Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Ficha de Identificacin.
Nombre: _______________________________________________________
Nombre del responsable:___________________________________________
Registro:______________ Fecha:______________________
Sexo__________ Edad___________
Ocupacin_______________________________________________________
Antecedentes Familiares:
Padre: Vivo Si____ No____
Enfermedades que padece:_________________________________________
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Madre: Viva Si____
No____
Enfermedades que padece:_________________________________________
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Hermanos: Cuntos? ______ Vivos _____
Enfermedades que padecen:________________________________________
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Otros:_________________________________________________________
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Antecedentes Personales Patolgicos.(Detallar
Cardiovasculares:_________________________________________
Neumologicos:___________________________________________
Gastroenterologicos:______________________________________
Endocrinos:______________________________________________
Renales:________________________________________________
Reumaticos:_____________________________________________
Ex alcohlico, ex fumador, ex drogadicto:______________________
Medicamentos utilizados:___________________________________
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_______________________________________________Otras
Especificaciones:_____________________________________
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Aparato
cardiovascular.
Disnea, tos
(seca. prod.), hemoptisis, dolor
precordial, palpitaciones, cianosis
edema y manifestaciones perifericas
(acfenos, fosfenos, sncope,
lipotimia,
cefalea, etc)
Aparato respiratorio.
Tos, disnea,
dolor torcico, hemoptisis, cianosis,
vomica, alteraciones de la voz.
Aparato Urinario.
Alteraciones de la
miccin (poliuria, anuria,
polaquiuria,oliguria, nicturia,
opsiuria,
disuria, tenesmo vesical, urgencia,
chorro, enuresis, incontenincia)
caracteres de la orina (volumen,
olor,
color, aspecto) dolor lumbar, edema
renal, hipertensin arterial, datos
clnicos
de anemia.
Aparato genital.
Criptorquidia,
fimosis, funcin sexual. Sangrado
genital,
flujo o leucorrea, dolor ginecolgico,
prurito vulvar.
Aparato
hematolgico. Datos
clnicos de anemia (palidez, astenia,
adinamia y otros), hemorragias,
adenopatas, esplenomegalia.
Sistema endocrino.
Bocio, letargia
bradipsiquia (lalia), intol. calor/frio,
nerviosismo,
hiperquinesis, carac. sexuales,
galactorrea, amenorrea,
ginecomastia,
obesidad, ruborizacin.
Sistema osteomuscular. ganglios,
xeroftalmia, xerostomia,
fotosensibilidad
artralgias/mialgias, Raynaud.
Sistema nervioso.
cefalea, sncope,
convulsiones, deficit transitorio,
vertigo,
confusion y obnub., vigilia/sueo,
paralisis y M, marcha y equilibrio,
sensibilidad.
Sistema sensorial.
visin, agudeza,
borrosa diplopia, fosgenos, dolor
ocular,
fotofobia, xeroftalmia, amaurosis,
otalgia,
otorrea y otorragia, hipoacusia,
tinitus,
olfaccin, epistaxis, secrecin,
Geusis,
Garganta (dolor)
Fonacin.
Psicosomtico.
Personalidad,
ansiedad, depresin, afectividad,
emotividad, amnesia, voluntad,
pensamiento, atencin, ideacin
suicida,
delirios.
Exploracin fsica:
Signos Vitales. Peso: _____ Talla: _____ IMC: ______ TA: ______
FC: _____ FR: _____ Temperatura: _____
Habitus exterior:
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Cabeza y Cuello:
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Trax:
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Abdomen:
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Extremidades.
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Genitales:
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Neurolgico y Estado Mental:
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Laboratorio:
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Estudios de Imagen.
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Otros___________________________________________________________
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Comentarios:
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IDx: ___________________________________________________
Tratamiento:
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Medico responsable y firma
Cedula profesional: _____________
Ficha de identificacin:
Nombre: _______________________________________________________
Nombre del responsable:___________________________________________
Registro:______________ Fecha:______________________
Nota de evolucin:
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Signos Vitales:
Peso: _____ Talla: _____ IMC: ______ TA: ______ FC: _____ FR: _____
Temperatura: _____
Laboratorios y Gabinete:
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DX: ____________________________________________________________
Tratamiento:
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Indicaciones y comentarios:
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Medico responsable y firma
Cedula profesional: _____________