MODELO DE HISTORIA CLNICA

Ctedra de Semiologa
FACULTAD DE FARMACIA Y BIOQUIMICA
Fecha: / / . ALUMNO: ______________________________

TEMA DE INVESTIGACION :____________________________

DATOS PERSONALES
Apellido y Nombre: ____________________________________________Edad___________________________.
Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupacin: _______________.
Domicilio: _____________________________________________________________. TE: ________________.
Residencia: _________________________________________________________________________________ .
MOTIVO DE CONSULTA
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2.
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ANTECEDENTES DE LA ENFERMEDAD ACTUAL

1- Sntomas Generales: fiebre,
perdida de peso, astenia, fatiga, otros. ___________________________________________________________________________
2 - Piel y faneras: prurito, lesiones
primarias y secundarias,
alteraciones de uas y cabellos,
otros.
3 - TCS: edema, tumoraciones,
otros.
4 - SOMA: dolor, tumefaccin,
fuerza muscular, limitacin del
movimiento, otros.
5 - Ap. Cardiovascular: disnea,
palpitaciones, dolor precordial,
sncope, claudicacin intermitente,
otros.
6 - Ap.Respiratorio: epistaxis, tos,
expectoracin, hemptisis, dolor
torcico, cianosis, otros.
7 - Ap. Digestivo: halitosis, disfagia, ______________________________________________________________
regurgitacin, acidez, pirosis,
nauseas y vmitos, hematemesis,
alteraciones del hbito intestinal,
otros.
ANAMNESIS SISTEMICA
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8 - Ap. Genitourinario: disuria,
polaquiuria, nicturia, hematuria,
incontinencia, dolor, alteraciones
ciclo menstrual, alteraciones
sexuales, otros
9 - Sistema Nervioso: cefalea,
mareos, vrtigo, sensibilidad,
motricidad, temblor, alteraciones de
la visin, audicin, otros.
PERSONALES
HABITOS
PATOLOGICOS
FAMILIARES
1-Inspeccin General
2-Mediciones y Controles
SIGNOS VITALES
3-Piel y faneras: color, turgor,
elasticidad, humedad,
temperatura, lesiones primarias,
lesiones secundarias, pelos y uas.
4-TCS: cantidad, distribucin,
vrices, circulacin colateral, edema, ___________________________________________________________________________
adenopatas, otros.
5-SOMA: huesos (conformacin y
sensibilidad), msculos,
articulaciones.
1-Cabeza y cuello: crneo, odos,
ojos, nariz, boca. Tiroides, cartidas, ___________________________________________________________________________
PVC, otros.
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ANTECEDENTES PERSONALES
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EXAMEN FISICO
Examen General
Estado de conciencia: __________________________________________.
Actitud: _____________________________________________________.
Decbito: ____________________________________________________.
Marcha: _____________________________________________________.
Facie: _______________________________________________________.
FC: _____________ TA: _____________ FR: __________ T: _______.
Peso: ___________ Altura: ___________ IMC: ___________________.
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Examen Segmentario
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2-Ap. Respiratorio: inspeccin, ___________________________________________________________________________
expansin de V y B, vibraciones ___________________________________________________________________________
vocales, claro pulmonar, murmullo ___________________________________________________________________________
vesicular, auscultacin de la voz, ___________________________________________________________________________
ruidos patolgicos, otros.
3-Mamas. ____________________________________________________________
4-Ap. Cardiovascular: precordio ___________________________________________________________________________
(inspeccin, zona mximo impulso, ___________________________________________________________________________
latidos patolgicos, ruidos cardacos ___________________________________________________________________________
normales y patolgicos), pulsos ___________________________________________________________________________
perifricos, auscultacin arterial,
otros.
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5-Abdomen: inspeccin, ___________________________________________________________________________
auscultacin, palpacin superficial y___________________________________________________________________________
profunda, puntos dolorosos, orificios___________________________________________________________________________
herniarios, percusin, otros. __________________________________________________________________________
6-Ap. Genitourinario: puo ___________________________________________________________________________
percusin, puntos reno-ureterales, ___________________________________________________________________________
examen genital, tacto rectal, otros. ______________________________
7-Sistema Nervioso: pares craneales. ___________________________________________________________________________
Motricidad (tono, trofismo, ___________________________________________________________________________
motricidad voluntaria y fuerza ___________________________________________________________________________
muscular). Reflejos superficiales y
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profundos. Sensibilidad (superficial
y profunda).
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Funcin cerebelosa. ___________________________________________________________________________
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LISTADO DE PROBLEMAS
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LISTADO DE DIAGNOSTICOS
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EXAMENES COMPLEMENTARIOS SOLICITADOS

TRATAMIENTO INICIAL