Ejemplo de Historia Clinica

m m m
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m m m  m  m m 
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 m m Ý

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m  
m mmmmmmmmmmmmmmmmmmmm m

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m mÝ
mmmmmmmmmmmmmmmmmmm m m m    m m m mm!mm"##m

 
m 
m Ficha de Identificación g
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m  m m  m m m   m mm  m   m   m    m m mm  m    g 
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uatos del Hospital

  m $&' m [
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§ntecedentes Heredo Familiares

' m  (m' m// mm-0m mm m mm, 'mm  m m  mm m    m  m 
m' m1  m m  m2m mm m m  mm1%m3mm1 4
m ' m   (m 1  m m  m m m   m   m m  m  5m #m   m  mm 
m " m 1  m m  m .-m m m  m  m  (m m + 
m  m // m m 6.m mm m  m 
m -m+  m m 4 m0$

m mm m  m  
m # m  (m*mm  m 4 mm m  m  
m # m  m-(mm  m 4 mm m  m  
m 7 ' m*m 4 m0mm8m mm m  m  
m 94 m (m9 %4 m9   m:m   # m 

§ntecedentes Personales No Patológicos p  m ; ' m   m   m   <  m m m  m m <  m ''  m  mm  'mm+ mm  m m mm  m  mm m3 m m 6m /  m )m m )(m  m ' m / %m m' m*m m 6m  m   m 6m m6m:m6m  m6m m.
m!mm  mm m m:mm  mm

 m  mm m4 mm m mm  m m  m=  >m:mm m ? m  m   m =  >
9 m  m  m   m m    
m  m  m   m  m / m     m  m  m '  m m '  m m 1  m %  m mm m'  m  m2m# 
m §
 *m/m m#
m  m m  m mm  m < (mm  mm  m  m: m m.m  mm #<mm    m  mm/  mm .mm 4 m  
m   (m m   m m   m m   m  m / m =  m   ' < m <  +  >m    m m.m  mm #m m  m  
m  m m '  < m  m m + m  1  mm  %
mm p   m 7m ' m   m m # m m m 4  m  m +  m + m Am + m :m @ '%m <
m !m  ' m m  m= m :m  >m m   
m 7m  / m m  m*m/m m# m m@ '%m / m#
m!m  m mm m/
§ntecedentes Personales Patológicos 
      B 4  m:m4  
m 
  $         94 m 1 m % m 4 / 
 § m  (m!4  / m p     ; m   m m +  <  m m   m m  ' @ m m   m m m m m)8m mm m:m m4 m m m)2m mm m m  m 1 m    m m   m 1  / m   m  m ' m  %mm   m  mm 
m 94 (m m   m/ m?4 m mm m 4 m m  m+  1 
m $ 
   mmm  %mm/  m+ m m(m   mm /  m4 m %m /
m mm7 4m:m +(m&C
m m Historia Clínica Gineco-Obstétricam ! mm m  m)6m m m m  m m  mm*$.m# m <  m  mm6m  m m# m mm1  m4 m  m 2m# m m  %m     m m  m 2D)m  m  m m # m m   m  
m B%m m / m  m m  m )-m m  m  @ m  m  m m   m  m  m /
 m m  
m ' m  m m  m m '  <
m 9 m '%m 4?m  mm %m 
m 1m*m4 m m3 m:m)m  m  
m+ mm ? m  (m*mm'mm ))
m94 m   m m'  < 
mE< m m  / m   m =,BE>m   m   m  / m m   m m    m  m   m   m : m m  m  m  m '  < 
m m  m1mm mm+ m m # mm / m  m=,EB>
m9 mm + m  <  m     m m   %m m   
m + m m ? m  %(m) mmF mm )
m+ m ' 'mm  (m)0mm'mm ))
m m  m  m  m m '  < m m *2m   m m 4 %m m / m  m 4m/ %(m "

 
  mm m8m  mm4 %m m m m m/   %m m1  / m m   m:m  mmm m m < %mm  m ' m m '  < m ="' m m  >m  m  m  m  /
m " m  m m  m   m   m m m m m )m /
Padecimiento §ctual Y    [    m  m m m / m m   4# m :m &' m  m  ' @ m m   m %m m  %m   m :m  m m '  m   m mm'  < mm*2m  mm4 %
m B m ' @ mm  m m8m+mm/ %
m !mm#
$mB m m m2(m+m m  mm+ 4  m m% mmm  m m  m' m m mm)D)m %m    mm m4 m m  mm  m.mm mm m mm  mm  m m  m    m :m :m m  m 1m  m   m m  ' @ m m  
m " m%mm %m  m m m2()m+
m 1m mm'  m m m2().m+mm  m  m  m m.mmm    m  m m 4m  m m   m :m :m m  m  %m ?' m   m

  m  m   m m  ' @ m m  
m m  m m     m m  m   m m %m m m) (m+mm*mm'mm ))mmm1 mmm m  # m

Im m  < m   # m  m m 'm   m ? m // m  m 1 m m  m # m   m m    
m  m m  m m

--m 4m :m  m   m m 68m 
m 4 (m 2m 7/ m (m 
m m  m *m m m  m '  m  m  m m   m  m , 
m 7m / m  / m  m +  m 4 /< m  m   m m  < m   1
mm !m 4 m #
$m m  m 1m  m  m m  (m  m   m m + 4  m m% mm  %m m mm.D)m m  mm# m m  mm  m)$ m+m mm m mm  mm  m m  ' m m  %m :m :m  m m   m 1  / (m H    m   m  m   m m  ' @ m m  
m " m +  4 m / 4 m m m .(m +m m   m @ m  m   m)mm    m  mm4m  m m @ m :m :m m  m    m   m  m   m m  ' @ m m  
m !m     m m%1  m m4  mmmmm4  m m m0(m+mm6m m'mm ))m  m m+ mm m+ mm < m m  1 mm / 
m m  m1m m  m m  m   %m m ' m  : m + m  m 1m   m  m   m    m m )m m 1  m / m   m1mm  m m m  %
m m #
$m   m  m  m  (m   m m + 4  m  m % m m   %m  m  m m 6D)m  m   m m # m m   m m   m $*m+m mm m mm  mm  m m ' mm %m:m :m  m m   m 1  / (m H    m   m  m   m m  ' @ m m  
m " m   m m   m  @ m   m  m *m mm    m  mm4m  m m ' mm %m:m:m m  m    m   m m   m m  ' @ m m  
m m   %m + m  m m  m m2mm   m m m m  # 
mm   m #
$m   m  m  m :m  m  m  m  m   # 
m m   %m + m  m m   m m .m m   m  m  m   # 
m Y
 §  m6m# mm+ 'm  mm ' @ mm  m+ :m mm  m:m  m m m m  # m m 
m m  %m + m  m m   m m 6m m    m  m  m  m   # m : m    
m 7m  m 3m  4%m m ' m 43 m    m m  mm  mm  
mm %
& (m m.D)m  m2D)
m" mm m    m m6mJ4m m mm%mm 
m94 (m; 
m    
  
% m m  m 1m m  m m / # (m  m  ' m m # m  m  m  'm m  m m/  m  m ' m  
m + m m ? m   (m)mm'mm ))m0(m+
m !   m7 %m;  m)mm  m) m+
m+ mm? m  (m .mm'mm ))m0(m+
m"    m)m ' m/# m  m  m2m+m m' m   
m + m m ? m   (m *m m 'm m ))m (m +
m   m 2m 4m /# m  /  m   m 2m +m  m ' m   
m + m m ? m   (m .m m 'm m ))m 0(m +
m 1   m )4m /# m  /  m

  m 2+m  m ' m   
m + m m ? m   (m .m m 'm m

))m0(m+
mH    m*m4m/# m /  m  m2m+m m' m  
m + m m ? m   (m .m m 'm m ))m 0(m +
m ":m "  4 m m +   m mmm/  m4 m= .m>m m 4 m  m 6+m m' m   
m + m m ? m   (m -m m 'm m ))m ) (m +
m  m % m :m    m   m )m  ' m /# m  m   m 6m +m  m ' m   
m + mm? m  (m-mm'mm ))m0(m+
m m

Interrogatorio por §paratos y Sistemas §    &    1m m   m  m *m /m m # m m   m   m  m  m m  m    mm.mm m# m  mm 4m  m m 4m # m :m m  m 4m # m ':m m   m  
mK m%m-mm'mm ))m m m) (m+
mm §      1m m   m /  m )m /m m # m m   m /m  m   m  m m 1  m m  m1 m  m m 4m  m :m m  m 4m  m ':m m   m   
m E m/  %m-mm'm m m.(m+
m §   [      7m  m  %4 m  
m §      m7m  m  %4 m  
 
Y   $   1m 4 m:m  4 m4 <  
mm 
g  m7m  m  %4 m  
 
    1(m"  m  
m '      1(mmm ' m # mm "$ (  1(m%mmmm mm'  <
m p
  )  1m 
à ploración Física  *     (m-mm'mmm ))m m m)-()m+m*m# mmmm4 m m   m*-
.mm %m m))D2mmm;4
mm  m    m)-mm  m   m26m
mm   m)
..m
mm " (m.0mJ
m  p     " m m  m  m 1 m m  m  m  m m  m   %4 m  %m  m  m #4 m  m   m  %m m m  m  % m m  m m ' m 4 '  m  m @ m   m :m ? m m / %m  m 43 m   1 m m m /   m 1 m  m m  / m   m  + m  m /    m m  m m

  m  m    mm m  mm  m   m m mm m   mm m   m:mm  m  # 
        [(  m  m %m m 3 (m  m   1  m  m  ' m m   %m4 m:m1 m 4 m  m  m   m:m m m' m +4
m m  m   %m m   m m   m 4 4 m   m =  m   m '  >m  m   '
m  / m / m :m  / m  'm m m 3 m %m    m  m 'm   m  
m [   m  m %m m   m m '/ m   m 4 /# (m   m m  m    m 1m  43 m  m m ' m +  
m m  m%m m 1(m   mm   m   m 4 m m  m m m   m m m  m  m 4m 3 m  m :m   
m m  m   %m  m 'm   m  m m   m m  m   %m m  m 1  m  m   %m  /
m m  m %m @ m 4 m :m  m m   m m   m  m %mm  %m  
       m  m %(m    m m  m + m  ' mm  m4 m m'm  mm1m  m4 m m mm  m   m  m  ' m  m  m ' m %m  / m   ' m 'm    
m " m  m m 1 m m  mm  %m  
mm m  %m m'm  m mm m   m   m  m  m   
m  @/ m  ' 5m  m m 1 m   m   m  m @/ m'' m:m m  m'  m  m  m / m :m ' 
m 1@ m   m m %m 
m 1@ m   m m  %m ' m m  m :m ' m m 'm :m 'm   m m   m  '
m Bm m   m  1m  m   m m    m 1@ m 1    m   m :m m  /4 m m :m   
m 4< m m  m   m   
m 4< m 1 m   
m 4< m / m  m D m m ' m @ m =/    m m)
.mmm  >
m  mm @ m m1@ m @ mm m  m m   m   @  m 4 m m   m m +  4 m  m ' m  %m  $/ m <  m m /  m   5m  m m  m :m   mm/  m 4# 
 g   " ' m m m m m ' m   
m  m  m %(m  m /'m m   m  m '   m m   m m !  m m :m  'm  m   m m  m 1 4m m  m  
m"' mm  m  


'  m  m %m + m  ' m   m :m + <  5m  ' m    m #4 m +? m m  / m   
m #' m  m   m    m +   m m'm  mm1m1 m:m'   mm  m m7 m5m# m   m  m m' m %
m mm m *m< m m=1  m m m  >m).m< m1 m:m).m m 'm    m  m ' m %m   m '  m 'm   m m 1
m " m m  m '  m  m 1 m m '   m m   m m L+  m m :m  'm   m 4 m    5m   m 
m 4 m   m   m 4 m  m  / m  'm m   m m %m  m 'm   m  
m "' m m  m  ' m   
m "   m  m 4 m   m   m +  
m"   m'  m4 m  m   m+   m%/m:m?/ m 
m #4  m  m /'m  m #4 m   m    m m +  
m " m   m m  1 4m m   m    m +   m 4 m m  m  
 %  m m %m @ m   m  m  %m   m 'm   m m 1m   %m4 m m mm m  m mm  m m m  %m m  '%m :m   
m m  m    m  m   m / m m  m  'm  m  m  m mm m  mm  m  m   mm m  
mm m%mm'  m3 (m4 m  m   m m '/ m m  4 m   m m  m  
m m  m     m '  m 3 m %/
m 4< m / m  m  m ' m m +  m-mm
m"' mm (m&# m+ m m %m% m m )*m 4 m :m  %m  m m m 4 
m &# m < m  m  %m% mm) m4 m:m %m  mm m4 
m"' mm L'(m7m  < %
m"' mm7+M ' +(m  
m9 mm < m' mm '4m: mmm mmm m 
m    [   m  m %(m  m   m # m  m 'm   m m 1m   m 4 m m  m m  m m  m  m  m  / m / m :m  / m  'm m   m m %m 'm    
m m  m   %(m Nm   m  m 4 4 m m  m  m   'm ='   m '  m 4  m/ m1 m/ m  m/ m 1 m   / >m  m :m %' m m  m  m  m   'm  m    m +    m :m % m m  m   m  m 1 m m 26m   m  m m # mm' m m m/  m m
m      m  m%(m  m    m  m    m   m  m 'm   mm 1m   %m4 m m mm m m:m# mm / m    
m  m    m m )-m  m  m 
m m  m   %(m  m  m  m ' m 
m   m  m  m 1 m  m  m ' m 
m '  m /  m  m  m   m  
mm m%(m  m  mm ' m+  
mm m  %(m  m/ m mm ' m+  
m %mm m/
  m  
m   m +4  m    m m   m   m < m +4  m   m m   m  m  %m  
m 7m % m m   m /'
m m  m   %m  m m   m    
m &  m  / m   m ' m 43 m    (m    (m  m %m   m   m   m  m m  m   m=)m >m  m m4
m 4 m4  m m  '
m    + "    m m%m% mmm m   m m m'm  mm1m + mm m m/'
mm m  %m+ mm m  'mmm m   m  m< m m mm m# m   m:m m1 mm m# m    m  m %m m m @ 
m m  m %(m  m m  m #m   
mmmm m  %m% m m m  m# mm  mm  m 44  m m1 m   mm26m  m m
m    §
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m#m  mm '/ m mm  1 mm# m
m m  m   %m m +   m  m ' m 1 m m  m  m   m '  m m m  / m  'm   m 1 m m   m m  m   %
mm m

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m m '' m'  m m m m m m  m m m m m  m

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m ,m  m  m  m 3m m  '    m  m ' # m +  m  m   m  1 m    m :m 1  m m m m   m   m  m m ? m m m '  < m :m   m m 'm m m  m m  m  m  %mm m m m  mm  m1%mm  m   < m m m mm m   m 13
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m



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m m m m m4?m mm4 'm: mm m1m    m  mm'  <
m

Problemas §ctivos [m  4 m4 m  (m, 'm [m [m [m [m

m mBBm 
m  %mm  m ;   m/ m  m " 'm1%(m  # m

Problemas Inactivos [m ;   m

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m 7 %m;  m)mm m mEmm&  m  m-m+
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m "    m.m4m/# m  m  m-m+m 6
m H    m*m4m/# m /  m  m2m+m .
m  m1% m:m71  m  m)m ' m/# m  m  m 6m+m -
m ":m"  4 m m+   m mmm/  m4 m= .m>m m 4 m   m 6+m 8
m   m4 mm1# m:m4 m/ m m m 2
m N m:m ' %m 0
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m   m/  m    % #   " $ ,  )
m # m  m


m )mm7 %m;  m  m2m+m *
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m

":mm"  4 m m+   m mmm/  m4 m= .m>m m 4 m  m) +m  m% m:m71  m  m m ' m  m 6m+m 6
m  1 mm m m .
m &4 m m m  m m*m m mm -
m 4 m  mm'  m  m 8
m "  m m  mm $&' m 2
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m , m  m


m 7 %m;  m)mm  m) m+m *
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m   m/  m [   % #    )
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m  mm  m *
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