INSTITUCIÓN: ____________________________________

INGRESO DEL PACIENTE

1. Fecha y hora de ingreso:

2. Servicio de ingreso:
3. Número de historia clínica:
4. Nombre del registrador:

HISTORIA CLINICA
I. ANAMNESIS:
A. DATOS DE FILIACION
1. Nombres:
2. Apellidos:
3. Tipo y Numero de identificación:
4. Edad:
5. Grupo étnico o raza:
6. Sexo:

B. DATOS PERSONALES

1. Escolaridad: 8. Estado civil:

2. Ocupación: 9. Religión:

3. Lugar procedencia: 10. Fuente de información:

4. Lugar de nacimiento: 11. Credibilidad

5. Dirección de residencia: 12. Régimen de seguridad social:

6. Barrio: 13. Entidad a la cual pertenece:

7. Estrato: 14. Iniciativa de consulta:

15. Nombre de acompañante: ___________________________
Parentesco: ____________Tel: ____________
16. Nombre de responsable: _______________________, Parentesco:
__________ Tel: ___________
 II. MOTIVO DE CONSULTA:

______________________________________________

III. EVOLUCION DE LA ENFERMEDAD ACTUAL:

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Estado actual del paciente: ____________________________

 IV. ANTECEDENTES
1. ANTECEDENTES PATOLOGICOS:
a. PERINATALES
_______________________________________________
_______________________________________________
b. POSNATALES
_______________________________________________
______________________________________________
c. INFANCIA:
_______________________________________________
_______________________________________________.
d. ADULTO:
_______________________________________________
_______________________________________________.
e. QUIRURGICOS:
_______________________________________________
_______________________________________________.
HOSPITALARIO:
_______________________________________________
_______________________________________________.
f. TRAUMATICO:
_______________________________________________
_______________________________________________.

g. TRANSFUSIONALES:
_______________________________________________
_______________________________________________.

h. FARMACOLOGICOS:
_______________________________________________
_______________________________________________.
i. ALÉRGICOS:
_______________________________________________
_______________________________________________.
2. ANTECEDENTES NO PATOLOGICOS:
a. INMUNIZACIÓN:
_______________________________________________
_______________________________________________.
b. PSICOSOCIALES:
 Hábitos

 Alimenticios:
__________________________________________
__________________________________________
__________________________________________
 Cigarrillo:
__________________________________________
__________________________________________
__________________________________________
 Alcohol:
__________________________________________
__________________________________________
 Drogas:
__________________________________________
__________________________________________
 Café:
__________________________________________
__________________________________________
 Estilo de vida:
______________________________________________
_____________________________________________.
 Condiciones de la vivienda:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
 Índice de hacinamiento
______________________________________________
______________________________________________
 ______________________________________________
______________________________________________
 Historia laboral
______________________________________________
______________________________________________
______________________________________________

c. HEMATOLÓGICOS
a. Grupo Sanguíneo_________________
b. RH _____________________
3. ANTECEDENTES FAMILIARES:
 Madre:
 Padre:
V. REVISION POR SISTEMAS
1. SISTEMA NEUROSENSORIAL
a. OJO:
___________________________________________
___________________________________________
b. OIDO:
___________________________________________
___________________________________________
c. NARIZ:
___________________________________________
___________________________________________
d. BOCA:
___________________________________________
___________________________________________
2. SISTEMA CARDIACO:
________________________________________________
________________________________________________

3. SISTEMA VASCULAR PERIFERICO:

________________________________________________
________________________________________________
4. SISTEMA RESPIRATORIO:
________________________________________________
________________________________________________

5. SISTEMA GASTROINTESTINAL:
________________________________________________
________________________________________________
6. SISTEMA MUSCULO-ESQUELETICO:
________________________________________________
________________________________________________

7. SISTEMA URINARIO:
________________________________________________
________________________________________________

8. GENITALES: MASCULINO:
________________________________________________
________________________________________________

9. SISTEMA ENDOCRINO:
a. HIPÓFISIS, SUPRARRENALES:
________________________________________________
________________________________________________
b. TIROIDES:
________________________________________________
________________________________________________

c. PARATIROIDES:
________________________________________________
________________________________________________
d. PÁNCREAS:
________________________________________________
________________________________________________
10. SISTEMA HEMATOPOYÉTICO:
________________________________________________
________________________________________________

11. PIEL Y ANEXOS

a. CAMBIOS EN LAS CARACTERÍSTICAS DE LA PIEL:
________________________________________________
________________________________________________
b. LESIONES EN LA PIEL:
________________________________________________
________________________________________________
c. OTRAS
________________________________________________
________________________________________________

d. CABELLO/PELO:
________________________________________________
________________________________________________

e. UÑAS
________________________________________________
________________________________________________
f.
12. SISTEMA LINFORETICULAR:
________________________________________________
________________________________________________

13. SISTEMA NERVIOSO CENTRAL:

________________________________________________
________________________________________________
 VI. EXAMEN FÍSICO

1. DESCRIPCIÓN GENERAL

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

2. SIGNOS VITALES

 Presión arterial:  Temperatura:

 Frecuencia cardiaca:  Talla:

 Frecuencia  Peso:
respiratoria:
 IMC:
 Pulso:
 Glasgow
 3. REGIONES DEL CUERPO HUMANO
 CABEZA Y CUELLO
Inspección
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Palpación
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Percusión
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Auscultación
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
 TORAX
Inspección
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Palpación
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

Percusión
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Auscultación
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
 ABDOMEN
Inspección
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Palpación
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Percusión
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Auscultación
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
 EXTREMIDADES SUPERIORES
Inspección
________________________________________________________
________________________________________________________
________________________________________________________
Palpación
________________________________________________________
________________________________________________________
________________________________________________________

 EXTREMIDADES INFERIORES
Inspección
________________________________________________________
________________________________________________________
________________________________________________________
Palpación
________________________________________________________
________________________________________________________
________________________________________________________

 GENITOUINARIO
Inspección
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
_______________________________________________________
Palpación
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Percusión
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Auscultación
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
_______________________________________________________
 PIEL Y FANELAS
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

 SISTEMA NERVISO CENTRAL

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
VII. DIAGNOSTICO
______________________________________________
______________________________________________
______________________________________________
______________________________________________

VIII. PLAN DE MANEJO O TRATAMIENTO

1.
2.
3.
4.
5.
6.
7.
IX. EXAMENES DE LABORATORIO Y GABINETE
 EVOLUCIÓN MEDICA

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

DIAGNÓSTICOS

1.

2.

3.

4.

5.

ANTECEDENTES

1.

2.

3.

SUBJETIVO

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
____________________________________________________
EXAMEN FÍSICO

SIGNOS VITALES

TA: ________ mmHg , FR________ Resp x´, SPO2 ______ %

FC:______ Lat x´ PULSO _____ Puls x´ Glasgow________
Glucosa _____ mg/dl

PIEL _______________________________________________
CABEZA____________________________________________
CARA ______________________________________________
OJOS _______________________________________________
NARIZ _______________________________________________
BOCA________________________________________________
CUELLO______________________________________________
CARDIO-PULMONAR
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ABDOMEN
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

GENITUURINARIO
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
EXTREMIDADES
_____________________________________________________
___________________________________________________
SNC
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANÁLISIS
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

PLAN A SEGUIR

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.