Historia Clínica Medicina
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The document contains a patient's medical history and physical examination report. It includes personal details, present illness, past medical history, social history, review of systems, physical exam findings for major body systems, diagnosis, and clinical impression. The physical exam section is highly detailed, covering vital signs, general appearance, skin, head, eyes, ears, nose/throat, neck, lungs, heart, abdomen, joints, muscles, extremities, and neurological system.
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Historia Clínica Medicina
- 1. Datos personales: Nombre: _____________________________________________________________ Genero: __________________ Edad: ____________________ Fecha de nacimiento: ___________________________________________________ Ocupación:_______________________________________________ Estado civil: ______________________________________________ Religión:_________________________________________________ Dirección:_______________________________________________________________ Nivel de escolaridad: ____________________________________________________ Nombre del servicio: _____________________________________________________ Numero de cama: _______________________________________________________ Numero de expediente: _________________________________________________ Fecha y hora de ingreso: ________________________________________________ Fecha y hora de historia: _________________________________________________ Datos otorgados por: ____________________________________________________ Confiabilidad de los datos: _______________________________________________
- 3. Antecedentes patológicos • Enfermedades de la infancia: ___________________________________________________________________ ___________________________________________________________________ • Enfermedades de la adolescencia: ___________________________________________________________________ ___________________________________________________________________ • Enfermedades de la edad adulta: ___________________________________________________________________ ___________________________________________________________________ • Hospitalizaciones: ___________________________________________________________________ ___________________________________________________________________ Intervenciones quirúrgicas: ___________________________________________________________________ ___________________________________________________________________ • Exámenes especiales ___________________________________________________________________ ___________________________________________________________________ • Alergias: ___________________________________________________________________ ___________________________________________________________________ • Transfusiones: ___________________________________________________________________ ___________________________________________________________________
- 4. Antecedentes no patológicos • Cafeísmo: ____________________________________________________ • Etilismo: _____________________________________________________ • Tabaquismo:_________________________________________________ • Drogas: ______________________________________________________ • Patrón de sueño: ______________________________________________ • Patrón de micción: ____________________________________________ • Patrón de defecación: __________________________________________ • Alimentación: ________________________________________________ • Hidratación: __________________________________________________ • Inmunizaciones: ______________________________________________ • Antecedentes familiares: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ • Ecológico-social: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
- 5. EXAMEN FÍSICO Apariencia general: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________________ Signos vitales: - Presión arterial: ______________ - Pulso: ______________________ - Frecuencia cardíaca: ____________ - Frecuencia respiratoria: _________ - Temperatura: _________________ - Peso: ________________________ - Talla: _______________________ - IMC: ____________________
- 6. - PIEL ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________________ - CABEZA ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________________________________________________ - OJOS ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________________ - OÍDOS ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________________________________________________ - NARIZ Y SENOS PARANASALES ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________________________________________________
- 7. - BOCA Y GARGANTA ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________________________________________________ - CUELLO ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________________ - TORAX - PULMONAR INSPECCION: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________________ PALPACIÓN: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________________ PERCUSIÓN: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________________
- 10. ÓSEO: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ MÚSCULAR: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ - EXTREMIDADES MIEMBRO SUPERIOR: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ MIEMBRO INFERIOR: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ - NEUROLÓGICO _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
- 11. PARES CRANEALES: I. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ II. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ III. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ IV. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ V. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ VI. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ VII. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
- 12. VIII. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ IX. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ X. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ XI. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ XII. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Fuerza Tono Sensibilidad ROT
- 15. UNIVERSIDAD AUTÓNOMA DE SANTA ANA UNASA ESCUELA DE MEDICINA HISTORIA CLINICA ALUMNO: _________________________________________________________ CÁTEDRA: ________________________________________________________ CATEDRÁTICO: ___________________________________________________ CICLO: ____________ FECHA: _______________________________________