HABITACION:_________ Republica Bolivariana de Venezuela Ministerio del Poder Popular para la Educación Superior Universidad del Zulia Facultad de Medicina Escuela de Medicina Catedra de Semiologia-Patologia Medica HUM-HC Guía para la elaboración de la Historia Clínica Integral A. Datos de Identificación: Nombre: Edad:
Sexo:
Grupo Étnico:
Religión:
Raza:
Grupo Sanguíneo:
Estado Civil:
Lugar y Fecha de nacimiento:
Dirección Actual:
Grado de instrucción:
Profesión/Ocupaci ón:
Fecha de Ingreso:
Información Suministrada por:
Teléfonos:
Parentesco:
Confiabilidad:
Nacionalidad:
B. Motivo de Consulta:_______________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. C. Enfermedad Actual: (Aparición, Localización, Intensidad, Carácter o Tipo, Irradiación, Agravantes, Aliviantes, Desencadenantes, Redivida/Frecuencia, Concomitante, Negativo Pertinente) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
D. Antecedentes D.1 Antecedentes Personales y Patologicos: Hábitos (indicar cantidad, frecuencia y desde cuando consume): a.Dieteticos:_________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. b.Alcoholicos:_______________________________________________________ ___________________________________________________________________ ___________________________________________________________________. c.Cafeicos:__________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. d.Tabaquismo:_______________________________________________________ ___________________________________________________________________ __________________________________________________________________. e.Drogas:___________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. f.Sueño:____________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. g.Sexuales:__________________________________________________________ ___________________________________________________________________. h.Ejercicios:_________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. i.Condiciones Higienicas:__________________________________________________________ ___________________________________________________________________. Enfermedades (Cuales a presentado, aparición y sus complicaciones) y Medicamentos (relacionados con las enfermedades anteriores, si ha ingestado algún otro medicamento y para que, Cantidades y frecuencia). ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Alergias:____________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
Hospitalizaciones (anteriores indicando fecha y cuantas veces e indicar la ultima hospitalización, fecha y de que fue) y Operaciones(anteriores indicando fecha y cuantas veces e indicar la ultima operación, fecha y de que fue): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Accidentes(anteriores indicando fecha e indicar las complicaciones): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Transfusiones y Transplantes (que ha tenido en su vida): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Trabajos (que ha tenido en el transcurso de su vida): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Vivienda(tipo de construcción, numero de ambientes, disposición de aguas blancas y negras, saneamiento ambiental): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Vacunas: Antivariólica: Antitífica: Antipolio: Trivalente: Antitetánica: P.F.D: B.C.G: Antigripal: Neumonía: Tuberculosis: Tosferina: Fiebre Tosferina: Parotiditis: Hepatitis: Amarilla: Otras:_________________________________________________________________ ______________________________________________________________________.
D.2 Antecedentes Familiares(Estado de salud o causa de muerte y edad de sus padres, hermanos, tíos y abuelos, junto antecedentes de diabetes, hipertensión, neuropatías, cardiopatías, cáncer, jaquecas, migrañas, epilepsia, ictéricia, artritis, nefropatías, enfermedades mentales): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. E. Revisión de Sistemas: Enfermedades Infecto-contagiosas: Rubéola: Parotiditis o Paperas: Varicela o Lechina: Dengue: Sarampión: Fiebre Tifoidea: Paludismo o Malaria: Fiebre Amarilla: Tuberculosis: Difteria: Tosferina o Coqueluche: Hepatitis: Otras:______________________________________________________________ Complicaciones:_____________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Enfermedades de Transmisión Sexual(ETS): Sífilis: VIH/SIDA: Gonorrea: VPH: Chancro Blando: Herpes: Candidiasis: Tricomonas: Otras:_____________________________________________________________. Complicaciones:_____________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
a. Psíquico (nerviosismo, ansiedad, angustia, preocupaciones personales o familiares o sociales o económicas o sexuales, como es su relación con los demás, como colaboraba con los grupos de trabajo, enfermedad mental o cambios en la conducta o memoria o juicio): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. b. Cabeza (Cefalea, migraña, trauma o cirugía craneana y sus secuelas o complicaciones): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. c. Ojos (Alteraciones de la visión, lagrimeo (epifora), visión borrosa, dolor o ardor, diplopía, fotobia, fatiga, manchas, uso de anteojos y desde cuando, operaciones, accidentes): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. d. Oídos (Otalgia, secreciones serosas o mucosas o purulentas (otorrea), otorragia, acufenos, tinitus, alteraciones de la audición, sordera, operaciones otológicas y sus consecuencias (miringotomia)): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. e. Nariz y Senos paranasales (secreciones nasales, epistaxis, obstrucción, rinitis, sinusitis, antecedentes de ulceraciones y operaciones, alteración de la olfacion como hiposmia, anosmia, parosmia): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
f. Boca y Garganta (ulceras o erupciones en labios, gingivorragia, dolor de boca o lengua, odontologías, caries dentales, condiciones higiénicas de la boca, halitosis, dientes faltantes, prótesis, glositis, tonsilitis, odinofagia, disfagia, cambios de la voz bitonal, ronquera, disfonía, afonía): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. g. Cuello (dolor, aumento de volumen (bocio, adenomegalias, abcesos), limitación de movimientos): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. h. Aparato Respiratorio (dolor torácico, dolor pleural, disnea, tos, hemoptisis, expectoración mucosa o serosa o purulenta, sibilancia, asma bronquial, neumonía, tuberculosis, enfisema, fístulas, tratamientos prolongados): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. i. Aparato Cardiovascular (dolor precordial o retroesternal, infarto del miocardio, angor o presión o angina pectoris, disnea evolutiva a los esfuerzos como ortopnea o disnea nocturna, edema agudo de pulmón, fiebre reumática, hipertensión arterial, palpitaciones, cianosis, taquicardia, sincope, soplos cardiacos, dolor o ulceraciones o enfriamiento o claudicación(cojera o defecto al deambular)en miembros inf., varices, antecedentes de picaduras): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
j. Aparato Digestivo (apetito, dolor abdominal, pirosis, llenura postpandrial(después de comer), regurgitación, vómitos, hematemesis, indigestión, intolerancia a los alimentos, ictericia, cólicos hepáticos, aumento del volumen abdomen, hepatitis o absceso hepático, disfagia, cambio en el patrón y tipo de evacuación, diarrea, constipación, melena(sangre oscura), heces pastosas, enterorragia, anorragia, flatulencia, amibiasis o otras parasitosis, disentería, tenesmo y pujo rectales, hemorroides, pancreatitis, hematoquecia): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. k. Aparato Genitourinario (dolor lumbar o pubico o perineal, incontinencia urinaria, diuresis, nicturia, polaquiuria, poliuria, oliguria, anuria, disuria, enuresis, pujo vesical, micción imperiosa, goteo terminal, retardo para comenzar a orinar, hematuria, piuria, coluria, dolor testicular, varicocele, nefritis, infección urinaria, infertilidad): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. l. Antecedentes Ginecológicos y Obstétricos (menarquia, menstruación, hípermenorrea, oligomenorrea, hipomenorrea, polimenorrea, amenorrea, metrorragia, menometrorragia, dismenorrea, fecha de la ultima regla, embarazo con su evolución y su complicación, aborto, toxemia gravídica, flujo vaginal(purulento, sanguinolento, leucorrea), sangramiento, dispareunia(disfunción orgásmica), menopausia con su edad y sintomatología (calor, sudoración, cambios de carácter), uso de anticonceptivos, operaciones ginecológicas con su evolución y complicaciones) : ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
m. Neuromuscular( dolor, neuralgia, radiculalgia, parestesia, anestesia, hipoestesia, hiperestesia, paresia, parálisis, atrofia de miembros, poliomielitis, temblor, convulsiones, tics, shocks, obnubilación, somnolencia(necesidad de dormir), estupor, coma, insomnio, mareos, vértigo, sensación de inestabilidad, lipotimias, hemiplejia, diaplejía, paraplejía): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. n. Articulaciones y Huesos(artralgias, dolor articular, artritis, deformidades y limitaciones articulares, nódulos subcutáneos, eritema de alas de mariposa(lupus eritematoso sistémico), peoriasis, reumatismos, deformidades de huesos, fracturas, osteoporosis, lordosis, dolor columna vertebral): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. ñ. Piel y Anexos (eritema, erupciones, pústulas, pápulas, vesículas, ulceras, costras, placas, cambios de coloración o textura, vitíligo, híperpigmentación, piel seca, híperqueratosis, urticaria (ronchas), prurito, alopecia, pérdida del vello corporal, hirsutismo, hipertricosis, cambios en uñas, onicomicosis, paroniquia, caída de uñas): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. o. Endocrino- Nutricional(historia nutricional, desarrollo de los caracteres sexuales, ginecomastia, pubertad retardada o precoz, intersexualidad, gigantismo, enanismo, diabetes, híper o hipo tiroidismo, tiroiditis, bocio, híper o hipo función suprarrenal, insuficiencia ovárica o testicular, perdida del apetito sexual, disfunción orgásmica o eréctil, sequedad vaginal, se evalúan mamas como hipo o híper trofia mamaria o presencia de nódulos o cáncer o algo, hipofunción poliglandular (panhipopituitarismo), hiperfunción hipofisiaria, acromegalia(aumento de producción de la HC), galactorrea, secreción inapropiada de la HAD, trastornos del metabolismo del calcio, espasmo, nefrolitiasis, tetania) y Hematopoyético (anemia y si a sido tratada, adenomegalias, fenómenos hemorrágicos sin causa, petequias, equimosis, hematomas, epistaxis): ___________________________________________________________________ ___________________________________________________________________
___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. F. Examen Físico Signos Vitales: -Presión Arterial:____________________________________________________. -Pulso:_____________________________________________________________. -Respiracion: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. -Temperatura: ___________________________________________________________________. -Peso y Talla: ___________________________________________________________________. Condición General del paciente: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Cabeza:____________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
Cuello:_____________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________. Torax:______________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ __________________________________________________________________. Abdomen:__________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________.
G. Hallazgos Positivos:________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ H. Diagnostico: Diagnostico Sindromatico:____________________________________________. Diagnostico Anatómico:______________________________________________. Diagnostico Funcional: _______________________________________________. Diagnostico Etiológico: _______________________________________________. Diagnostico Principal:________________________________________________. Diagnostico Diferencial: ___________________________________________________________________ ___________________________________________________________________.
I. Evolución Intrahospitalaria(recuento de cómo a evolucionado la sintomatología, y aparición de nuevos síntomas y signos, indicando fecha y hora): ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________.
