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MODELO DE HISTORIA CLNICA

Ctedra de Semiologa (Medicina I) UHMI N 1


Hospital Nacional de Clnicas
Fecha:

Mdico: ________________________________.

DATOS PERSONALES
Apellido y Nombre: _________________________________________________________________________.
Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupacin: _______________.
Domicilio: _____________________________________________________________. TE: ______________.
Residencia: ________________________________________________________________________________.
Otros: ____________________________________________________________________________________.

MOTIVO DE CONSULTA

ANTECEDENTES DE LA ENFERMEDAD ACTUAL

ANAMNESIS SISTEMICA
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1- Sntomas Generales: fiebre,
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perdida de peso, astenia, fatiga,
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otros.
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2 - Piel y faneras: prurito, lesiones ____________________________________________________________
primarias y secundarias,
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alteraciones de uas y cabellos,
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otros.
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3 - TCS: edema, tumoraciones,
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otros.
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4 - SOMA: dolor, tumefaccin,
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fuerza muscular, limitacin del
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movimiento, otros.
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5 - Ap. Cardiovascular: disnea,
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palpitaciones, dolor precordial,
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sncope, claudicacin intermitente, ____________________________________________________________
otros.
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6 - Ap.Respiratorio: epistaxis, tos, ____________________________________________________________
expectoracin, hemptisis, dolor
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torcico, cianosis, otros.
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7 - Ap. Digestivo: halitosis,
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disfagia, regurgitacin, acidez,
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pirosis, nauseas y vmitos,
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hematemesis, alteraciones del
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hbito intestinal, otros.
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8 - Ap. Genitourinario: disuria,
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polaquiuria, nicturia, hematuria,
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incontinencia, dolor, alteraciones
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ciclo menstrual, alteraciones
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sexuales, otros
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9 - Sistema Nervioso: cefalea,
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mareos, vrtigo, sensibilidad,
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motricidad, temblor, alteraciones
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de la visin, audicin, otros.
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ANTECEDENTES PERSONALES
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2- Inmunizaciones: de la infancia, ____________________________________________________________
antitetnica, antidiftrica, hepatitis ____________________________________________________________
B, antineumococcica, otras.
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3- Vivienda y medio ambiente.
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4- Psicosociales y
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socioeconmicos.
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5- Patolgicos: mdicos, alrgicos, ____________________________________________________________
quirrgicos, traumticos.
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6-Txico-Medicamentosos: tabaco, ____________________________________________________________
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alcohol, sustancias psicoactivas,
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medicamentos, otros.
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7-Epidemiolgicos: Chagas,
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HIV/Sida, Brucelosis,
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Toxoplasmosis, transfusiones,
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residencias anteriores, otros.
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8-Heredo-Familiares.
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9- Estudios preventivos: femeninos ____________________________________________________________
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masculinos.
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10- Otros.
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1-Fisiolgicos: menarca, ciclo
menstrual, fecha ltima
menstruacin, embarazos, partos,
alimentacin, actividad fsica,
sueo, diuresis y catarsis, actividad
sexual, otros.

1-Inspeccin General

EXAMEN FISICO
Examen General
Estado de conciencia: __________________________________________.
Actitud: _____________________________________________________.
Decbito: ____________________________________________________.
Marcha: _____________________________________________________.
Facie: _______________________________________________________.

2-Mediciones y Controles

FC: _____________ TA: _____________ FR: __________


T: _______.
Sat. O2: __________________.
Peso: _________ Altura: ________ IMC: ______Per. Abd:___________

3-Piel y faneras: color, turgor,


elasticidad, humedad,
temperatura, lesiones primarias,
lesiones secundarias, pelos y uas.

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4-TCS: cantidad, distribucin,


vrices, circulacin colateral,
edema, adenopatas, otros.

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5-SOMA: huesos (conformacin y


sensibilidad), msculos,
articulaciones.

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1-Cabeza y cuello: crneo, odos,


ojos, nariz, boca. tiroides,
cartidas, yugulares, otros.
2-Ap. Respiratorio: inspeccin,
expansin de V y B, vibraciones
vocales, claro pulmonar, murmullo
vesicular, auscultacin de la voz,
ruidos patolgicos, otros.
3-Mamas.
4-Ap. Cardiovascular: precordio
(inspeccin, zona mximo
impulso, latidos patolgicos,
ruidos cardacos normales y
patolgicos), pulsos perifricos,
auscultacin arterial, otros.
5-Abdomen: inspeccin,
auscultacin, palpacin superficial
y profunda, puntos dolorosos,
orificios herniarios, percusin,
otros.
6-Ap. Genitourinario: puo
percusin, puntos reno-ureterales,
examen genital, tacto rectal, otros.
7-Sistema Nervioso: pares
craneales. Motricidad (tono,
trofismo, motricidad voluntaria y
fuerza muscular). Reflejos
superficiales y profundos.
Sensibilidad (superficial y
profunda).
Funcin cerebelosa.

Examen Segmentario
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LISTADO DE PROBLEMAS

LISTADO DE DIAGNOSTICOS

METODOS COMPLEMENTARIOS SOLICITADOS

TRATAMIENTO INICIAL

EVOLUCIONES

EPICRISIS