HISTORIA CLNICA PSIQUITRICA

A. Ficha de identificacin.
Expediente no.
Nombre:______________________________________________________
Edad: ______________ Sexo________ Estado civil___________________
Fecha de Nacimiento ____________ Originario
de:____________________
Direccin:_____________________________________________________
Telfonos: casa___________________ trabajo_______________________
Ocupacin:____________________ Puesto _________________________
Escuela ______________________ Escolaridad mxima:_______________
Nivel socioeconmico: ________________ Religin: __________________
Persona o institucin que lo
refiere:________________________________
Nombre del responsable legal:
____________________________________
Fuente de informacin:__________________________________________
Fecha de elaboracin____________________________________________
B. Motivo de consulta.
Acude de manera: ( voluntaria, involuntaria, forzada,
condicionada )
Por presentar: (anotar textualmente lo referido por el paciente):
________
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Padecimiento actual. Cuadro clnico. caracterizado
por:______________
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Que inicia aproximadamente en: (fecha)
____________________________ De manera: (sbita, insidiosa,
incierta ) ___________________________
De caractersticas:(intenso, leve, moderado, variable, recurrente,
permanente) _________________________________________________
____________________________________________________________

Aparentemente desencadenado por:

_______________________________
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Coincidiendo con (eventos significativos):
___________________________
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Que ocasiona: (consecuencias fsicas, emocionales, cognitivas,
sociales)
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Evolucin: (Cronologa hasta el da de hoy)
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A. Antecedentes personales patolgicos

Enfermedades previas: (infecciosas, neurolgicas, metablicas,
txicas, etc)
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Traumatismos craneoenceflicos:
__________________________________
Prdida del conocimiento: (fecha y situacin
descriptiva):_______________
_____________________________________________________________
Crisis convulsivas: _____________________________________________
_____________________________________________________________
caractersticas: ________________________________________________
_____________________________________________________________

Uso y/o abuso de: (alcohol, marihuana, cocana, estimulantes,

sedantes,
hipnticos, otros.)
______________________________________________
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Accidentes: (descripcin y consecuencias):
__________________________
_____________________________________________________________
Cirugas: (descripcin): __________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
B. Antecedentes personales no patolgicos
Alimentacin: (adecuada, inadecuada, suficiente, insuficiente,
etc.) _____________________________________________________________
Desempeo familiar: (tipos de relacin, dinmica interpersonal,
conflictos ms frecuentes)
_______________________________________________
_____________________________________________________________
Desempeo laboral: (adecuado, inadecuado, ascensos, despidos,
inasistencias, puntualidad, etc.)
___________________________________
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Desempeo social: (relaciones interpersonales con amigos,
vecinos, compaeros, subordinados, autoridades):
__________________________
_____________________________________________________________
_____________________________________________________________
Estado de nimo habitual ________________________________________
_____________________________________________________________
Niveles de estrs habitual: (alto, medio, bajo)
_______________________
Hbitos higinicos: (adecuados, inadecuados)
_______________________
Tipo de vida: (sedentario, dinmico, etc.)
__________________________
Hbitos de sueo ______________________________________________

_____________________________________________________________Manej
o del tiempo libre _________________________________________
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Perfil ginecolgico (menarca, dismenorrea, gesta, para, etc.)
___________
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Sexualidad. (inicio, actitud, conflictiva, satisfaccin)
___________________
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C. Antecedentes familiares.
Familiares con trastornos del comportamiento:
parentesco______________
___________________________________________________________________
_______________________________________________________
_____________________________________________________________
Familiares con padecimientos crnicos:
parentesco____________________
_____________________________________________________________
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C. Dinmica familiar
Tipo de relacin entre los miembros de la familia nuclear:
Dependiente Independient Oposicionista Cooperadora
e

Agresiva
Devualuatoria
Displiscente
Voluble
Afectuosa

Cordial
Reforzadora
Emptica
Consistente
Inexpresiva

Intrusiva
Explotadora
Rgida
Pasiva
Jerarquizada

Respetuosa
Generosa
Flexible
Participativa
Desorganizada.

Familiograma:

Descripcin____________________________________________________
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D.Historia del desarrollo.
Embarazo: (planeado, deseado, estado emocional prevaleciente,
accidentes, amenazas de aborto, prematurez, eclampsia, etc):
_____________________________________________________________
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Parto y neonato:________________________________________________
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_____________________________________________________________Histor
ia de maduracin: sostn de cabeza________ sedestacin _________
pedestacin _________ deambulacin
______________________________ c. esfnteres (diurno y
nocturno)___________________________________ lenguaje hablado
_______________________________________________ lenguaje
escrito________________________________________________
socializacin___________________________________________________
_____________________________________________________________
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Historia acadmica: edad de ingreso
_______________________________ reaccin de

separacin___________________________________________
conductas habituales (tpicas y
atpicas)_____________________________
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desempeo acadmico __________________________________________
reprobacin __________________________ promedio ________________
Eventos significativos: (separaciones, prdidas objetales, cambios
de estatus, cambio de domicilio, muertes, etc.)
_________________________
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Historia laboral: (desempeo, productividad, ascensos, despidos,
conflictos con la autoridad, ausentismo, conflictiva interpersonal,
etc.)_____________
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E. Examen mental.
Aspecto: (alio: bueno, regular, malo.)
(higiene)._____________________
_____________________________________________________________
Disposicin: (buena, mala). ______________________________________
Conducta motora: (normal, anormal, disminuda, aumentada,
congruente, incongruente,
etc.)______________________________________________
_____________________________________________________________
_____________________________________________________________
Marcha: ______________________________________________________
Saludo: (cordial, tenso, agresivo, respetuoso, ausente, sincero,
obligado, etc.)
_________________________________________________________

Contacto visual: (adecuado, inadecuado, evasivo, retador, fijo,

variable, etc.)
_________________________________________________________
Estilo de vestimenta: (adecuado, inadecuado; caractersticas)
___________
_____________________________________________________________
Accesorios: (ausentes, escasos, excesivos, adecuados,
inadecuados)______
___________________________________________________________________
_______________________________________________________
Facies: (depresiva, ansiosa, inexpresiva, neurolgica,
etc.)______________
_____________________________________________________________
Lenguaje: (tono de voz, coherencia, congruencia, espontaneidad,
sinceridad, fluidez, amplitud, direccionalidad, claridad, amenidad,
tipos de contenido (describirlos), suspicacias, cinrcunloquios,
muletillas, neologismos, modismos, jerga, pararespuestas, etc.
__________________
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Orientacin en tiempo lugar y espacio:
_____________________________
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Alteraciones
sensoperceptuales____________________________________
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Funciones mentales superiores: (memoria, capacidad de sntesis,
abstraccin, clculo, juicio). ______________________________________
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Autoconcepto _________________________________________________
_____________________________________________________________

Atencin, concentracin _________________________________________

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Conciencia de enfermedad________________________________________
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Contratransferencia:_____________________________________________
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D.Exploracin fsica.
T.A.________________ Temp. ____________ pulso __________________
Cabeza:_______________________________________________________
_____________________________________________________________Fondo
de ojo__________________________________________________
Cuello________________________________________________________
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Trax_____________________________________________________________
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Abdomen_________________________________________________________
_________________________________________________________
Extremidades_____________________________________________________
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R.O.T.________________________________________________________
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Pares craneales________________________________________________
_____________________________________________________________
_____________________________________________________________
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Coordinacin motora, sensibilidad, fuerza y tono muscular,
lateralidad,
equilibrio_________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
________________________________________

E. Exmenes
Psicolgicos:
Personalidad _______________________________________________
Inteligencia ________________________________________________
Proyectivos ________________________________________________
Neuropsicolgicos __________________________________________
Otros _____________________________________________________
De laboratorio:
BH _______________________________________________________
perfil qumico _______________________________________________
perfil ginecolgico ___________________________________________
tiroideas ___________________________________________________
funcionamiento heptico
______________________________________
supresin de dexametasona
___________________________________
niveles de metales pesados
___________________________________
determinacin de sustancias en sangre: txicas y frmacos.
_______________________________________________________________
_____________________________________________________
EGO ______________________________________________________
Antidoping _________________________________________________
Otras _____________________________________________________
De gabinete:
Rx de crneo _______________________________________________
Electroencefalograma_________________________________________
mapeo cerebral ______________________________________________
potenciales evocados _________________________________________
tomografa cerebral (emisin de positrones)
_______________________
resonancia magntica cerebral
_________________________________
polisomnografa _____________________________________________
otras _____________________________________________________

F. Tratamientos previos
(prescripciones, respuesta a tratamientos, automedicacin)
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L. 1. Diagnstico Multiaxial
Eje I (Trastornos mentales y del comportamiento DSM IV)
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Eje II

(Trastornos de personalidad, mecanismos de defensa y caractersticas

desadaptativas de la
personalidad)

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Eje III (Enfermedades mdicas relacionadas)
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Eje IV (Problemas psicosociales y ambientales)
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Eje V (Evaluacin de la actividad global *Escala EEAG)
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L. 2. Diagnstico descriptivo.
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M. Pronstico _______________________________________________
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N. Plan teraputico
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O. Evolucin
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Mdico que elabor

Profesional

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Firma

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Cdula

Nombre y firma del mdico que elabora

cdula prof.