Historia Clínica Todo

7/23/2019 Historia Clnica Todo

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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA

HISTORIA CLNICA DE FISIOTERAPIA

ESPECIALIDAD: LESIN DE LOS PARES OCULOMOTORES

ANAMNESIS

FILIACIN

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Apellido paterno Apellido materno Nombre

Fe!a de naimiento: __________________________Edad:_________________

E"tado i#il: ________________________________ $%nero: M & ' F & '

Pro(e"i)n *+o o,pai)n: ______________________________________________

Domiilio: _______________________________Tel%(ono:___________________

Fe!a de on",lta: ______________________________________

Fe!a de e#al,ai)n iniial: _______________________________

Fe!a de e#al,ai)n (inal: _________________________________

Dato" obtenido" del: Paiente & ' Padre & ' Madre & ' Apoderado & '

Otro"____________________________

Nombre del Padre:

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Nombre de la madre:

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MOTIVO DE CONSULTA:

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ENFERMEDAD ACTUAL:

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ANTECEDENTES FAMILIARES:

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ANTECEDENTES PATOLGICOS:

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ANTECEDENTES NO PATOLGICOS:

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SIGNOS VITALES

Pe"o: ________________Talla:_____________ Temperat,ra:________________

Pre"i)n Arterial: ________________ Fre,enia Re"piratoria: ________________

Fre,enia Cardiaa: ____________________ P,l"o:_______________________

DESVIACIONES DEL GLOBO OCULAR

Ojo derecho Ojo i!"ierdoEndode"#iai)nE-ode"#iai)n.iperde"#iai)n.ipode"#iai)nDe"#iai)n dia/onal !aia arribaDe"#iai)n dia/onal !aia aba0o

FUER#A MUSCULAR

M"$c"%o B"e&' Re("%'r M'%'Reto ",periorReto in(erior

Reto e-ternoReto internoObli,o ",periorObli,o in(erior

REFLE)OS

Re*%ejo A"$e&+e Pre$e&+eMentoniano

A1"tio palpebral

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DIAGNOSTICO CLNICO:

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DIAGNOSTICO ,INESICO:

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OB)ETIVOS DE TRATAMIENTO

CORTO PLA2O

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MEDIANO PLA2O

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LAR$O PLA2O

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ABORDA)E TERAPEUTICO

CORTO PLA2O

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MEDIANO PLA2O

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LAR$O PLA2O

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PRONSTICO

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OBSERVACIONES

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CONCLUSIN

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RECOMENDACIONES

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HISTORIA CLNICA DE FISIOTERAPIA

ESPECIALIDAD: LESIN DEL TRI$EMINO

ANAMNESIS

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FILIACIN

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Apellido paterno Apellido materno Nombre

Fe!a de naimiento: __________________________Edad:_________________

E"tado i#il: ________________________________ $%nero: M & ' F & '

Pro(e"i)n *+o o,pai)n: ______________________________________________

Domiilio: _______________________________Tel%(ono:___________________

Fe!a de on",lta: ______________________________________




Otro"____________________________

Nombre del Padre:

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Nombre de la madre:

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MOTIVO DE CONSULTA:

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ENFERMEDAD ACTUAL:

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SIGNOS VITALES



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EVALUACION DEL TRIGEMINO:

DOLOR DEL TRI$EMINO TOPO$RAFICAMENTE:

Rama ",perior

Rama media

Rama in(erior

TIPO DE DOLOR:

Taladrante

P,n3anteS!o4Urente

INTENSIDAD DEL DOLOR:

ESCALA NUMERICA:

RESULTADO55555555555555555555555555555

ESCALA DE 6ON$:

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FRECUENCIA DEL DOLOR:

555555555555555555555555555555555555

555555555555555555555555555555555555

5555555555555555555555555555555555

TIEMPO DE DOLOR:

TIEMPO7879 SE$778;9 SE$;7878779 SE$

7787?9 SE$

AURA SENSORIAL:

@Siente antiipadamente del dolor

.ORMI$EOENTUMESIMIENTODOLOR

CONSTANTEOTROS

EBALUACION DE TROFISMO CUTANEO:

PIEL RILLANTEPIEL LISACIANOSISPALIDE2RU$OSIDADES.UMECTACION

ESCALA DE EBALUACION DEL TONO FACIAL:

$RAD

O

TONO RESP

89 Normal87 .ipotona Li/era

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8? .ipotona F,erte7 .ipertona Li/era? .ipertona F,erte

EBALUACION DE SENCIILIDAD:

TERMICA: Frio Calor

TACTIL: Li"o "pero Simple tato

DOLOROSA: P,n3ante Pre"i)n

DIAGNOSTICO CLNICO:

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DIAGNOSTICO ,INESICO:

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OB)ETIVOS DE TRATAMIENTO

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CORTO PLA2O

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MEDIANO PLA2O

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LAR$O PLA2O

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ABORDA)E TERAPEUTICO

CORTO PLA2O

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MEDIANO PLA2O

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LAR$O PLA2O

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PRONSTICO

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OBSERVACIONES

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CONCLUSIN

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RECOMENDACIONES

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Fe!a de on",lta: ______________________________________




Otro"____________________________

Nombre del Padre:

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Nombre de la madre:

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MOTIVO DE CONSULTA:

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ENFERMEDAD ACTUAL:

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SIGNOS VITALES




EVALUACION DE PARALISIS FACIAL

ESCALA DE HOUSE BRAC,MAN

$RADO 7

&NORMAL'

$RADO ?

&DISFUNCION

LEBE'

$RADO ;

&DISFUNCION

MODERADA'

$RADO G

&DISFUNCION

MODERADAMENTE

$RADO

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