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Historia Clnica

Tipo:
Datos de identificacin:
-Nombres y Apellidos:
-Edad: _________ -C.I:_________________________ -Sexo: ____________________
-Lugar y fecha de nacimiento: ________________________________________________
-Profesin: ____________________ -Ocupacin: ________________________________
-Raza: _______________________ -Religin: __________________________________
-Estado civil: __________________ -Precedencia por estado: ______________________
-Direccin y nmero telefnico: ______________________________________________

Datos del acompaante:


-Nombres y apellidos: ______________________________________________________
-Parentesco: ______________________
-Direccin y nmero telefnico: ______________________________________________

Motivo de consulta

Enfermedad actual:

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Antecedentes personales:
-Caf: __________________________________________________________________
-Tabaco (chimo): __________________________________________________________
-Alcohol: ________________________________________________________________
-Drogas (licitas e ilcitas): ___________________________________________________
-Sexual: _________________________________________________________________
-Alimentacin: ____________________________________________________________
-Actividad fsica: __________________________________________________________
-Sueo: _________________________________________________________________
Enfermedades infecciosas:
-ETS: __ -Parotiditis: __ -Influenza: __ -Zika: __ -Hepatitis: __ -TBC: __ -Neumonia: __
-H1N1: __ -Varicela: __ -Lepra: __ -Molusco: __ -Fiebre amarilla: ___ -Sarampin: __
-Difteria: __ -Dengue: ___ -Rubeola: __ -Chikungunya: ___

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Enfermedades alrgicas y asma:
-Asma: __ -Enfermedad del sueo: __ -Broncoespasmo: __ -Rinosinusitis: __
-Alergia a medicamentos: ___ -Alergia a alimentos: __
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Operaciones y accidentes:
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Enfermedades reconocidas:
-Dengue: __ -HTA: __ -Diabetes: __ -Enfermedades reumatoideas: __ -Artritis: __
-Lupus: __ -Dermatopatia: __ -Enfermedades renales: __ -Cncer: __
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Peso usual: ____________________
Condiciones higinicas personales:
-Bao: __________________________________________________________________
-Aseo bucal: _____________________________________________________________
Vivienda:
-Tipo de vivienda: ______________ -Techo: _______________ -Paredes: ____________
-Piso: ________________ -Ambientes: ________________________________________
-Servicios (agua): __________ -Miembros de la casa: ______________

Antecedentes familiares:

Mujer

Hombre Obesidad

Diabetes

HTA.

+Difunto

Revisin por sistema:

-Psquicos: ______________________________________________________________
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-Cabeza:
Cefalea (Alicia): ____________________________________________________________
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Ojos (dolor, inflamacin y trastorno de la visin) ___________________________________________
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Odos (otrorragia, otalgia, otitis, acucia): _______________________________________________
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Nariz y senos paranasales (dolor nasal, aumento de vlm, rinorragia, Rinosinusitis, trastornos de la olfaccin):
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Boca y garganta (prdidas dentales, ortodoncia, gingivorragia, periodontitis, aftas, ulceraciones, odinofagia, caries,
halitosis):__________________________________________________________________
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-Cuello (aumento de vlm, edema, dolor, movilidad): ________________________________________
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-Columna (dolor, movilidad): _________________________________________________________________________
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-Respiratorio (dolor, disnea, tos-expectoracin, hemoptisis, disfona, cianosis): _______________________

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-Cardiovasculares (dolor, disnea, edema, palpitaciones): ___________________________________
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Examen fsico:

-Signos vitales:
Peso: ___________ Talla: _____________ ndice de masa corporal: ________________

B der.

B izq.

T.A:
F.C:
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Pulso central: _____________

Frecuencia respiratoria:
________________________

Pulso perifrico:
Derecho

Izquierdo

P. temporal
P. carotideo
P. axilar
P. braquial
P. radial
P. inguinal
P. tibial posterior
p. malolo exterior.
-Apariencia general:
Sexo: _______ Raza: ____________ Edad aparente: ___________ Estatura: ________
Proporciones: ____________________________________________________________
Color de piel: _____________________________________________________________
Dificultad del lenguaje: _____________________________________________________
Elasticidad: ______________________________________________________________

-Cabeza:
Inspeccin:
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Palpacin:
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Ojos: ___________________________________________________________________
Cejas: _____________________________________________________________
Ojos: ______________________________________________________________
Hendidura palpebral: __________________________________________________
Insercin de las pestaas: ______________________________________________
Conjuntiva: __________________________________________________________
Esclertica: _________________________________________________________
Iris: _______________________________________________________________
Pupila: _____________________________________________________________
Agudeza visual: ______________________________________________________
Movimientos oculares: _________________________________________________
Campo visual: ________________________________________________________
Fondo de ojo: ________________________________________________________
Visin a color: ________________________________________________________
Nariz (simetra, fosas nasales, rinoplastia anterior, evaluacin del IPar): ____________________________________
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Odos: __________________________________________________________________
Prueba audiometrica: __________________________________________________
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Prueba de Weber: ____________________________________________________
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Boca: __________________________________________________________________
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Comisura: ____________________________________________________________
Mucosa, paladar, vula, amgdalas, lengua: _________________________________
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Cuello (inspeccin y palpacin): __________________________________________________
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