MODELO DE HISTORIA CLNICA

Fecha:

Mdico: ________________________________.

DATOS PERSONALES
Apellido y Nombre: _________________________________________________________________________.
Sexo: _____. Edad: ______. Estado Civil: _______________. Ocupacin: ____________________________.
Domicilio: _____________________________________________________________. TE: ______________.
Residencia: _______________________________________________________________________________ .

MOTIVO DE CONSULTA

ANTECEDENTES DE LA ENFERMEDAD ACTUAL

1- Sntomas Generales: fiebre,

perdida de peso, astenia, otros.

2 - Piel y faneras: prurito, lesiones

primarias y secundarias,
alteraciones de uas y cabellos,
otros.

3 - TCS: edema, tumoraciones,

otros.

4 - SOMA: dolor, tumefaccin,

fuerza muscular, limitacin del
movimiento, otros.

ANAMNESIS SISTEMICA
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5 - Ap. Cardiovascular: disnea,

palpitaciones, dolor precordial,
sncope, claudicacin intermitente,
otros.

6 - Ap.Respiratorio: epistaxis, tos,

expectoracin, hemptisis, dolor
torcico, cianosis, otros.

7 - Ap. Digestivo: halitosis,

disfagia, regurgitacin, acidez,
pirosis, nauseas y vmitos,
hematemesis, alteraciones del
hbito intestinal, otros.

8 - Ap. Genitourinario: disuria,

polaquiuria, nicturia, hematuria,
incontinencia, dolor, alteraciones
ciclo menstrual, alteraciones
sexuales, otros

9 - Sistema Nervioso: cefalea,

mareos, vrtigo, sensibilidad,
motricidad, temblor, alteraciones
de la visin, audicin, otros.

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ANTECEDENTES PERSONALES
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2- Inmunizaciones.
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3- Vivienda y medio ambiente.
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4- Socioeconmicos.
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5- Patolgicos: mdicos, alrgicos, ____________________________________________________________
quirrgicos, traumticos.
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6-Txico-Medicamentosos: tabaco, ____________________________________________________________
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alcohol, drogas ilcitas,
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medicamentos, otros.
1-Fisiolgicos : menarca, ciclo
menstrual, fecha ltima
menstruacin, embarazos, partos,
alimentacin, actividad fsica,
sueo, diuresis y catarsis, actividad
sexual, otros.

7-Epidemiologcos:Chagas,
HIV/Sida, Brucelosis,
Toxoplasmosis, transfusiones,
residencias anteriores, otros.
8-Heredo-Familiares.
9- Otros.

1-Inspeccin General

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EXAMEN FISICO
Examen General
Actitud: _____________________________________________________.
Decbito:
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Marcha:
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Facie:
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Estado de conciencia: __________________________________________.

2-Mediciones y Controles

FC: _____________ TA: _____________ FR: __________ T: _______.

Peso: ___________ Altura: ___________ IMC: ___________________.

3-Piel y faneras: color, turgor,

elasticidad, humedad,
temperatura, lesiones primarias,
lesiones secundarias, pelos y uas.

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4-TCS: cantidad, distribucin,

vrices, circulacin colateral,
edema, adenopatas, otros.

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5-SOMA: huesos (conformacin y

sensibilidad), msculos,
articulaciones.

1-Cabeza y cuello: crneo, odos,

ojos, nariz, boca. Tiroides,
cartidas, PVC, otros.
2-Ap. Respiratorio: inspeccin,
expansin de V y B, vibraciones
vocales, claro pulmonar, murmullo
vesicular, auscultacin de la voz,
ruidos patolgicos, otros.
3-Mamas.
4-Ap. Cardiovascular: precordio
(inspeccin, zona mximo impulso,
latidos patolgicos, ruidos
cardacos normales y patolgicos),
pulsos perifricos, auscultacin
arterial, otros.
5-Abdomen: inspeccin,
auscultacin, palpacin superficial
y profunda, puntos dolorosos,
orificios herniarios, percusin,
otros.
6-Ap. Genitourinario: puo
percusin, puntos reno-ureterales,
examen genital, tacto rectal, otros.
7-Sistema Nervioso: pares
craneales. Motricidad (tono,
trofismo, motricidad voluntaria y
fuerza muscular). Reflejos
superficiales y profundos.
Sensibilidad (superficial y
profunda).
Funcin cerebelosa.

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Examen Segmentario
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LISTADO DE PROBLEMAS

LISTADO DE DIAGNOSTICOS

METODOS COMPLEMENTARIOS SOLICITADOS

TRATAMIENTO INICIAL

EVOLUCIONES

EPICRISIS