HISTORIA CLNICA

I. ECTOSCOPIA:1. Estado aparente : __________________________________________________________________________2. Edad aparente: ____________________________________________________________________________3. Signos destacados : _________________________________________________________________________________________________________________________________________________________________

II. ANAMNESIS: Tipo de anamnesis Tipo de informacin

1. FILIACIN Nombre:__________________________________________________________________________________ Fecha de Nacimiento : ______________________ Edad:___________________________________________ Sexo : _______________________________ Raza: ______________________________________________ Religin: _____________________________ Estado civil : _________________________________________ Ocupacin: _______________________________________________________________________________ Lugar de nacimiento : _______________________________________________________________________ Procedencia: ______________________________________________________________________________ Fecha de ingreso : _________________ Fecha de realizacin de HC : ________________________________ Direccin: ________________________________________________________________________________ Persona responsable : ______________________________________________________________________

2. ENFERMEDAD ACTUALa. Motivo de consulta: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b. Tiempo de enfermedad : ____________________________________________________________________________________c. Forma de inicio: __________________________________________________________________________________________________________________________________________________________________________d. Curso de enfermedad: __________________________________________________________________________________________________________________________________________________________________________e. Sntomas principales : __________________________________________________________________________________________________________________________________________________________________________f. Descripcin cronolgica y evolucin: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________g. Funciones biolgicas: Apetito: __________________________________________________________________________ Sed: _____________________________________________________________________________ Sueo :___________________________________________________________________________ Miccin :_________________________________________________________________________ Defecacin :_______________________________________________________________________

3. ANTECEDENTES.A. PERSONALES GENERALES Residencia anterior: ____________________________________________________________________________________________________________________________________________________________ Aspecto Socioeconmico1. Grado de instruccin:___________________________________________________________2. Ocupaciones:_________________________________________________________________3. Vivienda:____________________________________________________________________4. Vestimenta :__________________________________________________________________5. Alimentacin :________________________________________________________________6. Hbitos nocivos: ________________________________________________________________________________________________________________________________________________________ FISIOLGICOS Desarrollo fsico Prenatales:__________________________________________________________________ Natales:_____________________________________________________________________ Post-Natales: ________________________________________________________________________________________________________________________________________________________ Desarrollo psquico:_____________________________________________________________ Antecedentes Obsttricos Menarqua:___________________________________________________________________ Primera Relacin Sexual: _______________________________________________________ Rgimen Catamenial :__________________________________________________________ Fecha de ltima parto:__________________________________________________________ Fecha de ltima regla :_________________________________________________________ Frmula Obsttrica: G:___________ P:__________ A:________HV:______ HM:__________

PATOLGICOS Enfermedades eruptivas: ____________________________________________________________________________________________________________________________________________________________ Inmunizaciones: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Enfermedades anteriores: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Enfermedades actuales : ___________________________________________________________________________________________________________________________________________________________ Medicacin habitual: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Enfermedades venreas: ____________________________________________________________________________________________________________________________________________________________ Transfusiones sanguneas: ____________________________________________________________________________________________________________________________________________________________ Intervenciones quirrgicas: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Traumatismos, lugar, diagnstico : ___________________________________________________________________________________________________________________________________________________________ Hospitalizaciones previas: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Alergias: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FAMILIARES: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. REVISIN ANAMNSICA DEL SISTEMAS Y APARATOSa. 1. Cabeza: _____________________________________________________________________________________________________________________________________________________________2. Ojos: ______________________________________________________________________________________________________________________________________________________________3. Odos : ______________________________________________________________________________________________________________________________________________________________4. Nariz: ______________________________________________________________________________________________________________________________________________________________5. Boca : _____________________________________________________________________________________________________________________________________________________________6. Faringe y laringe: ______________________________________________________________________________________________________________________________________________________________7. Cuello: ______________________________________________________________________________________________________________________________________________________________8. Aparato respiratorio: ______________________________________________________________________________________________________________________________________________________________9. Aparato cardiovascular: ______________________________________________________________________________________________________________________________________________________________ 10. Aparato gastrointestinal: ______________________________________________________________________________________________________________________________________________________________11. Aparato genito-urinario : ______________________________________________________________________________________________________________________________________________________________12. Sistema nervisoso: ______________________________________________________________________________________________________________________________________________________________13. Aparato locomotor: ______________________________________________________________________________________________________________________________________________________________14. Piel y anexos: ______________________________________________________________________________________________________________________________________________________________15. Uas: ______________________________________________________________________________________________________________________________________________________________16. Sistema linftico: ______________________________________________________________________________________________________________________________________________________________

III. EXAMEN FSICO1. EXAMEN GENERALA. Control de signos vitales 1. Presin arterial: _________________________________________________________________________2. Frecuencia del pulso: ______________________________________________________________________________________3. Frecuencia respiratoria : __________________________________________________________________4. Temperatura: ___________________________________________________________________________5. Peso: _________________________________________________________________________________6. Talla: _________________________________________________________________________________

B. Apreciacin general 1. Facies: ________________________________________________________________________________2. Tipo constitucional : ______________________________________________________________________3. Actitud: ________________________________________________________________________________4. Estado de nutricin : _____________________________________________________________________5. Estado de hidratacin : ___________________________________________________________________6. Estado de conciencia : ___________________________________________________________________7. Orientacin temporoespacial: ______________________________________________________________

C. Piel y faneras 1. Piel: _________________________________________________________________________________2. Uas : _______________________________________________________________________________3. Sistema piloso: ________________________________________________________________________

D. Tejido celular subcutneo. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________E. Sistema linftico: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________F. Aparato locomotor 1. Columna vertebral: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. Extremidades: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Articulaciones: ____________________________________________________________________________________________________________________________________________________________________________4. Msculos: ____________________________________________________________________________________________________________________________________________________________________________

2. EXAMEN REGIONALA. CABEZAa. Crneo: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b. Cara Frente: ____________________________________________________________________________________________________________________________________________________________ Ojos Prpados: ________________________________________________________________________________________________________________________________________________________ Esclertica: ________________________________________________________________________________________________________________________________________________________ Conjuntivas: ________________________________________________________________________________________________________________________________________________________ Pupilas: ________________________________________________________________________________________________________________________________________________________ Nariz: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Odos: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Boca Labios: ________________________________________________________________________________________________________________________________________________________ Lengua: ________________________________________________________________________________________________________________________________________________________ Dientes: ________________________________________________________________________________________________________________________________________________________ Encas: ________________________________________________________________________________________________________________________________________________________ Mucosa oral: ________________________________________________________________________________________________________________________________________________________

B. CUELLO 1. Tiroides: ______________________________________________________________________________________________________________________________________________________2. Ganglios: ______________________________________________________________________________________________________________________________________________________3. Trquea : ______________________________________________________________________________________________________________________________________________________4. Sistema vascular: ______________________________________________________________________________________________________________________________________________________

C. TRAX Y PULMONES Inspeccin Trax esttico: ________________________________________________________________________________________________________________________________________________________ Trax dinmico Simetra: _________________________________________________________________________ FR: _________________________________________________________________________ Amplitud: _________________________________________________________________________ Ritmo: _________________________________________________________________________ Palpacin: ____________________________________________________________________________________________________________________________________________________________ Percusin: ____________________________________________________________________________________________________________________________________________________________ Auscultacin: ____________________________________________________________________________________________________________________________________________________________

D. CARDIOVASCULARa. Regin del cuello: ____________________________________________________________________________________________________________________________________________________________b. Regin precordial Inspeccin: ____________________________________________________________________________________________________________________________________________________________ Palpacin: ____________________________________________________________________________________________________________________________________________________________ Percusin: ____________________________________________________________________________________________________________________________________________________________ Auscultacin: ____________________________________________________________________________________________________________________________________________________________

E. ABDOMEN Inspeccin: ____________________________________________________________________________________________________________________________________________________________ Auscultacin: ____________________________________________________________________________________________________________________________________________________________ Percusin: ____________________________________________________________________________________________________________________________________________________________ Palpacin Superficial: ______________________________________________________________________________________________________________________________________________________ Profunda: ______________________________________________________________________________________________________________________________________________________

F. GENITOURINARIO Punto reno-ureterales : ______________________________________________________________________________________________________________________________________________________Puo-percusin-lumbar: ______________________________________________________________________________________________________________________________________________________

G. SISTEMA NERVIOSO Conciencia: ______________________________________________________________________________ Funcin Motora: tono muscular: ____________________________________________________________________________ Trofismo muscular : ____________________________________________________________________________Fuerza muscular: ____________________________________________________________________________ Pares Craneales: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IV. DIAGNOSTICO SINDRMICO: __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________

V. HIPTESIS DIAGNOSTICA __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________

VI. PLAN DE TRABAJO_____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________VII. DIAGNOSTICO FINAL_____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________VIII. TRATAMIENTO _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________IX. EVOLUCIN _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________X. EPICRISIS _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________