LA UNIVERSIDAD DEL ZULIA

FACULTAD DE MEDICINA
ESCUELA DE MEDICINA
DEPARTAMENTO DE CIENCIAS DE LA CONDUCTA
CATEDRA DE PSICOLOGIA MDICA
HISTORIA CLNICA

Fecha:

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Realizada por: ___________________________________________________________
Nombres y Apellidos:

C.I.:________________________
Edad:

Sexo:
M

Lugar y Fecha de Nacimiento:

Estado Civil:

Raza:

Religin:

S C D V U
Grado de Instruccin:

Profesin u Ocupacin:

Ocupacin actual:

Empleo:
Si

Domicilio Habitual:

Telfonos:

Informacin aportada por:

Parentesco:

No

Confiabilidad:
Si Poco

MOTIVO DE CONSULTA:
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HISTORIA DE LA ENFERMEDAD ACTUAL:
(Inicio, duracin, intensidad, fluctuaciones y evolucin del cuadro clnico actual, factores precipitantes y
coincidentes, repercusiones personales y familiares, tratamientos recibidos)
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EXAMEN FISICO:
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EXAMEN MENTAL:

Historia Clnica
I.

Apariencia General y Conducta:

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II. Nivel Afectivo:

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III. Nivel Cognitivo:
Conciencia: ______________________________________

Orientacin: ___________________________________________

Atencin: ________________________________________

Concentracin: ________________________________________

Memoria: _____________________________________________________________________________________________________
Lenguaje: _____________________________________________________________________________________________________
Pensamiento: Curso: ___________________________________________________________________________________________
Contenido:_____________________________________________________________________________________________________
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Juicio y Razonamiento: ________________________________________________________________________________________
Inteligencia: __________________________________________________________________________________________________
Conciencia de enfermedad: __________________________________________ Insight: ________________________________
IV. Nivel Sensoperceptivo:
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V.

Nivel Actividad Psicomotora:

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VI.

Nivel Fisiolgico:

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ANTECENDENTES PERSONALES (Fsicos y Mentales):
Pre, peri y postnatal:

Historia Clnica
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Niez:
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Escolaridad:
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Adolescencia:
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Adultez:
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Vejez:
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Hbitos:
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Historia Laboral:
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Historia Mdica:
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Historia Clnica
Personalidad Previa:
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Situacin de vida actual:
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ANTECEDENTES FAMILIARES (Fsicos y Mentales):
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DINMICA FAMILIAR:
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ENTREVISTA CON FAMILIARES:
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DIAGNSTICO PRESUNTIVO:
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Entrevista realizada por: ______________________________________ Firma:

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PREGUNTAS QUE DEBES RESPONDER SOBRE ESTA HISTORIA CLNICA:

1. Identifica los problemas psicosociales presentes en el caso.
Toma en cuenta lo siguiente:
Factores de riesgo (predisponentes) para la enfermedad (grupo etario, sexo, herencia, exposicin, etc).
Factores desencadenantes: Situaciones de estrs (tanto reciente como crnico), cualquier cambio crtico
en su situacin vital, etc.

Historia Clnica

Cumplimiento (exitoso o no) de sus tareas segn la etapa del ciclo vital individual
Relaciones interpersonales (estables, conflictivas, etc.)
Dinmica familiar (roles familiares, autoridad, conflictos, etc.)
Estrategias de manejo o afrontamiento de su enfermedad (adaptativas o no),
Factores mantenedores de la enfermedad
2. Identifica los factores de proteccin o aspectos positivos (fortalezas) del paciente que pueden ayudarlo
a manejar su enfermedad actual.
3. Orienta una hiptesis que describa y explique cmo estos problemas influyen en la evolucin del
cuadro clnico.
Ojo: no estoy pidiendo una hiptesis diagnstica (un diagnstico clnico de la enfermedad del paciente)
sino que describas tus suposiciones de lo que est pasando con el paciente y su enfermedad.