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Historia Clnica
Ficha de identificacin
Nombre: ________________________________________________________________________
Edad:__________ Sexo:_____________________ Ocupacin: _____________________________
Fecha de nacimiento:________________________ Nacionalidad:__________________________
Estado civil: ___________________ Lugar de nacimiento:_________________________________
Domicilio:________________________________________________________________________
___________________________________Religin:______________________________________
Antecedentes Heredofamiliares
Padre:___________________________________________________________________________
Madre:__________________________________________________________________________
Hermanos:_______________________________________________________________________
Hijos:____________________________________________________________________________
Aseo de la casa:___________________________________________________________________
Higiene de alimentos:______________________________________________________________
Mascotas:________________________________________________________________________
Vida sexual:__________________ No. de parejas sexuales:________________________________
Mtodos anticonceptivos utilizados:___________________________________________________
Drogas:__________________________________________________________________________
Alcohol:__________________________________________________________________________
Tabaquismo:______________________________________________________________________
Tatuajes:_________________________________________________________________________
Enfermedades:____________________________________________________________________
Medicamentos:___________________________________________________________________
Hospitalizaciones:_________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Alergias:_________________________________________________________________________
Vacunas:_________________________________________________________________________
Padecimiento actual
Motivo de consulta:
________________________________________________________________________________
________________________________________________________________________________
Signos vitales
Frecuencia cardiaca Frecuencia respiratoria Tensin arterial Temperatura axilar
Somatometra
Talla Peso IMC Permetro abdominal
Habitus exterior
Condicin:_______________________________________________________________________
Edad:______ Sexo:____________
Constitucin:_____________________________________________________________________
Conformacin:____________________________________________________________________
Fascies:__________________________________________________________________________
Actitud:__________________________________________________________________________
Movimientos anormales:____________________________________________________________
Marcha:_________________________________________________________________________
Estado de conciencia:_______________________________________________________________
Aparato digestivo
ANOREXIA, HIPOREXIA, HIPEROREXIA:_________________________________________________
POLIDIPSIA: ______________________________________________________________________
NUSEAS: _______________________________________________________________________
VMITOS: _______________________________________________________________________
DISPEPSIA:_______________________________________________________________________
ODINOFAGIA: ____________________________________________________________________
RECTORRAGIA: ___________________________________________________________________
MELENAS: _______________________________________________________________________
ABDOMINALGIA: __________________________________________________________________
PIROSIS: _________________________________________________________________________
HEMATEMESIS: ___________________________________________________________________
ACOLIA: _________________________________________________________________________
METEORISMO: ____________________________________________________________________
TENESMO:_______________________________________________________________________
Aparato respiratorio
TOS:____________________________________________________________________________
DOLOR TORCICO: ________________________________________________________________
DISNEA: _________________________________________________________________________
HEMOPTISIS: _____________________________________________________________________
EPSTAXIS:________________________________________________________________________
CIANOSIS:________________________________________________________________________
Aparato cardiovascular
DOLOR TORCICO:_________________________________________________________________
EDEMAS: ________________________________________________________________________
DISNEA: _________________________________________________________________________
DISNEA PAROXSTICA NOCTURNA: ____________________________________________________
ORTOPNEA: ______________________________________________________________________
PALPITACIONES: __________________________________________________________________
SNCOPE, PRESNCOPE:_____________________________________________________________
Aparato urinario
DISURIA:_________________________________________________________________________
POLAQUIURIA: ___________________________________________________________________
INCONTINENCIA: __________________________________________________________________
POLIURIA, OLIGURIA, ANURIA: _______________________________________________________
NICTURIA: _______________________________________________________________________
HEMATURIA: _____________________________________________________________________
PROSTATISMO: ___________________________________________________________________
TENESMO: _______________________________________________________________________
Aparato genital
MENARQUIA: ____________________________________________________________________
RITMO MENSTRUAL: _______________________________________________________________
HIPERMENORREA, HIPOMENORREA: _________________________________________________
AMENORREA: ____________________________________________________________________
METRORRAGIA: ___________________________________________________________________
LEUCORREA: _____________________________________________________________________
DISMENORREA: __________________________________________________________________
DISPAREUNIA: ____________________________________________________________________
IMPOTENCIA: ____________________________________________________________________
LBIDO: __________________________________________________________________________
Sistema nervioso
CEFALEA: ________________________________________________________________________
CONVULSIONES: __________________________________________________________________
DFICIT TRANSITORIO: _____________________________________________________________
CONFUSIN: _____________________________________________________________________
OBNUBILACIN: __________________________________________________________________
MARCHA: ________________________________________________________________________
EQUILIBRIO: _____________________________________________________________________
LENGUAJE: ______________________________________________________________________
SUEO-VIGILIA: ___________________________________________________________________
Sistema hematolgico
ASTENIA: ________________________________________________________________________
PALIDEZ: ________________________________________________________________________
HEMORRAGIAS: ___________________________________________________________________
ADENOPATAS: ___________________________________________________________________
CABEZA
CUELLO
Inspeccin:_______________________________ Palpacin:_______________________________
Percusin:_______________________________ Auscultacin:_____________________________
TORAX
Piel:_____________________________________________________________________________
Forma:__________________________________________________________________________
Mamas:
Forma:____________ Tamao:______________ Simetra:______________ Arolas:____________
Pezones:___________________ Maniobras de los pectorales:______________________________
Piel: Retraccin Elevacin De naranja lcera Observaciones
Observaciones:____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
APARATO RESPIRATORIO
Tipo de Respiracin:________________________________________________________________
Tiraje:___________________________________________________________________________
APARATO CARDIOVASCULAR
Inspeccin:_______________________________________________________________________
Palpacin: AU:_____________ DU:______________ LCF:______________ MFA:_______________
Maniobras de Leopold:
________________________________________________________________________________
________________________________________________________________________________
Especuloscopa:___________________________________________________________________
Maniobra de Tarnier:_______________________________________________________________
Tacto Vaginal: ____________________________________________________________________
Score de Bishop: P ____ R ____ E ____ L ____ D ____
Membranas ovulares: __________________________ Presentacin: ________________________
Plano:_______________ Variedad de posicin: __________________________________________
Pelvimetra interna:________________________________________________________________
APARATO GENITOURINARIO
SISTEMA NERVIOSO
Estado de conciencia:_______________________________________________________________
Glasgow: Ocular:_________________Motor:__________________Verbal:____________________
Conducta:________________________________________________________________________
Lenguaje:_______________________ Pares craneales:____________________________________
Reflejos: Fotomotor: __________________ Acomodacin:_________________________________
Reflejos osteotendinosos:___________________________________________________________
Motricidad:___________________________ Babinski:____________________________________
Sensibilidad: __________________________ Temblor:____________________________________
Romberg:_____________________________ Taxia:______________________________________
Dismetra:___________________________ Rigidez de nuca:_______________________________
Fondo de ojo:_____________________________________________________________________
OSTEOMIOARTICULAR
Columna Vertebral:________________________________________________________________
Ejes seos:__________________________ Articulaciones:________________________________
Miembros:__________________________ Trofismo muscular:_____________________________