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UAGRM-FACULTAD DE CIENCIAS DE LA SALUD HUMANA | MEDICINA

 Univ. Gabriela Escalante Pessoa- Aux. Semiología Médica- UAGRM-MEDICINA-2015

HISTORIA CLINICA
FICHA DE IDENTIFICACION - FILIACIÓN
Apellido y Nombre: ………………………………………………………………………………………….
Edad:………… Fecha de nacimiento: …………………………Lugar:……………………….….… Fecha y hora:……/……/……… -….…:.……
Género: …………………………… Estado civil: …………………………C.I.………………........... N° de la historia clínica: ……………………
Profesión: ……………………………………………Ocupación:…………………………..………...... Cama: ………………………………………………
Domicilio actual: …………………………………………………………….Telf.:..………………..…... Sala:
Procedencia: ………………………………………… Nacionalidad.:……………..….………….….. ………………………………………………...
Religión: ………………………………….Grado de instrucción: …………………………...….….. Fecha de ingreso: ……/…………/…………
Fuente de la información:………………………………Confiabilidad: ……………………………………

MOTIVO DE CONSULTA
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ANTECEDENTES DE LA ENFERMEDAD ACTUAL

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 Univ. Gabriela Escalante Pessoa- Aux. Semiología Médica- UAGRM-MEDICINA-2015

ANTECEDENTES PERSONALES NO PATOLOGICOS

 Hábitos alimenticios:
Dieta: …………………………………………………………………………………………………………………………………………………………………………
Desayuno:………………………………………..Almuerzo:………………………………………..Cena:………………………………………………………
 Hábitos adquiridos:
Alcohol: …………………………………………………………………………………………………………………………………………………………………….
Tabaco: ……………………………………………………………………………………………………………………………………………………………………..
Drogas: ……………………………………………………………………………………………………………………………………………………………………..
Medicamentos: ………………………………………………………………………………………………………………………………………………………..
Transfusiones: ………………………………………………………………………………………………………………………………………………………….
Inmunizaciones: ……………………………………………………………………………………………………………………………………………………….
Alergia: ……………………………………………………………………………………………………………………………………………………………………
 Hábitos fisiológicos:
Diuresis:………………………………………………………………………….Catarsis:……………………………………………………………………………
ANTECEDENTES PERSONALES PATOLOGICOS
Enfermedades congénitas: ………………………………………………………………………………………………………………………………………..
Enfermedades propias de la infancia: ………………………………………………………………………………………………………………………..
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Enfermedades de la adolescencia: …………………………………………………………………………………………………………………………….
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Enfermedad en adulto: ……………………………………………………………………………………………………………………………………………...
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ANTECEDENTES HOSPITALARIOS
Clínicos: ……………………………………………………………………………………………………………………………………………………………………
Quirúrgicos: ………………………………………………………………………………………………………………………………………………………………
Traumáticos: ……………………………………………………………………………………………………………………………………………….…………….

ANTECEDENTES HEREDO- FAMILIARES

Padre: ………………………………………………………………………………………………………………………………………………………………..………
Madre: ……………………………………………………………………………………………………………………………………………….………….………….
Hermanos:…………………………………………………………………………………………………………………………………………………………………
Pareja:………………………………………………………………………………………………………………………………………………………………………..
Hijos: ................................................................................................................................................................................

ANTECEDENTES GINECO-OBSTETRICOS
Menarca:……………………………………………………Telarca:…………………….……………………Pubarca:…………….………………………..…
FUM:…………………………………………………………Catatemia:.................................................................................……….
Menopausia:……………………………………………………………………………………………………………………………..………………………………
Vida sexual activa ………………………………………………………………………………………………………………..………………………………..….
Métodos anticonceptivos:…………………………………………………………………………………………………………………………………………
Gestaciones:…………………………………………………………………………….Partos:…………………………..…………………………………….…
Abortos:………………………………............................................... Cesáreas:……………………………………………………..……..…..
Complicaciones:……………………………………………………………………………………………………………………………………………….……….
ANTECEDENTES PSICOSOCIALES
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 Univ. Gabriela Escalante Pessoa- Aux. Semiología Médica- UAGRM-MEDICINA-2015

ANÁLISIS POR APARATOS Y SISTEMAS

 SISTEMA NERVIOSO CENTRAL: …………………………………………………………………………………………………………………………..……

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 SISTEMA CARDIOVASCULAR: ………………………………………………………………………………………………………………………………..…
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 SISTEMA RESPIRATORIO:………………………………………………………………………………………………………………………………………….
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 SISTEMA GASTROINTESTINAL: …………………………………………………………………………………………………………………………………
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 SISTEMA GENITOURINARIO: ……………………………………………………………………………………………………………………………………
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 SISTEMA OSTEOMIOARTICULAR: …………………………………………………………………………………………………………………………….
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EXAMEN FÍSICO GENERAL
o Inspección o estado general
Impresión general:…………………………………………………………………………………………………………………………………………………….
Estado de conciencia:………………………………………………………………………………………………………………………………………………..
Orientación temporo-espacial:……………………………………………………………………………………………………………………………………
Posición: ……………………………………………………………………………………………………………………………………………………………………
Actitud: ……………………………………………………………………………………………………………………………………………………………………..
Marcha: …………………………………………………………………………………………………………………………………………………………………….
Facie:…………………………………………………………………………………………………………………………………………………………………………
Biotipo:………….……………………………………………………………………………………………………………………………………………………………
Estado nutricional: …………………………………………………………………………………………………………………………………………………….
o Sistema tegumentario piel y faneras
-Aspecto y coloración:……………………………………………………………………………………………………………………………………………..…
-Lesiones:…………………………………………………………………………………………………………………………………………………………….…….
-Distribución pilosa:………………………………………………………………………………………….……………………………………………………….
Uñas:
-Circulación colateral:……………………………………………………………………………………………………………………………………………..…
-Llenado capilar:…………………………………………………………………………………………………………………………………………………………

o SIGNOS VITALES:
FC: ……..……………….……………….FR: ……………………..……..….……………….
PA: ……….……………………………… PULSO: ……………………………………….….Presión palpatoria:…………………………………………….
T° axilar: ……………………………….T° rectal: …………………………………………
Peso: …………………………………….Talla: ……………………………………………..IMC:……………………………………………………………………

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 Univ. Gabriela Escalante Pessoa- Aux. Semiología Médica- UAGRM-MEDICINA-2015

EXAMEN FÍSICO SEGMENTARIO

o CABEZA
Craneo:………………………………………………………………………………………………………………………………………………………………………
Ojos:……………………………………………………………………………………………………………………………………………………………………………
Oídos:…………………………………………………………………………………………………………………………………………………………………………
Nariz:………………………………………………………………………………………………………………………………………………….………………………
Boca:…….………………………………………………………………………………………………………………………………………………………………….…
o CUELLO:
Inspección:…………………………………………………………………………………………………………………………….…………………………………..
Palpación:………………………………………………………………………………………………………………….……………………………….……………...
Percusión:…………………………………………………………………………………………………………..………………………………………………………
Auscultación:…………………………………………………………………….………………………….…………………………….………………………………
o TORAX
-ANTERIOR
Inspección:…………………………………………………………………………………………………………………………….…………………………………..
Palpación:………………………………………………………………………………………………………………….……………………………….……………...
Percusión:…………………………………………………………………………………………………………..………………………………………………………
Auscultación:…………………………………………………………………….………………………….…………………………….………………………………
-POSTERIOR
Inspección:…………………………………………………………………………………………………………………………….…………………………………..
Palpación:………………………………………………………………………………………………………………….……………………………….……………...
Percusión:…………………………………………………………………………………………………………..………………………………………………………
Auscultación:…………………………………………………………………….………………………….…………………………….………………………………
o ABDOMEN
Inspección:…………………………………………………………………………………………………………………………….…………………………………..
Auscultación:………………………………………………………………………………………………………………….……………………………….…………
Percusión:…………………………………………………………………………………………………………..………………………………………………………
Palapación:..…………………………………………………………………….………………………….…………………………….………………………………
o PELVIS
Inspección:…………………………………………………………………………………………………………………………….…………………………………..
Palpación:………………………………………………………………………………………………………………….……………………………….……………...
Percusión:…………………………………………………………………………………………………………..………………………………………………………
Auscultación:…………………………………………………………………….………………………….…………………………….………………………………
o MIEMBROS O EXTREMIDADES
Extremidades superiores:
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Extremidades inferiores:
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o EXAMEN FISICO OSTEOMUSCULAR

Columna vertebral:
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Ejes óseos:……………………………………………………………………………………………………………………………………………..……….………….
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Articulaciones:…………………………………………………..………………………………………………………………………..…………..………………..
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 Univ. Gabriela Escalante Pessoa- Aux. Semiología Médica- UAGRM-MEDICINA-2015

o EXAMEN NEUROLÓGICO
 Nivel de conciencia
- Escala de coma de Glasgow:……………………………………………………………………………………………………………………
- Fasia:……………………………………………………………………………………………………………………………………………………….
- Gnosia:……………………………………………………………………………………………………………………………………………………
- Praxia:………………………………………………………………………………………………………………………………………………………
- Pares craneales:
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 Examen de motilidad y sensibilidad:
- Trofismo:…………………………………………………………………………………………………………………………………………………
- Tono:………………………………………………………………………………………………………………………………………………….……
- Fuerza:…………………………………………………………………………………………………………………………………………………….
- Reflejo osteotendinoso:…………………………………………………………………………………………………………………..………
- Reflejo cutáneo superficial:……………………………………………………………………………………………………………………..
- Sensibilidad superficial:…………………………………………………………………………………………………………………………..
- Sensibilidad profunda:…………………………………………………………………………………………………………………………….

DIAGNOSTICO PRESUNTIVO

o ………………………………………………………………………………………………………………………………………………………………………
o ………………………………………………………………………………………………………………………………………………………………………
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DIAGNOSTICOS DIFERENCIALES

o ………………………………………………………………………………………………………………………………………………………………………
o ………………………………………………………………………………………………………………………………………………………………………
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NOMBRE Y FIRMA DEL MEDICO

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 Univ. Gabriela Escalante Pessoa- Aux. Semiología Médica- UAGRM-MEDICINA-2015

EXAMENES COMPLEMENTARIOS

LABORATORIO:
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ELECTROCARDIOGRAMA:
Ritmo: ………………………………………………………FC: …………………………………Eje QRS: ………………………………………………………….
Onda P: …………………………………………………...QRS: ………………………………………………………………………………………………………..
Onda T: ……………………………………………………ST: ……………………………………………………………………………………………………………
PR: ……………….QTc: ………………………………….Conclusión: ……………………………………………………………………………………………..
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RADIOGRAFIA DE TORAX:
Partes blandas: ………………………………………………………………………………………………………………………………………………………….
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Partes óseas: …………………………………………………………………………………………………………………………………………………………….
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Campos pulmonares: ………………………………………………………………………………………………………………………………………………..
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Silueta cardiovascular: ……………………………………………………………………………………………………………………………………………….
Índice cardiotorácico: …………………………………………………………………………………………………………………………………………………
Conclusiones: …………………………………………………………………………………………………………………………………………………………….
OTROS ESTUDIOS:
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PLAN TERAPEUTICO:
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NOMBRE Y FIRMA DEL MEDICO

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 Univ. Gabriela Escalante Pessoa- Aux. Semiología Médica- UAGRM-MEDICINA-2015

EVOLUCIÓN CLÍNICA
Pág. N°: …………………N° HC: …..……..

Ap. Paterno Ap. Materno Nombre Servicio Departamento

Paciente: ………………………………………………………………………………………………………………. …………………… ……………………….

Fecha y Hora Registre la información clínica diaria, según esquema SOAP, evolución sintomatológica, apreciación
subjetiva del estado del paciente, cabios sinológicos visibles, plan de estudios diagnósticos y
terapéuticos, sus justificativos y análisis de resultados.

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NOMBRE Y FIRMA DEL MEDICO

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