Sei sulla pagina 1di 4

HISTORIA CLINICA CURSO SEMIOLOGIA – HMC

I.FILIACION

APELLIDOS Y NOMBRES E.CIVIL:________________________________________

__________________________________________ DNI:___________________________________________

__________________________________________ TELEFONO:_____________________________________

NA:_______________________________________ LUGAR DE NACIMIENTO:__________________________

EDAD:___________________________________ LUGAR DE PROCEDENCIA:_________________________

SEXO:______________________________________ FECHA DE INGRESO A EMERGENCIA:_________________

INSTRUCCIÓN:_______________________________ FECHA DE INGRESO A UUHH:_______________________

OCUPACIÓN:________________________________ PERSONA RESPONSABLE:__________________________

INFORMANTES:__________________________________________________________________________________

INFORMACIÓN CONFIABLE: ( SI ) ( NO )

MOTIVO DE INGRESO:_____________________________________________________________________________

II. ANTECEDENTES

INMUNIZACIONES:________________________________________________________________________________

ENFERMEDADES ANTERIORES ( Criterios de DX; RP; Duración;Hospitalizaciones; ETS; complicaiones, procedimientos)

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

HOSPITALIZACIONES:______________________________________________________________________________

INTERVENCIONES QUIRURGICAS:

_______________________________________________________________________________________________
_______________________________________________________________________________________________

ALERGIA A MEDICAMENTOS:_______________________________________________________________________

MEDICACIÓN HABITUAL:___________________________________________________________________________

USO O ABUSO DE SUSTANCIAS TOXICAS: ALCOHOL ( ) TABACO ( ) DROGAS ( ) FRECUENCIA:__________

ESFERA SEXUAL Y RESPRODUCTIVA: M:_______________ FUM:______________ RC:___________________

RS:_______________ G:____ P:___________________

FECHA DE ULTIMO PARTO:______________________ MÉTODOS ANTICONCEPTIVOS:_______________________

GRUPO SANGUINEO Y FACTOR RH:_____________________________________________________


ANTECEDENTES EPIDEMIOLÓGICOS

VIAJES:_________________________________________________________________________________________
CONTACTO CON PERSONA ENFERMA:________________________________________________________________

CRIANZA DE ANIMALES DOMESTICOS:_____________________________ VACUNAS:__________________________

ENFERMEDADES PROFESIONALES:___________________________________________________________________

ACCIDENTES DE TRABAJO:__________________________________________________________________________

SERVICIOS BÁSICOS

MATERIAL:__________________ HABITACIONES:______________ CANTIDAD DE HABITANTES:_____________

AGUA:_________________ DESAGUE:___________________ ELECTRICIDAD:________________________

III.ENFERMEDAD ACTUAL

TE:_______________ FORMA DE INICIO:_______________ CURSO:______________

SINTOMAS Y SIGNOS PRINCIPALES__________________________________________________________________

RELATO CRONOLOGICO
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

FUNCIONES BIOLÓGICAS

APETITO:______________________ SED:_______________________ ORINA:_________________________

DEPOSICIONES:______________________ SUEÑO:____________________ PESO ANT.______________________

IV. EXÁMEN CLINICO

T:_____ °C P:_______ PA:____/_____ FR:__________ SaO2: ____________

PVC:________________ PESO:__________________ TALLA:_____________________

FUNCIONES GENERALES (Estado de conciencia, estado general, nutrición, hidratación, posición, actitud,
colaboración):___________________________________________________________________________________
_______________________________________________________________________________________________

PIEL Y FANERAS:__________________________________________________________________________________

TCSC:__________________________________________________________________________________________
_______________________________________________________________________________________________
EXAMEN POR REGIONES, APARATOS Y SISTEMAS

1.- CABEZA:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

2.- CUELLO:
_______________________________________________________________________________________________
_______________________________________________________________________________________________

3.- TORAX:
_______________________________________________________________________________________________
_______________________________________________________________________________________________

4.-APARATO RESPIRATORIO
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

5.- APARATO CARDIOVASCULAR


_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

6.- ABDOMEN
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

7.-GENITOURINARIO
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

8.- LOCOMOTOR
_______________________________________________________________________________________________
_______________________________________________________________________________________________

10.- LINFATICO
_______________________________________________________________________________________________
______________________________________________________________________________________________

11.- NEUROLÓGICO
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
VI. PRESUNCIONES DIAGNOSTICAS

1.-_____________________________________________________________________________________________

2.-_____________________________________________________________________________________________

3.-_____________________________________________________________________________________________

4.-_____________________________________________________________________________________________

VII. PLAN DE TRABAJO


_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________

__________________________ ____________________________ __________________________

CLAUDIA MENDOZA A BETZY CUETO H MARYLIN FLORES S

UUHH:_____________ N°cama:_______________

APELLIDOS Y NOMBRES
_________________________________________________