UNIVERSIDAD CATLICA

SANTO TORIBIO DE MOGROVEJO

FACULTAD DE MEDICINA
ESCUELA DE MEDICINA

HISTORIA CLINICA
Asignatura: Fisiopatologa Semiologa - Anatoma Patolgica I
Semestre: 2013-I
Ciclo Acadmico: V
Tutor: ...
Nombre: .
Unidad:

ECTOSCOPIA
a.- Estado de gravedad aparente: ____________________________________
b.- Edad aparente: ________________________________________________
c.- Signo(s) destacado(s): ___________________________________________
ANAMNESIS
FILIACIN
a.- Nombre: ____________________________________________
b.- Edad: _______________________________________________
c.- Sexo: _______________________________________________
d.- Raza: _______________________________________________
e.- Estado civil: __________________________________________
f.- Ocupacin: ___________________________________________
g.- Grado de instruccin: __________________________________
h.- Lugar de nacimiento: __________________________________
i.- Procedencia: _________________________________________
j.- Fecha de ingreso: ______________________________________
ENFERMEDAD ACTUAL
Tiempo de Enfermedad: ____________________
Forma de inicio: __________________________
Curso de la enfermedad: ___________________
Sntomas principales:
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Descripcin cronolgica
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Apetito: _____________________
Orina: ______________________
Variacin ponderal: ________________________

Sed: __________________________
Deposiciones: __________________
Estado basal: ___________________

ANTECEDENTES PERSONALES
A. NO PATOLGICOS
Nacimiento:
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Desarrollo fsico:
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Desarrollo psquico:
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Aspectos Socioeconmicos:
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Residencias y viajes anteriores:
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Hbitos y costumbres:
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Inmunizaciones:
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B. PATOLGICOS
Enfermedades previas:
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Accidentes y secuelas:
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Intervenciones quirrgicas:
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Medicacin habitual o transfusiones:
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Alergias:
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C. GINECOLGICOS Y OBSTTRICOS
Menarqua: _____________________________ FUR: ___________________________
Ritmo catamenial: ________________________________________________________
Gestacin y partos:
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Mtodos anticonceptivos:
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Enfermedades ginecolgicas:
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ANTECEDENTES FAMILIARES
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REVISIN ANAMNSICA DE SISTEMAS Y APARATOS:

Para completar los datos de la enfermedad actual y antecedentes, se har la revisin anamnsica ordenada
de todos los sistemas y aparatos
Generales: ______________________________________________________________________________
Cabeza: _________________________________________________________________________________
Ojos: ___________________________________________________________________________________
Odos: __________________________________________________________________________________
Nariz: __________________________________________________________________________________
Boca: ___________________________________________________________________________________
Faringe y laringe: _________________________________________________________________________
Cuello: _________________________________________________________________________________
Mamas: ________________________________________________________________________________
Aparato respiratorio: ______________________________________________________________________
Aparato cardiovascular: ____________________________________________________________________
Aparato gastrointestinal: ___________________________________________________________________
Aparato genito-urinario: ___________________________________________________________________
Neuropsiquitrico: ________________________________________________________________________
Aparato locomotor: _______________________________________________________________________
Piel y anexos: ____________________________________________________________________________
Sistema linftico: _________________________________________________________________________
EXAMEN FSICO
SIGNOS VITALES
PA: _____/_____ mmHg FC: ________ FR: _______ T: ________ Peso: _______ Talla: ______
Sat O2: __________
APRECIACIN GENERAL
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PIEL Y ANEXOS
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TEJIDO CELULAR SUBCUTANEO
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SISTEMA LINFTICO
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REGIONAL
CRNEO:
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CARA:
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CUELLO:
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TORAX PULMONES:
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CARDIOVASCULAR:
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ABDOMEN:
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GENITO-URINARIO:
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APARATO LOCOMOTOR:
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NEUROLGICO:
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HIPOTESIS DIAGNSTICA
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Sustentado por los siguientes datos
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Sustentado por los siguientes datos
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Sustentado por los siguientes datos
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PLAN DIAGNSTICO
Exmenes de Laboratorio
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Exmenes por imgenes

____________________________________ Qu espera encontrar: ______________________________
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CUAL ES EL MECANISMO FISIOPATOLGICO QUE SUSTENTA EL O LOS PROBLEMAS DE SALUD DEL

PACIENTE
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FIRMA DEL TUTOR: ____________________________

FECHA DE CALIFICACIN: _______________________