Historia_Clinica_sin_llenar[1][1].doc

E.A.P. Medicina Humana

Medicina interna II 

 HISTORIA CLÍNICA

ANAMNESIS: FILIACIÓN Nombre: …………………………………………………………………… ………………………………………………………………………………………………………………………. …………………………………………………. Edad: …………………………………………………………………………… ………………………………………………………………………………….………………………………………. …….………………………………………. Sexo: …………………………………………………………………………… ………………………………………………………………………………….………………………………………. …….………………………………………. Raza: …………………………………………………………………… ………………………………………………………………………………….………………………………………. …………….………………………………………. Ocupación: ………………………………………………………………………… …………………………………………………………………………….……………………………………… ….……………………………………… Estado Civil: …………………………………………………………………………..………………………… …………………………………………………………………………..………………………………………. ……………. Grado de Instrucción: Instrucci ón: …………………………………………………………………………… …………………………………………………………………………………………………………. ……………………………. Reliión: ……………………………………………………………………………………………………………………… Idioma: ………………………………………………………………………… ………………………………………………………………………………………………………………………... ……………………………………………... !ec"a de Nacimiento: ………………………………………………………………………………………………………… #uar de Nacimiento: ………………………………………………………………..………………………………………. #uar de $rocedencia: ………………………………………………………………...……………………………………… %iempo en el luar de residencia: …………………………………………………….………………………………………. &omicilio: …………………………………………………………………………….………………………………………. $ersona Responsable: ………………………………………………………………………………………………………… !ec"a de Inreso: ……………………………………………………………………..………………………………………. 'odo de Inreso: ……………………………………………………………………..………………………………………. !ec"a de (istoria Cl)nica: …………………………………………………………………………………………………….

ENFERMEDAD ACTUAL %iempo de en*ermedad: ………………………………………………………………………………………………………. !orma de inicio: ………………………………………………………………………………………………………………. Curso de la en*ermedad: ……………………………………………………………………………………………………… S)ntomas principales: …………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………… Relato: …………………………………………………………………………… ………………………………………………………………………………………………………………………… ……………………………………………  ………………………………………………………………………………………………………………………............... ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ….……………………………………………………………………………………………………………………………...  

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E.A.P. Medicina Humana

Medicina interna II 

FUNCIONES BIOLÓGICAS ,petito: ………………………………………………………………………………………………… Sed: ……………………………………………………………………………………………………… Orina: …………………………………………………………………………………………………… &eposiciones: …………………………………………………………………………………………… Sue-o: …………………………………………………………………………………………………… $eso: ………………………………………………………………………………………………………

ANTECEDENTES ANTECEDENTES PERSONALES GENERALES ivienda: ………………………………………………………………………………………………………………………  …………………………………………………………………………………………………………………………........... ,limentación: ………………………………………………………………………………………………………………… estimenta: …………………………………………………………………………………………………………………… (/bitos nocivos: ……………………………………………………………………………………………………………… Situación socio0económica: ………………………………………………………………………………………………….. ia1es: ………………………………………………………………………………………………………………………… Residencias anteriores: ……………………………………………………………………………………………………….. Ocupación 2 ocupaciones anteriores: ………………………………………………………………………………………… Inmunizaciones: ……………………………………………………………………………………………………………… ,lerias: ………………………………………………………………………………………………………………………. %rans*usiones sanu)neas: ……………………………………………………………………………………………………

ANTECEDENTES PERSONALES FISIOLÓGICOS $renatales: …………………………………………………………………………………………………………………….  Natales: ……………………………………………………………………………………………………………………….. #actancia: …………………………………………………………………………………………………………………….. &esarrollo psicomotor: ………………………………………………………………………………………………………..

ANTECEDENTES PERSONALES PATOLÓGICOS En*ermedades en la In*ancia: …………………………………………………………………………………………………. En*ermedades en la Ni-ez: …………………………………………………………………………………………………… En*ermedades en la ,dolescencia: …………………………………………………………………………………………… En*ermedades en la 3uventud: ………………………………………………………………………………………………... En*ermedades en la ,dultez: …………………………………………………………………………………………………. En*ermedades en la ,ncianidad: ……………………………………………………………………………………………... (ospitalizaciones ,nteriores: ………………………………………………………………………………………………… Intervenciones 4uir5ricas: …………………………………………………………………………………………………… ,ccidentes: ……………………………………………………………………………………………………………………

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E.A.P. Medicina Humana

Medicina interna II 

ANTECEDENTES FAMILIARES $adres: ………………………………………………………………………………………………………………………… Esposo: ………………………………………………………………………………………………………………………... (i1os: ………………………………………………………………………………………………………………………….. (ermanos: …………………………………………………………………………………………………………………….. Compa-eros de %raba1o: ……………………………………………………………………………………………………… ecinos: ……………………………………………………………………………………………………………………….

EXAMEN FÍSICO FUNCIONES VITALES %emperatura:……………………………………..

!recuencia Card)aca: ……………………………………

!recuencia del $ulso: …………………………….

!recuencia Respiratoria:…………………………………

$resión ,rterial: ………………………………….

$eso: ……………………………………………………..

%alla:……………………………………………...

I'C:……………………………………………………..

FACIES: ………………………………………………………………………………………………………………………….. ESTADO GENERAL :……………………………………………………………………………………………………………. ESTADO DE NUTRICIÓN :……………………………………………………………………………………………………... ESTADO HIDRATACIÓN :……………………………………………………………………………………………………… TIPO MORFOLÓGICO :………………………………………………………………………………………………………… ACTITUD:………………………………………………………………………………………………………………………… MARCHA:………………………………………………………………………………………………………………………… PIEL Y FANERAS: ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………….................................... ……………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………

TEJIDO CELULAR SUBCUTÁNEO: …………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………

TEJIDO LINFÁTICO: ................................................................................................................................................................... ............................................................................................................................................................................................................ ............................................................................................................................................................................................................

REGIÓN MAMARIA: ................................................................................................................................................................... ...........................................................................................................................................................................................................

SISTEMA OSTEO-ARTICULAR: ............................................................................................................................................... ............................................................................................................................................................................................................ ............................................................................................................................................................................................................

SISTEMA MUSCULAR: ............................................................................................................................................................... ............................................................................................................................................................................................................

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E.A.P. Medicina Humana

Medicina interna II 

EXAMEN REGIONAL: CABEZA: Crá!": ..................................................................................................................................................................................... ...................................................................................................................................................................................................

R!#$% "r&$'(r$(: ...................................................................................................................................................................... ....................................................................................................................................................................................................

R!#$% ()r$*)+(r , (.'"$/!(: ................................................................................................................................................ ....................................................................................................................................................................................................

R!#$% (.(+: ............................................................................................................................................................................ ....................................................................................................................................................................................................

R!#$% "r(+: .............................................................................................................................................................................. ....................................................................................................................................................................................................

CUELLO: •

COLUMNA CERVICAL: …………………………………………………………………….......................................

•

TRÁ0UEA Y CARTÍLAGO TIROIDES: …………………………………………………………………………….

•

GLÁNDULA TIROIDES: ……………………………………………………………………………………………...

•

VASOS SANGUÍNEOS: ……………………………………………………………………..........................................

•

GANGLIOS: …………………………………………………………………………………………………………….

TÓRAX Y PULMONES: •

INSPECCIÓN: ………………………………………………………………………………………………………….. .............................................................................................................................................................................................

•

PALPACIÓN: ................................................................................................................................................................... .............................................................................................................................................................................................

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PERCUSIÓN: …………………………………………………………………………………………………………... .............................................................................................................................................................................................

•

AUSCULTACIÓN:........................................................................................................................................................... .............................................................................................................................................................................................

APARATO CARDIOVASCULAR: EXTREMIDADES: ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………

CUELLO: ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………

REGIÓN PRECORDIAL INSPECCIÓN: ………………………………………………………………………………………………………….. •

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E.A.P. Medicina Humana

•

Medicina interna II 

PALPACIÓN: …………………………………………………………………………………………………………... ………………………………………………………………………………………………………………………….....

•

PERCUSIÓN: …………………………………………………………………………………..………………………. …………………………………………………………………………………………………………………………….

•

AUSCULTACIÓN: …………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………

EXAMEN DE ABDOMEN: •

INSPECCIÓN:………………………………………………………………………………………………………...... …………………………………………………………………………………………………………………………….

•

AUSCULTACIÓN: ……………………………………………………………………………………………………..

•

PERCUSIÓN: …………………………………………………………………………………………………………... .............................................................................................................................................................................................

•

PALPACIÓN: ……………………………………………………………………………………………........................ ……………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………….

TACTO RECTAL: ......................................................................................................................................................................... APARATO GENITO-URINARIO: APARATO URINARIO: •

INSPECCIÓN: …………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………….

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PALPACIÓN: ………………………………………………………………………………………........................

•

PERCUCIÓN: ……………………………………………………………………………………………………... ………………………………………………………………………………………………………………………..

EXAMEN NEUROLÓGICO: ESTADO DE CONCIENCIA: ................................................................................................................................................ GLASGO1:.....................................................................................................................................................................................  +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++   Historia Clínica

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E.A.P. Medicina Humana

Medicina interna II 

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PARES CRANEALES: I 2(r:……………………………………………………………………………………………………. II 2(r:…………………………………………………………………………………………………… • •

…………………………………………………………………………………………………………… •

III2(r:…………………………………………………………………………………………………. ……………………………………………………………………………………………………………………… …

• •

IV 2(r:………………………………………………………………………………………………….. V 2(r:…………………………………………………………………………………………………...... …………………………………………………………………………………………………………….

• • • •

VI 2(r:…………………………………………………………………………………………………. VII 2(r:  ……………………………………………………………………………………………….. VIII 2(r:………………………………………………………………………………………………. IX - X 2(r: ……………………………………………………………………………………………….. ...........................................................................................................................................................

• •

XI 2(r:………………………………………………………………………………………………….. XII 2(r:…………………………………………………………………………………………………

FUNCIÓN MOTORA: ............................................................................................................................................................ ....................................................................................................................................................................................................

FUNCIÓN SENSITIVA: .........................................................................................................................................................  

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FUNCIONES SUPERIORES: ................................................................................................................................................ ....................................................................................................................................................................................................

IMPRESIÓN DIAGNÓSTICA SINDRÓMICA: ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………….... .................................................................................................................................................................................................... .................................................................................................................................................................................................... .................................................................................................................................................................................................... .................................................................................................................................................................................................... .................................................................................................................................................................................................... ....................................................................................................................................................................................................

 +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++   Historia Clínica

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E.A.P. Medicina Humana

Medicina interna II 

.................................................................................................................................................................................................... .................................................................................................................................................................................................... ....................................................................................................................................................................................................

DISCUSIÓN CLÍNICA

................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ...................................................................................................................................  +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++   Historia Clínica

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E.A.P. Medicina Humana

Medicina interna II 

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E.A.P. Medicina Humana

Medicina interna II 

……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………............... EVOLUCION DEL PACIENTE

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E.A.P. Medicina Humana

Medicina interna II 

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E.A.P. Medicina Humana

Medicina interna II 

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