FACULTAD DE MEDICINA

ESCUELA DE MEDICINA
Nombre
Unidad o Rotacin

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: .. Caso:

HISTORIA CLINICA ORIENTADA AL PROBLEMA DE SALUD

I. REGISTRO DE DATOS BASICOS
A. ANAMNESIS
1. ECTOSCOPIA
a.- Estado de gravedad aparente: __________________________________
b.- Edad aparente
:__________________________________
c.- Signo(s) destacado(s)
:__________________________________
2. FECHA DE ELABORACION:____________________________________
3. FILIACIN
a.Nombre y apellidos: ________________________________________
b.Edad: ____________________________________________________
c.Sexo: _____________________________________________________
d.Raza: _____________________________________________________
e.Estado civil: _______________________________________________
f.Ocupacin: ________________________________________________
g.Grado de instruccin: _______________________________________
h.
Religin: __________________________________________________
i.Lugar y fecha de nacimiento: _________________________________
j.Lugar de procedencia: _______________________________________
k.Fecha de ingreso: ___________________________________________
l.Direccin, telfono:__________________________________________
m.
Informante: ________________________________________________
n.Confiabilidad de datos:_______________________________________
4. ENFERMEDAD ACTUAL
Tiempo de Enfermedad: _________________
Forma de inicio : _______________________
Curso de la enfermedad: _________________
Circunstancia de conocimiento:____________________________________
Sntomas principales:_____________________________________________
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Descripcin cronolgica y evolucin:
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Funciones biolgica :
Apetito: ________________Sed: __________________Sueo: ________
Orina: _________________ Deposiciones: __________ Peso: _______
5. ANTECEDENTES
A. PERSONALES
A.1.GENERALES
Hogar: origen de la familia, procedencia y composicin del
Hogar: __________________________________________________
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Vivienda: _______________________________________________
_______________________________________________________
Educacin: ______________________________________________
________________________________________________________
Ocupacin actual y anterior: _______________________________
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Condicin econmica: ________________________________________
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Vestido: _____________________________________________________
Alimentacin: ________________________________________________
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Sueo: ______________________________________________________
Recreacin y actividades sociales:________________________________
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Hbitos nocivos:_______________________________________________
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Residencias y viajes previos: ____________________________________
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Descripcin de un da en la vida del paciente:______________________
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A.2.FISIOLGICOS
a.1. Prenatales:__________________________________________________
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a.2. Natales:_____________________________________________________
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a.3. Post-natales:_________________________________________________
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a.4. Crecimiento y desarrollo:_______________________________________
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a.5. Hbitos, conducta y reaccin emocional:___________________________
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a.6. Inmunizaciones:______________________________________________
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a.7. Pubertad y adolescencia:_______________________________________
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a.8.Antecedentes Gineco-obsttricos:________________________________
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a.9.Menopausia o climaterio:_______________________________________
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A.3.PATOLGICOS:
a.1. Enfermedades previas:____________________________________________
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a.2. Hospitalizaciones previas:_________________________________________
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a.3. Reacciones de hipersensibilidad o alergias:____________________________
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a.4. Accidentes y traumatismos:________________________________________
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a.5. Intervenciones quirrgicas:________________________________________
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a.6. Medicacin habitual:_____________________________________________
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B. FAMILIARES:
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7. REVISIN ANAMNESICA 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 : _________________________________________________

B. EXAMEN FISICO
A. EXAMEN GENERAL
1. SIGNOS VITALES
PA: ____/____ mmHg FC: _____FR: ____ T: _____ Sat. O2:______
2. APRECIACION GENERAL:
2.1. Apariencia general:_______________________________________
2.2. Estado nutricional, de hidratacin, higiene, talla, peso:_____________
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2.3. Estado mental:_____________________________________________
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3. PIEL Y FANERIOS:____________________________________________
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4. TEJIDO CELULAR SUBCUTANEO:______________________________
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5. SISTEMA LINFATICO:_________________________________________
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B. EXAMEN PO REGIONES
6. CABEZA:
6.1. CRANEO:_________________________________________________
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6.2. CARA:_____________________________________________________
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7. CUELLO:______________________________________________________
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8. TORAX :
8.1. APARATO RESPIRATORIO:_________________________________
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8.3. APARATO CARDIOVASCULAR:______________________________
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9. ABDOMEN:____________________________________________________
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10. RECTO:
Inspeccin:______________________________________________________
Palpacin:______________________________________________________
Prstata:________________________________________________________
11. GENITO-URINARIO:
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12. SISTEMA MUSCULO-ESQUELETICO:
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13. SISTEMA NERVIOSO:
1. Conciencia:____________________________________________________
2. Funcin motora:
2.1. Voluntario:_________________________________________________
2.2. Involuntario:
2.2.1. Tono muscular:_________________________________________
2.2.2. Reflejos:
- Superficiales:_________________________________________
- Profundos:___________________________________________
3. Funcin cognoscitiva (general)
3.1. Protoptica o grosera:
3.1.1. Superficial:
- Termoalgsica:________________________________________
- Tctil, grosera:________________________________________
3.1.2. Profunda:
- Barognosia (peso):______________________________________
- Batiestesia (posicin):___________________________________
- Parestesia (presin):____________________________________
- Palestesia (vibracin):__________________________________
3.2. Epicrtica o discriminativa:
- Morfognosia:_________________________________________
- Hylognosia:__________________________________________
- Esterognosia:________________________________________
- Dermolexia:__________________________________________
- Grafiestesia:__________________________________________

II. IDENTIFICACIN DE LOS PROBLEMAS DE SALUD E HIPOTEISIS

DIAGNSTICAS
PROBLEMAS DE SALUD
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
4. _____________________________________________________
HIPOTESIS DIAGNTICA
Problema 1:_____________________________________________________
Hiptesis diagnostica:
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Problema 2:_____________________________________________________
Hiptesis diagnstica
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Problema 3:______________________________________________
Hiptesis diagnostica:
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III. PLAN DE TRABAJO
A. Plan Diagnstico B. Plan teraputico

C. Plan educativo

A. PLAN DIAGNSTICO:
Exmenes de Laboratorio
______________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
Exmenes por imgenes
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
____________________________ Qu espera encontrar: _____________________
Procedimientos:
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B. PLAN TERAPEUTICO:
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C. PLAN EDUCATIVO:
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IV. EVOLUCION:
SUBJETIVO:_____________________________________________________
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OBJETIVO:____________________________________________________________
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APRECIACIN:________________________________________________________
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PLAN:_________________________________________________________________
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V.- DIAGNOSTICO(S) FINAL(ES):
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VI. EPICRISIS
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