PRESENTADO POR:_________________________________________ FECHA:_____________

UNIVERSIDAD SANTIAGO DE CALIPROGRAMA TERAPIA RESPIRATORIA

HISTORIA CLINICA ADULTO

DATOS DE IDENTIFICACION

NOMBRE Y APELLIDOS _________________________________________________________

No. HC___________________________ FECHA DE INGRESO ______________

EDAD ______________ SERVICIO DE INGRESO___________

No. IDENTIFICACION_____________________ SERVICIO ACTUAL __________

GENERO F______ M _______ CAMA No. ________________

RAZA ___________________ EPS ____________________________

SISBEN___________________ OTROS__________________________

ESTADO CIVIL ______________________ ESTRATO SOC.___________________

PROCEDENCIA ______________________ CIUDAD _________________________

NIVEL DE ESCOLARIDAD _________________ BARRIO ________________________

OCUPACION ACTUAL __________________ INFORMANTE __________________

GRUPO SANGUINEO ________________ RH _______________

MOTIVO DE CONSULTA

________________________________________________________________________________

_______________________________________________________________________________

ENFERMEDAD ACTUAL

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

ANTECEDENTES PERSONALES

PATOLOGICOS__________________________________________________________________

________________________________________________________________________________

OCUPACIONALES _______________________________________________________________

________________________________________________________________________________

FARMACOLOGICOS______________________________________________________________

________________________________________________________________________________

HOSPITALARIOS_________________________________________________________________

________________________________________________________________________________

QUIRURGICOS___________________________________________________________________

________________________________________________________________________________

TRAUMATICOS__________________________________________________________________

________________________________________________________________________________

ALERGICOS_____________________________________________________________________

TOXICOLOGICOS________________________________________________________________

________________________________________________________________________________

AMBIENTALES _________________________________________________________________

________________________________________________________________________________

EPIDEMIOLOGICOS______________________________________________________________

________________________________________________________________________________

SOCIOECONOMICOS_____________________________________________________________

______________________________________________________________________________

VENEREOS______________________________________________________________________

TRANSFUNSIONALES____________________________________________________________

PSICOLOGICOS Y/O PIQUIATRICOS _______________________________________________

GINECOOBSTRETICOS

G ___________ P _______ C _________ A__________ FUM ___________

CITOLOGIAS __________________________________________________________________

MAMOGRAFIA _________________________________________________________________

ANTECEDENTES FAMILIARES

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

REVISION POR SISTEMAS Y EXAMEN FISICO

CABEZA

________________________________________________________________________________

________________________________________________________________________________

OJOS

________________________________________________________________________________

________________________________________________________________________________

NARIZ Y SENOS PARANASALES

________________________________________________________________________________

________________________________________________________________________________

BOCA Y GARGANTA

________________________________________________________________________________

________________________________________________________________________________

OIDOS

________________________________________________________________________________

________________________________________________________________________________

CUELLO

________________________________________________________________________________

________________________________________________________________________________

MAMAS

________________________________________________________________________________

ABDOMEN

________________________________________________________________________________

________________________________________________________________________________

EXTREMIDADES

________________________________________________________________________________

________________________________________________________________________________

GENITOURINARIO

________________________________________________________________________________

________________________________________________________________________________

PIEL

________________________________________________________________________________

________________________________________________________________________________

SIGNOS VITALES

FR ________ To _________ FC _________ PULSO _________ T/A _____________

EXAMEN FISICO DEL SISTEMA RESPIRATORIO

INSPECCION

RITMO DE LA RESPIRACIÓN

________________________________________________________________________________

AMPLITUD

________________________________________________________________________________

TIPO DE TORAX

_______________________________________________________________________________

PATRON RESPIRATORIO

________________________________________________________________________________

SIMETRIA TORACICA

________________________________________________________________________________

SIGNOS DE DIFICULTAD RESPIRATORIA

________________________________________________________________________________

OTROS HALLAZGOS

________________________________________________________________________________

________________________________________________________________________________

PALPACION

COLUMNA VERTEBRAL

________________________________________________________________________________

CLAVICULAS

________________________________________________________________________________

ESTERNON (maniobra de Pittres)

________________________________________________________________________________

COSTILLAS

________________________________________________________________________________

ESCAPULAS

________________________________________________________________________________

DISTENSIBILIDAD TORACICA O EXPANSIBILIDAD

________________________________________________________________________________

ELASTICIDAD TORACICA

________________________________________________________________________________

FREMITO VOCAL TACTIL

________________________________________________________________________________

FREMITO BRONQUICO

________________________________________________________________________________

PERCUSION

CARA ANTERIOR

________________________________________________________________________________

________________________________________________________________________________

CARA POSTERIOR

________________________________________________________________________________

________________________________________________________________________________

CARA LATERAL

________________________________________________________________________________

________________________________________________________________________________

AUSCULTACION

RUIDOS RESPIRATORIOS NORMALES

________________________________________________________________________________

________________________________________________________________________________

RUIDOS SOBREAGREGADOS

________________________________________________________________________________

________________________________________________________________________________

AUSCULTACION DE LA VOZ

________________________________________________________________________________

________________________________________________________________________________

IMPRESIÓN DIAGNOSTICA

________________________________________________________________________________

________________________________________________________________________________

PARACLINICOS

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

DIAGNOSTICO DEFINITIVO

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

TRATAMIENTO MEDICO

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

______________________________________________________________.

TRATAMIENTO DE TERAPIA RESPIRATORIA

1._______________________________________________________________________________

2._______________________________________________________________________________

3._______________________________________________________________________________

4._______________________________________________________________________________

5._______________________________________________________________________________

6._______________________________________________________________________________

7._______________________________________________________________________________

EVOLUCION

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

OBSERVACIONES

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________