Modelo historia.
Enviado por gabydvnoriega • 17 de Mayo de 2016 • Reseñas • 465 Palabras (2 Páginas) • 102 Visitas
MODELO DE HISTORIA CLÍNICA
Cátedra de Medicina I (Semiología) – UHMI Nº 1
Hospital Nacional de Clínicas
Fecha: / / . Médico: ________________________________.
DATOS PERSONALES
Apellido y Nombre: _________________________________________________________________________.
Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupación: _______________.
Domicilio: _____________________________________________________________. TE: ______________.
Residencia: _______________________________________________________________________________ .
MOTIVO DE CONSULTA |
ANTECEDENTES DE LA ENFERMEDAD ACTUAL |
ANAMNESIS SISTEMICA | |
| ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. |
2 - Piel y faneras: prurito, lesiones primarias y secundarias, alteraciones de uñas y cabellos, otros. | |
3 - TCS: edema, tumoraciones, otros. | |
4 - SOMA: dolor, tumefacción, fuerza muscular, limitación del movimiento, otros. | |
5 - Ap. Cardiovascular: disnea, palpitaciones, dolor precordial, síncope, claudicación intermitente, otros. | |
6 - Ap.Respiratorio: epistaxis, tos, expectoración, hemóptisis, dolor torácico, cianosis, otros. | |
7 - Ap. Digestivo: halitosis, disfagia, regurgitación, acidez, pirosis, nauseas y vómitos, hematemesis, alteraciones del hábito intestinal, otros. | |
8 - Ap. Genitourinario: disuria, polaquiuria, nicturia, hematuria, incontinencia, dolor, alteraciones ciclo menstrual, alteraciones sexuales, otros | |
9 - Sistema Nervioso: cefalea, mareos, vértigo, sensibilidad, motricidad, temblor, alteraciones de la visión, audición, otros. |
ANTECEDENTES PERSONALES | |
1-Fisiológicos : menarca, ciclo menstrual, fecha última menstruación, embarazos, partos, alimentación, actividad física, sueño, diuresis y catarsis, actividad sexual, otros. 2- Inmunizaciones. 3- Vivienda y medio ambiente. 4- Socioeconómicos. 5- Patológicos: médicos, alérgicos, quirúrgicos, traumáticos. | ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ |
6-Tóxico-Medicamentosos: tabaco, alcohol, sustancias de uso indebido, medicamentos, otros. | |
7-Epidemiológicos: Chagas, HIV/Sida, Brucelosis, Toxoplasmosis, transfusiones, residencias anteriores, otros. | |
8-Heredo-Familiares. 9- Estudios preventivos. 10- Otros. |
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