Post on 08-Jul-2015
Datos personales:
Nombre: _____________________________________________________________
Genero: __________________
Edad: ____________________
Fecha de nacimiento: ___________________________________________________
Ocupación: _______________________________________________
Religión de los padres: _________________________________________________
Dirección: _______________________________________________________________
Nombre del servicio: _____________________________________________________
Numero de cama: _______________________________________________________
Numero de expediente: _________________________________________________
Fecha y hora de ingreso: ________________________________________________
Fecha y hora de historia: _________________________________________________
Datos otorgados por: ____________________________________________________
Parentesco: _____________________________
Confiabilidad de los datos: _______________________________________________
Consulta por: ____________________________________________________________
Presente enfermedad
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Antecedentes personales
Historia prenatal:
Madre De ______ De Edad, G P P A V .
Enfermedades Durante El Embarazo: .
Medicamentos: .
Drogas: .
Alcohol: .
Tabaco : .
Controles Médicos: En .
Exámenes Realizados: .
Parto
Fecha: .
Lugar: .
Edad Gestacional: .
Tipo De Parto: .
Antecedentes neonatales
Respiro Espontáneamente Necesito Reanimación .
Se Dio De Alta Junto Con La Madre .
Control médico
En .
Inmunizaciones: .
Bcg: .
Dpt + Hib + Hb Y Opv: .
Spr: .
Influenza: .
Rotavirus: .
Alimentacion
SMLD Hasta .
Edad De Ablactación: .
Jugos, Frutas Y Vegetales: .
Huevos: .
Carnes: .
Dieta Actual: .
Alergias: .
# Evacuaciones: .
Estreñimiento: .
Crecimiento Y Desarrollo
Adecuado Para La Edad .
Fijación De La Mirada: .
Sonrisa Social: .
Junto Las Manos En La Línea Media: .
Sostuvo Al Cabeza: .
Dio Vuelta: .
Se Sentó: .
Gateo: .
Camino: .
Hablo: .
Antecedentes patológicos
• Enfermedades de la infancia:
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• Enfermedades de la adolescencia:
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• Enfermedades de la edad adulta:
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• Hospitalizaciones:
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Intervenciones quirúrgicas:
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• Exámenes especiales
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• Alergias:
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• Transfusiones:
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• Antecedentes familiares:
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• Ecológico-social:
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EXAMEN FÍSICO
Apariencia general: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signos vitales:
- Presión arterial: ______________
- Pulso: ______________________
- Frecuencia cardíaca: ____________
- Frecuencia respiratoria: _________
- Temperatura: _________________
- Peso: ________________________
- Talla: _______________________
- IMC: ____________________
- PIEL
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- CABEZA
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- OJOS
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- OÍDOS
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- NARIZ Y SENOS PARANASALES ________________________________________________________________________________
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- BOCA Y GARGANTA
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- CUELLO
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- TORAX
- PULMONAR
INSPECCION:
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PALPACIÓN:
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PERCUSIÓN:
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AUSCULTACIÓN:
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- CARDÍACO
INSPECCION:
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PALPACIÓN:
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PERCUSIÓN:
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AUSCULTACIÓN:
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- ABDOMEN
INSPECCIÓN:
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AUSCULTACIÓN:
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PERCUSION:
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PALPACIÓN:
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ARTICULACIONES:
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HUESOS:
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MÚSCULAR:
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- EXTREMIDADES
MIEMBRO SUPERIOR:
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MIEMBRO INFERIOR:
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- NEUROLÓGICO
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Fuerza Tono Sensibilidad ROT
DIAGNÓSTICO:
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TRATAMIENTO:
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RAZONAMIENTO CLÍNICO:
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UNIVERSIDAD AUTÓNOMA DE SANTA ANA
UNASA
ESCUELA DE MEDICINA
HISTORIA CLINICA
ALUMNO: _________________________________________________________
CÁTEDRA: ________________________________________________________
CATEDRÁTICA: ___________________________________________________
CICLO .
FECHA: _______________________________________