HOSPITAL CENTRAL DE LAS FUERZAS ARMADAS

RESIDENCIA DE MEDICINA INTERNA

HISTORIA CLINICA
Fecha:_______________
Firma: Dr. _________________R1MI
Hora:_______________

DATOS GENERALES
Nombre: Sexo:________ Edad: ________ Estado Civil: ______________
Ocupación: Raza:_____________ Rango: ________________________Institución: ____________
Religión: ___________________________________________ Procedencia: ________________________________________________
Residencia: _____________________________________________________________________________________________________
Informante: _______________________________________ Referimiento: ________________________________________________

MOTIVOS DE CONSULTA

1. 4.

2 5.

3 6.

HISTORIA DE LA ENFERMEDAD ACTUAL

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1
ANTECEDENTES PERSONALES PATOLOGICOS

INMUNIZACIÓN:______________________________________________________________________________________________
ENFERMEDADES NIÑEZ: __________________________________________________________________________________________
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ENFERMEDADES ADOLESCENCIA ____________________________________________________________________________________
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ENFERMEDADES ADULTEZ: _______________________________________________________________________________________
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ANTECEDENTES HOSPITALARIOS: __________________________________________________________________________________
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ANTECEDENTES QUIRURGICOS: ____________________________________________________________________________
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ANTECEDENTES TRAUMATICOS _____________________________________________________________________________________
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ANTECEDENTES ALERGICOS : _____________________________________________________________________________________
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ANTECEDENTES MEDICAMENTOSOS: ________________________________________________________________________________
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ANTECEDENTES TRANSFUCIONALES: ________________________________________________________________________________

ANTECEDENTES HEREDO FAMILIARES

PADRE: ________________________________________________________________________________________________________
MADRE:________________________________________________________________________________________________________
HERMANOS: ____________________________________________________________________________________________________
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HIJOS: ________________________________________________________________________________________________________

ESFERA SPICOSEXUAL
TELARQUIA:_________ PUBARQUIA _________ 1ER COITO_______NÚMERO DE CONYUGES:_______ FUM:___________
MENARQUIA:_______ G ____ P_____ A______ C______
ANTECEDENTES SOCIO-ECONÓMICOS

INGRESOS: __________________________________________HABITAD: ________________________________________

CONDICIONES DE LA VIVIENDA:_______________________________________________________________________________
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NO. DE HABITACIONES: _________________ NO. PERSONAS CON QUIEN VIVE: _____________________________
DEPOSICIÓN DE EXCRETAS: _____________________________________________________________________________________
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DEPOSICIÓN DE BASURA: _________________________________________________________________________________________
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AGUA: ________________________________________________________________________________________________________
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ANIMALES DOMESTICOS: ______________________________________________________________________________________

2
HABITOS TÓXICOS
FUMADOR:___________________________________________________________________________________________________

TIZANAS:____________________________________________________________________________________________________

ALCOHOL:___________________________________________________________________________________________________

CAFÉ:_______________________________________________________________________________________________________

DROGAS:____________________________________________________________________________________________________

REVISIÓN POR SISTEMAS

VISIÓN ___________________________________________________________________________________________________
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AUDICION _____________________________________________________________________________________________________
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OLFATO ________________________________________________________________________________________________________
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GUSTO ________________________________________________________________________________________________________
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TACTO ________________________________________________________________________________________________________
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SISTEMA CARDIOVASCULAR ______________________________________________________________________________________
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SISTEMA RESPIRATORIO _________________________________________________________________________________________
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SISTEMA GASTROINTESTINAL _____________________________________________________________________________________
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SISTEMA GENITOURINARIO ______________________________________________________________________________________
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SISTEMA LINFO-HEMATOPOYETICO ________________________________________________________________________________
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SISTEMA MUSCULO-ESQUELETICO _________________________________________________________________________________
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PIEL Y ANEXOS _________________________________________________________________________________________________
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EXAMEN FISICO
ASPECTO GENERAL
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TA: _____/_____ mmhg FC: ______ lat/min FR:_______ resp/min TEMP: _____ oC
PESO: _____libras ____ Kg. TALLA __________ cms __________ mts. IMC: _____ m²

3
PIEL y ANEXOS: ________________________________________________________________________________________________
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CABEZA:.______________________________________________________________________________________________________
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OJOS._________________________________________________________________________________________________________
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OIDO:_________________________________________________________________________________________________________
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NARIZ:.________________________________________________________________________________________________________
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BOCA:_________________________________________________________________________________________________________
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CUELLO_____________________________________________________________________________________________________
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MAMAS:.____________________________________________________________________________________________________
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TORAX:._______________________________________________________________________________________________________
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CORAZON.__________________________________________________________________________________________________
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PULMONES:____________________________________________________________________________________________________
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ABDOMEN:____________________________________________________________________________________________________
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GENITALES EXTERNOS: ___________________________________________________________________________________
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TACTO RECTAL_____________________________________________________________________________________________
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TACTO VAGINAL____________________________________________________________________________________________
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EXTREMIDADES SUPERIORES:____________________________________________________________________________
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EXTREMIDADES INFERIORES:_____________________________________________________________________________
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4
EXAMEN NEUROLÓGICO

Nivel De Conciencia (Escala De Glasgow) _____/15 = (AO ___/4 RM _____/ 6 RV _____/5 )

Contenido De Conciencia (Memoria, Orientación, Conducta, Entorno) _____________________________________________________
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Pares Craneales _________________________________________________________________________________________________
Fondo De Ojo ___________________________________________________________________________________________________
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Fuerza Y Tono Muscular__________________________________________________________________________________________
Marcha______________________________________________________________________________________________________
Reflejos Osteotendinosos_________________________________________________________________________________________
Pruebas Cerebelosas _____________________________________________________________________________________________
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Sensibilidad ____________________________________________________________________________________________________
Signos De Irritación Meníngea ___________Kerning, ____________Brudzinski, __________Rigidez de nuca

LABORATORIOS

GB: GR: Glic: PT: Otros:

N: Hb: Urea: TPT:
PLAQ: Hcto: Creat: Tipi:

RADIOGRAFIA DE TORAX
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ELECTROCARDIOGRAMA
Ritmo: ___________________________
FC: ________________ ciclos x minuto
Eje QRS: ____________ grados
Onda P: ____________ segundos
Intervalo PR: ________ segundos
QRS: ______________ segundos
Onda T: _______________________________________________________________________________________________________
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Segmento ST: __________________________________________________________________________________________________
Intervalo QT: ________ segundos
Conclusión: ____________________________________________________________________________________________________
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DIAGNOSTICO
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
4. _________________________________________________________________________________
5. _________________________________________________________________________________

Dr. _________________ R1M