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.
