C T E D RA D E S E M I O LO G A

Historia Clnica

Br.:__________________________________________________________C.I.:______________________________
Fecha: _________________

DATOS PERSONALES

Nombres y apellidos: ______________________________________________________________C.I: __________________ Edad:

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Sexo: ______________________ Estado civil:_____________________ Grupo tnico:__________________ Raza:
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Ocupacin: ______________________________ Profesin:__________________________________ Nro. De
Historia:______________
Grado de instruccin:______________________________ Residencia habitual:
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Lugar y fecha de nacimiento:
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Direccin habitual:_______________________________________________________________________________________________
Telfono: ______________________________ Religin: _____________________________ Ubicacin:
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Fecha y hora de ingreso:____________________________________________________ Sala/Cama:
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Persona de contacto:
Nombre y Apellido: __________________________________________________________Telefono:____________________________
Direccion del contacto:___________________________________________________________________________________________

MOTIVO DE CONSULTA
ENFERMEDAD ACTUAL

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ENFERMEDAD ACTUAL
ENFERMEDAD ACTUAL
ENFERMEDAD ACTUAL

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Hallazgos positivos: _____________________________________________________________________________

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Negativos pertinentes: ___________________________________________________________________________
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Dx. Probable: _______________________________________________ Dx. Diferencial._____________________
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NO PATOLGICOS:
Alcohol:
Tabaco:
Drogas:
Inmunizaciones:
Alimentacin:
Actividad Fsica:
Vivienda:
SI
NO
Observaciones:
SI
NO
Observaciones:
SI
NO
Observaciones:

Observaciones:

ANTECEDENTES PERSONALES

SI
Caf:
NO

Peso usual:

Preferencia sexual:

Otras observaciones:

ANTECEDENTES FAMILIARES
PATOLGICOS:
Adulto:
Quirrgicos:
Traumatolgicos:
Alrgicos:
Infancia:
SI
NO
Observaciones:
SI
NO
Observaciones:
SI
NO
Observaciones:
SI
NO
Observaciones:
SI
NO
Observaciones:
Gineco-Obsttricos:
Menarca:
Menopausia:
Ciclo Menstrual:
Transfusiones:

Otras enfermedades
reconocidas:

SI
NO
Observaciones:
FUM:

GESTAS
PARTOS
ABORTOS
CESREAS

Padres:
Vivos:
Fallecidos:
Causas:
Hermanos:
Vivos:
Fallecidos:
Causas:
Hijos:
Vivos:
Fallecidos:
Causas:
Estado:
Estado:
Estado:

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Psquico

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Cabeza

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Cuello

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Columna

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Aparato
Respiratori
o

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Aparato
Cardiovasc
ular

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Sistema
Digestivo

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Urinario

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Ginecolgic
os

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Neurolgico _
s
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Msculos y
articulacion
es

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Piel

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EXAMEN POR SISTEMAS

EXAMEN FSICO

Impresin General: __________________________________________________________________________

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Estado de conciencia: ________________________________________________________________________
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Ubicacin: _________________________________________________________________________________
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Actitud: ___________________________________________________________________________________
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Sistema
Posicin: __________________________________________________________________________________
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Endocrino
Marcha: ___________________________________________________________________________________
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Fascie: ____________________________________________________________________________________
Signos vitales: FC: ______lat/min. FR: ______resp/min T_________C Pulso ( Radial) _____________
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puls/ min
_
P.A derecha: De cubito dorsal: ________________mmHg
Sentado: ____________mmHg De pie:
_____________mmHg _________________________________________________________________________
Sistema
_
P.A izquierda:
De cubito
dorsal: ________________mmHg
Sentado: ____________mmHg De pie:
Hematopoy
____________mmHg
tico

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Lugar de toma de presin:____________________________________________________________________
Peso: _________________ Kg. Talla: ______________________ mt/cm IMC: _______________________
Observaciones: ______________________________________________________________________________
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EXAMEN
Apariencia General:______________________________________________________________________________
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Olfatorio
PARES CRANEALES

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ptico

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Motor Ocular
Comn

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Troclear

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Trigmino

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Motor Ocular
Externo

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Facial

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Vestibulococl
ear

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Glosofarnge
o

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Neumogstri
co

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Espinal

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Hipogloso

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PULSOS

Pulso
Temporal
Carotideo
Axilar
Braquial
Radial

Lado Derecho

Lado
izquierdo

Inguinal
Poplteo
Tibial
posterior
Pedio

EXTREMIDADES: (Inspeccion y palpacin) __________________________________________________

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PSIQUICO Y FUNCIONES SUPERIORES (Neurologicos, funciones motoras, funciones sensitivas,
funciones cerebelosas, maniobras meningeas, movimientos involuntarios)
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ORGANOS GENITALES
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CORAZON ( Inspeccin; Palpacin; Auscultacin; Focos

Cardiacos)_________________________________
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ABDOMEN (Inspeccin; Auscultacin; Percusin; Palpacin)______________________________________
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COLUMNA VERTEBRAL: ___________________________________________________________

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____________________________________________________________ TORAX (Inspeccin,
palpacin, percusin, auscultacin)___________________________________
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________________________________________ PULMONES (Inspeccin, Palpacin, Percusin,
Auscultacin):_______________________________
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