador activo____ alergias_________
cncer ____________ artritis__________
hepatitis______
diabetes ___ Parkinson______
otra?cual?
________________________________________________________________________________________descripcio
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TOS: HTA____ infarto_____ hemofilia_____ albinismo____ enf. Transmisin sexual: sfilis,
gonorrea, VIH,
Fumador activo____ alergias_________
cncer ____________
artritis__________ hepatitis______
diabetes ___ Parkinson______
otra?cual?
________________________________________________________________________________________descripcio
n________________________________________________________________________________________________
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HERMANOS HTA____ infarto_____ hemofilia_____ albinismo____ enf. Transmisin sexual: sfilis,
gonorrea, VIH,
Fumador activo____ alergias_________
cncer ____________
artritis__________ hepatitis______
diabetes ___ Parkinson______
otra?cual?
________________________________________________________________________________________descripcio
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ANTECEDENTES PERSONALES
Tipo de parto_____________ prematuro A trmino
complicaciones______________________________________
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Leche materna? Hasta qu edad?
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Esquema de inmunizacin completo?
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Enfermedades de la infancia: varicela rubeola sarampin polio meningitis
infecciones_______________________ traumas_____________________________ otra? Cul?
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Descripcin y
tratamientos____________________________________________________________________________
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Enfermedades en la
adolescencia______________________________________________________________________ vida sexual
activa?
descripcin y tratamientos______________________________________________________
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Hospitalizaciones________________________________________________________________________________
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Intervenciones
quirrgicas____________________________________________________________________________
Transfusiones sanguneas

donacin de sangre

tipo de sangre______

Ultima visita al mdico y razn por la que fue


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ANTECEDENTES ODONTOLGICOS
Erupcin dentaria normal? (secuencia y
tiempo):_________________________________________________________
Denticin completa? (cordales):
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Restauraciones y tipo de stas y ubicacin:
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ltima visita al odontlogo y razn por la que fue:


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Tratamiento endodntico, periodntico u ortodntico:
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Prtesis:
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HBITOS Y VICIOS
Cepillado: cuantas veces al da____ tiempo______ enjuague bucal__________________________ seda
dental______
Alcoholismo_____ cigarrillo_____ drogas__________________________ onicofagia (comerse las uas)
_____ queilofagia (comerse los labios) _____ bruxismo_______________

VALORACIN DE RGANOS Y SISTEMAS


CABEZA:
Cefaleas: ______ Traumas craneoceflicos: ______ Accidente cerebro-vascular: ______
Tumefacciones: ______ Cirugas: ______ otro: ___________________________________________________
Descripcin de padecimientos:
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CUELLO:
Adenopatas:
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Sintomatologa dolorosa: ______ dificultad de movimiento (lateralidad y flexin): _______
otro: __________________
Descripcin de padecimientos:
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OJOS:
Miopa (dificultad para ver objetos distantes): ______ Hipermetropa (dificultad para ver objetos
cercanos): _______ Astigmatismo (problema en la curvatura de la crnea, que impide el enfoque claro de los objetos
cercanos y lejanos): _______ Diplopa (visin doble): ______ Fotofobia (intolerancia a la luz): ______
otro: ________________________________

Descripcin de padecimientos:
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ODOS:
Otalgia (dolor de odo): ______ Otoliquia (salida de liquido cfalo raqudeo): _______ Otorrea
(flujo mucoso o purulento): _______ Tinnitus (escuchar ruidos): ______ Otorragia (salida de
sangre): ______ Otitis (inflamacin): _____
Descripcin de padecimientos:
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NARIZ:
Rinorrea (exudado seroso o purulento): ______ Anosmia (incapacidad para oler): _______
Hiposmia (disminucin del sentido del olfato): _______ Cacosmia (percepcin de malos olores):
______ Epistaxis (salida de sangre): ______ Parosmia (falsa percepcin de sensaciones
olorosas): _____
Descripcin de padecimientos:
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BOCA:
Halitosis (mal aliento): ______ Hiposialia (disminucin de secrecin salivar): _______ Asialia
(ausencia de saliva):____ Xerostoma (sensacin de sequedad en la boca): ______ Sialorrea
(salida saliva por la boca): ______
Disgeusia: (distorsin del sentido del
gusto): _____ Ageusia (ausencia del sentido del gusto): ______
Descripcin de padecimientos:
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SISTEMA CARDIO-VASCULAR:
Taquicardia (aumento de frecuencia cardiaca): ______ Bradicardia (disminucin de la
frecuencia cardiaca): _______ Hipertensin: ____ Hipotensin ______ Alteraciones
hematolgicas _____ otra: ______________________________
Descripcin de padecimientos:
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SISTEMA RESPIRATORIO:
Disnea (insuficiencia respiratoria): ______ Apnea del sueo (interrupcin de respiracin
mientras duerme): _______ Taquipnea (aumento de frecuencia respiratoria): ______ Bronquitis:
____ Hemoptisis (toser sangre): ______
TBC: _____ Asma: _____ Neumona:
_______
Descripcin de padecimientos:
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SISTEMA ENDOCRINO:
Diabetes: ______ Pancreatitis: _______ Hipotiroidismo: ______ Hipertiroidismo: _____
Acromegalia: ______
Descripcin de padecimientos:
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SISTEMA GASTROINTESTINAL:
Diarrea: ______ Colon irritable: _______ Estreimiento: ______ Gastritis: _____ Nauseas:
______ Vmitos: ________
Descripcin de padecimientos:
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SISTEMA GENITO-URINARIO:
Ao de menarquia (primer ciclo menstrual): _______________ Perodo, regular o no?
_________________________
ETS: Sfilis: _____ VIH: _____ Gonorrea: ______ Herpes: ______ estuvo embarazada?______
Abort?____________
Hematuria (sangre en la orina): ______ Poliuria (gasto urinario excesivo): ______ Oliguria
(disminucin en produccin de orina): ______ Insuficiencia renal: ________
Descripcin de padecimientos:
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SISTEMA MUSCULO ESQUELTICO:
Crepitaciones (ruido crujiente): ______ Fracturas: _______ Luxaciones: ______ Mialgias: ____ _
Cirugas seas: _____ Descripcin de padecimientos:
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SISTEMA NERVIOSO CENTRAL:
Depresin: ______ Ansiedad: _______ Convulsiones: ______ Meningitis: _____ Insomnio: _____
Inconsciencia: _____ Amnesia: ______ Ataxia (disminucin de la capacidad de coordinar los
movimientos): ______ Parlisis: ______
Descripcin de padecimientos:
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PIEL Y ANEXOS:
Acn: ______ Dermatitis: ______ Alopecia: ______
Descripcin de padecimientos:
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EXAMEN FSICO GENERAL


Edad Cronolgica: _______ Edad aparente coincide con edad cronolgica?_______ Tez (color):
__________
Tipo Constitucional:
Brevilneos
Normolneos
Longilneos

poca estatura, gruesos y corpulentos, cuello corto, trax ancho, musculatura bien desarrollada y
extremidades relativamente pequeas
grupo intermedio con una conformacin corporal armnica
altos, delgados, de cuello y trax alargados, musculatura pobre y extremidades largas

Estado de salud aparente:

Estado nutricional:

Facie compuesta? ______ Estado emocional:


Orientado en: Tiempo, lugar, espacio, persona y autosiquis?_____
Marcha normal?______

Peso:_______ Estatura:_________

SIGNOS VITALES
Presin: ______________ Pulso: _______________ Temperatura: _________ Frecuencia respiratoria:
_____________
EXAMEN FSICO REGIONAL
CABEZA: Braquioceflico (corta y ancha)
Mesoceflico (intermedio)

Dolicoceflico (larga y estrecha)

Posicin central?______ inclinacin hacia: ________________________ Perfil: cncavo convexo


Implantacin capilar: Androide (con entradas frontotemporales)

Ginecoide (sin entradas)

Color cabello: ___________ buena consistencia, distribucin y adherencia?


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Simetra facial
Alopecia

Ectoparsitos

Prurito

CARA: (regiones: geniana, palpebral, nasal, labial, mentoniana, maseterina, cigomtica)


TERCIO SUPERIOR:
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TERCIO MEDIO:
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TERCIO INFERIOR:
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OJOS
Color: ____________ Pupilas isocrmicas?______ Miosis (contraccin de pupila) y midriasis (dilatacin de
pupila) buena no tiene Globos oculares en distancia y posicin normal?______ movimientos
oculares buenos?_______ normotelorismo?
NARIZ
Posicin centrada
Perforaciones
palpacin

Desviacin del tabique nasal


Secreciones

ODOS
Pabellones auriculares normales y simtricos

Fosas nasales simtricas


Dolor a la

Perforaciones

tamao:

_______________
la palpacin

Conducto auditivo externo limpio y sin secreciones anormales?______ Dolor a

CUELLO
Simtrico
extensin
lateralidad
Tumefacciones
ATM
Buena apertura
Crepitaciones

Posicin central al cuerpo


rotacin
Manchas
Sintomatologa

Responde a flexin
Fistulas

Limitacin en protrusin, retrusin y lateralidad


Chasquidos
Desviacin mandibular

CADENAS GANGLIONARES
Mastoidea______ Occipital______ Genianos______ Yugulocarotdeos______ Yuxtacervicales______
Mandibulares____ Descripcin:
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EXAMEN ESTOMATOLGICO
LABIOS: piel perioral
sana?:___________________________________________________________________________
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Borde bermelln continuo?:
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Linea de Klein continua?:
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Semimucosa labial (color, descamaciones, surcos)
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Presenta selle labial normal?______
MUCOSA LABIAL:
INFERIOR: Vascularizacin buena
brillante
Indentaciones

deficiente
color: ______________ hmeda
Ndulos a la palpacin
Frenillo labial
inferior(vascularizacin, color e insercin): ____________________________________________________
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Lesiones elementales:
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INFERIOR: Vascularizacin buena
brillante
Indentaciones

deficiente
color: ______________ hmeda
Ndulos a la palpacin
Frenillo labial
superior(vascularizacin, color e insercin): ___________________________________________________
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Lesiones elementales:
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MUCOSA YUGAL (dividir en tercios anterior medio y posterior): Lnea alba marcada
Induraciones a la palpacin
papila de Stensen? A qu nivel?
________________________________________ Indentaciones
en qu tercios?
________________________________
Lesiones elementales:
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PALADAR DURO: tercio anterior: Papila incisiva


Rugas palatinas normales?

Color: ____________ asintomtica?

Tercio medio y posterior: torus?


Lesiones elementales:
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PALADAR BLANDO: Liso
Color: _________

Brillante

Mvil

Buena vascularizacin

OROFARINGE:
Uvula: nica?
Color rosado?
mvi?
Tamao aproximado: __________
Ubicada centralmente?
forma cnica?
bien vascularizada?
Pilares amigdalinos anteriores de color rosa?
Amigdalas: rosa?
ovalada?
Mamelonada?
Pilares amigdalinos
posteriores de color rosa?
Pared posterior de la
orofaringe hmeda?
bien vascularizada?
LENGUA
CARA DORSAL: tercio anterior: papilas filiformes alteradas?
papilas fungiformes
alteradas?
Indentaciones?
Tercio medio: papilas filiformes alteradas?
papilas fungiformes alteradas
Tercio posterior: papilas caliciformes normales?
Cara lateral: papilas foleadas en buen estado? Indentaciones?
Induraciones a la
palpacin?
Sintomatologa dolorosa?
CARA VENTRAL: mucosa: hmeda?
brillante?
bien vascularizada?
Venas raninas clinicamente normales?
Se observan los pliegues fimbriados (nuhn y
blandin)?
Frenillo lingual, insercin (tercio de cara ventral de lengua y piso de boca):
____________________________________
PISO DE BOCA: mucosa: hmeda?
Carnculas clnicamente sanas?

brillante?
bien vascularizada?
plicas linguales clnicamente sanas?

TABLA MANDIBULAR INTERNA: lesiones tumorales?


Mucosa clnicamente sana?
TABLA MANDIBULAR EXTERNA: lesiones tumorales?
Mucosa clnicamente sana?
ENCA: Enrojecida en OD:
_____________________________________________________________________________
Sangrado a la
palpacion?
exudado purulento o seroso?
Resecin en OD:
_______________________
DIENTES: N dientes arcada superior: ______ N dientes arcada inferior: ______ ausencia clinica
de OD: _____________
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SALIVA: presenta alteracin de color?


normal?
TIPO DE OCLUSIN:

Consistencia fluida?

Secresion

OVERBITE:
OVERJET:
APERTURA MXIMA: