historia clinica cirugia
TRANSCRIPT
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HISTORIA CLINICA
I. ANAMNESIS Datos de Filiación:
Nombre y Ap.:________________________________________________ Fecha de Nacimiento:_____________________________ Lugar de Nacimiento:_____________________________ Edad:________________ Sexo:________________ Grado de Instrucción:___________________ Profesión u Ocupación:__________________________________ Estado Civil:__________________________ Domicilio:____________________ Localidad:_______________ Teléfono:__________________ D.N.I:_______________ Fecha de Ingreso:________________________________
II. MOTIVO DE CONSULTA___________________________________________________________________
II.1HISTORIA ACTUAL DE LA ENFREMEDAD Tiempo de la Enfermedad:_____________________________ Forma de Inicio:____________________________________ Curso de la Enfermedad:______________________________
II.2SIGNOS Y SINTOMAS DE LA ENFERMEDAD __________________________________________________________________________________________________________________________________________________
II.3RELATO DE LA ENFERMEDAD ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
III. ANTECEDENTES PERSONALES
Alergias __________________________________________
III.1 ANTECEDENTES GINECOOBSTETRICOS Menarquía:________________________ Régimen Coterminal:_________________ Menopausia:_______________________ Formula Obstétrica:
III.2 ANTECEDENTES PATOLOGICOS Enfermedades
Sistémicas:______________________
G P A
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Enfermedades Sanguíneas:_____________________
IV. EXAMEN CLINICOIV.1 Examen Físico General:
_____________________________________________________________________________________________________________________________________________
IV.1.1 Ectoscopia:__________________________________________________________________________________________
IV.1.2 Signos Vitales Pulso:_____________________ Presión Arterial:___________________
IV.2 EXAMEN FISICO REGIONAL- EXOBUCAL
Cráneo: ________________________________________________________________________________________________________________________________________________________________________________________________________
Cara: ________________________________________________________________________________________________________________________________________________________________________________________________________
- ENDOBUCAL Encía:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Piezas Dentarias (generalidades): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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V. EXAMENES AUXILIARES V.1 Exámenes de Laboratorio:
V.1.1 Tiempo de Sangría:_____________________
V.1.2 Tiempo de Coagulación:__________________
V.1.3 Tiempo de Protrombina:__________________
V.1.4 Glucemia:________________________
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V.2Exámenes Rx: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VI. DIAGNOSTICOVI.1 Diagnostico Presuntivo:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VI.2 Diagnostico Definitivo:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VII. PRONOSTICO:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VIII. PLAN DE TRATAMIENTO:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
IX. EPICRISIS_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Fecha: __/__/___
Firma: