HISTORIA CLINICA CÁTEDRA DE MEDICINA INTERNA GASTROENTEROLOGÍA

UNIVERSIDAD CENTRAL DEL ECUADOR

CARRERA DE MEDICINA

CÁTEDRA DE MEDICINA INTERNA

GASTROENTEROLOGÍA

Fajardo Cabrera Natalia Elizabeth

CASO CLÍNICO

DATOS DE FILIACIÓN

NOMBRE:¬¬______________________________

EDAD: ¬________________________________

SEXO: ¬________________________________

ETNIA: ¬_______________________________

ESTADO CIVIL: ¬_________________________

PROFESIÓN: ¬___________________________

FECHA DE NACIMIENTO: ¬_________________

LUGAR DE NACIMIENTO: ¬____________________

RESIDENCIA OCASIONAL: ¬___________________

RESIDENCIA ACTUAL: ¬_______________________

RELIGIÓN: ¬________________________________

GRUPO SANGUÍNEO: ¬_______________________

LATERALIDAD: ¬____________________________

INSTRUCCIÓN: ____________________________

MOTIVO DE CONSULTA:_____________________________________________________________________

ENFERMEDAD ACTUAL:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REVISIÓN DE SISTEMAS

APARATO RESPIRATORIO: __________________________________________________________________

APARATO CARDIOCIRCULATORIO: ___________________________________________________________

APARATO DIGESTIVO: _____________________________________________________________________

APARATO GENITO-URINARIO: _______________________________________________________________

APARATO ENDOCRINO_____________________________________________________________________

APARATO NERVIOSO: _____________________________________________________________________

APARATO LOCOMOTOR: _ __________________________________________________________________

ÓRGANOS DE LOS SENTIDOS: ________________________________________________________________

ANTECEDENTES NO PATOLÓGICO (HÁBITOS):

• Alimentación:____________________________________________________

• Miccional: _______________________________________________________

• Defecatorio : _____________________________________________________

• Alcohol: _________________________________________________________

• Drogas: _________________________________________________________

• Tabaco: _________________________________________________________

• Sueño: __________________________________________________________

• Exposición a carburantes de biomasa: _________________________________

• Alergias: _________________________________________________________

• Ejercicio: _________________________________________________________

• Medicamentos: ___________________________________________________

ANTECEDENTES PATOLOGICOS PERSONALES:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________

ANTECEDENTES GINECOOBSTÉTRICOS

• Menarquía: _________________________

• Inicio de vida Sexual: __________________

• ETS: ________________________________

• Gestas: _____________________________

• Cesáreas: ___________________________

• Abortos: ____________________________

• Hijos vivos: __________________________

• FUM: _______________________________

ANTECEDENTES QUIRÚRGICOS

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

ANTECENDENTES PATOLOGICOS FAMILIARES:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HISTORIA FAMILIAR Y SOCIAL:

• Años de matrimonio: _______________________________________________________________

• Número de hijos: __________________________________________________________________

• Relaciones intrafamiliares: __________________________________________________________

• Habitación

o Propiedad: ________________________________________________________________

o Tipo de construcción: _______________________________________________________

o Número de habitaciones: ____________________________________________________

o Servicios básicos: ___________________________________________________________

o Animales domésticos: _______________________________________________________

...