Historia Clínica Todo

UNIVERSIDAD DE AQUINO BOLIVIA
CARRERA DE FISIOTERAPIA Y KINESIOLOGIA

HISTORIA CLNICA DE FISIOTERAPIA
ESPECIALIDAD: LESIN DE LOS PARES OCULOMOTORES
ANAMNESIS
FILIACIN
__________________________________________________________________
Apellido paterno
Apellido materno
Nombre
Fecha de nacimiento: __________________________Edad:_________________

Estado civil: ________________________________ Gnero: M ( )
F( )
Profesin y/o ocupacin: ______________________________________________

Domicilio: _______________________________Telfono:___________________
Fecha de consulta: ______________________________________
Fecha de evaluacin inicial: _______________________________
Fecha de evaluacin final: _________________________________
Datos obtenidos del: Paciente (
) Padre (
) Madre (
) Apoderado (
Otros____________________________
Nombre del Padre:
_________________________________________________________________
Nombre de la madre:
_________________________________________________________________
MOTIVO DE CONSULTA:
__________________________________________________________________
__________________________________________________________________
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ENFERMEDAD ACTUAL:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ANTECEDENTES FAMILIARES:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ANTECEDENTES PATOLGICOS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ANTECEDENTES NO PATOLGICOS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
GRUPO JENOPIPA

SIGNOS VITALES
Peso: ________________Talla:_____________ Temperatura:________________
Presin Arterial: ________________ Frecuencia Respiratoria: ________________
Frecuencia Cardiaca: ____________________ Pulso:_______________________
DESVIACIONES DEL GLOBO OCULAR
Ojo derecho
Ojo izquierdo
Endodesviacin
Exodesviacin
Hiperdesviacin
Hipodesviacin
Desviacin diagonal hacia arriba
Desviacin diagonal hacia abajo
FUERZA MUSCULAR
Musculo
Recto superior
Recto inferior
Recto externo
Recto interno
Oblicuo superior
Oblicuo inferior
Buena
Regular
Mala
REFLEJOS
Reflejo
Mentoniano
Acstico palpebral
Ausente
Presente
GRUPO JENOPIPA

DIAGNOSTICO CLNICO:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
DIAGNOSTICO KINESICO:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
OBJETIVOS DE TRATAMIENTO
CORTO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MEDIANO PLAZO
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
LARGO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ABORDAJE TERAPEUTICO
CORTO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MEDIANO PLAZO
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
LARGO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
PRONSTICO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
OBSERVACIONES
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
CONCLUSIN
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
RECOMENDACIONES
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ESPECIALIDAD: LESIN DEL TRIGEMINO
ANAMNESIS
GRUPO JENOPIPA

FILIACIN
__________________________________________________________________
Apellido paterno
Apellido materno
Nombre

F( )

) Padre (
) Madre (
) Apoderado (
Otros____________________________
Nombre del Padre:
_________________________________________________________________
Nombre de la madre:
__________________________________________________________________
MOTIVO DE CONSULTA:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ENFERMEDAD ACTUAL:
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SIGNOS VITALES
GRUPO JENOPIPA

EVALUACION DEL TRIGEMINO:
DOLOR DEL TRIGEMINO TOPOGRAFICAMENTE:
Rama superior
Rama media
Rama inferior
TIPO DE DOLOR:
Taladrante
Punzante
Shock
Urente
INTENSIDAD DEL DOLOR:

ESCALA NUMERICA:
RESULTADO
ESCALA DE WONG:
GRUPO JENOPIPA

FRECUENCIA DEL DOLOR:
TIEMPO DE DOLOR:
TIEMPO
1-10 SEG.
11-30 SEG
31-50 SEG
51-70 SEG
71-90 SEG
91-110 SEG
11-120 SEG
AURA SENSORIAL:
Siente anticipadamente del dolor?
HORMIGEO
ENTUMESIMIENTO
DOLOR
CONSTANTE
OTROS
EVALUACION DE TROFISMO CUTANEO:

PIEL BRILLANTE
PIEL LISA
CIANOSIS
PALIDEZ
RUGOSIDADES
HUMECTACION
ESCALA DE EVALUACION DEL TONO FACIAL:
GRAD
TONO
O
-0
-1
Normal
Hipotona Ligera
RESP.
GRUPO JENOPIPA

-2
+1
+2
Hipotona Fuerte
Hipertona Ligera
Hipertona Fuerte
EVALUACION DE SENCIBILIDAD:
TERMICA:
TACTIL:
Frio
Liso
DOLOROSA:
Calor
spero
Punzante
Simple tacto
Presin
DIAGNOSTICO CLNICO:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
GRUPO JENOPIPA

CORTO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MEDIANO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
LARGO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
CORTO PLAZO
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MEDIANO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
LARGO PLAZO
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
PRONSTICO
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
OBSERVACIONES
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
CONCLUSIN
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
RECOMENDACIONES
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ESPECIALIDAD: LESIN DEL FACIAL
ANAMNESIS
FILIACIN
__________________________________________________________________
Apellido paterno
Apellido materno
Nombre

F( )

GRUPO JENOPIPA

) Padre (
) Madre (
) Apoderado (
Otros____________________________
Nombre del Padre:
_________________________________________________________________
Nombre de la madre:
_________________________________________________________________
MOTIVO DE CONSULTA:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ENFERMEDAD ACTUAL:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
GRUPO JENOPIPA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SIGNOS VITALES
EVALUACION DE PARALISIS FACIAL
ESCALA DE HOUSE BRACKMAN
GRADO
(NORMAL)
GRADO
GRADO
GRADO
GRADO
GRADO
(DISFUNCION
(DISFUNCION
(DISFUNCION
(DISFUNCION
(PARALISIS
LEVE)
MODERADA)
MODERADAMENTE
SEVERA)
TOTAL)
GRUPO JENOPIPA

SEVERA)
ESCALA DEL TONO FACIAL (0 AL +2)

-0 TONO SIMETRICO Y NORMAL
(NORMOTONIA)
-1 HIPOTONIA LIGERA
-2 HIPOTONIA FUERTE
+1 HIPOTONIA LIGERA
+2 HIPOTONIA FUERTE
ESCALA DE EVALUACION DE SINCINESIAS FACIALES

0 NO HAY SINCINESIAS
1 SINCINESIAS MODERADA
2 SINCINESIA IMPORTANTE
3 SINCINESIA BASTANTE
CONSIDERADA
ESCALA DE FUERZA MUSCULAR

EN REPOSO
EN MOVIMIENTO
0 PARALISIS COMPLEJA
0.5 FASACULACIONES
1 CONTRACCION SIN MOVIMIENTO
1+ PRINCIPIO DE MOVIMIENTO
2 MOVIMIENTO IMPORTANTE SIN SIGNO DE FUERZA
2+ PRIMER SIGNO DE FUERZA
2.5 VARIOS SIGNOS DE FUERZA
3- MOVIMIENTO CASI SIMETRICOS
3 MOVIMIENTO SIMETRICOS
GRUPO JENOPIPA

FUNCION MOTORA A TRAVEZ DE RDENES VERBALES

o
o
o
o
o
CIERRE LOS PARPADOS

MANDE UN BESO
FRUNZA LAS CEJAS
LEVANTE LAS CEJAS
CARA TRISTE
o
o
o
o
o
FRUNZA LA NARIZ
FRUNZA LAS CEJAS
INFLE LOS CACHETES
SONRA
MUERDA
GRUPO JENOPIPA
o
o
o
SIGNOS DE LA PARALISIS
o
o
o
FU
o
E
o
LAGO
o
EXT
o
T
o
DI
o
ASI
MA
PI
FTALM
ROPI
ME
DO
ON
TRI
DE
SI
PIP
D
E
B
E
L
L
o
o
FUNCION SENSITIVA
PRESENTE
AUSENTE
SENSIBILIDAD
CALOR
FRIO
TERMICA
SENSIBILIDAD
TACTIL
SENSIBIBILIDA
D DOLOROSA
o
o
o
o
o
o
o
o
o
o
Evaluacin de reflejos
PRESENTE
MENTONIANO
OGLABELAR
NASO-PALPEBRAL
ACSTICO-FACIAL
AUSENTE
o
o
o
o
o
o
o
o
o
o
o
AFECCION TOPOGRAFICA
________________________________________________________________
____________________________________________________________
________________________________________________________DIAG
NOSTICO CLNICO:
o
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________
CORTO PLAZO
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________
o
o
MEDIANO PLAZO
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________
o
LARGO PLAZO
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________
CORTO PLAZO
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
________________________________________________
o
o
MEDIANO PLAZO
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
________________________________________________
o
LARGO PLAZO
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
________________________________________________
PRONSTICO
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
______________________________
OBSERVACIONES
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________
o
CONCLUSIN
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
________________________________________________
RECOMENDACIONES
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________

Historia Clínica Todo

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Historia Clínica Todo

Încărcat de

Drepturi de autor:

Formate disponibile

UNIVERSIDAD DE AQUINO BOLIVIA

CARRERA DE FISIOTERAPIA Y KINESIOLOGIA

Fecha de nacimiento: __________________________Edad:_________________

Profesin y/o ocupacin: ______________________________________________

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

HISTORIA CLNICA DE FISIOTERAPIA

UNIVERSIDAD DE AQUINO BOLIVIA

Fecha de nacimiento: __________________________Edad:_________________

Profesin y/o ocupacin: ______________________________________________

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

INTENSIDAD DEL DOLOR:

UNIVERSIDAD DE AQUINO BOLIVIA

EVALUACION DE TROFISMO CUTANEO:

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

HISTORIA CLNICA DE FISIOTERAPIA

Fecha de nacimiento: __________________________Edad:_________________

Profesin y/o ocupacin: ______________________________________________

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

UNIVERSIDAD DE AQUINO BOLIVIA

ESCALA DEL TONO FACIAL (0 AL +2)

ESCALA DE EVALUACION DE SINCINESIAS FACIALES

ESCALA DE FUERZA MUSCULAR

UNIVERSIDAD DE AQUINO BOLIVIA

FUNCION MOTORA A TRAVEZ DE RDENES VERBALES

CIERRE LOS PARPADOS

S-ar putea să vă placă și

Fecha de nacimiento: __________Edad:_

Fecha de nacimiento: __________Edad:_

Fecha de nacimiento: __________Edad:_