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HISTORIA CLINICA DERMATOLOGICA

NOMBRE Y APELLIDOS: __________________________________________________________________

EDAD: _________________ SEXO: ________ RAZA:____________
CEDULA DE IDENTIDAD: ____________________ OCUPACIÓN: ________________________________
DIRECCION:_________________________________________________ TELEFONO:_________________
ESTADO:____________MUNICIPIO: ____________ASIC: _______________CONSULTORIO:___________

CONSULTA

FECHA: ______/_____/______ HORA: _____________

MOTIVO DE CONSULTA: _________________________________________________________________

HISTORIA DE LA ENFERMEDAD ACTUAL:

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ANTECEDENTES PATOLOGICOS PERSONALES:________________________________________________
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ANTECEDENTES PATOLOGICOS FAMILIARES:_________________________________________________

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ANTECEDENTES QUIRURGICOS:__________________________________________________________
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ANTECEDENTES OBSTETRICOS:__________________________________________________________
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HABITOS TOXICOS: _____________________________________________________________________

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ALERGIA A MEDICAMENTOS: _____________________________________________________________

TRANSFUSIONES: ______________________________________________________________________

TRAUMATISMOS: ______________________________________________________________________

VACUNACION: _________________________________________________________________________
 HISTORIA PSICOSOCIAL
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 INTERROGATORIO POR SISTEMAS O APARATOS

APARATO RESPIRATORIO:________________________________________________________________
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APARATO CARDIOVASCULAR:_____________________________________________________________
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APARATO DIGESTIVO: ___________________________________________________________________

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APARATO GENITOURINARIO: _____________________________________________________________

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SISTEMA HEMOLINFOPOYETICO:__________________________________________________________
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SISTEMA NERVIOSO:____________________________________________________________________
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SISTEMA ENDOCRINO:___________________________________________________________________
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SISTEMA OSTEOMIOARTICULAR:__________________________________________________________
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 EXAMEN FISICO GENERAL

PESO:_________ TALLA:_________ IMC:_________________ Temperatura:________

FC:_______ TA:_________ FR:______ PULSO:________

PIEL:
COLOR:_____________________________________________________________________________
HUMEDAD:__________________________________________________________________________
CONSISTENCIA:_______________________________________________________________________
TEXTURA:____________________________________________________________________________
ALTERACIONES DERMATOLÓGICAS:_______________________________________________________
PIGMENTOS IRREGULARES:______________________________________________________________

EXPLORACIÓN DERMATOLÓGICA

TOPOGRAFIA DESCRIPCIÓN
TIPO: LOCALIZADA_____ GENERALIZADA________
SEGMENTO AFECTADO CABEZA___ TÓRAX___ BRAZOS___ TRONCO___
REGIÓN AFECTADA EXPUESTA____ CUBIERTA_____ AMBOS_____
SIMETRÍA SIMÉTRICA_______ ASIMÉTRICA________
LOCALIZACIÓN ESPECIAL CUELLO______ PALMAS______
PLANTAS________

MORFOLOGÍA DESCRIPCIÓN
NUMERO DE LESIONES:__________________________
TAMAÑO:______________________________________________________________________
MODO DE AGRUPACIÓN: ___________________________________________________
CARACTERÍSTICAS

LÍMITES Y BORDES:___________________________________________________
COLOR: ____________________________________________________________________
COMPARACIÓN CON OTRA ENFERMEDAD CONOCIDA:

EVOLUCIÓN: ___________________________________________________
SÍNTOMAS: ___________________________________________________

FANERAS:

PELO:________________________________________________________________________________
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UÑAS:________________________________________________________________________________
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TCS:_________________________________________________________________________________
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PANICULO ADIPOSO:____________________________________________________________________
 EXAMEN FISICO REGIONAL

CRANEO:______________________________________________________________________________
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CARA: _______________________________________________________________________________
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CUELLO: _____________________________________________________________________________
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TIROIDES: ____________________________________________________________________________
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GANGLIOS LINFATICOS DE CABEZA Y CUELLO: ________________________________________________
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TORAX: ______________________________________________________________________________
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MAMAS: _____________________________________________________________________________
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AXILAS: ______________________________________________________________________________
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ABDOMEN: ___________________________________________________________________________
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COLUMNA VERTEBRAL: _________________________________________________________________
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EXTREMIDADES: _______________________________________________________________________
 EXAMEN FISICO POR SISTEMAS

SISTEMA RESPIRATORIO:_________________________________________________________________
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SISTEMA CARDIOVASCULAR:______________________________________________________________
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SISTEMA DIGESTIVO: ___________________________________________________________________

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SISTEMA GENITOURINARIO: ______________________________________________________________

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SISTEMA HEMOLINFOPOYETICO:__________________________________________________________
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SISTEMA NERVIOSO
NIVEL DE CONCIENCIA: __________________________________________________________________
ORIENTACION: ________________________________________________________________________
MEMORIA: ___________________________________________________________________________
LENGUAJE: ___________________________________________________________________________
TAXIA ESTATICA
ROMBERG SIMPLE:_____________________________________________________________________
ROMBERG SENSIBILIZADO:_______________________________________________________________
TAXIA DINAMICA:______________________________________________________________________
PRAXIA: ______________________________________________________________________________
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MOTILIDAD: __________________________________________________________________________
TONO MUSCULAR:______________________________________________________________________
REFLECTIVIDAD: _______________________________________________________________________
SENSIBILIDAD SUPERFICIAL:______________________________________________________________
SENSIBILIDAD PROFUNDA:_______________________________________________________________

PARES CRANEALES
PAR I:________________________________________________________________________________
PAR II:________________________________________________________________________________
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PAR V:________________________________________________________________________________
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PAR VII:______________________________________________________________________________
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PAR VIII:______________________________________________________________________________
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PAR IX:_______________________________________________________________________________
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PAR XI:_______________________________________________________________________________
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PAR XII:______________________________________________________________________________
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IMPRESIÓN DIAGNOSTICA:
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RESUMEN SINDROMICO:
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DIAGNOSTICO DIFERENCIAL:
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COMPLEMENTARIOS INDICADOS:
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INDICACIONES MEDICAS:
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FECHA DE PROXIMA CONSULTA:______/_____/______

FIRMA Y SELLO:________________