Historia Clinica

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Historia Clinica

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Michael Santos

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I .

datos de identificación
II. ANAMNESIS
1.- Fuente de la historia clínica y confianza que merecen los datos.
2.-Motivo de consulta:
3.- Enfermedad actual
4.- ANTECEDENTES PERSONALES
A.- PATOLÓGICOS
B.- NO PATOLÓGICOS
C.- ANTECEDENTES FAMILIARES
D.- ANTECEDENTES G.O.B.
5.- REVISIÓN POR SISTEMAS
6.- Examen físico regional
7.- Examen físico general
8.- Exámenes complementarios
9.-Diagnostico
10.- Tratamiento

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