SEMIOLOGIA

HISTORIA CLINICA ACADEMICA.

ESPINOZA MENENDEZ CARLOS JOSUE.

1.-DATOS FILIATORIOS:

Apellido y Nombre ............................................................................................................................................................

Edad: ......................Sexo: .....................................................Ocupación ……………………....................................................

Fecha de Nacimiento: .................................................Número de Historia Clínica: .........................................................

Estado Civil: …………….................Nacionalidad: .................................Residencia Actual: .................................................

Grado de Instrucción: ...................................Religión: ..................................Fecha de Internación: ……………………………

MOTIVO DE CONSULTA:

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HISTORIA DE LA ENFERMEDAD ACTUAL Y SUS ANTECEDENTES.

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2.-ANTECEDENTES PERSONALES:

1)Fisiológicos
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2) Patológicos:
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3) De medio
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4)Hábitos tóxicos

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5) Vacunación
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6) Medicacion

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3.-ANTECEDENTES HEREDOFAMILIARES:

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4.- SIGNOS VITALES:

FC: .......................PA: .........................FR: …………………............. Tº Axilar: .............................Tº bucal: ............................

Peso Habitual (KG): ........................Peso actual (KG): ............................Talla: ...............................IMC…………………………

5.- EXAMEN FISICO

EXAMEN FISICO GENERAL:

Biotipo: .............................................................................Marcha: ..................................................................................

Facies: ...............................................................................Actitud: ..................................................................................

Piel, Mucosas y
Fanera………………………………………………………………………………………………............................................................................
Tejido celular subcutáneo (TCS) y panículo adiposo………………………………………………………………………………………………….

EXAMEN FÍSICO REGIONAL.

CABEZA:

Cráneo: …………………………………………………………………………………………………….……………………………………………………………....

Cara: .................................................................................................................................................................................
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Cuero Cabelludo:…………………………………………………………………………………………………………………………………………………………
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Ojos:……………………………………………………………………………………………………………………………………..........................................
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Oidos:……………………………………………………………………………………………………………………………….............................................
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Nariz: ….……………………………………………………………………………………………………………………………….........................................
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Boca: …….…………………………………………………………………………………………………………………………….........................................
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Orofaringe:…………………………………………………………………………………………………………………………….......................................
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CUELLO:

Inspección:

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Palpación:

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Percusión:

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Auscultación:

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TORAX:

Inspección:

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Palpación:

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Percusión:

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Auscultación:

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ABDOMEN:

Inspección:

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Auscultación:

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Percusión:

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Palpación:

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EXAMEN FÍSICO POR APARATOS O SISTEMAS.

APARATO RESPIRATORIO:

Inspección:

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Palpación:

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Percusión:

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Auscultación:

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APARATO CARDIOVASCULAR:

Inspección:
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Palpación:
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Percusión:

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Auscultación:

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SISTEMA VASCULAR PERIFÉRICO

Inspección:

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Palpación:

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Percusión:

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Auscultación:

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APARATO DIGESTIVO

BUCAL:

Inspección:

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Auscultación:

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Percusión:

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ABDOMINAL:

Inspección:

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Auscultación:

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Percusión:

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Palpación:

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RECTAL:

Inspección:

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Palpación:

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