UNIVERSIDAD DE GUAYAQUIL

FACULTAD DE CIENCIAS MEDICAS

ESCUELA DE MEDICINA
Periodo Lectivo 2018-2019
SEXTO SEMESTRE – Grupo

Estudiante(s):

HISTORIA CLINICA
HOSPITAL LUIS VERNAZA

Sala:_______________ Cama:___ Nº Historia Clinica_____________

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ANAMNESIS O INTERROGATORIO
DATOS DE FILIACION
Apellidos y Nombres: __________________________________________
Lugar y Fecha de Nacimiento____________________________________
Edad: _______ Raza: ______________ Sexo:___________ Religión:_______________

Estado Civil: ___________ Nº de Hijos ___ Instrucción: ________

Ocupación:_________

Lugar de Procedencia: ____________________

Lugar de Residencia: _____________ Dirección Domiciliaria: ____________________
Teléfonos: ______________________
Fecha de la atención y/ingreso: __________________
Fecha de la Historia Clínica: __________________

MOTIVO DE LA CONSULTA: ___________________________________________

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EVOLUCION DE LA ENFERMEDAD ACTUAL

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Interrogatorio dirigido del Aparato Afecto:
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EMUNTORIOS
Diuresis:
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Defecación:
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HISTORIA MENSTRUAL Y OBSTETRICA EN LA MUJER

Menarquia: ________________ Menapmia:___________________
Inicio de la vida sexual______________ FUM____________ Menopausia: __________

Gestas: ________ Para:_______ Abortos:_____ Nacidos vivos:_____

Mortinatos:_______
Partos normales: _________ Cesáreas________

SIGNOS VITALES:
Presión Arterial: Pulso: Temperatura: Frecuencia Resp.

HABITOS Y ENCUESTA SOCIAL

Alcohol:
Café:
Drogas:
Vivienda:
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Agua Potable: ___________________
Excretas: _______________________
Nº de Habitantes de la vivienda: _____ Animales Domésticos: ___________
Alimentación: __________________________________________________________
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ANTECEDENTES PATOLOGICOS PERSONALES

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ANTECEDENTES PATOLOGICOS FAMILIARES

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EXAMEN FISICO
Inspección General
Actitud o postura:
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Facies: _________________ Hábito corporal_________________
Talla____________
Estado Nutricional: ____________________

Piel y Faneras:
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Marcha y movimientos:
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Inspección regional
Cabeza: __________ Cuello__________
Tórax:
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Abdomen:
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Extremidades:
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EXAMEN DEL APARATO AFECTO

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PALPACION
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PERCUSION
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AUSCULTACION
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EXAMENES COMPLEMENTARIOS
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Exámenes a realizar:
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Diagnóstico Presuntivo:
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Diagnóstico Definitivo:
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Tratamiento
Prescripciones médicas:
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Cuidados de Enfermería y dieta:
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Tratamiento Quirúrgico:
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Record
Anestèsico________________________________________________________

Protocolo Quirúrgico________________________________________________

Firma____________________________________