HISTORIA CLNICA ACADMICA

l. INTERROGATORIO:Directo: ( ) Indirecto ( )Nombre y parentesco del informante (en caso de no ser el paciente) _______________________________________FICHA DE IDENTIFICACINNombre del paciente: ____________________________________________________________________________Apellido paterno Apellido materno Nombre(s)Gnero: Masculino ( ) Femenino ( ) Edad _____________Lugar y fecha de nacimiento: ______________________________________________________________________Da/mes/ao Ciudad Municipio Estado PasDomicilio: _______________________________________________________________________________________Calle y nmero Colonia_________________________________________________________________________________________________Delegacin poltica Municipio Entidad federativa_________________________________________________________________________________________________Cdigo postal TelfonoEstado civil: Soltero[a]: ( ) Casado[a]: ( ) Unin libre: ( ) Divorciado[a]: ( ) Viudo[a]: ( )Escolaridad:___________________________________ Profesin u ocupacin: _______________________Religin:______________________________________ Nacionalidad: ________________________________Ocupacin: Empleado ( ) Pensionado ( ) Desempleado ( ) Jubilado ( )Persona responsable del paciente:_________________________________________________________________________________________________Nombre completo Direccin completa_________________________________________________________________________________________________Telfono particular ______________________________ Telfono donde labora ___________________________

ANTECEDENTES

Antecedentes heredo-familiares: (abuelos, padres, tos, cnyuge, hijos, primos). Investigar: diabetes mellitus, enfermedades tiroideas, hipertensin arterial, cardiopatas, nefropatas, enfermedades broncopulmonares, neurolgicas mentales, enfermedades infectocontagiosas, reumticas y neoplsicas._______________________________________________________________________________________________________________________________________________________________________________________________________

Antecedentes personales no patolgicos:Alimentacin (cantidad y frecuencia en el consumo de alimentos por semana: leche, carne, huevo, verduras, frutas,cereales, leguminosas, etctera)._______________________________________________________________________________________________________________________________________________________________________________________________________

Habitacin: tipo de vivienda (jacal, departamento, vecindad, casa sola); distribucin de la vivienda (nmero de cuartosy servicios, nmero de personas por habitacin, convivencia con animales, tipo y nmero); higiene de la vivienda(iluminacin, ventilacin); bao (intra o extradomiciliario, individual o compartido)._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hbitos higinicos individuales (aseo personal, bao, cambio de ropa, lavado de manos, aseo dental)._______________________________________________________________________________________________________________________________________________________________________________________________________

Ocupacin actual y previa (fecha y duracin; condiciones del trabajo, horas que labora, higiene laboral, exposicin afactores de riesgo laboral)._______________________________________________________________________________________________________________________________________________________________________________________________________

Uso de tiempo libre (horario de descanso y recreacin, deportes y pasatiempos, vacaciones)._______________________________________________________________________________________________________________________________________________________________________________________________________

Inmunizaciones. Vacunas y nmero de dosis (Sabin, DPT, pentavalente, BCG, etctera). Biolgicos (suero antirrbico,antialacrn, anticrotlico, gammaglobulina, anti-Rh)._____________________________________________________________________________________________________________________________________________________________________________________________________

Conciencia de enfermedad.________________________________________________________________________________________________

Antecedentes gneco-obsttricos: menarca, ciclo menstrual (frecuencia, duracin, cantidad, dismenorrea); inicio de vida sexual activa (VSA), nmero de parejas, nmero de embarazos, nmero de partos, abortos, cesreas, mtodo anticonceptivo, fecha de ltima menstruacin, enfermedades de transmisin sexual, menopausia, climaterio, Papanicolaou y lactancia materna._____________________________________________________________________________________________________________________________________________________________________________________________________

Antecedentes androlgicos: circuncisin, criptorquidia, poluciones nocturnas, inicio de VSA, nmero de parejas, enfermedad de transmisin sexual, trastornos de la ereccin y andropausia._____________________________________________________________________________________________________________________________________________________________________________________________________

Antecedentes personales patolgicos: infectocontagiosos, enfermedades exantemticas, enfermedades crnicodegenerativas y parasitarios, alrgicos, quirrgicos, traumticos, transfusionales, convulsivos, adicciones (tabaquismo, alcoholismo, drogas) y hospitalizaciones previas._____________________________________________________________________________________________________________________________________________________________________________________________________

PADECIMIENTO ACTUALMotivo y circunstancia de la consulta.________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Sntoma o molestia principal (semiologa, fecha y modo de inicio, causa real o aparente, evolucin, estado actual).__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Sntomas o molestias acompaantes (semiologa, fecha y modo de inicio, causa real o aparente, evolucin, estado actual).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Estudios paraclnicos realizados. Resultados:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Teraputica empleada. Resultados:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

INTERROGATORIO POR APARATOS Y SISTEMAS

Aparato respiratorio: rinorrea, rinolalia, epistaxis, tos, expectoracin, disfona, hemoptisis, vmica, cianosis, dolor torcico, disnea y sibilancias audibles a distancia.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Aparato digestivo: hambre, apetito, alteraciones de la masticacin y salivacin, disfagia, halitosis, nusea, vmito, rumiacin, regurgitacin, pirosis, aerofagia, eructos, meteorismo, distensin abdominal, flatulencia, hematemesis, ictericia, caractersticas de la heces fecales, diarrea, constipacin, acolia, hipocolia, melena, rectorragia, parsitos, lienteria, esteatorrea, pujo, tenesmo y prurito anal.__________________________________________________________________________________________________________________________________________________________________________________________________

Aparato cardiovascular: palpitaciones, dolor precordial, disnea de esfuerzo, disnea paroxstica, apnea, cianosis, acfenos, fosfenos, tinnitus, sncope, lipotimias y edema.______________________________________________________________________________________________________________________________________________________________________________________________________

Aparato renal y urinario: dolor renoureteral, disuria, anuria, oliguria, poliuria, polaquiuria, hematuria, piuria, coluria, urgencia, incontinencia, caractersticas del chorro, nictmero, goteo terminal y edema.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Aparato genital masculino: alteraciones de la libido, prctica sexual (homo, hetero o bisexual), nmero de parejas sexuales, priapismo, alteraciones de la ereccin y de la eyaculacin, secrecin uretral, dolor testicular, alteraciones escrotales, sensacin de cuerpo extrao en el perin y enfermedades (infecciones) de transmisin sexual.________________________________________________________________________________________________________________________________________________________Aparato genital femenino: leucorrea, hemorragias transvaginales, alteraciones menstruales, alteraciones de la libido, prctica sexual (homo, hetero o bisexual), nmero de parejas, mtodo de proteccin contra enfermedades (infecciones) de transmisin sexual, alteraciones del sangrado menstrual, dispareunia, perturbaciones y alteraciones sexuales, amenorrea y Papanicolaou._______________________________________________________________________________________________________________________________________________________________________________________________________

Sistema endocrino: intolerancia al fro y al calor, hipo o hiperactividad, aumento de volumen del cuello, polidipsia, polifagia, poliuria, cambios en los caracteres sexuales secundarios y aumento o prdida de peso._______________________________________________________________________________________________________________________________________________________________________________________________________

Sistema hematopoytico y linftico: palidez, disnea, fatigabilidad, astenia, palpitaciones, sangrado, equimosis, petequias y adenomegalias._______________________________________________________________________________________________________________________________________________________________________________________________________

Piel y anexos: coloracin, pigmentacin, prurito, caractersticas del pelo, uas, lesiones (primarias y secundarias), hiperhidrosis y xerodermia._______________________________________________________________________________________________________________________________________________________________________________________________________

Musculoesqueltico: mialgias, dolor seo, artralgias, alteraciones en la marcha, hipotona, disminucin del volumen muscular, limitacin de movimientos y deformidades._______________________________________________________________________________________________________________________________________________________________________________________________________

Sistema nervioso: cefalea, paresias, plegias, parlisis, parestesias, movimientos anormales (temblores, tics, corea), alteraciones de la marcha, vrtigo y mareos._______________________________________________________________________________________________________________________________________________________________________________________________________

rganos de los sentidos: alteraciones de la visin, de la audicin, del olfato, del gusto y del tacto (hipo, hiper o disfuncin). Mareo y sensacin de lquido en el odo._______________________________________________________________________________________________________________________________________________________________________________________________________

Esfera psquica: tristeza, euforia, alteraciones del sueo (insomnio, hipersomnia, disomnia), terrores nocturnos, ideaciones (alucinatorias, delirantes, obsesivas, suicidas), miedo exagerado a situaciones comunes, irritabilidad, apata. Relaciones personales.____________________________________________________________________Sntomas generales: fiebre, astenia, adinamia, aumento o prdida de peso y modificaciones del hambre (hiporexia, anorexia, hiperorexia).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. EXPLORACIN FSICADebe realizarse en presencia y con la supervisin del tutor y contar con la autorizacin del paciente, respetando siempre la privacidad y el pudor de ste.Realizar exploracin fsica completa y aplicar en los segmentos corporales en que sea pertinente los procedimientos de inspeccin, palpacin, percusin, auscultacin y exploracin instrumental.

Signos vitales y somatometra:Pulso:_____ por min Presin arterial (PA): _____ mm.Hg. Temp. _____C Frecuencia respiratoria (FR):_____por minFrecuencia cardiaca (FC):_____ por min Peso: _______ kg Talla: _______ m ndice de masa corporal:________Otros pertinentes: ___________________________________

Inspeccin general (habitus exterior): gnero, edad aparente, estado de alerta y orientacin, integridad, estado nutricional, facie, constitucin, conformacin, actitud, lenguaje, movimientos anormales, caractersticas de la piel y los anexos, cooperacin, vestido, alio y marcha.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CabezaCrneo: inspeccin, palpacin, percusin y, si es necesario, auscultacin.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Cara: inspeccin, palpacin percusin y, si es necesario, auscultacin.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Ojos:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Odos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nariz:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Boca:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Cuello: inspeccin, palpacin percusin y, si es necesario, auscultacin.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trax: inspeccin, palpacin, percusin, auscultacin y exploracin instrumental.________________________________________________________________________________________________________________________________________________________________________________________________________

Regin precordial:_______________________________________________________________________________________________________________________________________________________________________________________________________

Glndulas mamarias:_______________________________________________________________________________________________________________________________________________________________________________________________________

Abdomen: inspeccin, auscultacin, palpacin, percusin y, en caso necesario, medicin._______________________________________________________________________________________________________________________________________________________________________________________________________

Regin inguino-crural: inspeccin, auscultacin, palpacin y percusin._______________________________________________________________________________________________________________________________________________________________________________________________________

Genitales externos: inspeccin, palpacin (tacto) y exploracin instrumental. Siempre en presencia del tutor o la enfermera y con autorizacin del paciente._______________________________________________________________________________________________________________________________________________________________________________________________________

Tacto vaginal (idem)._______________________________________________________________________________________________________________________________________________________________________________________________________

Tacto rectal (idem)._______________________________________________________________________________________________________________________________________________________________________________________________________

Extremidades: torcicas y plvicas. Inspeccin, palpacin, percusin, auscultacin y, en caso necesario, medicin._______________________________________________________________________________________________________________________________________________________________________________________________________

Columna vertebral: inspeccin, palpacin, percusin._______________________________________________________________________________________________________________________________________________________________________________________________________Exploracin neurolgica: estado de alerta, funciones mentales superiores, pares craneales, motricidad, tono,marcha, coordinacin, reflejos osteotendinosos y cutneos, sensibilidad (superficial y profunda)._______________________________________________________________________________________________________________________________________________________________________________________________________

Procesamiento de la informacinDIAGNSTICOSSintomticos:_______________________________________________________________________________________________________________________________________________________________________________________________________Signolgicos:_______________________________________________________________________________________________________________________________________________________________________________________________________Sindromticos:_______________________________________________________________________________________________________________________________________________________________________________________________________Anatomotopogrficos:_______________________________________________________________________________________________________________________________________________________________________________________________________Fisiopatolgicos:_______________________________________________________________________________________________________________________________________________________________________________________________________Por laboratorio y/o gabinete e imagenologa. Anatomopatolgico._______________________________________________________________________________________________________________________________________________________________________________________________________Etiolgico:_______________________________________________________________________________________________________________________________________________________________________________________________________Nosolgico:_______________________________________________________________________________________________________________________________________________________________________________________________________Diferenciales:_______________________________________________________________________________________________________________________________________________________________________________________________________Integral:_______________________________________________________________________________________________________________________________________________________________________________________________________

8Plan de manejo, pronsticos y criterios de referenciaPLAN DE MANEJO Y TRATAMIENTO SUGERIDO_____________________ __________________________________________________________________________________________________________________________________________________________________________________

Pronsticos: para la vida, el rgano, la funcin, la calidad de vida, la esttica.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Criterios de referencia:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nombre del alumno ___________________________________________________ Grupo_____________________

Vo.Bo. Tutor-clnico Vo.Bo. Tutor-coordinador(Nombre y firma) (Nombre y firma)Fecha de elaboracin___________________________

Referencias consultadas (tres):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________