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Universidad Juárez Autónoma De Tabasco

División Académica Multidisciplinaria De Comalcalco


Estudio En La Duda. Acción En La Fe

Asignatura

Propedéutica Médica

Trabajo

Historia Clínica

Alumno

José Eduardo Torres Olan

Profesor

DR. Rafael Hernández Aguilar

R/a sur 4ta sección, Comalcalco, Tabasco


Historia clínica
1. Ficha de Identificación
L.R.D.M 55 Nacionalidad
Nombre Edad Mexicana
Ranchería Santa Teresa 2da Sección Catolico Municipio
Domicilio Religión
Cárdenas
Cardenas Grupo A+ Estado
Lugar De Origen
Sanguíneo Tabasco
Casado Masculino Código postal
Estado Civil Sexo
86500
15 de Marzo del 2019 Ocupación No. Afiliación
Fecha De Ingreso
Campesino
Secundaria Acompañante No. Celular
Escolaridad
Esposa

2. Motivo de Consulta

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3. Antecedentes Heredo-Familiares (abuelos, padres, tíos, cónyuge, hijos y primos)


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4. Antecedentes No Patológicos

Carnes Frutas Y Cereales Y


Alimentos Carnes Rojas Agua Lácteos
Blancas Verduras Legumbres
Raciones Por
Día

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5. Antecedentes Patológicos (Infectocontagiosos, enfermedades exantemáticas, enfermedades crónicodegenerativas y parasitarios,


alérgicos, quirúrgicos, traumáticos, transfusionales, convulsivos, adicciones (tabaquismo, alcoholismo, drogas) y hospitalizaciones
previas)

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6. Antecedentes Gineco-Obstétricos

Menarquia Opsomenorrea Polimenorrea NG


FUM Proimenorrea Oligomenorrea NP
Partos Hipermenorrea Amenorrea MPF

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7. Antecedentes Andrológicos

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8. Padecimiento Actual

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9. Interrogatorio Por Aparatos Y Sistemas
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Aparato Respiratorio
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Aparato Digestivo
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Aparato Cardiovascular
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Aparato Urinario
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Aparato Reproductor
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Aparato Endocrino
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Sistema
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Hematopoyético Y
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Linfático
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Sistema Musculo- ___________________________________________________________________________
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Sistema Nervioso
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Piel Y Anexos
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Órganos de los Sentidos
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Esfera Psíquica
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10. Exploración Física

Signos Vitales
Presión Arterial Frecuencia Cardiaca Frecuencia Respiratoria Pulso

Temperatura Corporal Glucometría Llenado Capilar Oximetría de Pulso


Otros Parámetros
Estatura Peso Talla IMC

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Cabeza ___________________________________________________________________________
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ojos
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Nariz
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Oídos
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Cavidad Oral
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Cuello
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Tórax
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Abdomen
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Genitales
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Extremidades
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Sistema Nervioso
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Sistema Linfático
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Piel
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11. Impresión Diagnostica

A. Diagnóstico Diferencial

B. Diagnostico
12. Exámenes Solicitados

13. Terapéutica

14. Referido (a)

15. Indicaciones