UNIVERSIDAD DEL ZULIA

FACULTAD DE MEDICINA
ESCUELA DE MEDICINA
CATEDRA DE SEMIOLOGIA Y PATOLOGIA MDICA
HOSPITAL CENTRAL DR. URQUINAONA
HISTORIA CLINICA INTEGRAL
DATOS DE IDENTIFICACION
NOMBRE Y APELLIDO:
EDAD:
SEXO:
GRUPO ETNICO:
OCUPACION:
LUGAR Y FECHA DE NACIMIENTO:
DIRECCION ACTUAL:
LUGAR DE RESIDENCIA HABITUAL (procedencia):
OTROS DATOS DE INTERES:
DATOS APORTADOS POR:
MOTIVO DE CONSULTA
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ENFERMEDAD ACTUAL
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REVISION DE SISTEMAS Y ANTECEDENTES PATOLOGICOS

PSIQUICO
NERVIOSISMO: ______________________________________________________________________________________
ANSIEDAD:__________________________________________________________________________________________
PREOCUPACIONES (personales, familiares, sociales, econmicas, sexuales):
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CALIDAD DE RELACION CON LOS DEMAS: _________________________________________________________________
GRADO DE COLABORACION CON TRABJOS EN GRUPO: _______________________________________________________
ENFERMEDAD MENTAL RECONOCIDA O CAMBIOS DE CONDUCTA:
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MEMORIA O JICIO: ___________________________________________________________________________________

CABEZA
CEFALEA (ubicacin, carcter e irradiacin, frecuencia, acompaantes, tratamiento):
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TRAUMAS O CIRUGIAS CRANEANAS Y SUS SECUELAS:
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OJOS
ALTERACIONES DE LA VISION:
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DOLOR Y/O ARDOR: ____________________________________________________________________________________________
EPIFORA: _____________________________________________________________________________________________________
VISION BORROSA: ______________________________________________________________________________________________
DIPLOPIA: ____________________________________________________________________________________________________
FOTOFOBIA: ___________________________________________________________________________________________________
ESCOTOMAS: __________________________________________________________________________________________________
USO DE ANTEOJOS: _____________________________________________________________________________________________
TIPO DE VISION DE REFRACCION: __________________________________________________________________________________
OPERACIONES: ________________________________________________________________________________________________
ACCIDENTES: __________________________________________________________________________________________________
OIDOS
OTALGIA: _____________________________________________________________________________________________________
SECRECIONES (serosas, mucosas, purulentas)________________________________________________________________________
OTORREA: ____________________________________________________________________________________________________
OTORRAGIA: __________________________________________________________________________________________________
ACUFENOS O TINNITUS:
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ALTERACIONES EN LA AUDICION: _________________________________________________________________________________
SORDERA: ____________________________________________________________________________________________________
OPERACIONES OTOLOGICAS Y SUS CONSECUENCIAS (miringotoma):
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NARIZ Y SENOS PARANASALES

SECRECIONES NASALES O POST-NASALES (serosas, mucosas, purulentas):
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EPISTAXIS: ____________________________________________________________________________________________________
OBSTRUCCION NASAL: __________________________________________________________________________________________
RINITIS ALERGICA RECONOCIDA: __________________________________________________________________________________
SINUSITIS: ____________________________________________________________________________________________________
ANTECEDENTES DE ULCERACIONES Y OPERACIONES:
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ALTERACIONES DE LA OLFACION (hiposmia, anosmia, parosmia, cacosmia ):
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DOLOR EN SENOS PARANASALES: _________________________________________________________________________________
FRACTURAS: __________________________________________________________________________________________________
BOCA Y GARGANTA
ULCERACIONES O ERUPCIONES EN LOS LABIOS:
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GINGIVORRAGIA: _______________________________________________________________________________________________
DOLOR EN LA BOCA O LENGUA:
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ODONTALGIAS: ________________________________________________________________________________________________
CARIES DENTALES: ______________________________________________________________________________________________
CONDICIONES HIGIENICAS DE LA BOCA: ____________________________________________________________________________
HALITOSIS: ____________________________________________________________________________________________________
DIENTES FALTANTES: ___________________________________________________________________________________________
PROTESIS (fijas, mviles, completas): _______________________________________________________________________________
GLOSITIS: _____________________________________________________________________________________________________
TONSILITIS: ___________________________________________________________________________________________________
ODINOFAGIA:
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DISFAGIA: ____________________________________________________________________________________________________
CAMBIOS EN LA VOZ (voz bitonal, ronquera, disfona, afona):
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ACOTASIONES:_________________________________________________________________________________________________
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CUELLO
DOLOR:
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AUMENTO DE VOLUMEN (bocio, adenomegalias, abscesos):
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LIMITACION DE LOS MOVIMIENTOS:
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CARACTERISTICAS FISICAS:
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APARATO RESPIRATORIO
DOLOR TORACICO:
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DOLOR PLEURAL:
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DISNEA:______________________________________________________________________________________________________
TOS: _________________________________________________________________________________________________________
HEMOPTISIS: __________________________________________________________________________________________________
EXPECTORACION (mucosa, serosa o purulenta):
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SIBILANCIA (antecedentes de asma bronquial):
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NEUMONIA: ___________________________________________________________________________________________________
ANTECEDENTES TUBERCULOSOS (manchas en los pulmones o tratamiento prolongados, fistulas en la pared torcica):
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VOMICA: _____________________________________________________________________________________________________
EFINSEMA RECONOCIDO: ________________________________________________________________________________________
APARATO CARDIOVASCULAR
DOLOR PRECORDIAL O RETROESTERNAL: ___________________________________________________________________________
ANTECEDENTES DE ANGOR PECTORIS O DE INFARTO MIOCARDICO:
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DISNEA EVOLUTIVA A LOS ESFUERZOS: _____________________________________________________________________________
ORTOPNEA: ___________________________________________________________________________________________________
DISNEA PAROXISTICA NOCTURNA: _________________________________________________________________________________
EDEMA AGUDO DE PULMON: _____________________________________________________________________________________
FIEBRE REUMATICA: ____________________________________________________________________________________________
HIPERTENSION ARTERIAL RECONOCIDA: ____________________________________________________________________________
PALPITACIONES: _______________________________________________________________________________________________
CIANOSIS: ____________________________________________________________________________________________________
TAQUICARDIA:_________________________________________________________________________________________________
SINCOPE: _____________________________________________________________________________________________________
SOPLOS CARDIACOS: ____________________________________________________________________________________________
DOLOR O O ULCERACIONES EN MIEMBROS INFERIORES (claudicacin intermitente) :
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FRIALDAD EN MIEMBROS INFERIORES: _____________________________________________________________________________
VARICES: _____________________________________________________________________________________________________
ANTECEDENTES DE PICADURAS POR REDUVIDEOS: ____________________________________________________________________

APARATO DIGESTIVO
APETITO:
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DOLOR ABDOMINAL (intestinal, biliar, gstrico, pancretico) :
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PIROSIS:______________________________________________________________________________________________________
LLENURA POSTPRANDIAL:________________________________________________________________________________________
INDIGESTION (dispepsia):________________________________________________________________________________________
REGURGITACION: ______________________________________________________________________________________________
VOMITOS:
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HEMATEMESIS:________________________________________________________________________________________________
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INTOLERANCIA A LOS ALIMENTOS:
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ICTERICIA:
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COLICOS HEPATICOS (litiasis, Aparicin, Lugar):
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AUMENTO DE VOLUMEN DEL ABDOMEN:
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ANTECEDENTES DE HEPATITIS O ABSCESO HEPATICO:
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DISFAGIA: ____________________________________________________________________________________________________
CAMBIOS EN EL PATRON Y EN EL TIPO DE EVACUACIONES (Diarrea, Constipacin, Melena, Heces pastosas, Enterorragia, Anorragia) :
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FLATULENCIAS: ________________________________________________________________________________________________
PARASITOSIS RECONOCIDAS (AMIBIASIS):
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DISENTERIA:
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TENESMO Y PUJOS RECTALES:
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HEMORROIDES:
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PANCREATITIS RECONOCIDA: _____________________________________________________________________________________
HEMATOQUECIA:
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APARATO GENITO URINARIO

DOLOR LUMBAR, SUPRAPUBICO O PERINEAL:
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INCONTINENCIA O RETENCION URINARIA:
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PATRON DE DIURESIS:
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NICTURIA: ____________________________________________________________________________________________________
POLAQUIURIA: _________________________________________________________________________________________________
POLIURIA: ____________________________________________________________________________________________________
OLIGURIA: ____________________________________________________________________________________________________
ANURIA:______________________________________________________________________________________________________
DISURIA: _____________________________________________________________________________________________________
TENESMO Y PUJOS VESICALES: ____________________________________________________________________________________
ENURESIS: ____________________________________________________________________________________________________
MICCION IMPERIOSA: ___________________________________________________________________________________________
CAMBIOS EN EL CHORRO DE ORINA (goteo terminal, retardo para comenzar a orinar):
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HEMATURIA: __________________________________________________________________________________________________
PIURIA:_______________________________________________________________________________________________________
COLURIA: _____________________________________________________________________________________________________
DOLORTESTICULAR (VARICOCELE):
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NEFRITIS O INFECCIONES URINARIAS RECONOCIDAS:
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INFERTILIDAD (OLIGOSPERMIA O AZOOSPERMIA RECONOCIDAS):
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ENFERMEDADES VENEREAS (SIFILIS, GONORREA, CHANCRO BLANDO, HERPES GENITAL, CONTACTOS POR AFECTADOS CON S.I.D.A.):
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ANTECEDENTES GINECOLOGICOS Y OBSTETRICOS

MENARCA: ____________________________________________________________________________________________________
DURACION: __________________________________________________________________________________________________
INTERVALOS Y CARACTERISTICAS DE LAS MENSTRUACIONES: ______________________________________________________
HIPERMENORREA:______________________________________________________________________________________________
HIPOMENORREA:_______________________________________________________________________________________________
POLIMENORREA: _______________________________________________________________________________________________
OLIGOMENORREA: _____________________________________________________________________________________________
AMENORREA: _________________________________________________________________________________________________
METRORRAGIA: _______________________________________________________________________________________________
MENOMETRORRAGIA: __________________________________________________________________________________________
DISMENORREA: _______________________________________________________________________________________________
FECHA DE ULTIMA REGLA: _______________________________________________________________________________________
EMBARAZOS (EVOLUCION Y COMPLICACIONES): _____________________________________________________________________
ABORTOS: ____________________________________________________________________________________________________
TOXEMIA GRAVIDICA: __________________________________________________________________________________________
FLUJO VAGINAL (PURULENTO, SANGUINOLENTO, LEUCORREA): _________________________________________________________
SANGRAMIENTO POSTCOITAL: ___________________________________________________________________________________
DISPAREUNIA: _______________________________________________________________________________________________
DISFUNCION ORGASMICA: ______________________________________________________________________________________
SINTOMATOLOGIA DE LA MENOPAUSIA (OLEADAS DE CALOR, CRISIS DE SUDORACION, CAMBIOS DE CARCTER):
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EDAD DE INCIO DE LA MENOPAUSIA: ______________________________________________________________________________
CLIMATERIO: __________________________________________________________________________________________________
USO DE ANTICONCEPTIVOS: ______________________________________________________________________________________
OPERACIONES GINECOLOGICAS Y SU EVOLUCION: ___________________________________________________________________
NEUROMUSCULAR
DOLOR, NEURALGIA: _________________________________________________________________________________________
RADICULALGIA: _______________________________________________________________________________________________
DOLOR HOMBRO-MANO: _______________________________________________________________________________________
PARESTESIA: _______________________________________________________________________________________________
ANESTESIA: _______________________________________________________________________________________________
HIPOESTESIA: _______________________________________________________________________________________________
HIPERESTESIA: _______________________________________________________________________________________________
PARESIA: _______________________________________________________________________________________________
PARALISIS: _______________________________________________________________________________________________
HEMIPLEJIA: _______________________________________________________________________________________________
DIPLEJIA BRAQUIAL: ___________________________________________________________________________________________
PARAPLEJIA: _______________________________________________________________________________________________
ATROFIA DE MIEMBROS: _______________________________________________________________________________________
A.C.V.A O POLIOMELITIS RECONOCIDAS: ________________________________________________________________________
TEMBLOR, CONVULSIONES, TICS, SHOCK:____________________________________________________________________________
OBNUBILACION: _______________________________________________________________________________________________
SOMNOLENCIA: _______________________________________________________________________________________________
ESTUPOR: _______________________________________________________________________________________________
COMA: _______________________________________________________________________________________________
INSOMNIO: _______________________________________________________________________________________________
LIPOTIMIAS: _______________________________________________________________________________________________
MAREOS, VERTIGO, SENSACION DE INESTABILIDAD:___________________________________________________________________

ARTICULACIONES Y HUESOS
ARTRALGIA: _______________________________________________________________________________________________
DOLOR PERIARTICULAR: ________________________________________________________________________________________
ARTRITIS (DOLOR, TUMEFACCION, CALOR Y RUBOR ARTICULARES):
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LIMITACION DE LA EXCURSION ARTICULAR: _________________________________________________________________________
DEFORMIDADES ARTICULARES: __________________________________________________________________________________
NODULOS SUBCUTANEOS: ______________________________________________________________________________________
ERITEMA EN ALAS DE MARIPOSA: _________________________________________________________________________________
PSORIASIS: ____________________________________________________________________________________________________
REUMATISMO: _______________________________________________________________________________________________
DEFORMIDADES DE LOS HUESOS: ________________________________________________________________________________
FRACTURAS CON TRAUMAS MINIMOS: ____________________________________________________________________________
OSTEOPOROSIS: _______________________________________________________________________________________________
LORDOSIS Y DISMINUCION DE ESTATURA EN ANCIANOS: _______________________________________________________________
DOLOR EN LA COLUMNA VERTEBRAL: _____________________________________________________________________________
PIEL Y ANEXOS
ERITEMA: _____________________________________________________________________________________________________
ERUPCIONES: _______________________________________________________________________________________________
PAPULAS:_____________________________________________________________________________________________________
VESICULAS: _______________________________________________________________________________________________
ULCERAS: _______________________________________________________________________________________________
COSTRAS: _______________________________________________________________________________________________
PLACAS: _______________________________________________________________________________________________
CAMBIOS DE COLORACION Y TEXTURAS: ___________________________________________________________________________
VITILIGO: _______________________________________________________________________________________________
CARATE: _______________________________________________________________________________________________
MANCHAS CAF CON LECHE: ___________________________________________________________________________________
HIPERPIGMENTACION: ____________________________________________________________________________________
PIEL SECA: _______________________________________________________________________________________________
HIPERQUERATOSIS: ____________________________________________________________________________________________
URTICARIA RONCHAS: ________________________________________________________________________________________
PRURITO: _______________________________________________________________________________________________
HIPERTRICOSIS: _______________________________________________________________________________________________
HIRSUTISMO: _______________________________________________________________________________________________
ALOPECIA: _______________________________________________________________________________________________
PERDIDA DEL VELLO CORPORAL: _________________________________________________________________________________
CAMBIOS TROFICOS EN LAS UAS: _______________________________________________________________________________
ONICOMICOSIS: _______________________________________________________________________________________________
PARONIQUIA: _______________________________________________________________________________________________
CAIDA DE LAS UAS: ___________________________________________________________________________________________
OTROS: _______________________________________________________________________________________________

ENDOCRINO Y NUTRICIONAL

HISTORIA NUTRICIONAL: _______________________________________________________________________________________

DESARROLLO PONDOESTATURAL (CORRELACIONARLO CON LA FAMILIA CUANDO SEA PERTINENTE):
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DESARROLLO DE LOS CARACTERES SEXUALES: _______________________________________________________________________
TELARCA: _____________________________________________________________________________________________________
PUBARCA: ____________________________________________________________________________________________________
MENARCA: ____________________________________________________________________________________________________
EYACULACIONES ESTANDO DORMIDO: ____________________________________________________________________________
GINECOMASTIA: _______________________________________________________________________________________________
CAMBIOS DEL VELLO Y LA VOZ: ___________________________________________________________________________________
PUBERTAD RETARDADA,PUBERTAD PRECOZ:_________________________________________________________________________
INTERSEXUALIDAD : ___________________________________________________________________________________________
GIGANTISMO:_________________________________________________________________________________________________
ENANISMO: ___________________________________________________________________________________________________
MANIFESTACIONES DE DIABETES MELLITUS O DIABETES RECONOCIDA: ___________________________________________________
HIPER O HIPOFUNCION TIROIDEA: ________________________________________________________________________________
TIROIDITIS: ___________________________________________________________________________________________________
OTROS BOCIOS NO TOXICOS: ____________________________________________________________________________________
HIPER O HIPOFUNCION SUPRARRENAL: ___________________________________________________________________________
INSUFICIENCIA OVARICA O TESTICULAR: ___________________________________________________________________________
DISFUNCION ORGASMICA Y ERECTIL: ______________________________________________________________________________
PERDIDA DEL APETITO SEXUAL: __________________________________________________________________________________
SEQUEDAD DE LA VAGINA: _______________________________________________________________________________________
HIPOTROFIA MAMARIA Y TESTICULAR: _____________________________________________________________________________
AMENORREA: _________________________________________________________________________________________________
SINTOMATOLOGIA DE HIPOFUNCION POLIGLANDULAR (PANHIPOPITUITARISMO): __________________________________________
HIPERFUNCION HIPOFISARIA: ____________________________________________________________________________________
GALACTORREA CON AMENORREA: ________________________________________________________________________________
GIGANTISMO: ___________________________________________________________________________________________
ACROMEGALIA: ________________________________________________________________________________________________
DISFUNCION NEUROHIPOFISARIA: _________________________________________________________________________________
DIABETES INSIPIDA O SECRECION INAPROPIADAMENTE ELEVADA DE H.A.D. :
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TRASTORNOS DEL METABOLISMO DEL CALCIO (ESPASMOS, NEFROLITIASIS, TETANIA):
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HEMATOPOYETICO
TIPO DE SANGRE: ______________________________________________________________________________________________
TRANSFUSIONES PREVIAS: _______________________________________________________________________________________
ANEMIA RECONOCIDA Y TRATAMIENTO: ____________________________________________________________________________
PARASITOSIS INTESTINALES RECONOCIDAS: _________________________________________________________________________
ANEMIA ACOPLADA A ICTERICIA: _________________________________________________________________________________
ADENOMEGALIAS: ______________________________________________________________________________________________
FENOMENOS HEMORRAGICOS SIN CAUSA APARENTE: _______________________________________________________________
PETEQUIAS: ______________________________________________________________________________________________
EQUIMOSIS: ___________________________________________________________________________________________________
HEMATOMAS: _________________________________________________________________________________________________
EPISTAXIS:____________________________________________________________________________________________________
INFECTO-CONTAGIOSAS
FIEBRE TIFOIDEA: ______________________________________________________________________________________________
VARICELA: ____________________________________________________________________________________________________
PAROTIDITIS: __________________________________________________________________________________________________
RUBEOLA: ____________________________________________________________________________________________________
SARAMPION: __________________________________________________________________________________________________
DENGUE: _____________________________________________________________________________________________________
FIEBRE AMARILLA: ______________________________________________________________________________________________
DIFTERIA: _____________________________________________________________________________________________________
TOSFERINA: ___________________________________________________________________________________________________
VACUNACIONES (P.F.D, B.C.G., ANTIVARIOLICA, ANTITIFICA, ANTIPOLIO, ANTITETANICA, TRIPLE):
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OPERACIONES, ACCIDENTES Y HOSPITALIZACIONES
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ANTECEDENTES PERSONALES
HABITOS (CEFICOS, TABAQUICOS, ALCOHOLICOS, CHIMO, MEDICAMENTOSOS Y/O DROGADICCION, ESPECIFICAR CANTIDADES Y
FRECUENCIA): ___________________________________________________________________________________________________
SUEO: ______________________________________________________________________________________________
PESO HABITUAL: ______________________________________________________________________________________________
TRABAJO: _____________________________________________________________________________________________________
VIVIENDA (TIPO DE CONSTRUCCION, NUMERO DE AMBIENTES, DISPOSICION DE AGUAS BLANCAS Y NEGRAS, SANEAMIENTO
AMBIENTAL: ____________________________________________________________________________________________________
ANTECEDENTES FAMILIARES
ESTADO DE SALUD O EDAD Y CAUSA DE MUERTE DE LOS PADRES Y HERMANOS:
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ANTECEDENTES DE DIABETES, HIPERTENSION, CORONARIOPATIAS, NEUMOPATIAS,CANCER,JAQUECA,EPILEPSIA,ICTERICIA,AETRITIS,
NEFROPATIAS, ENFERMEDADES MENTALES:
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EXAMEN FISICO
SIGNOS VITALES
TENSION ARTERIAL