WENDY CAROL VIERA AGÜERO

HISTORIA CLINICA
Unidad de trasplante hepático-HNGA

1. FILIACIÓN
 APELLIDOS Y NOMBRES:________________________________________
 CAMA:________  EDAD:___________  SEXO: ______________

 RAZA:_________
 NATURAL DE :_________________________________________________
 PROCEDENCIA:________________________________________________
 TIEMPO DE PROCEDENCIA:______________________________________
 ESTADO CIVIL: ________________________________________________
 OCUPACIÓN: __________________________________________________
 INSTRUCCIÓN:_________________________________________________
 RELIGION:____________________________________________________
 DOMICILIO:____________________________________________________
 TELEFONO: ___________________________________________________
 PERSONA RESPONSABLE:______________________________________
 FECHA DE INGRESO: ___________________________________________
 MODO DE INGRESO: ____________________________________________
 FECHA HISTORIA CLÍNICA: _____________________________________
 ANAMNESIS:___________________________________________________

2. ENFERMEDAD ACTUAL

 TIEMPO DE ENFERMEDAD:______________________________________
 FORMA DE INICIO:______________________________________________
 CURSO:_______________________________________________________
 SINTOMAS PRINCIPALES:
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 RELATO CRONOLÓGICO:

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 FUNCIONES BIOLOGICAS:

 Apetito:_____________________________________________________
 Sed: ________________________________________________________
 Sueño: _____________________________________________________
 Orina: ______________________________________________________
 Deposiciones: _______________________________________________

 REVISION POR APARATOS Y SISTEMAS:

 PIEL Y
FANERAS:___________________________________________________
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 TCSC:_______________________________________________________
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 ARTICULACIONES:___________________________________________
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 HUESOS:____________________________________________________
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  MUSCULOS:_________________________________________________
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 S.
RESPIRATORIO:______________________________________________
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 S.CARDIOVASCULAR:_________________________________________
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 S.DIGESTIVO:________________________________________________
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 S,RENAL:____________________________________________________
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 S,NEUROLOGICO:____________________________________________
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3. ANTECEDENTES PERSONALES

3.1. ANTECEDENTES PERSONALES GENERALES

 VIVIENDA:_________________________________________________
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 ALIMENTACION:___________________________________________
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 VESTIMENTA: _____________________________________________
 SITUACION ECONOMICA:
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 OCUPACIONES ANTERIORES:
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 RESIDENCIAS
PREVIAS:_________________________________________________
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 HABITOS NOCIVOS:
-Alcohol: __________________________________________________
-Tabaco: __________________________________________________
-Drogas: __________________________________________________

 INMUNIZACIONES: _________________________________________
 ALERGIAS: _______________________________________________
 CRIANZA DE ANIMALES: ____________________________________

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3.2. ANTECEDENTES PERSONALES FISIOLOGICOS

 PRENATALES:
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 NATALES:
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 ANTECEDENTES OBSTETRICOS
-Menarquia: ________________________________________________
-Menopausia: ______________________________________________
-Fecha de última regla: _______________________________________
-Gestaciones:_______________________________________________
-Paridad: __________________________________________________
-Abortos:___________________________________________________

3.3. ANTECEDENTES PERSONALES PATOLOGICOS

 ENFERMEDADES PREVIAS:
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 HOSPITALIZACIONES Y CIRUGIAS
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3.4. ANTECEDENTES FAMILIARES

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4. EXAMEN FISICO

4.1. FUNCIONES VITALES:

 Pulso: ____________
 Presion arterial: ____________
 Temperatura: _____________
 Frecuencia respiratoria: ____________
 Frecuencia cardiaca: ____________
 Peso: ____________
 Talla: ____________
 IMC: _____________

4.2. EXAMEN GENERAL

 ESTADO GENERAL:__________________________________________
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 ESTADO DE NUTRICION:_____________________________________
 ESTADO DE HIDRATACION:__________________________________
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 ESTADO DE CONCIENCIA Y GRADO DE COLABORACION:__
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 PIEL Y FANERAS: ___________________________________________
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 TCSC:_____________________________________________________
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 OSTEO-ARTICULAR:_________________________________________
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 SISTEMA LINFATICO:________________________________________
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4.3. EXAMEN REGIONAL

A. CABEZA

 CRÁNEO:_________________________________________________
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 CARA:____________________________________________________
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 REGIÓN ORBITARIA:________________________________________
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 REGIÓN NASAL:___________________________________________
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 REGIÓN AURICULAR Y MASTOIDES:__________________________

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 REGIÓN ORAL:_____________________________________________
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 REGIÓN OROFARINGEA:____________________________________
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B. CUELLO

 INSPECCIÓN:______________________________________________
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 PALPACIÓN:_______________________________________________
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 AUSCULTACIÓN:___________________________________________
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C. MAMAS

 INSPECCIÓN:______________________________________________
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 PALPACIÓN:_______________________________________________
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D. TÓRAX Y PULMONES

 INSPECCIÓN:______________________________________________
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 PALPACIÓN:_______________________________________________
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 PERCUSIÓN:_______________________________________________
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 AUSCULTACIÓN:___________________________________________
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E. CORAZON

 INSPECCIÓN:______________________________________________
 PALPACIÓN:_______________________________________________
 AUSCULTACIÓN:___________________________________________
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F. ABDOMEN

 INSPECCIÓN:______________________________________________
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 AUSCULTACIÓN:___________________________________________
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 PERCUSIÓN:_______________________________________________
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 PALPACIÓN:_______________________________________________
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5. SINDROMES

1.______________________________________________________________
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