Historia Clnica

l. INTERROGATORIO:
Directo: ( ) Indirecto ( )
Nombre y parentesco del informante (en caso de no ser el paciente)
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FICHA DE IDENTIFICACIN
Nombre del paciente:
Nombre(s)

Apellido

paterno

Gnero: M a s c u l i n o ( ) F e m e n i n o

Apellido materno

( )

Edad_____________
Lugar y fecha de nacimiento:
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Da/mes/ao

Ciudad, Municipio, Estado, Pas

Domicilio:
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Calle , Nmero Y Colonia

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Delegacin poltica

Municipio

Entidad federativa

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Cdigo

postal

Telfono

Estado civil:
Soltero[a]: ( ) Casado[a]: ( ) Unin libre: ( ) Divorciado[a]: ( ) Viudo[a]: ( )
Escolaridad:______________________________________________________
Profesin u
ocupacin:________________________________________________________
Religin:__________________________________________________________
Nacionalidad:______________________________________________________
Ocupacin:
Empleado ( ) Pensionado ( ) Desempleado ( ) Jubilado ( )
Persona responsable del paciente:
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Nombre
completo
Direccin completa
Telfono particular ______________________________
Telfono donde laboral___________________________
ANTECEDENTES PERSONALES
Antecedentes heredo-familiares:
(abuelos, padres, tos, cnyuge, hijos, primos). Investigar: diabetes
mellitus,enfermedades tiroideas, hipertensin arterial, cardiopatas, nefropatas,
enfermedades broncopulmonares, neurolgicas mentales, enfermedades
infectocontagiosas, reumticas y neoplsicas.
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Antecedentes personales no patolgicos:

Alimentacin (cantidad y frecuencia en el consumo de alimentos por semana:

leche, carne, huevo, verduras, frutas,cereales, leguminosas, etctera).
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Habitacin: tipo de vivienda (jacal, departamento, vecindad, casa sola);
distribucin de la vivienda (nmero de cuartosy servicios, nmero de personas por
habitacin, convivencia con animales, tipo y nmero); higiene de la vivienda
(iluminacin, ventilacin); bao (intra o extradomiciliario, individual o compartido).
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Hbitos higinicos individuales (aseo personal, bao, cambio de ropa, lavado de
manos, aseo dental).
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Ocupacin actual y previa (fecha y duracin; condiciones del trabajo, horas que
labora, higiene laboral, exposicin factores de riesgo laboral).
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Uso de tiempo libre (horario de descanso y recreacin, deportes y pasatiempos,
vacaciones).
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Inmunizaciones. Vacunas y nmero de dosis (Sabin, DPT, pentavalente, BCG,
etctera). Biolgicos (suero antirrbico,antialacrn, anticrotlico, gammaglobulina,
anti-Rh).
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Conciencia de enfermedad:
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Antecedentes gneco-obsttricos:
Menarca, ciclo menstrual (frecuencia, duracin, cantidad, dismenorrea); inicio
devida sexual activa (VSA), nmero de parejas, nmero de embarazos, nmero de
partos, abortos, cesreas, mtodo anticonceptivo, fecha de ltima menstruacin,
enfermedades de transmisin sexual, menopausia, climaterio, Papanicolaou y
lactancia materna.
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Antecedentes androlgicos:
Circunscisin, criptorquidia, poluciones nocturnas, inicio de VSA, nmero de
parejas,enfermedad de transmisin sexual, trastornos de la ereccin y
andropausia.
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Antecedentes personales patolgicos:
Infectocontagiosos, enfermedades exantemticas, enfermedades crnicodegenerativas y parasitarios, alrgicos, quirrgicos, traumticos, transfusionales,
convulsivos, adicciones (tabaquismo,alcoholismo, drogas) y hospitalizaciones
previas.
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PADECIMIENTO ACTUAL
Motivo y circunstancia de la consulta.
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Sntoma o molestia principal (semiologa, fecha y modo de inicio, causa real o

aparente, evolucin, estado actual).
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____ Sntomas o molestias acompaantes (semiologa, fecha y modo de inicio,
causa real o aparente, evolucin, estado actual).
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__________________________________________________________________________ Estudios
paraclnicos realizados.
Resultados:
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Teraputica empleada. Resultados:
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INTERROGATORIO POR APARATOS Y SISTEMAS

Aparato respiratorio:
Rinorrea, rinolalia, epistaxis, tos, expectoracin, disfona, hemoptisis, vmica,
cianosis, dolor torcico, disnea y sibilancias audibles a distancia.
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Aparato digestivo:
Hambre, apetito, alteraciones de la masticacin y salivacin, disfagia, halitosis,
nusea, vmito, rumiacin, regurgitacin, pirosis, aerofagia, eructos, meteorismo,
distensin abdominal, flatulencia, hematemesis, ictericia, caractersticas de la
heces fecales, diarrea, constipacin, acolia,hipocolia, melena, rectorragia,
parsitos, disentera, esteatorrea, pujo, tenesmo y prurito anal.
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Aparato cardiovascular:
palpitaciones, dolor precordial, disnea de esfuerzo, disnea paroxstica, apnea,
cianosis,acfenos, fosfenos, tinnitus, sncope, lipotimias y edema.
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Aparato renal y urinario:

Dolor renoureteral, disuria, anuria, oliguria, poliuria, polaquiuria, hematuria, piuria,
coluria, urgencia, incontinencia, caractersticas del chorro, nictmero, goteo
terminal y edema.
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Aparato genital masculino:
Alteraciones de la libido, prctica sexual (homo, hetero o bisexual), nmero de
parejas sexuales, priapismo, alteraciones de la ereccin y de la eyaculacin,
secrecin uretral, dolor testicular, alteraciones escrotales, sensacin de cuerpo
extrao en el perin y enfermedades (infecciones) de transmisin sexual.

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Aparato genital femenino:
Leucorrea, hemorragias transvaginales, alteraciones menstruales, alteraciones de
la libido, prctica sexual (homo, hetero o bisexual), nmero de parejas, mtodo de
proteccin contra enfermedades (infecciones) de transmisin sexual, alteraciones
del sangrado menstrual, dispareunia, perturbaciones y alteraciones sexuales,
amenorrea y Papanicolaou.
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Sistema endocrino:
Intolerancia al fro y al calor, hipo o hiperactividad, aumento de volumen del cuello,
polidipsia, polifagia, poliuria, cambios en los caracteres sexuales secundarios y
aumento o prdida de peso.
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Sistema hematopoytico y linftico:

Palidez, disnea, fatigabilidad, astenia, palpitaciones, sangrado, equimosis,
petequias y adenomegalias.
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Piel y anexos:
Coloracin, pigmentacin, prurito, caractersticas del pelo, uas, lesiones
(primarias y secundarias),hiperhidrosis y xerodermia.
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Musculoesqueltico:
Mialgias, dolor seo, artralgias, alteraciones en la marcha, hipotona, disminucin
del volumen muscular, limitacin de movimientos y deformidades.
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Sistema nervioso:
Cefalea, paresias, plegias, parlisis, parestesias, movimientos anormales
(temblores, tics, corea),alteraciones de la marcha, vrtigo y mareos.
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rganos de los sentidos:

Alteraciones de la visin, de la audicin, del olfato, del gusto y del tacto (hipo,
hiper odisfuncin). Mareo y sensacin de lquido en el odo.
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Esfera psquica:
Tristeza, euforia, alteraciones del sueo (insomnio, hipersomnia, disomnia),
terrores nocturnos, ideaciones (alucinatorias, delirantes, obsesivas, suicidas),
miedo exagerado a situaciones comunes, irritabilidad, apata. Relaciones
personales.
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Sntomas generales:
Fiebre, astenia, adinamia, aumento o prdida de peso y modificaciones del
hambre (hiporexia, anorexia, hiperorexia).
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II. EXPLORACIN FSICA
Signos vitales y somatometra:
Pulso:_____ por min Presin arterial (PA): _____ mm.Hg. Temp. _____C
Frecuencia respiratoria (FR):_____por minFrecuencia cardiaca (FC):_____
por min Peso: _______ kg Talla: _______ m ndice de masa
corporal:________ Otros pertinentes: ___________________________________
Inspeccin general (habitus exterior)
: gnero, edad aparente, estado de alerta y orientacin, integridad,
estadonutricional, facie, constitucin, conformacin, actitud, lenguaje, movimientos
anormales, caractersticas de la piel y losanexos, cooperacin, vestido, alio y
marcha.
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Cabeza
Crneo: inspeccin, palpacin, percusin y, si es necesario, auscultacin.
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______________________________ Cara: inspeccin, palpacin percusin y, si es
necesario, auscultacin.
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____ Ojos:
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____ Nariz:
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____ Boca:
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Cuello:
inspeccin, palpacin percusin y, si es necesario, auscultacin.
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Trax:
inspeccin, palpacin, percusin, auscultacin y exploracin instrumental. _Regin
precordial: Glndulas mamarias:
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Abdomen:
inspeccin,
auscultacin
, palpacin, percusin y, en caso necesario, medicin.
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Regin inguino-crural:

inspeccin,
auscultacin
, palpacin y percusin.
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Genitales externos:
inspeccin, palpacin (tacto) y exploracin instrumental.
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Tacto vaginal
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Tacto rectal
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Extremidades:
torcicas y plvicas. Inspeccin, palpacin, percusin, auscultacin y, en caso
necesario, medicin.
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Columna vertebral:
inspeccin, palpacin, percusin.
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Exploracin neurolgica:
estado de alerta, funciones mentales superiores, pares craneales, motricidad,
tono,marcha, coordinacin, reflejos osteotendinosos y cutneos, sensibilidad
(superficial y profunda).
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Procesamiento de la informacin

DIAGNSTICOS
Sintomticos:
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_____________________________________________Signolgicos:
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Sindromticos:
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_____________________________________________Anatomotopogrficos:
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_________ Fisiopatolgicos:
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Por laboratorio y/o gabinete e imagenologa. Anatomopatolgico.
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Etiolgico:
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Nosolgico:
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Diferenciales:
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_ Integral:
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PLAN DE MANEJO Y TRATAMIENTO SUGERIDO

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Pronsticos
: Para la vida, el rgano, la funcin, la calidad de vida, la esttica.
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Criterios de referencia:
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Nombre del alumno
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Grupo _______________________________________________________________
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V o . B o .
T u t o r - c l n i c o
Referencias consultadas (tres):
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