HISTORIA CLÍNICA PSICOLÓGICA CASIC (3)
-
Upload
dario-javier -
Category
Documents
-
view
160 -
download
0
Transcript of HISTORIA CLÍNICA PSICOLÓGICA CASIC (3)
HISTORIA CLÍNICA PSICOLÓGICA
Fecha………………………… Nº Historia....................I. DATOS PERSONALESNombre …………………………………………………………….. CC…….………………
Edad …..………….. Fecha de nacimiento 09-04-97……………… Sexo M F
Estado civil S UL C Se. D V Instrucción N P S Su. T
Procedencia………………………… Residencia………………………… Teléfono……………….
Domicilio…………………………………………………………………………………………………….
Profesión……………………………. Ocupación…………………………. Religión……………….
Condiciones de atención Propia voluntad SI No Solo SI NO Consciente Si No
II. MOTIVO DE CONSULTA O PROBLEMA ACTUAL
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………..
Estudio Socio-económico…………………………………………………………………………………
HISTORIA DE LA ENFERMEDAD
a. Enfermedad actual y evolución………………………………………………..
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………..
ESTRUCTURA FAMILIAR
Nombre Edad Parentesco Ocupación
…..……………………….. ……… …........ ….………
……..…………………….. …..... …………… …………
…….…………………….. ……… …………… ……………
…..……..………………….. ………. ……………. ……………..
…………………………….. ………… ………………. …………………
Genograma
1
a. Grupo familiar de origen……………………….............................................................................
………………………………………………………………………………………………………………..
b. Grupo familiar propio…………………………………………………………………………………
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
Antecedentes patológicos familiares……………………………………………………………………….
………………………………………..……………………………………………………………………..
Familiar responsable……………………………………………………………………………………….
III. PSICOANAMNÉSIS PERSONAL, NORMAL Y PATOLÓGICA
a. Etapaprenatal….……………………………………………….
…………………………………………………………………………………………………………
………………………………………..
b. Etapa natal……..…......………………………………………………………………………………..
………………………………………………………………………………………………………………..
c. Etapa postnatal………………………………………………………………………………………...
………………………………………………………………………………………………………………..
d. Infancia……………………………..………………………………………………………………......
………………………………………………………………………………………………………………..
e. Pubertad………..…………………………………………………………………………………..
………………………………………………………………………………………………..
f. Adolescencia……………………………………………………………………………………………
………………………………………………………………………………………………………………..
g. Juventud………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
h. Adultez………………………………………………………………………………………………….
………………………………………………………………………………………………………………..
i. Madurez y senectud……………………………………………………………………………………
………………………………………………………………………………………………………………..
PSICOANAMNÉSIS SOCIAL NORMAL Y PATOLÓGICA
a. Historia escolar………………………………………………………………………………………...
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
b. Historial social……………………….…………………………………………..……………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
2
c. Historial laboral………………………………………………………………………………………..
…………………………………………………………………………………………………………
………………………………………………………………………………………………………………..
d. Historial psicosexual…………………………………………………………………………………...
………………………………………………………………………......................................................
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
IV. ANAMNÉSIS MÉDICA
a. Enfermedades más relevantes………………………………………………………………………....
b. Intervenciones quirúrgicas………..…………………………………………………………………..
V. EXAMEN DE EXPLORACIÓN MENTAL
a. Consciencia……………………………………………………………………………………………..
Orientación autopsíquica……………….. alopsíquica……………….. Somatopsíquica…………..
Vigilia……………………...……………… Consciencia de enfermedad……………………………….
b. Atención...................................................................................................................................................
c. Sensopercepciones..................................................................................................................................
d. Memoria………………………………………………………………………………………………...
e. Afectividad……………………………………………………………………………………………...
f. Inteligencia……………………………………………………………………………………………..
g. Pensamiento…………………………………………………………………………………………….
h. Lenguaje………………………………………………………………………………………………..
i. Voluntad..................................................................................................................................................
j. Instintos………………………………………………………………………………………………...
k. Hábitos………………………………………………………………………………………………….
l. Juicio y razonamiento………………………………………………………………………………….
VI. REACTIVOS PSICOLOGICOS
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
VII. RESULTADOS
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
3
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
VIII. DIAGNÓSTICO DIFERENCIAL
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
IX. DIAGNÓSTICO
Entidad clínica…............................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
Personalidad...................................................................................................................................................
..........................................................................................................................................................................
X. PRONÓSTICO
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
XI. TRATAMIENTO
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
XII. RECOMENDACIONES
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
4
MODELO DE EVALUACIÓN CASIC
AREA COGNITIVA
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
AREA AFECTIVA
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
AREA SOMÁTICA
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
AREA INTERPERSONAL
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
AREA CONDUCTUAL Y COMPORTAMENTAL
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
5
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
6