FORMATO HISTORIA CLÍNICA
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Transcript of FORMATO HISTORIA CLÍNICA
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UNIVERSIDAD TÉCNICA DE MACHALA ESCUELA DE MEDICINA
HISTORIA CLÍNICA
DATOS DE FILIACIÓN:Nombres: ________________________________________________________________________Edad: _____________________________Sexo: ______________________________Etnia: ______________________________Religión: ___________________________Estado civil: _________________________Instrucción: _________________________
Ocupación: _____________________________Lugar de nacimiento: _____________________Lugar de vivienda: ________________________N° de cama: _____________________________Fecha de ingreso: ________________________Fecha de realización HC: ___________________
MOTIVO(S) DE INGRESO O CONSULTA_____________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ______________________________________
ENFERMEDAD ACTUAL____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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REAS______________________________________________________________________________________________________________________________________________________________________
ANTECEDENTES PERSONALES NO PATOLÓGICOS______________________________________________________________________________________________________________________________________________________________________
ANTECEDENTES PERSONALES PATOLÓGICOS____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ANTECEDENTES PATOLÓGICOS FAMILIARES_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HÁBITOS:NO TÓXICOS______________________________________________________________________________________________________________________________________________________________________
TÓXICOS_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SEXUALES___________________________________________________________________________________
CONDICIÓN SOCIO-ECONÓMICA______________________________________________________________________________________________________________________________________________________________________
FUENTE DE INFORMACION:____________________________________________________________COMENTARIO:__________________________________________________________________________________________________________________________________________________________
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EXAMEN FÍSICOSIGNOS VITALES F.C________ lpm T.A _______ mmHg T º _______ º C F.R _______ rpm Sat. O2 ____ % FiO ____ %
IMC_______ kg/m2
- PESO:________- TALLA:_______
ICC_________ cm2
- CINTURA_________- CADERA__________
EXAMEN SOMÁTICO GENERALApariencia general: ______________________________________Facie:_________________________________________________Biotipo:________________________________________________Estado nutricional:_______________________________________Actitud:________________________________________________Deambula:______________________________________________Actividad psicomotriz:____________________________________
PIEL Y FANERASPiel:__________________________________________________________________________________________________________________________________________________________________Uñas:_________________________________________________________________________________________________________________________________________________________________Pelo:__________________________________________________________________________________________________________________________________________________________________
EXAMEN FÍSICO REGIONALCabeza:_______________________________________________________________________________________________________________________________________________________________Oído:_________________________________________________________________________________________________________________________________________________________________Ojos:__________________________________________________________________________________________________________________________________________________________________Nariz:_________________________________________________________________________________________________________________________________________________________________Boca:_________________________________________________________________________________________________________________________________________________________________Cuello:________________________________________________________________________________________________________________________________________________________________
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RESPIRATORIOINSPECCION_________________________________________________________________________PALPACION____________________________________________________________________________________________________________________________________________________________PERCUSION____________________________________________________________________________________________________________________________________________________________AUSCULTACION_________________________________________________________________________________________________________________________________________________________
CARDÍACOINSPECCION_________________________________________________________________________PALPACION_________________________________________________________________________PERCUSION_________________________________________________________________________AUSCULTACION_________________________________________________________________________________________________________________________________________________________
DIGESTIVOINSPECCION____________________________________________________________________________________________________________________________________________________________AUSCULTACION_________________________________________________________________________________________________________________________________________________________PERCUSION____________________________________________________________________________________________________________________________________________________________PALPACION____________________________________________________________________________________________________________________________________________________________
GENITO URINARIOINSPECCION_________________________________________________________________________PALPACION_________________________________________________________________________PERCUSION_________________________________________________________________________AUSCULTACION______________________________________________________________________TACTO RECTAL:______________________________________________________________________
SOMAINSPECCION:___________________________________________________________________________________________________________________________________________________________PALPACION:____________________________________________________________________________________________________________________________________________________________
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NEUROLÓGICOEXAMEN MENTAL: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXAMEN MOTOR:FUERZA MUSCULAR_____________________________________________________________________________________________________________________________________________________REFLEJOS:- BICIPITAL_______________________- _______________________________- TRICIPITAL______________________- _______________________________- ROTULIANO_____________________- _______________________________- CUTÁNEOPLANTAR_______________- _______________________________
TAXIA______________________________________________________________________________PRAXIA_____________________________________________________________________________
PARES CRANEALESOLFATORIO:_________________________________________________________________________OPTICO:_______________________________________________________________________________________________________________________________________________________________MOC:_________________________________________________________________________________________________________________________________________________________________TROCLEAR:__________________________________________________________________________MOE:______________________________________________________________________________TRIGÉMINO:___________________________________________________________________________________________________________________________________________________________FACIAL:________________________________________________________________________________________________________________________________________________________________AUDITIVO:_____________________________________________________________________________________________________________________________________________________________GLOSOFARINGEO:____________________________________________________________________NEUMOGASTRICO:___________________________________________________________________ESPINAL:___________________________________________________________________________HIPOGLOSO MAYOR:_________________________________________________________________
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EXAMEN SENSITIVO:SENSIBILIDAD SUPERFICIAL
- TÁCTIL_______________________________________________________________________- DOLOROSA Y TÉRMICA__________________________________________________________
SENSIBILIDAD PROFUNDA- PALESTESIA__________________________________________________________- BATIESTESIA_________________________________________________________- BAROGNOSIA________________________________________________________
DIAGNÓSTICOS PRESUNTIVOS: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
REALIZADO POR:__________________________________________________________________________