Historia clinica adulto 1 terapeuta respiratorio
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Historia clinica adulto 1 terapeuta respiratorio
- 1. PRESENTADO POR:_________________________________________ FECHA:_____________ UNIVERSIDAD SANTIAGO DE CALI PROGRAMA TERAPIA RESPIRATORIA HISTORIA CLINICA ADULTO DATOS DE IDENTIFICACION NOMBRE Y APELLIDOS _________________________________________________________ No. HC___________________________ FECHA DE INGRESO ______________ EDAD ______________ SERVICIO DE INGRESO___________ No. IDENTIFICACION_____________________ SERVICIO ACTUAL __________ GENERO F______ M _______ CAMA No. ________________ RAZA ___________________ EPS ____________________________ SISBEN___________________ OTROS__________________________ ESTADO CIVIL ______________________ ESTRATO SOC.___________________ PROCEDENCIA ______________________ CIUDAD _________________________ NIVEL DE ESCOLARIDAD _________________ BARRIO ________________________ OCUPACION ACTUAL __________________ INFORMANTE __________________ GRUPO SANGUINEO ________________ RH _______________ MOTIVO DE CONSULTA ________________________________________________________________________________ _______________________________________________________________________________ ENFERMEDAD ACTUAL ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
- 2. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ANTECEDENTES PERSONALES PATOLOGICOS__________________________________________________________________ ________________________________________________________________________________ OCUPACIONALES _______________________________________________________________ ________________________________________________________________________________ FARMACOLOGICOS______________________________________________________________ ________________________________________________________________________________ HOSPITALARIOS_________________________________________________________________ ________________________________________________________________________________ QUIRURGICOS___________________________________________________________________ ________________________________________________________________________________ TRAUMATICOS__________________________________________________________________ ________________________________________________________________________________ ALERGICOS_____________________________________________________________________ TOXICOLOGICOS________________________________________________________________ ________________________________________________________________________________ AMBIENTALES _________________________________________________________________ ________________________________________________________________________________ EPIDEMIOLOGICOS______________________________________________________________ ________________________________________________________________________________ SOCIOECONOMICOS_____________________________________________________________ ______________________________________________________________________________ VENEREOS______________________________________________________________________ TRANSFUNSIONALES____________________________________________________________ PSICOLOGICOS Y/O PIQUIATRICOS _______________________________________________
- 3. GINECOOBSTRETICOS G ___________ P _______ C _________ A__________ FUM ___________ CITOLOGIAS __________________________________________________________________ MAMOGRAFIA _________________________________________________________________ ANTECEDENTES FAMILIARES ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ REVISION POR SISTEMAS Y EXAMEN FISICO CABEZA ________________________________________________________________________________ ________________________________________________________________________________ OJOS ________________________________________________________________________________ ________________________________________________________________________________ NARIZ Y SENOS PARANASALES ________________________________________________________________________________ ________________________________________________________________________________ BOCA Y GARGANTA ________________________________________________________________________________ ________________________________________________________________________________
- 5. EXAMEN FISICO DEL SISTEMA RESPIRATORIO INSPECCION RITMO DE LA RESPIRACIÓN ________________________________________________________________________________ AMPLITUD ________________________________________________________________________________ TIPO DE TORAX _______________________________________________________________________________ PATRON RESPIRATORIO ________________________________________________________________________________ SIMETRIA TORACICA ________________________________________________________________________________ SIGNOS DE DIFICULTAD RESPIRATORIA ________________________________________________________________________________ OTROS HALLAZGOS ________________________________________________________________________________ ________________________________________________________________________________ PALPACION COLUMNA VERTEBRAL ________________________________________________________________________________ CLAVICULAS ________________________________________________________________________________
- 6. ESTERNON (maniobra de Pittres) ________________________________________________________________________________ COSTILLAS ________________________________________________________________________________ ESCAPULAS ________________________________________________________________________________ DISTENSIBILIDAD TORACICA O EXPANSIBILIDAD ________________________________________________________________________________ ELASTICIDAD TORACICA ________________________________________________________________________________ FREMITO VOCAL TACTIL ________________________________________________________________________________ FREMITO BRONQUICO ________________________________________________________________________________ PERCUSION CARA ANTERIOR ________________________________________________________________________________ ________________________________________________________________________________ CARA POSTERIOR ________________________________________________________________________________ ________________________________________________________________________________ CARA LATERAL ________________________________________________________________________________ ________________________________________________________________________________
- 7. AUSCULTACION RUIDOS RESPIRATORIOS NORMALES ________________________________________________________________________________ ________________________________________________________________________________ RUIDOS SOBREAGREGADOS ________________________________________________________________________________ ________________________________________________________________________________ AUSCULTACION DE LA VOZ ________________________________________________________________________________ ________________________________________________________________________________ IMPRESIÓN DIAGNOSTICA ________________________________________________________________________________ ________________________________________________________________________________ PARACLINICOS ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ DIAGNOSTICO DEFINITIVO ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ TRATAMIENTO MEDICO ________________________________________________________________________________ ________________________________________________________________________________
- 8. ________________________________________________________________________________ ________________________________________________________________________________ ______________________________________________________________. TRATAMIENTO DE TERAPIA RESPIRATORIA 1._______________________________________________________________________________ 2._______________________________________________________________________________ 3._______________________________________________________________________________ 4._______________________________________________________________________________ 5._______________________________________________________________________________ 6._______________________________________________________________________________ 7._______________________________________________________________________________ EVOLUCION ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ OBSERVACIONES ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________