MODELO DE HISTORIA CLNICA

Hospital
Fecha:

Mdico: ________________________________.

DATOS PERSONALES
Apellido y Nombre:
_________________________________________________________________________.
Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupacin:
_______________.
Domicilio: _____________________________________________________________. TE: ______________.
Residencia:
_______________________________________________________________________________ .

MOTIVO DE CONSULTA

ANTECEDENTES DE LA ENFERMEDAD ACTUAL

ANAMNESIS SISTEMICA
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1- Sntomas Generales: fiebre,
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perdida de peso, astenia, fatiga,
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otros.
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2 - Piel y faneras: prurito, lesiones _____________________________________________________________
primarias y secundarias,
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alteraciones de uas y cabellos,
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otros.
_____________________________________________________________
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3 - TCS: edema, tumoraciones,
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otros.
_____________________________________________________________
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4 - SOMA: dolor, tumefaccin,
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fuerza muscular, limitacin del
_____________________________________________________________
movimiento, otros.
_____________________________________________________________
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5 - Ap. Cardiovascular: disnea,
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palpitaciones, dolor precordial,
_____________________________________________________________
sncope, claudicacin intermitente, _____________________________________________________________
otros.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
6 - Ap.Respiratorio: epistaxis, tos, _____________________________________________________________
expectoracin, hemptisis, dolor
_____________________________________________________________
torcico, cianosis, otros.
_____________________________________________________________
______________________________
_____________________________________________________________
7 - Ap. Digestivo: halitosis,
_____________________________________________________________
disfagia, regurgitacin, acidez,
_____________________________________________________________
pirosis, nauseas y vmitos,
_____________________________________________________________
hematemesis, alteraciones del
_____________________________________________________________
hbito intestinal, otros.
_____________________________________________________________
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8 - Ap. Genitourinario: disuria,
_____________________________________________________________
polaquiuria, nicturia, hematuria,
___________________________________________________
incontinencia, dolor, alteraciones
_____________________________________________________________
ciclo menstrual, alteraciones
_____________________________________________________________
sexuales, otros
_____________________________________________________________
_____________________________________________________________
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9 - Sistema Nervioso: cefalea,
_____________________________________________________________
mareos, vrtigo, sensibilidad,
_____________________________________________________________
motricidad, temblor, alteraciones
_____________________________________________________________
de la visin, audicin, otros.
____________________________________________________.

ANTECEDENTES PERSONALES
_____________________________________________________________
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2- Inmunizaciones.
_____________________________________________________________
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3- Vivienda y medio ambiente.
_____________________________________________________________
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4- Socioeconmicos.
_____________________________________________________________
_____________________________________________________________
5- Patolgicos: mdicos, alrgicos, _____________________________________________________________
quirrgicos, traumticos.
_____________________________________________________________
_____________________________________________________________
6-Txico-Medicamentosos: tabaco, _____________________________________________________________
_____________________________________________________________
alcohol, sustancias de uso
___________________________________________________
indebido, medicamentos, otros.
_____________________________________________________________
_____________________________________________________________
7-Epidemiolgicos: Chagas,
_____________________________________________________________
HIV/Sida, Brucelosis,
_____________________________________________________________
Toxoplasmosis, transfusiones,
_____________________________________________________________
residencias anteriores, otros.
_____________________________________________________________
_____________________________________________________________
8-Heredo-Familiares.
_____________________________________________________________
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9- Estudios preventivos.
___________________________________________________
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10- Otros.
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1-Fisiolgicos : menarca, ciclo
menstrual, fecha ltima
menstruacin, embarazos, partos,
alimentacin, actividad fsica,
sueo, diuresis y catarsis, actividad
sexual, otros.

1-Inspeccin General

EXAMEN FISICO
Examen General
Estado de conciencia: __________________________________________.
Actitud: _____________________________________________________.
Decbito: ____________________________________________________.
Marcha: _____________________________________________________.
Facie: _______________________________________________________.

2-Mediciones y Controles

FC: _____________ TA: _____________ FR: __________ T: _______.

Peso: ___________ Altura: ___________ IMC: ___________________.

3-Piel y faneras: color, turgor,

elasticidad, humedad,
temperatura, lesiones primarias,
lesiones secundarias, pelos y uas.

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
________________________________________________________.

4-TCS: cantidad, distribucin,

vrices, circulacin colateral,
edema, adenopatas, otros.

_____________________________________________________________
_____________________________________________________________
__________________________________________________________.

5-SOMA: huesos (conformacin y

sensibilidad), msculos,
articulaciones.

_____________________________________________________________
_____________________________________________________________
__________________________________________________________.

1-Cabeza y cuello: crneo, odos,

ojos, nariz, boca. Tiroides,
cartidas, PVC, otros.
2-Ap. Respiratorio: inspeccin,
expansin de V y B, vibraciones
vocales, claro pulmonar, murmullo
vesicular, auscultacin de la voz,
ruidos patolgicos, otros.
3-Mamas.
4-Ap. Cardiovascular: precordio
(inspeccin, zona mximo
impulso, latidos patolgicos,
ruidos cardacos normales y
patolgicos), pulsos perifricos,
auscultacin arterial, otros.
5-Abdomen: inspeccin,
auscultacin, palpacin superficial
y profunda, puntos dolorosos,
orificios herniarios, percusin,
otros.
6-Ap. Genitourinario: puo
percusin, puntos reno-ureterales,
examen genital, tacto rectal, otros.
7-Sistema Nervioso: pares
craneales. Motricidad (tono,
trofismo, motricidad voluntaria y
fuerza muscular). Reflejos
superficiales y profundos.
Sensibilidad (superficial y
profunda).
Funcin cerebelosa.

Examen Segmentario
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4

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LISTADO DE DIAGNOSTICOS

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EPICRISIS