Model medical history

CLINIC HISTORY

Hospital:

Service: Bed: Date of preparation of the HCL:

Date of entry into service:

L.- ANAMNESIS

HISTORY TYPE: Direct: Indirect:

FILIATION:

FIRST NAME:

SEX: AGE: RACE: LANGUAGE: RELIGION:

DATE OF BIRTH: ____ / ____ / ____ BIRTHPLACE: ______________________

PLACE OF ORIGIN: _________________________ MARITAL STATUS: __________________

DEGREE OF INSTRUCTION: _______________________ OCCUPATION: ______________________

PERSON IN CHARGE:_________________________________________________________

Phone: ________________________ ADDRESS: _________________________________

RESPONSIBLE FOR DEVELOPMENT OF MEDICAL HISTORY: ___________________________

2. PRESENT ILLNESS

Sick time:

Home form:

Course:

Symptoms and signs:

.

.

.

.

.

TALE OF DISEASE

3. Biological functions

Appetite : ............................ Thirst: .............................. .. Dream: ........................... .. Sweat: ............................

Urine: ................................................ .. Deposition: ....................................................

4. BACKGROUND

Birth:

Type of delivery:

Delivery care by:

Lactation:

Growth and psychomotor development:

immunizations:

Menarche: G / E / P: Menopause:

SOCIOECONOMIC BACKGROUND

Property type: Number of rooms:

Housing hygiene:

Exposure to wood or smoke:

Animal husbandry: How many animals:

Basic services: Electricity: Water: Drain:

BACKGROUND AND NUTRITIONAL FOOD HABITS

Supply Type:

harmful habits: Alcohol: Snuff: C / day: times a month.

Tea coffee:

Medication: Drugs: Marijuana: Cocaine: Other:

BACKGROUND PATHOLOGICAL

hereditary and congenital diseases:

previous illnesses and treatment received:

previous hospitalizations:

Operations:

allergies:

Blood transfusions: Number:

Intoxications:

FAMILY BACKGROUND

Father:

Mother:

Brothers:

Children:

L.- GENERAL PHYSICAL EXAMINATION

CONTROL OF VITAL SIGNS: FR: ...... ... FC: O2 Sat ...... .. .......... FIO2: ...... .. Temperature: .......

Blood pressure: ………………. Weight: ..................... Size: .................. URN: .................. ..

GENERAL ASPECT

Constitution:

Position: Attitude:

March: Degree of cooperation: Memory:            

CONSTITUTION, NUTRITIONAL STATE AND HYDRATION

Nutritional status:

Hydration status:

Skin and Appendages

Skin and mucous membranes: Temperature: Hydrated:

Elasticity: Color: Brightness: Injury:

Edema: Duro: Blando: Fovea:

Hair: Implementation:                                     

Distribution:

Annexes or Appendages: Nails: Appearance: Color: Thickness:

Capillary refill: More than 2 seconds: Less than 2 seconds:

II APPARATUS AND SYSTEMS REVIEW

1. HEAD

a) Skull

Shape: Size: Consistency:

Scalp:

b) face

Eyes: Pupils: Eyebrows and eyelashes:

Eyeballs:

eyelids:

View:

c) ears

Pavilions: Implementation:

Hearing:

d) nose

Position and shape: Size:

respiratory movements:

Nostrils:

Smell:

e) mouth

Lips: Language: Mucous:

Sense of taste:

Teeth:

Palate:

Oropharynx:

2. NECK                                                                                                                    

Size: Position:

Form: Jugular:

movements:

Tenderness: Pain movement:

lymph:

3. TORAX

Armpits examination: Lymph:

underarm hair:

Breast examination:

Respiratory

Inspection:

Palpation:

Percussion:

Auscultation:

Cardiovascular System

Inspection:

Palpation:

Percussion:

Auscultation:

4. ABDOMEN

Inspection:

Palpation:

Percussion:

Auscultation:

LIVER:                                                                                        BAZO:

Inspection: Inspection:

Probing: Probing:

Percussion: Percussion:

5. GENITO URINARIO

Inspection:

anterior surface of the abdomen:

Lumbar region:

external genitalia:

Distribution of pubic hair:

Palpation:

Kidney palpation: Maneuver: Positive: Negative:

Urethral reno points: Upper right () Top Left () Middle right ()

Middle left () right Inferior () Lower left ()

Costovertebral points:

Points lumbar cost:

Prostate anal sphincter: Size: Consistency:

Percussion:

Fist lumbar percussion (Murphy):

Right left:

Auscultation:

murmur is heard: Not much is heard:

6. COLUMN

7. LIMBS

superior:

Inspection:

Palpation:

Mobility:

below:

Inspection:

Palpation:

Mobility:

8. REVIEW NEUROLOGICO

facies:

Attitude:

March:

Awareness:

Lucido: Obtunded: Drowsiness or stupor: Coma:

Pain response:

suitable:                           

Decortication left:

bilateral decortication:                    

Decortication right:                                   

Descerebración left:   

Descerebración right:            

Bilateral decerebrate:

GCS:

Opening of the Eyes	verbal answer	Motor response
espontanea 4	oriented 5	Obey orders 6
A voice 3	confusing 4	Locate pain 5
The Pain 2	Inappropriate words 3	Remove pain 4
none 1	Incomplete Words 2	Pain flexes 3
	none 1	Extends Pain 2
		none 1

LEVELS
V	14 to 15
IV	11 to 13
III	8 to 10
II	5 to 7
I	3. 4

MOBILITY:

MOTOR FORCE:

SENSITIVITY:

REFLEXES:

REFLECTION	VIA AFFERENT	VIA EFFERENT
Orbicularis	PAR V	VII
masseteric	PAR V	V
Bicipital	C5 - C6	C5 - C6
tricipital	C6 - C7	C6 - C7
Radial	C6 - C7	C6 - C7
brachioradialis	C5 - C6	C5 - C7
pronator ulna	C7 - C8	C7 - C8
Quadriceps (knee)	L2 - L3 - L4	L2 - L3 - L4
sural triceps (aquiliano)	L5 - S1 - S2	L5 - S1 - S2

cranial

I.- OLFACTORY:

OPHTHALMIC II:

PATETICO III:

IV oculomotor:

V.- TRIGEMINAL:

VI.- oculomotor:

FACIAL VII.-:

VIII.- AUDITIVO:

IX: GLOSSOPHARYNGEUS:

X: pneumogastric:

XI: SPINAL:

XII: HYPOGLOSSAL MAYOR:

TOP FEATURES:

Language:

Knowledge or gnosis:

PRINTING DIAGNOSED: ICD-10

WORK PLAN: (Diet, processing, analysis)

Download MODEL MEDICAL HISTORY :   PDF / Word