Antecedentes Personales y Familiares, Gineco-Obstétricos y Exploración Física, Esquemas y mapas conceptuales de Semiología

¡Descarga Antecedentes Personales y Familiares, Gineco-Obstétricos y Exploración Física y más Esquemas y mapas conceptuales en PDF de Semiología solo en Docsity! ESTABLECIMIENTO: FECHA……………………………………………………HORA……………………………………………. SERVICIO SALA CAMA HISTORIA CLÍNICA MÉDICA AP. PATERNO AP. MATERNO NOMBRE Iniciales………………………….. Nacionalidad…………………………………………Departamento…………………………………Provincia……………………………………. Fecha de nacimiento………………………...Edad………………………Sexo………………………Estado Civil………………………......... Domicilio………………………………………………………………………Teléfon/Celular…………………………………………………………… Procedencia………………………………………………………Residencia actual……………………………………………………………….. … Ocupación…………………………………………………………………………………………………………………………………………………………….. Grado de escolaridad……………………………………………………Religión…………………………………………………………………………. Fuente de información……………………………………………………………………………………………………………………………………………………. 1. MOTIVO DE CONSULTA __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 2. ENFERMEDAD ACTUAL __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 3. ANTECEDENTES PATOLÓGICOS Enfermedad Infectocontagiosa ________________________________________________________________ Enfermedad.cronico.degenerativa_______________________________________________________________ Traumatológicos_____________________________________________________________________________ Hospitalizaciones previas_____________________________________________________________________ Quirúrgicos_________________________________________________________________________________ Alérgicos___________________________________________________________________________________ Transfusiones____________________ Medicamentos______________________________________________________________________________ __________________________________________________________________________________________ Especifique_________________________________________________________________________________ ___________________________________________________________________________ 4. ANTECEDENTES PERSONALES NO PATOLÓGICOS Vivienda___________________________________________________________________________________ Alimentación ______________________________________________________________________________ Toxicomanías: Consumo de bebidas alcohólicas: ___________________________________________________ consumo de cigarrillos: ______________________________________________________________________ Sustancias controladas: _________________________Infusiones: ___________________________________ Inmunizaciones: __________________________ Diuresis___________________Catarsis__________________ Otros._____________________________________________________________________________________ _________________________________________________________________________________________ 5. ANTECEDENTE FAMILIAR Padre: Vivo Si____ No____ Enfermedades que padece: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Madre: Viva Si____ No____ Enfermedades que padece: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Hermanos: ¿Cuántos? ______ Vivos _____ Muertos______ Enfermedades que padecen: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ AUSCULTACIÓN_______________________________________________________________________________ _________________________________________________________________________________________ CARDIACO INSPECCIÓN_________________________________________________________________________________ _________________________________________________________________________________________ PALPACIÓN__________________________________________________________________________________ _________________________________________________________________________________________ PERCUSIÓN__________________________________________________________________________________ _________________________________________________________________________________________ AUSCULTACIÓN_______________________________________________________________________________ _________________________________________________________________________________________ ABDOMEN INSPECCIÓN_________________________________________________________________________________ __________________________________________________________________________________________ AUSCULTACIÓN_______________________________________________________________________________ __________________________________________________________________________________________ PERCUSIÓN__________________________________________________________________________________ __________________________________________________________________________________________ PALPACIÓN__________________________________________________________________________________ __________________________________________________________________________________________ GENITOURINARIO_____________________________________________________________________________ __________________________________________________________________________________________ EXTREMIDADES______________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ NEUROLÓGICO_______________________________________________________________________________ _________________________________________________________________________________________ DIAGNÓSTICO_____________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________