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Modelo de Historia Clínica

Modelo de Historia Clínica

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Published by: Antorchaman on Aug 28, 2009
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06/24/2013

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MODELO DE HISTORIA CLÍNICA
Fecha: / / . Médico: ________________________________.
DATOS PERSONALES
Apellido y Nombre: _________________________________________________________________________.Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupación: _______________.Domicilio: _____________________________________________________________. TE: ______________.Residencia: _______________________________________________________________________________ .
MOTIVO DE CONSULTAANTECEDENTES DE LA ENFERMEDAD ACTUALANAMNESIS SISTEMICA1
 
1- Síntomas Generales: fiebre, perdida de peso, astenia, fatiga,otros.2 - Piel y faneras: prurito, lesiones primarias y secundarias,alteraciones de uñas y cabellos,otros.3 - TCS: edema, tumoraciones,otros.4 - SOMA: dolor, tumefacción,fuerza muscular, limitación delmovimiento, otros.5 - Ap. Cardiovascular: disnea, palpitaciones, dolor precordial,síncope, claudicación intermitente,otros.6 - Ap.Respiratorio: epistaxis, tos,expectoración, hemóptisis, dolor torácico, cianosis, otros.7 - Ap. Digestivo: halitosis,disfagia, regurgitación, acidez, pirosis, nauseas y vómitos,hematemesis, alteraciones delhábito intestinal, otros.8 - Ap. Genitourinario: disuria, polaquiuria, nicturia, hematuria,incontinencia, dolor, alteracionesciclo menstrual, alteracionessexuales, otros9 - Sistema Nervioso: cefalea,mareos, vértigo, sensibilidad,motricidad, temblor, alteracionesde la visión, audición, otros. _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ______________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ___________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ____________________________________________________.
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ANTECEDENTES PERSONALES
1-Fisiológicos : menarca, ciclomenstrual, fecha últimamenstruación, embarazos, partos,alimentación, actividad física,sueño, diuresis y catarsis, actividadsexual, otros.2- Inmunizaciones.3- Vivienda y medio ambiente.4- Socioeconómicos.5- Patológicos: médicos, alérgicos,quirúrgicos, traumáticos.6-Tóxico-Medicamentosos: tabaco,alcohol, sustancias de usoindebido, medicamentos, otros.7-Epidemiológicos: Chagas,HIV/Sida, Brucelosis,Toxoplasmosis, transfusiones,residencias anteriores, otros.8-Heredo-Familiares.9- Estudios preventivos.10- Otros. _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ___________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ___________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ___________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ___________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  _____________________________________________________________  ___________________________________________________ 
EXAMEN FISICO3

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