Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Fecha de elaboracin:
Interrogatorio
1. Ficha de Identificacin
Nombre ______________________________________ Edad____ Sexo _____ Raza ______________
Nacionalidad _________________ Edo. Civil ____________ Ocupacin _________________________
Lugar de Origen ________________ Lugar de residencia__________________ Domicilio ____________
_________________________________Persona responsable _______________________________
Religin _____________ Piso (servicio) _____________ Cama ______ fecha de ingreso______________
2. Antecedentes
a)
Tuberculosis
Diabetes Mellitus
Hipertensin
Carcinomas
Cardiopatas
Hepatopatas
Nefropatas
Enf.endocrinas
Enf. Mentales
Epilepsia
Asma
Enf. Hematolgicas
Sfilis
Heredo Familiares
b) Personales Patolgicos
Enf. Infecciosas de la infancia _____________________________
Tb , Enf. Venreas, Fiebre Tifoidea, Salmonelosis, Neumonas,
Paludismo, Parasitosis, Enf. Alrgicas, Pad. Articulares
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Intervenciones Quirrgicas ______________________________
Hosp______________________________________________
Traumatismos (acc) ___________________________________
Perdida del conocimiento ________________________________
Intolerancia a medicamentos _____________________________
Transfusiones ______________
c)
Personales No patolgicos
Hbitos personales. bao ___________defecacin ___________ lav. dientes ___________ habitacin (ctos, piso, techo,
ven, hab, servicios) _____________________________________________________________________
Tabaquismo (cig/da/aos) _______________________ Alcoholismo (beb/frec) ______________________ Toxicomanas
(esp/da/aos)
__________________
Alimentacin
(f/
tipo)
_______res_____pollo______fruta_____
cerdo
Trabajo/Desc
________ Pasatiempos
___________
d)
Gineco obsttricos
3. Padecimiento Actual
4. Sntomas Generales
1. Astenia
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2. Adinamia
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3. anorexia
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4. fiebre
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5. perdida de peso
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Sistema
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osteomuscular.
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Sistema
nervioso. cefalea,
sncope,
convulsiones,
deficit
transitorio, vertigo, confusion y
obnub., vigilia/sueo, paralisis y M,
marcha y equilibrio, sensibilidad.
sensorial.
visin,
agudeza,
borrosa
diplopia,
fosgenos, dolor ocular, fotofobia,
xeroftalmia,
amaurosis,
otalgia,
otorrea y otorragia, hipoacusia,
tinitus,
olfaccin,
epistaxis,
secrecin, Geusis, Garganta (dolor)
Fonacin.
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Sistema
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Psicosomtico.
Personalidad,
ansiedad, depresin, afectividad,
emotividad, amnesia, voluntad,
pensamiento, atencin, ideacin
suicida, delirios.
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6. Diagnsticos anteriores
Exploracin Fsica
1. Signos Vitales
1. FC:
2. TA:
3. FR:
4. Temperatura
5. Peso actual:
6. Peso anterior:
7. Peso ideal:
2. Exploracin general
2. cuello
3. trax
4. abdomen
5. miembros
6. genitales
7. otros
Comentario
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Diagnostico
(especificar )
Pronostico
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Tratamiento _______________________________________________________________________________
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