HOJA CLÍNICA MÉDICA

Nombre y Apellido del paciente:…………………………………………………………N°de cama………….......

Nombre del apoderado (a) o esposo (a):………………………………Relación con el paciente:…………………….....
Nacionalidad:………………………….Departamento:…………………………..Provincia:…………………….....
Fecha de nacimiento:…………………….Edad:……………Sexo:…………….…Estado Civil:……………………
Domicilio:………………………………………………………..Teléfono:……………..Celular:………………
Ocupación:…………………………………Fecha de Internación:………………………...Hora:………………...
FUENTE DE INFORMACIÓN:……………………………………………………………………………………..
1. MOTIVO DE CONSULTA:
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2. ENFERMEDAD ACTUAL:
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3. ANTECEDENTES PERSONALES:
PATOLÓGICOS:
Clínicos:………………………………………………………………………………………………..............................
Quirúrgicos:……………………………………………………………………………………………….......................
Alérgicos:…………………………………………………………………………………………………......................
Traumáticos:………………………………………………………………………………………………......................
NO PATOLÓGICOS:
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4. ANTECEDENTES FAMILIARES:
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5. ANTECEDENTES GINECOOBSTÉTRICOS:
Menarca:………………..….Gestas:……………..….Partos:……..…………Abortos:…………….Cesáreas:….…………........
FUM:…………………………Fecha del ultimo parto:…………….…………..……MAC:…………….………………….
6. EXAMEN FÍSICO GENERAL:
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P.A.:……………………………..……F.C.:…………………….………..….F.R.:…………………………………...
Peso:……………………Talla:………….………T°C:…………………….....…I.M.C.:………………………………...
7. EXAMEN FÍSICO SEGMENTARIO:
Cabeza:………………………………………………………………………………………………………………
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Cara:…………………………………………………………………………………………………………………
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Ojos:…………………………………………………………………………………………………………………
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Oídos:…………………………………………………………………………………………………………………
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Nariz:…………………………………………………………………………………………………………………
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Boca:…………………………………………………………………………………………………………………
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Cuello:…………………………………………………………………………………………………………………
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Tórax:…………………………………………………………………………………………………………………
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Corazón:………………………………………………………………………………………………………………
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Pulmones:………………………………………………………………………………………………………………
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Abdomen y Pelvis: ……………………………………………………………………………………………….........
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Extremidades: …………………………………………………………………………………………………….......
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Examen Neurologico: ………………………………………………………………………………………………….
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8. IMPPRESIÓN DIAGNÓSTICO Y COMENTADA:……………………………………………………………………………........
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9. LABORATORIOS:……………………………………………………………………………………………………
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10. MANEJO DE DIETA Y TRATAMIENTO:………………………………………………………………………………….....
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