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)
