Professional Documents
Culture Documents
HISTORIA CLÍNICA
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Nombres Apellido Paterno Apellido Materno
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Pag. 2
1.4. ANTECEDENTES PERSONALES.
(Perinatales, desarrollo psicomotor, lenguaje, control de esfínteres, sueño, onicofagia y otros).
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Pag. 3
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Pag. 4
1.12. DINAMICA FAMILIAR.
(Tipo de familia, características de los progenitores, características de los hermanos).
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Pag. 5
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2.2 CONDUCTA.
(Movimientos, posturas, estereotipas, tics, manierismos, negativismo, ecopraxia, relación con el entrevistador, coopera durante la
entrevista o no lo hace).
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2.3 PENSAMIENTO.
LENGUAJE Y MUESTRA DEL LENGUAJE
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Pag. 6
2.4 SENSOPERCEPCION.
(Ilusiones, alucinaciones: visuales, olfativas, auditivas, táctiles, cinestésicas, cenestésicas, macropsias, micropsias, otros).
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2.5 AFECTIVIDAD.
(Síntomas depresivos, maniacos, irritabilidad, agresividad, labilidad, afectiva, disociación ideo-afectiva, aplanamiento, otros).
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2.6 ATENCION.
(Hipoprosexia, hiperprosexia, distractibilidad, otras).
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2.7 ORIENTACION.
(Tiempo, persona y lugar).
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2.8 MEMORIA.
(Reciente y remota, amnesia, confabulación, falsos reconocimientos, fenómeno de lo nunca visto, de lo ya visto, otros).
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2.9 INTELIGENCIA.
(Estimación clínica, rasgos de deterioro, capacidad de abstracción).
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Pag. 7
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IMPRESIÓN DIAGNOSTICA
3.1 DIAGNOSTICO.
3.1.1 CIE10. ………………………………………………………………………………………………………………………………………….
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3.4 FIRMA.
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3.5 FECHA.
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