HABITACION:_________

Republica Bolivariana de Venezuela

Ministerio del Poder Popular para la Educacin Superior
Universidad del Zulia
Facultad de Medicina
Escuela de Medicina
Catedra de Semiologia-Patologia Medica
HUM-HC
Gua para la elaboracin de la Historia Clnica Integral
A. Datos de Identificacin:
Nombre:
Edad:

Sexo:

Grupo tnico:

Religin:

Raza:

Grupo
Sanguneo:

Estado Civil:

Lugar y Fecha de
nacimiento:

Direccin Actual:

Grado de
instruccin:

Profesin/Ocupaci
n:

Fecha de Ingreso:

Informacin
Suministrada por:

Telfonos:

Parentesco:

Confiabilidad:

Nacionalidad:

B. Motivo de Consulta:_______________________________________________
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C. Enfermedad Actual: (Aparicin, Localizacin, Intensidad, Carcter o Tipo,
Irradiacin, Agravantes, Aliviantes, Desencadenantes, Redivida/Frecuencia,
Concomitante, Negativo Pertinente)
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D. Antecedentes
D.1 Antecedentes Personales y Patologicos:
Hbitos (indicar cantidad, frecuencia y desde cuando consume):
a.Dieteticos:_________________________________________________________
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b.Alcoholicos:_______________________________________________________
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c.Cafeicos:__________________________________________________________
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d.Tabaquismo:_______________________________________________________
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e.Drogas:___________________________________________________________
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f.Sueo:____________________________________________________________
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g.Sexuales:__________________________________________________________
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h.Ejercicios:_________________________________________________________
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i.Condiciones
Higienicas:__________________________________________________________
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Enfermedades (Cuales a presentado, aparicin y sus complicaciones) y
Medicamentos (relacionados con las enfermedades anteriores, si ha ingestado
algn otro medicamento y para que, Cantidades y frecuencia).
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Alergias:____________________________________________________________
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Hospitalizaciones (anteriores indicando fecha y cuantas veces e indicar la

ultima hospitalizacin, fecha y de que fue) y Operaciones(anteriores indicando
fecha y cuantas veces e indicar la ultima operacin, fecha y de que fue):
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Accidentes(anteriores indicando fecha e indicar las complicaciones):
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Transfusiones y Transplantes (que ha tenido en su vida):
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Trabajos (que ha tenido en el transcurso de su vida):
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Vivienda(tipo de construccin, numero de ambientes, disposicin de aguas
blancas y negras, saneamiento ambiental):
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Vacunas:
Antivarilica:
Antitfica:
Antipolio:
Trivalente:
Antitetnica:
P.F.D:
B.C.G:
Antigripal:
Neumona:
Tuberculosis:
Tosferina:
Fiebre
Tosferina:
Parotiditis:
Hepatitis:
Amarilla:
Otras:_________________________________________________________________
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D.2 Antecedentes Familiares(Estado de salud o causa de muerte y edad de sus

padres, hermanos, tos y abuelos, junto antecedentes de diabetes, hipertensin,
neuropatas, cardiopatas, cncer, jaquecas, migraas, epilepsia, ictricia, artritis,
nefropatas, enfermedades mentales):
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E. Revisin de Sistemas:
Enfermedades Infecto-contagiosas:
Rubola:
Parotiditis o Paperas:
Varicela o Lechina:
Dengue:
Sarampin:
Fiebre Tifoidea:
Paludismo o Malaria:
Fiebre Amarilla:
Tuberculosis:
Difteria:
Tosferina o Coqueluche:
Hepatitis:
Otras:______________________________________________________________
Complicaciones:_____________________________________________________
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Enfermedades de Transmisin Sexual(ETS):
Sfilis:
VIH/SIDA:
Gonorrea:
VPH:
Chancro
Blando:
Herpes:
Candidiasis:
Tricomonas:
Otras:_____________________________________________________________.
Complicaciones:_____________________________________________________
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a. Psquico (nerviosismo, ansiedad, angustia, preocupaciones personales o

familiares o sociales o econmicas o sexuales, como es su relacin con los
dems, como colaboraba con los grupos de trabajo, enfermedad mental o
cambios en la conducta o memoria o juicio):
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b. Cabeza (Cefalea, migraa, trauma o ciruga craneana y sus secuelas o
complicaciones):
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c. Ojos (Alteraciones de la visin, lagrimeo (epifora), visin borrosa, dolor o
ardor, diplopa, fotobia, fatiga, manchas, uso de anteojos y desde cuando,
operaciones, accidentes):
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d. Odos (Otalgia, secreciones serosas o mucosas o purulentas (otorrea),
otorragia, acufenos, tinitus, alteraciones de la audicin, sordera, operaciones
otolgicas y sus consecuencias (miringotomia)):
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e. Nariz y Senos paranasales (secreciones nasales, epistaxis, obstruccin, rinitis,
sinusitis, antecedentes de ulceraciones y operaciones, alteracin de la olfacion
como hiposmia, anosmia, parosmia):
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f. Boca y Garganta (ulceras o erupciones en labios, gingivorragia, dolor de boca

o lengua, odontologas, caries dentales, condiciones higinicas de la boca,
halitosis, dientes faltantes, prtesis, glositis, tonsilitis, odinofagia, disfagia,
cambios de la voz bitonal, ronquera, disfona, afona):
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g. Cuello (dolor, aumento de volumen (bocio, adenomegalias, abcesos),
limitacin de movimientos):
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h. Aparato Respiratorio (dolor torcico, dolor pleural, disnea, tos, hemoptisis,
expectoracin mucosa o serosa o purulenta, sibilancia, asma bronquial,
neumona, tuberculosis, enfisema, fstulas, tratamientos prolongados):
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i. Aparato Cardiovascular (dolor precordial o retroesternal, infarto del
miocardio, angor o presin o angina pectoris, disnea evolutiva a los esfuerzos
como ortopnea o disnea nocturna, edema agudo de pulmn, fiebre reumtica,
hipertensin arterial, palpitaciones, cianosis, taquicardia, sincope, soplos
cardiacos, dolor o ulceraciones o enfriamiento o claudicacin(cojera o defecto
al deambular)en miembros inf., varices, antecedentes de picaduras):
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j. Aparato Digestivo (apetito, dolor abdominal, pirosis, llenura

postpandrial(despus de comer), regurgitacin, vmitos, hematemesis,
indigestin, intolerancia a los alimentos, ictericia, clicos hepticos, aumento
del volumen abdomen, hepatitis o absceso heptico, disfagia, cambio en el
patrn y tipo de evacuacin, diarrea, constipacin, melena(sangre oscura),
heces pastosas, enterorragia, anorragia, flatulencia, amibiasis o otras
parasitosis, disentera, tenesmo y pujo rectales, hemorroides, pancreatitis,
hematoquecia):
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k. Aparato Genitourinario (dolor lumbar o pubico o perineal, incontinencia
urinaria, diuresis, nicturia, polaquiuria, poliuria, oliguria, anuria, disuria,
enuresis, pujo vesical, miccin imperiosa, goteo terminal, retardo para
comenzar a orinar, hematuria, piuria, coluria, dolor testicular, varicocele,
nefritis, infeccin urinaria, infertilidad):
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l. Antecedentes Ginecolgicos y Obsttricos (menarquia, menstruacin,
hpermenorrea, oligomenorrea, hipomenorrea, polimenorrea, amenorrea,
metrorragia, menometrorragia, dismenorrea, fecha de la ultima regla,
embarazo con su evolucin y su complicacin, aborto, toxemia gravdica, flujo
vaginal(purulento, sanguinolento, leucorrea), sangramiento,
dispareunia(disfuncin orgsmica), menopausia con su edad y sintomatologa
(calor, sudoracin, cambios de carcter), uso de anticonceptivos, operaciones
ginecolgicas con su evolucin y complicaciones) :
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m. Neuromuscular( dolor, neuralgia, radiculalgia, parestesia, anestesia,

hipoestesia, hiperestesia, paresia, parlisis, atrofia de miembros, poliomielitis,
temblor, convulsiones, tics, shocks, obnubilacin, somnolencia(necesidad de
dormir), estupor, coma, insomnio, mareos, vrtigo, sensacin de inestabilidad,
lipotimias, hemiplejia, diapleja, parapleja):
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n. Articulaciones y Huesos(artralgias, dolor articular, artritis, deformidades y
limitaciones articulares, ndulos subcutneos, eritema de alas de
mariposa(lupus eritematoso sistmico), peoriasis, reumatismos, deformidades
de huesos, fracturas, osteoporosis, lordosis, dolor columna vertebral):
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. Piel y Anexos (eritema, erupciones, pstulas, ppulas, vesculas, ulceras,
costras, placas, cambios de coloracin o textura, vitligo, hperpigmentacin,
piel seca, hperqueratosis, urticaria (ronchas), prurito, alopecia, prdida del
vello corporal, hirsutismo, hipertricosis, cambios en uas, onicomicosis,
paroniquia, cada de uas):
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o. Endocrino- Nutricional(historia nutricional, desarrollo de los caracteres
sexuales, ginecomastia, pubertad retardada o precoz, intersexualidad,
gigantismo, enanismo, diabetes, hper o hipo tiroidismo, tiroiditis, bocio, hper o
hipo funcin suprarrenal, insuficiencia ovrica o testicular, perdida del apetito
sexual, disfuncin orgsmica o erctil, sequedad vaginal, se evalan mamas
como hipo o hper trofia mamaria o presencia de ndulos o cncer o algo,
hipofuncin poliglandular (panhipopituitarismo), hiperfuncin hipofisiaria,
acromegalia(aumento de produccin de la HC), galactorrea, secrecin
inapropiada de la HAD, trastornos del metabolismo del calcio, espasmo,
nefrolitiasis, tetania) y Hematopoytico (anemia y si a sido tratada,
adenomegalias, fenmenos hemorrgicos sin causa, petequias, equimosis,
hematomas, epistaxis):
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F. Examen Fsico
Signos Vitales:
-Presin Arterial:____________________________________________________.
-Pulso:_____________________________________________________________.
-Respiracion:
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-Temperatura:
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-Peso y Talla:
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Condicin General del paciente:
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Cabeza:____________________________________________________________
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Cuello:_____________________________________________________________
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Torax:______________________________________________________________
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Abdomen:__________________________________________________________
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G. Hallazgos
Positivos:________________________________________________________
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H. Diagnostico:
Diagnostico Sindromatico:____________________________________________.
Diagnostico Anatmico:______________________________________________.
Diagnostico Funcional: _______________________________________________.
Diagnostico Etiolgico: _______________________________________________.
Diagnostico Principal:________________________________________________.
Diagnostico Diferencial:
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I. Evolucin Intrahospitalaria(recuento de cmo a evolucionado la

sintomatologa, y aparicin de nuevos sntomas y signos, indicando fecha y
hora):
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