Datos personales:

Nombre: _____________________________________________________________

Genero: __________________

Edad: ____________________

Fecha de nacimiento: ___________________________________________________

Ocupación:_______________________________________________

Estado civil: ______________________________________________

Religión:_________________________________________________

Dirección:_______________________________________________________________

Nivel de escolaridad: ____________________________________________________

Nombre del servicio: _____________________________________________________

Numero de cama: _______________________________________________________

Numero de expediente: _________________________________________________

Fecha y hora de ingreso: ________________________________________________

Fecha y hora de historia: _________________________________________________

Datos otorgados por: ____________________________________________________

Confiabilidad de los datos: _______________________________________________

Consulta por:____________________________________________________________

Presente enfermedad

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Antecedentes patológicos

• Enfermedades de la infancia: ______________________________________________________________________________________________________________________________________

• Enfermedades de la adolescencia: ______________________________________________________________________________________________________________________________________

• Enfermedades de la edad adulta: ______________________________________________________________________________________________________________________________________

• Hospitalizaciones: ______________________________________________________________________________________________________________________________________

Intervenciones quirúrgicas: ______________________________________________________________________________________________________________________________________

• Exámenes especiales ______________________________________________________________________________________________________________________________________

• Alergias:______________________________________________________________________________________________________________________________________

• Transfusiones: ______________________________________________________________________________________________________________________________________

Antecedentes no patológicos

• Cafeísmo: ____________________________________________________

• Etilismo: _____________________________________________________

• Tabaquismo:_________________________________________________

• Drogas: ______________________________________________________

• Patrón de sueño: ______________________________________________

• Patrón de micción: ____________________________________________

• Patrón de defecación: __________________________________________

• Alimentación: ________________________________________________

• Hidratación: __________________________________________________

• Inmunizaciones: ______________________________________________

• Antecedentes familiares: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• Ecológico-social: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

EXAMEN FÍSICO

Apariencia general: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signos vitales:

- Presión arterial:

______________

- Pulso: ______________________

- Frecuencia cardíaca:

____________

- Frecuencia respiratoria:

_________

- Temperatura:

_________________

- Peso: ________________________

- Talla: _______________________

- IMC: ____________________

- PIEL__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- CABEZA___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- OJOS__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- OÍDOS___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- NARIZ Y SENOS PARANASALES___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- BOCA Y GARGANTA________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- CUELLO__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- TORAX

- PULMONARINSPECCION:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PALPACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PERCUSIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AUSCULTACIÓN:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

- CARDÍACOINSPECCION:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PALPACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PERCUSIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AUSCULTACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- ABDOMEN

INSPECCIÓN:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

AUSCULTACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PERCUSION:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PALPACIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ARTICULACIONES: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ÓSEO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MÚSCULAR: __________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

- EXTREMIDADES

MIEMBRO SUPERIOR: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MIEMBRO INFERIOR: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- NEUROLÓGICO

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PARES CRANEALES:

I. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. ______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

III. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IV. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VI. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VII. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IX. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

X. ______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

XI. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

XII. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Fuerza Tono Sensibilidad ROT

REFLEJOS ESPECIALES:

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DIAGNOSTICO:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________

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COMENTARIO DEL CASO:

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UNIVERSIDAD AUTÓNOMA DE SANTA ANAUNASAESCUELA DE MEDICINA

HISTORIA CLINICA

ALUMNO: _________________________________________________________

CÁTEDRA: ________________________________________________________

CATEDRÁTICO: ___________________________________________________

CICLO: ____________

FECHA: _______________________________________