HISTORIA CLNICA

HOSPITAL:
SERVICIO: Medicina CAMA ____________

I. ECTOSCOPA:

1.1.- Estado de Gravedad:__________________________________________________________

1.2.- Edad Aparente: _____________________________________________________________
1.3.- Facies o signos destacados:
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II. ANAMNESIS: ____________________

2.1.- Filiacin:
a) Nombre: __________________________________________________________________________
b) Edad: _______________________
c) Fecha de nacimiento: ______________________________________
d) Sexo: _______________________
e) Raza: _________________________
f) Ocupacin: _________________________________
g) Estado Civil: ___________________________________
h) Grado de Instruccin: ____________________________
i) Religin: _______________________
j) Idioma: _____________________________
k) Lugar de Nacimiento: ___________________________
l) Lugar de Procedencia: ____________________________
m) Tiempo en el Lugar de Procedencia: ______________________________
n) Domicilio: __________________________________________________
o) Persona Responsable: __________________________________________
p) Fecha de Ingreso: __________________________________ Hora de ingreso: _______________
q) Forma de ingreso: ___________________________________________
r) Fecha de Historia Clnica: __________________________________
s) Hora de Historia Clnica: ___________________________________
t) N de historia clnica: _____________________________

2.2.- Enfermedad Actual:

a) Sntomas Principales:
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b) Tiempo de Enfermedad: _____________________________

c) Forma de Inicio: _____________________________
d) Curso de la Enfermedad: _____________________________
e) Relato Cronolgico:
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III.-FUNCIONES BIOLGICAS:

ACTUAL
- Apetito
- Sed:
- Orina:
- Deposiciones:
- Sueo:

IV. ANTECEDENTES:

a) Personales:
- Vivienda: __________________________________________________________________________
-N de personas: ______________________________________________________________________
-Crianza de animales: _________________________________________________________________
- Luz: ______________________________________________________________________________
- Agua: _____________________________________________________________________________
- Desage: __________________________________________________________________________
- Alimentacin: ______________________________________________________________________
- Vestimenta: ________________________________________________________________________
- Hbitos Nocivos: ____________________________________________________________________
- Situacin econmico social: ____________________________________________________
- Psicosociales:________________________________________________________________

b) Antecedentes personales patolgicos

Enfermedades de la infancia: ____________________________________________________
Enfermedades de la adolescencia_________________________________________________
Enfermedades juventud ________________________________________________________
Enfermedades adultez: _________________________________________________________
Hospitalizaciones: _____________________________________________________________
Operaciones anteriores: _________________________________________________________
Inmunizaciones: _______________________________________________________________
Alergias: _____________________________________________________________________
Transfusiones Sanguneas: ________________________________________________________

c) Antecedentes Familiares:
Padre: ____________________________________________________________________________
Madre: ___________________________________________________________________________
Hermanos: ________________________________________________________________________
Abuelos: ________________________________________________________________________
Cnyuge: ________________________________________________________________________
Hijos: ___________________________________________________________________________
V. EXAMEN FISICO.

a. CONTROL DE SIGNOS VITALES

ACTUAL
- Temperatura:
- Frecuencia Respiratoria:
- Frecuencia Cardiaca:
- Frecuencia del pulso
- Presin arterial:
- Peso
- Talla
- IMC

b. ASPECTO GENERAL:
Facies:_______________________________________________________________________
Tipo constitucional:____________________________________________________________
Actitud:_____________________________________________________________________
Estado de gravedad: ___________________________________________________________
Estado de nutricin:____________________________________________________________
Estado de hidratacin:__________________________________________________________
Estado mental y grado de colaboracin:_____________________________________________

C. REVISIN POR APARATOS Y SISTEMAS

a. Estado de la Piel:
-Color: ______________________________________________________________________
-Humedad:___________________________________________________________________
-Turgencia:___________________________________________________________________
b. T.C.S.C:_______________________________________________________________________
c. Vasos Linfticos:________________________________________________________________
d. Ojos:__________________________________________________________________________
e. Boca: _________________________________________________________________________
f. Nariz: _________________________________________________________________________
g. Odos: _________________________________________________________________________
h. Gusto: ________________________________________________________________________
i. Garganta: _____________________________________________________________________
j. Cuello: ________________________________________________________________________
k. Mamas: _______________________________________________________________________
l. Trax: ________________________________________________________________________
m. Cardiovascular: ________________________________________________________________
n. Abdomen: _____________________________________________________________________
o. Genitourinario: _________________________________________________________________
p. Endocrino: _____________________________________________________________________
q. Neurologa: ____________________________________________________________________
r. Muscular: _____________________________________________________________________
s. Osteoarticular: _________________________________________________________________

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VI. PLANTEAMIENTO PRELIMINAR

DIAGNSTICO SINDRMICO:

1.________________________________________________________________________
2.________________________________________________________________________
3.________________________________________________________________________
4.________________________________________________________________________
5.________________________________________________________________________
6.________________________________________________________________________
7.________________________________________________________________________

IMPRESIN DIAGNSTICA CLNICA:

1.________________________________________________________________________
2.________________________________________________________________________
3.________________________________________________________________________
4.________________________________________________________________________

VII. PLAN DE TRABAJO.

7.1 EXMENES AUXILIARES

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7.2 TRATAMIENTO INICIAL

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VIII. RESULTADOS DE EXMENES AUXILIARES

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IX. DIAGNSTICO DEFINITIVO

1.________________________________________________________________________
2.________________________________________________________________________
3.________________________________________________________________________
4.________________________________________________________________________
X. TRATAMIENTO
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XI. EVOLUCIN

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XII. PRONSTICO

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