Datos personales:

Nombre: _____________________________________________________________

Genero: __________________

Edad: ____________________

Fecha de nacimiento: ___________________________________________________

Ocupación: _______________________________________________

Religión de los padres: _________________________________________________

Dirección: _______________________________________________________________

Nombre del servicio: _____________________________________________________

Numero de cama: _______________________________________________________

Numero de expediente: _________________________________________________

Fecha y hora de ingreso: ________________________________________________

Fecha y hora de historia: _________________________________________________

Datos otorgados por: ____________________________________________________

Parentesco: _____________________________

Confiabilidad de los datos: _______________________________________________

Consulta por: ____________________________________________________________

Presente enfermedad

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Antecedentes personales

Historia prenatal:

Madre De ______ De Edad, G P P A V .

Enfermedades Durante El Embarazo: .

Medicamentos: .

Drogas: .

Alcohol: .

Tabaco : .

Controles Médicos: En .

Exámenes Realizados: .

Parto

Fecha: .

Lugar: .

Edad Gestacional: .

Tipo De Parto: .

Antecedentes neonatales

Respiro Espontáneamente Necesito Reanimación .

Se Dio De Alta Junto Con La Madre .

Control médico

En .

Inmunizaciones: .

Bcg: .

Dpt + Hib + Hb Y Opv: .

Spr: .

Influenza: .

Rotavirus: .

Alimentacion

SMLD Hasta .

Edad De Ablactación: .

Jugos, Frutas Y Vegetales: .

Huevos: .

Carnes: .

Dieta Actual: .

Alergias: .

# Evacuaciones: .

Estreñimiento: .

Crecimiento Y Desarrollo

Adecuado Para La Edad .

Fijación De La Mirada: .

Sonrisa Social: .

Junto Las Manos En La Línea Media: .

Sostuvo Al Cabeza: .

Dio Vuelta: .

Se Sentó: .

Gateo: .

Camino: .

Hablo: .

Antecedentes patológicos

• Enfermedades de la infancia:

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• Enfermedades de la adolescencia:

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• Enfermedades de la edad adulta:

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• Hospitalizaciones:

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Intervenciones quirúrgicas:

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• Exámenes especiales

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• Alergias:

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• Transfusiones:

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• Antecedentes familiares:

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• Ecológico-social:

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EXAMEN FÍSICO

Apariencia general: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signos vitales:

- Presión arterial: ______________

- Pulso: ______________________

- Frecuencia cardíaca: ____________

- Frecuencia respiratoria: _________

- Temperatura: _________________

- Peso: ________________________

- Talla: _______________________

- IMC: ____________________

- PIEL

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- CABEZA

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- OJOS

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- OÍDOS

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- NARIZ Y SENOS PARANASALES ________________________________________________________________________________

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- BOCA Y GARGANTA

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- CUELLO

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- TORAX

- PULMONAR

INSPECCION:

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PALPACIÓN:

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PERCUSIÓN:

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AUSCULTACIÓN:

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- CARDÍACO

INSPECCION:

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PALPACIÓN:

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PERCUSIÓN:

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AUSCULTACIÓN:

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- ABDOMEN

INSPECCIÓN:

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AUSCULTACIÓN:

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PERCUSION:

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PALPACIÓN:

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ARTICULACIONES:

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HUESOS:

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MÚSCULAR:

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- EXTREMIDADES

MIEMBRO SUPERIOR:

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MIEMBRO INFERIOR:

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- NEUROLÓGICO

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Fuerza Tono Sensibilidad ROT

DIAGNÓSTICO:

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TRATAMIENTO:

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RAZONAMIENTO CLÍNICO:

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UNIVERSIDAD AUTÓNOMA DE SANTA ANA

UNASA

ESCUELA DE MEDICINA

HISTORIA CLINICA

ALUMNO: _________________________________________________________

CÁTEDRA: ________________________________________________________

CATEDRÁTICA: ___________________________________________________

CICLO .

FECHA: _______________________________________