FORMATO HISTORIA CLÍNICA
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This document contains a clinical history form from the School of Medicine at the Technical University of Machala. The form collects identifying and demographic information about a patient such as their name, age, sex, ethnicity, occupation, and medical history. It documents the patient's chief complaints, current illness, past medical history, habits, and socioeconomic status. The second half of the form contains the results of the patient's physical examination including vital signs, general appearance, and a systems review. [/SUMMARY]
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FORMATO HISTORIA CLÍNICA
- 1. UNIVERSIDAD TÉCNICA DE MACHALA ESCUELA DE MEDICINA HISTORIA CLÍNICA DATOS DE FILIACIÓN: Nombres: ________________________________________________________________________ Edad: _____________________________ Sexo: ______________________________ Etnia: ______________________________ Religión: ___________________________ Estado civil: _________________________ Instrucción: _________________________ Ocupación: _____________________________ Lugar de nacimiento: _____________________ Lugar de vivienda: ________________________ N° de cama: _____________________________ Fecha de ingreso: ________________________ Fecha de realización HC: ___________________ MOTIVO(S) DE INGRESO O CONSULTA _____________________________________ ______________________________________ _____________________________________ ______________________________________ _____________________________________ ______________________________________ ENFERMEDAD ACTUAL ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
- 2. REAS ___________________________________________________________________________________ ___________________________________________________________________________________ ANTECEDENTES PERSONALES NO PATOLÓGICOS ___________________________________________________________________________________ ___________________________________________________________________________________ ANTECEDENTES PERSONALES PATOLÓGICOS ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ANTECEDENTES PATOLÓGICOS FAMILIARES ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ HÁBITOS: NO TÓXICOS ___________________________________________________________________________________ ___________________________________________________________________________________ TÓXICOS ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ SEXUALES ___________________________________________________________________________________ CONDICIÓN SOCIO-ECONÓMICA ___________________________________________________________________________________ ___________________________________________________________________________________ FUENTE DE INFORMACION:____________________________________________________________ COMENTARIO:_______________________________________________________________________ ___________________________________________________________________________________
- 3. EXAMEN FÍSICO SIGNOS VITALES F.C________ lpm T.A _______ mmHg T º _______ º C F.R _______ rpm Sat. O2 ____ % FiO ____ % IMC_______ kg/m2 - PESO:________ - TALLA:_______ ICC_________ cm2 - CINTURA_________ - CADERA__________ EXAMEN SOMÁTICO GENERAL Apariencia general: ______________________________________ Facie:_________________________________________________ Biotipo:________________________________________________ Estado nutricional:_______________________________________ Actitud:________________________________________________ Deambula:______________________________________________ Actividad psicomotriz:____________________________________ PIEL Y FANERAS Piel:_______________________________________________________________________________ ___________________________________________________________________________________ Uñas:______________________________________________________________________________ ___________________________________________________________________________________ Pelo:_______________________________________________________________________________ ___________________________________________________________________________________ EXAMEN FÍSICO REGIONAL Cabeza:____________________________________________________________________________ ___________________________________________________________________________________ Oído:______________________________________________________________________________ ___________________________________________________________________________________ Ojos:_______________________________________________________________________________ ___________________________________________________________________________________ Nariz:______________________________________________________________________________ ___________________________________________________________________________________ Boca:______________________________________________________________________________ ___________________________________________________________________________________ Cuello:_____________________________________________________________________________ ___________________________________________________________________________________
- 5. NEUROLÓGICO EXAMEN MENTAL: ___________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ EXAMEN MOTOR: FUERZA MUSCULAR__________________________________________________________________ ___________________________________________________________________________________ REFLEJOS: - BICIPITAL_______________________ - _______________________________ - TRICIPITAL______________________ - _______________________________ - ROTULIANO_____________________ - _______________________________ - CUTÁNEOPLANTAR_______________ - _______________________________ TAXIA______________________________________________________________________________ PRAXIA_____________________________________________________________________________ PARES CRANEALES OLFATORIO:_________________________________________________________________________ OPTICO:____________________________________________________________________________ ___________________________________________________________________________________ MOC:______________________________________________________________________________ ___________________________________________________________________________________ TROCLEAR:__________________________________________________________________________ MOE:______________________________________________________________________________ TRIGÉMINO:________________________________________________________________________ ___________________________________________________________________________________ FACIAL:_____________________________________________________________________________ ___________________________________________________________________________________ AUDITIVO:__________________________________________________________________________ ___________________________________________________________________________________ GLOSOFARINGEO:____________________________________________________________________ NEUMOGASTRICO:___________________________________________________________________ ESPINAL:___________________________________________________________________________ HIPOGLOSO MAYOR:_________________________________________________________________
- 6. EXAMEN SENSITIVO: SENSIBILIDAD SUPERFICIAL - TÁCTIL_______________________________________________________________________ - DOLOROSA Y TÉRMICA__________________________________________________________ SENSIBILIDAD PROFUNDA - PALESTESIA__________________________________________________________ - BATIESTESIA_________________________________________________________ - BAROGNOSIA________________________________________________________ DIAGNÓSTICOS PRESUNTIVOS: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ REALIZADO POR: __________________________________________________________________________