Formato de Historia Clinica

Programa de Enseñanza Clínica Complementaria

1. Programa de Enseñanza Clínica Complementaria
HISTORIA CLINICA
FICHA DE IDENTIFICACION:
Nombre:____________________________________________________Edad:___________Sexo:________
Ocupación:________________Estado Civil:_____________Nacionalidad:____________________________
Residencia_____________________Escolaridad:________________________Religión:_________________
Servicio:________________________Cama:________ No. Expediente:______________________________
ANTECEDENTES HEREDOFAMILIARES:
Padres: ........................Vivos: ................................Fallecidos:..............................................................................
………………………… ……Causas:..................................................................................
Hermanos:....................Vivos:................................Fallecidos:..............................................................................
………………………… …… Causas:..................................................................................
Hijos:............................Vivos:..................................Fallecidos:............................................................................
Causas:……............................................................................
Diabetes Mellitus tipo 2 SI ⃝ NO ⃝__________________________________________________________
Hipertensión Arterial SI ⃝ NO ⃝__________________________________________________________
Tuberculosis SI ⃝ NO ⃝__________________________________________________________
Cáncer SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar) SI ⃝ NO ⃝__________________________________________________________
ANTECEDENTES PERSONALES NO PATOLOGICOS:
1) Hábitos Tóxicos:
Alcohol: __________________________Tabaco:_________________________Drogas:_________________
2) Fisiológicos:
Alimentación:____________________________________________________________________________
Dipsia:__________________________________________________________________________________
Diuresis: ________________________________________________________________________________
Catarsis:_________________________________________________________________________________
Somnia:_________________________________________________________________________________
Otros:__________________________________________________________________________________

ANTECEDENTES PERSONALES PATOLOGICOS:

2. Infancia:_________________________________________________________________________________
Adulto:__________________________________________________________________________________
Diabetes Mellitus tipo 2 SI ⃝ NO ⃝__________________________________________________________
Hipertensión Arterial SI ⃝ NO ⃝__________________________________________________________
Tuberculosis SI ⃝ NO ⃝__________________________________________________________
Cáncer SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar) SI ⃝ NO ⃝__________________________________________________________
Quirúrgicos:______________________________________________________________________________
Traumatológicos:_________________________________________________________________________
Alérgicos: _______________________________________________________________________________
Otros: __________________________________________________________________________________
GINECO-OBSTÉTRICOS:
FUM: / / FPP: / / EDAD GESTACIONAL: semanas.
Menarca:_______RM (Rit. Menstr)____/___ IRS____Nº de parejas____Flujo genital____________________
Gestas:.............Partos:.............Cesáreas:...............Abortos: ____________ Anticonceptivos: SI ⃝ NO ⃝
Tipo: ______________________ Tiempo: __________Última toma: ________________________________
Cirugías ginecológicas (especificar)___________________________________________________________
Otros: __________________________________________________________________________________

PADECIMIENTO ACTUAL
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3. INTERROGATORIO POR APARATOS Y SISTEMAS
Aparato respiratorio:
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Aparato digestivo:
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Aparato cardiovascular:
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Aparato renal y urinario:
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Aparato genital:
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Sistema endocrino:
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Sistema hematopoyético y linfático:
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Piel y anexos:
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Musculo esquelético:
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Sistema nervioso:
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4. ________________________________________________________________________________________
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Órganos de los sentidos:
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Síntomas generales:
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EXPLORACIÓN FÍSICA:
Impresión General: _______________________________________________________________________
Signos Vitales: FC__________TA:_________FR: _______PULSO:____________ TEMPERATURA: _________
Peso actual: ________Talla: __________BMI:___________

Inspección general:
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Cabeza:
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Cuello:
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Tórax:
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5. ________________________________________________________________________________________
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Abdomen:
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Tacto vaginal y rectal:
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Extremidades:
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Exploracion neurológica:
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EXAMENES COMPLEMENTARIOS:
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DIAGNOSTICO PRESUNTIVO:
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PLAN TERAPÉUTICO:
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NOMBRE, CEDULA Y FIRMA DEL MEDICO
TRATANTE:_______________________________________________________________________________