Historia Clinica Dermatologica PDF

HISTORIA CLINICA DERMATOLOGICA 1RA. VEZ ____________

SUB. _____________ 

Fecha: ____________________________  Nombre*:   ____________________________________________________________________________  Edad: _________________ Sexo: _______________ Fecha de Nacimiento: _____________________  Estado Civil: _____________________ Ocupación: Ocupación: _________________________________________  Domicilio: _______________________________________________________________________ ____________________________________________________________________________  _____  Colonia: _________________________________________________C. _________________________________________________C... ________________________  Ciudad: ___________________________________ Estado: __________________________________  !el"#ono:

$______%______________________ Celular: $______%_______________________________ 

Correo Electrónico: ________________________________________________________________ ____________________________________________________________________  ____ 

Expl!ac"#$ De!%a&l#'"ca TOPOGRAFIA

DESCRIPCION

Tipo

Localizada o generalizada

Segmento afectado

Cara, Tra!, "razo#, Tronco

Regin afectada

E!p$e#ta o c$%ierta

Simetr&a

Sim'trica o a#im'trica

Localizacin e#pecial

C$ello, Palma#, Planta#, Genitale#

(ORFOLOGIA Tipo

DESCRIPCION (onomrfico o Polimrfico N)m* Le#ione#

Tama+o

(odo agr$pacin

Caracteri#tica# Limite# o %orde#

Color 

Comparacin con otra enfermedad conocida

DESCRIPCION EOL-CION

Ag$da o Crnica

SINTO(AS

Comezon, Ardor, Pr$rito, Calor, Otro#

I

&nterro'atorio Paciente femenina de 23 a+o# de edad, #in antecedente# de importancia, ac$de a la con#$lta 4ace 5 me#e# por pre#entar la# le#ione# 4ipocrmica# ante# de#crita#, #e le 4ace diagn#tico de itiligo, 6 #e empez a tratar con fototerapia, Elidel 78 en crema, A9itil crema, Cla%e#ol 6 %lo:$eador #olar -m%rella, la paciente refiere me;or&a de#de la < #emana de tratamiento con lo ante# mencionado, 6 a la e!ploracin dermatolgica #e confirma al o%#er9ar ne9o# de repigmentacin en la# le#ione# adem=# de cam%io en la coloracin de la# le#ione# de $na acromia a $na coloracin m=# ro#ada

PADECI(IENTO ACT-AL

FEC.A / (ODO DE APARICION APARICION

CA-SA O CA-SAS APARENTES

EOL-CION

TRATA(IENTOS TRATA(IENTOS PREIOS

OTRAS DER(ATOSIS PREIAS

 ANTECENDENTES  ANTECENDENTES PERSONALES PERSONALES

 ANTECEDENTES  ANTECEDENTES FA(ILIARE FA(ILIARES S 0Importante# de ac$erdo al ca#o1

LESIONES PRI(ARIAS

LESIONES SEC-NDARIAS

MACULA O MANCHA RONCHA PAPULA

NODULO

 

ESCAMA COSTRA

   

ESCARA EROSION

GOMA

ABCESO QUISTE

 

 

ULCERACION GRIETAS Y FISURAS VERRUCOSIDAD

QUERATOSIS ATROFIA ESCLEROSIS CICATRIZ LIQUENIFICACION

DIAGNOSTICO PRINCIPAL>

SEC-NDARIOS?

E@A(ENES CO(PLE(ENTARIOS

TRATA(IENTO?

NEOFORMACION NEOFORMACION O TUMOR COMEDON

 

 

EXCORIACION

NUDOSIDAD VESICULA AMPOLLA PUSTULA

OTRAS

 

SURCO O TUNEL FISTULA INFILTRACION PLACA CONJUGACION DE LESIONES

E(O)C&ON + SE,&-EN!O DE !/! !/!/-&EN!O: FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________  FEC0/: $___1_________1______% _________________________________________________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________   ______________________________________________________________________________________   _____________________________________________________________________ _________________