By Dr.

Carlos Fernando Uc Ku

Historia Clinica

HISTORIA CLINICA GERIATRICA

INTERROGATORIO:
1. FICHA DE IDENTIFICACIN
1.1. Nombre Completo:
Apellido paterno
1.2. Gnero: M (
)F(
1.3. Edad: _____ Aos
1.4. Fecha de nacimiento:

Apellido materno

Nombre (s):

Da

Mes

Ao

1.5. Lugar de nacimiento:

1.6. Estado civil: Soltero (
1.7. Lugar de residencia:

Municipio
) Casado (

Estado
) Viudo (

) Unin Libre (

Municipio Estado
1.8. Domicilio:__________________________________________________________________________________
1.9. Telfono: _________________________________________________________________________________
1.10. Familiar con quien
vive:
Apellido paterno
Apellido materno Nombre (s):
1.11. Si vive solo:
Pariente ms cercano:
Apellido paterno
Apellido materno Nombre (s):
Direccin:_________________________________________________________________________________
Telfono: __________
1.12. Escolaridad: Primaria __ Secundaria __ Preparatoria/Bachillerato __ Licenciatura___ Otro_______________
1.13. Ocupacin: ____________________
1.14. Religin: _____________________
1.15. Hobbie (Pasatiempos): ____________________________________________________________________
1.16. Derechohabiente: IMSS:__ ISSTE:__ SEGURO POPULAR:__
1.17. Fecha y hora de estudio:
___:___
Hora
Da Mes Ao
1.18. Nmero de expediente: ______________________
2.

2.1.

2.2.

2.3.

2.4.
2.5.

ANTECEDENTES HEREDO FAMILIARES:

a. Tuberculosis, Diabetes Mellitus, Hipertensin, Carcinomas, Cardiopatas, Hepatopatas, Nefropatas,
Enf.endocrinas, Enf. Mentales, Epilepsia, Asma, Enf. Hematolgicas, Sfilis
b. Investigar etiologa y edades de Morbimortalidad en abuelos, padres, hijos, conyuges, hermanos.
Abuelos:
Abuelo paterno: ____________________________________________________________________________
Abuela paterna: ____________________________________________________________________________
Abuelo materno: ___________________________________________________________________________
Abuela materna: ___________________________________________________________________________
Padres:
Padre:____________________________________________________________________________________
Madre: ___________________________________________________________________________________
Hermanos: (# de hermanos, lugar ocupado):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Cnyuge: _________________________________________________________________________________
Hijos:_____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

By Dr. Carlos Fernando Uc Ku

Historia Clinica

2.6. Nietos:
___________________________________________________________________________________________
__________________________________________________________________________________________
2.7. Otros (tios, primos):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2.8. Antecedentes:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
3. ANTECEDENTES PERSONALES NO PATOLGICOS
3.1. Habitacin: Cuartos____ Piso:_______________ Techo:_______________ Ventanas:_______________
Servicios: :_______________ Personas con las que comparte la habitacin :_____
3.2. Convivencia:
Animales: :_______________, Cuantos:____ (Dentro) o (Fuera de la casa/habitacin
3.3. Alimentacin:
A. Desayuno:
_______________________________________________________________________________________
_________________________________________________________________________________
B. Almuerzo:
_______________________________________________________________________________________
_________________________________________________________________________________
C. Cena:
_______________________________________________________________________________________
_________________________________________________________________________________
D. Alimentacin (f/ tipo) _______res_____pollo______fruta_____ cerdo ______
3.4. Higiene:
Bao ___________defecacin ___________ lav. dientes ___________
3.5. Toxicomanas:
Tabaquismo (cig/da/aos) _______________________ Alcoholismo (beb/frec) ______________________
Toxicomanas (esp/da/aos)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
3.6. Inmunizaciones (Vacunas):
___________________________________________________________________________________________
___________________________________________________________________________________________
4. ANTECEDENTES PERSONALES PATOLGICOS:
4.1. Hereditarios:
___________________________________________________________________________________________
___________________________________________________________________________________________
4.2. EEAPI:
____________________________________________
A. Varicela: Si__ No__ Edad: ___aos,
____________________________________________
B. Rubiola: Si__ No__ Edad: ___aos,
____________________________________________
C. Sarampin: Si__ No__ Edad: ___aos,
____________________________________________
D. Escarlatina: Si__ No__ Edad: ___aos,
E. Exantema Sbito: Si__ No__ Edad: ___aos, ____________________________________________
F. Eritema Infeccioso: Si__ No__ Edad: ___aos,
4.3. Enfermedades (Padecidas hasta la fecha, Enfermedades Frecuentes) :
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

By Dr. Carlos Fernando Uc Ku

Historia Clinica

4.4. Antecedentes :
4.4.1. Quirrgicos:
1. Cx_____________________________________ Cundo?_____________ Cmo?____________________
Donde?_________________________ Por qu?_______________________________________________
2. Cx_____________________________________ Cundo?_____________ Cmo?____________________
Donde?_________________________ Por qu?_______________________________________________
3. Cx_____________________________________ Cundo?_____________ Cmo?____________________
Donde?_________________________ Por qu?_______________________________________________
4.4.2. Traumticos:
1. Tipo de traumatismo (accidentes):_____________________________ Magnitud: _________________
Fecha: ________Tx Recivido:________________
2. Tipo de traumatismo (accidentes):_____________________________ Magnitud: _________________
Fecha: ________Tx Recivido:________________
3. Tipo de traumatismo (accidentes):_____________________________ Magnitud: _________________
Fecha: ________Tx Recivido:________________
4.4.3. Transfusionales:
Sangre: ___ Suero:___ Plasma:___ Plaquetas:___
Motivo: ____________________________________
4.4.4. Grupo Sanguneo y Rh: _______________________________
4.4.4. Alrgicos:
Medicamentos:_______________________________________
Alimentos: __________________________________________
Ambientales: ________________________________________
Otros (Plasticos, latex, etc.)______________________________
5. ANTECEDENTES GINECOOBSTETRICOS
5.1. Menarca: ______aos
5.2. Ritmo (Cada cuantos das?)y periodicidad (Cuanto dura el sangrado?): _______________________
5.3. Inicio vida sexual activa: _______aos
5.4. Gesta: ______________ FUG: ______________
5.5. Para (Embarazos llevados a trmino): ______________ FUP: ______________
5.6. Abortos: ______________ FUA: ______________
5.7. Cesreas: ______________ FUC: ______________
5.8. Obitos(muerte fetal in tero antes de su viabilidad) ______________ FUO: ______________
5.9. FUM: ______________
5.10. Otros:
__________________________________________________________________________________________
__________________________________________________________________________________________
6. PADECIMIENTO ACTUAL
6.1. Qu, cmo, cundo, dnde:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6.2. Semiologa:

Antigedad (cundo comenz? Cunto dura? con qu frecuencia ocurre?)

Localizacion
Irradiacion
Calidad
Intencidad
Agravantes/Alivio
Circunstancias en las que ocurre: Factores ambientales, actividades personales, reacciones emocionales u otras situaciones que
pueden contribuir
Manifestaciones relacionadas

______________________________________________________________________________________________
______________________________________________________________________________________________

By Dr. Carlos Fernando Uc Ku

Historia Clinica

______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
6.2. Evolucin:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6.3. Estado actual: Cmo se siente en este momento?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6.4. Teraputica previa: (tratamientos anteriores)
7.

INTERROGATORIO POR APARATOS Y SISTEMAS

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Aparato cardiovascular. Disnea, tos (seca.
_________________________________________________________
prod.), hemoptisis, dolor precordial,
_________________________________________________________
palpitaciones, cianosis
_________________________________________________________
edema y manifestaciones perifericas (acfenos,
_________________________________________________________
fosfenos, sncope, lipotimia, cefalea, etc)
_________________________________________________________
_________________________________________________________
Aparato digestivo. halitosis, boca seca,
masticacin, disfagia(odino), pirosis, nausea,
vomito, (hematemesis), dolor abd. meteorismo y
flatulencias, constipacin, diarrea, rectorragia,
melenas, pujo y tenesmo, Ictericia coluria y
acolia, prurito cutneo, hemorragias.

By Dr. Carlos Fernando Uc Ku

Aparato respiratorio. Tos, disnea, dolor torcico,
hemoptisis, cianosis, vomica, alteraciones de la
voz.

Aparato Urinario. Alteraciones de la miccin

(poliuria, anuria, polaquiuria,oliguria, nicturia,
opsiuria, disuria, tenesmo vesical, urgencia,
chorro, enuresis, incontenincia) caracteres de la
orina (volumen, olor, color, aspecto) dolor
lumbar, edema renal, hipertensin arterial, datos
clnicos de anemia.
Aparato genital. Criptorquidia, fimosis, funcin
sexual. Sangrado genital, flujo o leucorrea, dolor
ginecolgico, prurito vulvar.

Aparato hematolgico. Datos clnicos de anemia

(palidez, astenia, adinamia y otros),
hemorragias, adenopatas, esplenomegalia.

Sistema endocrino. Bocio, letargia

bradipsiquia (lalia), intol. calor/frio,
nerviosismo,
hiperquinesis, carac. sexuales, galactorrea,
amenorrea, ginecomastia, obesidad,
ruborizacin.
Sistema osteomuscular. ganglios, xeroftalmia,
xerostomia, fotosensibilidad
artralgias/mialgias, Raynaud.

Sistema nervioso. cefalea, sncope,

convulsiones, deficit transitorio, vertigo,
confusion y obnub., vigilia/sueo, paralisis y M,
marcha y equilibrio, sensibilidad.

Sistema sensorial. visin, agudeza, borrosa

diplopia, fosgenos, dolor ocular, fotofobia,
xeroftalmia, amaurosis, otalgia, otorrea y
otorragia, hipoacusia, tinitus, olfaccin,
epistaxis, secrecin, Geusis, Garganta (dolor)
Fonacin.
Psicosomtico. Personalidad, ansiedad,
depresin, afectividad, emotividad, amnesia,
voluntad, pensamiento, atencin, ideacin
suicida, delirios.

Historia Clinica
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

By Dr. Carlos Fernando Uc Ku

II.

Historia Clinica

Exploracin fsica

1. Signos vitales:
1.1. TA: __________ mmHg
1.2. FC: __________lpm
1.3. FR: __________Rpm
1.4. Temp.: _______C
1.5. Antropometra:
1.5.1. Peso: _______ kg.
1.5.2. Talla: _______ mts
1.5.3. IMC: _______ kg/m2
2. Impresin general:
2.1. Sexo: ______________________
2.2. Edad: ______________________
2.3. Fascies caracterstica: _________________________
2.4. Talla: ___________________
2.5. Constitucin: ___________________________________

2.6. Conformacin: ______________________________________

2.7. Integridad: _________________________________________
2.8. Posicin y actitud escogidas: ___________________________
2.9. Marcha: ___________________________________________________
2.10. Movimientos anormales: _____________________________________
2.11. Conciencia: _______________________________________________
2.12. Orientacin (Timepo, espacio, persona): _______________________________________________
2.13. Cooperacin: ______________________________________________
2.14. Nivel socioeconmico cultural: _______________________________
3. Cabeza:
3.1 Crneo:
Tamao: normocfalo, microcfalo, macrocfalo
Forma: braquicfalo, dolicocfalo, turricefalo Permetro craneano (en nios)
Cara: simetra, aumento de volumen, movimientos involuntarios, presencia de lesiones.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Frente: tamao, simetra de pliegues _______________________________________________________________
Arco periorbitario ______________________________________________________________________________
Cejas ________________________________________________________________________________________
Prpados: parpadeo, simetra _____________________________________________________________________
Pestaas_________________________________________________________________________________
Ojos:
Globo ocular. Tamao: exoftalmia, enoftalmia. Tensin
________________________________________________________________________________________
________________________________________________________________________________________
Conjuntiva ocular y palpebral:
________________________________________________________________________________________
________________________________________________________________________________________
Escleras (color): __________________________________________________________________________

By Dr. Carlos Fernando Uc Ku

Historia Clinica

Iris (color, simetra): _______________________________________________________________________

Pupila: __________________________________________________________________________________
Crnea, Reflejo fotomotor, movimientos oculares, agudeza visual.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Nariz:
Tamao________________________________________
Tabique nasal: posicin: ___________________________
Mucosa nasal: permeabilidad, olfato, aleteo nasal. Coriza:
______________________________________________________________________________________________
______________________________________________________________________________________________
Boca:
halitosis: _________________________________________________________________________________
Labios: __________________________________________________________________________________
Encas: ___________________________________________________________________________________
Dentadura: oclusin, masticacin: _____________________________________________________________
Higiene: __________________________________________________________________________________
Lengua y gusto: ___________________________________________________________________________
Paladar duro: ______________________________________________________________________________
Paladar blando: ____________________________________________________________________________
Glndulas salivares: salivacin: _______________________________________________________________
Amgdalas:________________________________________________________________________________
Faringe: __________________________________________________________________________________
Deglucin: _____________________________________________________________________________________
Odos: forma, tamao, posicin, simetra. Audicin:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Pabelln auricular: _______________________________________________________________________________
Conducto auditivo externo: higiene, secreciones: _______________________________________________________
4. Cuello:
Movilidad: _____________________________________________________________________________________
Tiroides: tamao__________________________________________________________________________
Trquea: ________________________________________________________________________________
Yugulares: pulso carotdeo, sensibilidad, aumentos de volumen, masa, rigidez.:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
5. Trax: Forma, simetra, uso musculatura accesoria, retraccin o abombamiento de espacios intercostales,
elasticidad, expansin, movilidad de la caja torcica, dolor, masas, percusin. Lesiones, cicatrices, cambios de
coloracin:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Corazn: auscultacin ruidos cardiacos y arritmias:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Pulmones: auscultacin ruidos pulmonares:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

By Dr. Carlos Fernando Uc Ku

Historia Clinica

Mamas:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Axilas
Simetra, textura, aumento de volumen, presencia de masas, retraccin, secreciones, cambio de coloracin,
sensibilidad.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
6. Abdomen:
Forma: plano, excavado, distendido, abombado, globuloso, en delantal: ____________________________________
Ombligo: aspecto:
______________________________________________________________________________________________
__________________________________________________________________________________
Permetro abdominal: simetra, coloracin, cicatrices, lesiones, circulacin colateral, dolor, resistencia, masas, ruidos
hidroareos, matidez. Timpanismo, ascitis, organomegalias:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________
Zona gltea, intergltea y anal: hemorroides, edema lumbosacro:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
7. Genitales: Grado (Etapa) de Taner, hemorragia, dolor, secreciones, inflamacin, masas, higiene:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Vello pubiano:
________________________________________________________________________________________
________________________________________________________________________________________
o Genitales femeninos
Labios mayores:
___________________________________________________________________________
___________________________________________________________________________
Cltoris:
___________________________________________________________________________
___________________________________________________________________________
Meato urinario:
___________________________________________________________________________
___________________________________________________________________________
Labios menores:
___________________________________________________________________________
___________________________________________________________________________
Abertura vaginal (introito):
___________________________________________________________________________
___________________________________________________________________________

By Dr. Carlos Fernando Uc Ku

Historia Clinica

Zona perineal:
___________________________________________________________________________
___________________________________________________________________________
o Genitales masculinos
Pene: color, secreciones:
___________________________________________________________________________
___________________________________________________________________________
Prepucio:
____________________________________________________________________
____________________________________________________________________
Glande: esmegma:
____________________________________________________________________
____________________________________________________________________
Meato urinario:
____________________________________________________________________
____________________________________________________________________
Testculos: tamao, consistencia:
___________________________________________________________________________
___________________________________________________________________________
8. Columna vertebral:
Movimientos, alineacin, deformidades, vicios, sensibilidad, curvatura:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Regin cervical: __________________________________________________________________________
Regin torcica: __________________________________________________________________________
Regin lumbar: ___________________________________________________________________________
Regin sacra: ____________________________________________________________________________
9. Extremidades:
Coloracin, pulsos, sensibilidad, higiene. Edema, varices:
______________________________________________________________________________________________
______________________________________________________________________________________________
Tono muscular: flaccidez, contracturas, atrofia, hipertrofia. Fuerza y resistencia. Movilidad: rango de
movimientos, limitaciones:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Articulaciones: dolor, aumento de volumen, calor, rigidez, deformidad:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Alineacin de extremidades: genu valgum (X), genu varum (0): ____________________________________
Brazos, manos y dedos:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Pies y tobillos: pie valgo, pie varo. Dolor. Queratodermia, hallux valgus, dedo en martillo_
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
10. Exploracin especial y/o armada:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

By Dr. Carlos Fernando Uc Ku

Historia Clinica

11. Valoracin geritrica integral:

Actividades de la vida diaria:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Actividades instrumentales de la vida diaria:
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________
Mini-mental state:
________________________________________________________________________________________
________________________________________________________________________________________
Edo. Depresivo:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

I.

II.

III.

Diagnsticos:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Plan teraputico:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Nombre y firma:
__________________________________________________________

10