Facultad de medicina Escuela de medicina

HISTORIA CLINICA

ASIGNATURA: FISIOPATOLOGA, SEMIOLOGA Y ANATOMA PATOLGICA ISEMESTRE: 2015-ICICLO ACADMICO: V

NOMBRE: _______________________________________________________TUTOR: _________________________________________________________UNIDAD: ___________ECTOSCOPIAESTADO DE GRAVEDAD APARENTE: __________________________________________EDAD APARENTE: ________________________________________________________SIGNO(S) DESTACADO(S): __________________________________________________

ANAMNESIS: ___________

FILIACINNombre: ______________________________________________DNI: __________________________________________________Edad: _________________________________________________Sexo: _________________________________________________Raza: _________________________________________________Estado civil: ____________________________________________Ocupacin: ____________________________________________Religin: ______________________________________________Grado de instruccin: ____________________________________Lugar de nacimiento: ____________________________________Direccin: _____________________________________________Lugar de procedencia: ___________________________________Persona de contacto: ____________________________________Telfono de contacto: ___________________________________Datos confiables ( ) Datos No confiables ( )Fecha de ingreso: ________________________________________

ENFERMEDAD ACTUALTiempo de Enfermedad: ____________________Forma de inicio: __________________________Curso de la enfermedad: ___________________

Sntomas y signos principales:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DESCRIPCIN CRONOLGICA_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FUNCIONES BIOLGICASApetito: __________________________________ Sed: ________________________________________Orina: ____________________________________ Deposiciones: ________________________________Variacin ponderal: _________________________ Estado basal: _________________________________Sueo: ___________________________________ Estado de nimo:______________________________

ANTECEDENTES PERSONALESA. NO PATOLGICOSNacimiento:______________________________________________________________________________________________________________________________________________________________________________Desarrollo fsico:______________________________________________________________________________________________________________________________________________________________________________Desarrollo psquico:______________________________________________________________________________________________________________________________________________________________________________Aspectos Socioeconmicos:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Residencias y viajes anteriores:______________________________________________________________________________________________________________________________________________________________________________Hbitos y costumbres:______________________________________________________________________________________________________________________________________________________________________________Inmunizaciones:______________________________________________________________________________________________________________________________________________________________________________B. PATOLGICOSEnfermedades previas:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Accidentes y secuelas:______________________________________________________________________________________________________________________________________________________________________________Intervenciones quirrgicas:______________________________________________________________________________________________________________________________________________________________________________Medicacin habitual o transfusiones:______________________________________________________________________________________________________________________________________________________________________________Alergias:______________________________________________________________________________________________________________________________________________________________________________C. GINECOLGICOS Y OBSTTRICOSMenarqua: _____________________________ FUR: ___________________________Ritmo catamenial: ________________________________________________________Gestacin y partos:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mtodos anticonceptivos:______________________________________________________________________________________________________________________________________________________________________________Enfermedades ginecolgicas:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ANTECEDENTES FAMILIARES_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REVISIN ANAMNSICA DE SISTEMAS Y APARATOS:Para completar los datos de la enfermedad actual y antecedentes, se har la revisin anamnsica ordenada de todos los sistemas y aparatosGenerales: ______________________________________________________________________________Cabeza: ________________________________________________________________________________Ojos: __________________________________________________________________________________Odos: _________________________________________________________________________________Nariz: __________________________________________________________________________________Boca: __________________________________________________________________________________Faringe y laringe: _________________________________________________________________________Cuello: _________________________________________________________________________________Mamas: ________________________________________________________________________________Aparato respiratorio: ______________________________________________________________________Aparato cardiovascular: ___________________________________________________________________Aparato gastrointestinal: ___________________________________________________________________Aparato genito-urinario: ___________________________________________________________________Neuropsiquitrico: _______________________________________________________________________Aparato locomotor: _______________________________________________________________________Piel y anexos: ____________________________________________________________________________Sistema linftico: _________________________________________________________________________

EXAMEN FSICOSIGNOS VITALESPA: _____/_____ mmHg FC: ________ FR: _______ T: ________ Peso: _______ Talla: ______IMC:_____kg/m2 Sat O2: _____ FIO2:______

APRECIACIN GENERAL_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PIEL Y ANEXOS_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________TEJIDO CELULAR SUBCUTANEO_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SISTEMA LINFTICO_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REGIONALCRNEO:______________________________________________________________________________________________________________________________________________________________________________

CARA:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CUELLO:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

TORAX PULMONES:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CARDIOVASCULAR:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ABDOMEN:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

GENITO-URINARIO:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

APARATO LOCOMOTOR:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NEUROLGICO:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HIPOTESIS DIAGNSTICA _____________________________________________________Sustentado por los siguientes datos___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________Sustentado por los siguientes datos___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________Sustentado por los siguientes datos___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLAN DIAGNSTICO

Exmenes de Laboratorio____________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: ______________________________

Exmenes por imgenes____________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: __________________________________________________________________ Qu espera encontrar: ______________________________

CUAL ES EL MECANISMO FISIOPATOLGICO QUE SUSTENTA EL O LOS PROBLEMAS DE SALUD DEL PACIENTE

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FIRMA DEL TUTOR: ____________________________FECHA DE CALIFICACIN: __________

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