Monografia Epi Historia Clinica2015

7/23/2019 Monografia Epi Historia Clinica2015

http://slidepdf.com/reader/full/monografia-epi-historia-clinica2015 1/13

PROFESOR: PEZUA VIVANCO.



UNIVERSIDAD NACIONAL DE INGENIERÍA

INDICE

1. FILIACION …………………………………………………………………………....…..pág. 32. ANAMNESIS……………………………………………………………………….…..…..pág. 32.1. MOTIVO DE CONSULTA……………………………………………….….….…..pág.42.2. ENFERMEDAD ACTUAL………………………………………………….….……..pág. 42.3. ANTECEDENTES PERSONALES……………………………………….………..pág.42.4. ANTECEDENTES FAMILIARES………………………………………….………..pág.52.5. REVISION POR SISTEMAS…………………………………………….…………..pág. 63. EXAMEN FISICO…………………………………………..…………………….

………..pág. 3.1. EXAMEN GENERAL…………………………………………………….……………..pág. !3.2. EXAMEN REGIONAL.………………………………………………………………..pág. 113.3. EXAMEN NEUROLOGICO………………………………………….……………..pág. 124. IMPRESI"N DIAGNOSTICA O DIAGNOSTICO……………………………..pág.13

4.1. PARACLINICOS…………………………………………………………………….…..pág. 144.2.

DIAGNOSTICO………………………………………………………………………...pág.145. TRATAMIENTO…………………………………………………………..………………..pág. 156. EVOLUCION………………………………………………………………………….……..pág. 15. FIRMA DELMEDICO……………………………………………………………………..pág.15!.EPICRISIS……………………………………………………………………………………..pág. 16

EPIDEMIOLOGIA Página 2




HISTORIA CLÍNICA

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1. FILIACION2. ANAMNESIS2.1. MOTIVO DE CONSULTA2.2. ENFERMEDAD ACTUAL2.3. ANTECEDENTES PERSONALES2.4. ANTECEDENTES FAMILIARES2.5. REVISION POR SISTEMAS3. EXAMEN FISICO3.1. EXAMEN GENERAL3.2. EXAMEN REGIONAL.3.3. EXAMEN NEUROLOGICO

4. IMPRESI"N DIAGNOSTICA O DIAGNOSTICO4.1. PARACLINICOS4.2. DIAGNOSTICO5. TRATAMIENTO6. EVOLUCION. FIRMA DEL MEDICO!. EPICRISIS

1. DATOS DE FILIACION1. N(?) *(p+'(@2. E0#0 #p#)-' @3. E0#0 *)(-(+9g%*# @4. S( @5. R#B# @6. E&'#0( *%=%+ @. O*/p#*%9- @!. N#*%0( - @. P)(*0-*%# @1. R&%0-' - @ D%)**%9-@ T+.


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16. N(?) 0+ 0%*(@1. N(?) 0+ 0(*-'@ D).

2. ANAMNESIS

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2.3. ANTECEDENTES PERSONALES M0%*(&S#+/0 g-)#+ 0+ p#*%-'


http://es.wikipedia.org/wiki/Semiolog%C3%ADa_cl%C3%ADnica


http://es.wikipedia.org/wiki/Entrevista_cl%C3%ADnica

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http://es.wikipedia.org/wiki/Entrevista_cl%C3%ADnica





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/+',p#)#7 p)%-( %-'#*'( ( *%*#')%B 0 p%&%('(%#7 %-')(0/B*# + 00(,-0%* < p#+p +# p#)0 =#g%-#+7 /)')# < */++(. V)%8/ 'p)#'/)#+(-g%'/0 < #p+%'/0 0+ *#-#+ =#g%#-+. D&*)%?# +# p(&%*%9-7 '##(7 ()#7*(-&%&'-*%# < (=%+%0#0 0+ */++( < &/ &-&%?%+%0#0 # +# #-%p/+#*%9-.A +# p#+p#*%9- ?%#-/#+7 ')#' 0 0+%%'#) + K')( < (=#)%(&7 -('#-0( +'##(7 0(+() < *(-&%&'-*%#. I-&)' /- &p*/+( < =%&/#+%* +#& p#)0&=#g%-#+& < */++( /')%-(.A +# &p*/+( *(p%# =#+/ p#)0& =#g%-#+&7 p+%g/&- &*)*%(-&7 # -%=+0+ */++(7 #p#)%-*%# /%&'& 0 -#?('$. S 0? )#+%B#) #-'& 0+ '#*'(=#g%-#+;

APARATO LOCOMOTOR/&/ 0(+()7 -)(*%%-'( < 0()%0#0 0 +#& #)'%*/+#*%(-&7. D0(& -p#+%++( 0 '#?()7 g)(&() 0 +# '%?%#7 &'#0( 0 +(& K&*/+(& /')(8*(&7 $%p(( $%p)')(8#(&;7 (?&)= 0%)-*%#& - + '##( < +(-g%'/0 0 +#& p%)-#&&%'),#;7 *%)*/+#*%9- - +#& #-(&7 p%)-#& < p%& - p(&%*%9- =)'%*#+ <#*(&'#0#7 =#)%*&7 *%#-(&%& - +#& #-(& < p%&7 0%)-*%# 0 +#'p)#'/)# 0 +#& ')%0#0&.A-(#+,#& L(*#+&S% - p#*%-' & /# ( /&')# =%0-*%# 0 /-# #-(#+,# +(*#+7 '#+ *((*+/+%'%& ( '/() #?0(%-#+7 & () 0&*)%?%)+# - 0'#++&7 ?#( /-

-*#?B#%-'( &p#)#0(. E&'# )/'%-# 0? &g/%)& - +# #<(),# 0 +(&*#&(&. VASCULAR PERIFERICOD&*)%?# *#?%(& ')98*(& - +# p%+ *(+() #p#)%-*%#7 g)(&()7 p%+%8*#*%(-;.Ep+() '(0(& +(& p/+&(& p)%)%*(& #& %p()'#-'& *#)('%0(7 #%+#)7?)#/%#+7 )#0%#+7 */?%'#+7 %-g/%-#+7 p(p+,'(7 p0%(7 '%?%#) p(&')%();%0-'%8*#-0( )%'(7 #p+%'/07 )*/-*%#. R#+%B#) &% & -*&#)%( p)/?# 0A++-7 p)'$&7 ')-0+?/)g.

SISTEMA NERVIOSOESFERA MENTAL1; *(-*%-*%#7 &'#0( +K*%0(7 &(-(+%-'(7 &'/p()(&(7 *(#. =) '#?%-&*#+# 0 G+#&g(;2; ()%-'#*%9-E- p)&(-# J/%- & C(( & ++## & $(?) ( /);.E- &p#*%( D9-0 &'á D 0(-0 =%-( D9-0 -#*%9;E- '%p( J/ 0,# ++g( E- / & E- / *$# E& 0 -(*$;3; ()%#

R*%-'. S p)g/-'# &(?) $*$(& ?#&#0(& - + #- / & &'#$#*%-0( =). C/#+. E& +# K+'%# p)g/-'#7 / & + $%B( C(( ++g( # &'





*/#)'( C#%-#-0( ( *#)g#0(.R('#@ & %-'))(g# &(?) $*$(& p#&#0(&4; &'#0( 0 á-%(7 /%*%( < )#*%(*%-%(7 %-')(&p**%9-7 p)(&p**%9-.%-'+%g-*%# /-*%(-& *(g-%'%=#& &/p)%()&;

3.1. EXAMEN REGIONAL. OLFATORIO@ &/& #+')#*%(-& p/0- &) A-(&%#. C#&*(&%#. >%p(&%&.A+/*%-#*%(-& (+#'()%#&7 - +#& / & p)*%?#- (+()& / -( %&'-7 #-'&0 $#*) + #- & #%-#- +(& *()-'& p)()#0(&;7 p)(*&(&%-Q##'()%(&7 g)%p7 &%-/&%'%&7 0&=%#*%9- 0+ '#?%/.

"PTICO@ &% -( & = -#0# $#?+(& 0 *g/)# ( #?+%(p,#7 = *(&#&?())(&#& ( ?/+'(&7 & $#?+# 0 =%&%9- 0 ?/+'(&H7 &% &(+( & *#p#B 0 *(-'#)+(& 00(& 0 +#& #-(&7 $#< &(+( =%&%9- */-'# 00(&. C(- +( #-')%() &p+()# +# #g/0B =%&/#+.

CANPIMETRIA@ %&'- =#)%(& '(0(&7 + á& /&#0( & + 0 *(p#)#*%9-.FONDO DE OO@ *(- + ('#+(&*(p%(

MOTOR OCULAR COMUN PATETICO@ 0%#-' +# (=%+%0#0 0+ g+(?((*/+#)7 +# /&*/+#'/)# %-'),-&*# & p+()# 0%#-' + -9-( 0#*((0#*%9-.

TRIGEMINO@ & p+()#- &/& ')& )##&@ ('á+%*#7 p() + )Q( *()-#-(.M#%+#) &/p)%()7 p() +# %-)=#*%(- &-&%'%=# 0 +# *#)#. M#%+#) %-)%()7 p()+# %-)=#*%(- ('()#7 #&'%*#0()#;. S/ )## 0%# 0# +# &-&%?%+%0#0p)(/-0#.

MOTOR OCULAR EXTERNO@ g%)( 0+ g+(?( (*/+#) $#*%# /)#.FACIAL@ +# %-)=#*%(- ('()# 0 +# *#)#7 )(-'#+7 +=#0()7 0+ #+# 0 +#-#)%B7 ()?%*/+#) 0 +(& p#)p#0(& < 0 +(& +#?%(&;. L# p#)á+%&%& 0 &' K+'%(0# + #g('#+(. R%&()%(7 #&'%*#0()& < */'á-(& 0+ */++(. L# p()*%9-&-&%'%=# 0+ #*%#+7 / & á& ?%- &-&()%#+7 & p+()# /-'( *(- +#*/)0# 0+ ',p#-( g/&'( 0 +# p/-'# 0 +# +-g/#;.AUDITIVO@ +# )## *(+#) p() 0%( 0+ 0%#p#&9- ( &%p+-'p)(0/*%-0( -9-(& #*K&'%*(&7 0? &) *(p#)#'%=# -') #?(&*(+#)&. L# )## =&'%?/+#) & p+()# 0%#-' +# %-<**%9- 0 #g/# ),#7&'# p)(0/*%)á =)'%g(7 0&=%#*%9- 0 +# *#?B# $#*%# + %&( +#0(7 & /&#

+# p)/?# 0 +# &%++# g%)#'()%#.GLOSOFARINGEO@ +# p#)' ('()# & p+()# p() + )Q( -#/&(&( < ')#g#)#g/# +# p#)#+%&%& 0 &' -)=%( *#/&# 0%&#g%#.VAGO NEUMOGASTRICO;@ S =#+/# + '(-( 0 +# =(B )(-/)#7 =(B?%'(-#+;7 )Q( *#)('%0( p(&%'%=( ?)#0%*#)0%# $%p('-&%(-;. ESPINAL@ E=#+/ +(& /&*/+(& ')#p*%(7 &')-(*+%0(#'(%0(7 +=#-'#-0(+(& $(?)(& ( g%)#-0( +# *#?B# (p(-%-0(+ /)B# # &'(& (=%%-'(&. >IPOGLOSO @ S =#+/# ()0-#-0(+ #+ p#*%-' (=) +# +-g/#7 &#*#)+# <(=)+# - '(0(& +(& &-'%0(&.3.2. EXAMEN NEUROLOGICO

E=#+/#) +(& )Q(& =%*)#+&7 */'#-( #?0(%-#+& &/p)8*%#+&; <(&'('-0%-(&(& p)(/-0(&;. P)&-*%# 0 *+(-/&7 )Q(& p#'(+9g%*(&





#?%-&:%7 &/**%9- - #0/+'(&7 '*;.V)%8*#) &%g-(& -,-g(& )%g%0B 0 -/*#; :)-%g < ?)/0B%-&:%. P)/?#&*)?+(&#& /%+%?)%(7 R(?)g7 *(()0%-#*%9- ( #'#%#;. L-g/# 0%&#)')%#7##&%# ('()# ( &-&%'%=#;7

E=#+/ &-&%?%+%0#0 @ S/p)8*%#+ ')%*#7 0(+()(&# < 'á*'%+;7 P)(/-0#&-'%0( 0 p(&%*%9-7 =%?)#*%9-7 p&#-'B; C()'%*#+ E&')(g-(&%#70%&*)%%-#*%9- 0 0(& p/-'(&7 g)#&'&%#7 '(p(g-(&%#;

E=#+/ ('%+%0#0 &%&'# ('(); @ p#)# =#+/#) +# /)B# 0 %?)(&&/p)%()& %-)%()& & /&# +# p)/?# 0 %-g#BB%-% < #)). E=#+/ +'(-( /&*/+#) %-&p**%(-#-0( + =(+/- /&*/+#)7 =#+/ + ')(p%&(*)*%%-'( /&*/+#);7 =#+/ (=%%-'(& #-()#+& %*(+(g,#&7#&*%*/+#*%(-&7 '?+()&7 *(-=/+&%(-&7 *()#&7 #''(&%&7 *#+#?)&;

N('# @ +# /)B# /&*/+#) & =#+K# ()0-á-0(+ #+ p#*%-' # )#+%B#)(=%%-'(& A*'%=(&; )#+%Bá-0(+ /&'0 +(& (=%%-'(& #*'%=(&; ( -*(-')# )&%&'-*%#. L(& (=%%-'(& 0?- &) &gK- +(& '%p(& 0(=%%-'(& / '-g# 0%*$( &g-'( # =#+/#) Q%9-7 '-&%9-7#?0/**%9-7 #0/**%9-7 )('#*%9-. '*.;

A+g/-(& (0+(& 0 $%&'()%# *+,-%*# & %-*+/< /- ?)= )&/- 0 +(&0#'(& p(&%'%=(& -*(-')#0(& - +# =#+/#*%9- 0+ p#*%-'p/-'(& á&%p()'#-'&; # #-)# 0 #-á+%&%& p#)# -'(-*& &% %'%) /-# %p)&%9-0%#g-(&'%*#

4. IMPRESI"N DIAGNOSTICA /%*%(& *+,-%*(& / & %'- &gK- +(& &%g-(& < &,-'(#& 0+ p#*%-'=#)%(&; p)( #/- -( & $# *(-8)#0(

1. 2. 3. 4.

4.1. PARACLINICOSR+#*%(-#0(& < *($)-'& *(- +# %p)&%9- 0%#g-(&'%*# S ?/&*# *(-8)#)( 0&*#)'#) 0%#g-9&'%*(&;

4.2. DIAGNOSTICO /%*%( *+,-%*( / & %' +/g( 0 *(-8)#)+( 0%#-' + #*'( *+,-%*( (p(&')%() # á-& 0 +#?()#'()%( p#)#*+,-%*(&;

P)&/-'%=(@ E& + 0%#g-9&'%*( / & $#* # /- p#*%-' &%- *(-8)#) p()0%(& 0 #p(<( 0%#g-9&'%*(W & /- 0%#g-9&'%*( $%p(''%*(7 p)( / ()%-'#+ ')#'#%-'(. Ep+(@ #+g/%- p)&-'# 8?) #+'# < )%g%0B 0 -/*#7-'(-*& + 0%#g-9&'%*( p)&/-'%=( p/0 ()/+#)& *(( -%-g%'%&-%-g(*9*%*#.





O')( p+(@ & 0'*'# /-# #&# - /- p*$( 0 /-# /) 0 á& 0 5#(&@ p/0- ()/+#)& /-( ( á& 0%#g-9&'%*(& p)&/-'%=(& - &' *#&(7p(0),# ()/+#)& *(( D. p)&/-'%=( /- /%&' &?á*( *(( p)%)#(p*%9-7 < /- *á-*) ##)%( *(( &g/-0#.

D8-%'%=(@ E& + 0%#g-9&'%*( 8-#+7 #p()'#0( p() 0%(& *+,-%*(& < 0 #p(<(0%#g-9&'%*(7 0 (0( / - /- p)(*&( 0 #'-*%9- 0+ p#*%-'7 &0&*#)'# ( *(-8)# /- 0%#g-9&'%*( p)&/-'%=( < & *(-&%0)# / +08-%'%=( ()%-'# + p+#- 0 ')#'#%-'( < + p)(-9&'%*( 0+ p#*%-'.E- +(& p+(& #-')%()&7 + D. p)&/-'%=( 0 M-%-g%'%& M-%-g(*9*%*#p#&#),# # &) D. 08-%'%=( &% +#& p)/?#& +( *(-8)#-@ */+'%=( ?#*')%#-( 0+,/%0( *#+())#/,0( p(&%'%=( #+ -%-g(*(*( #g-' *#/&#+;.E- + &g/-0( p+(7 & *(-8)#),# + *á-*) ##)%( &% /-# ?%(p&%##*/&# *+/+#& #+%g-#&W & 0&*#)'# + p)&/-'%=( 0 /%&' &?á*( -& *#&(.

5. TRATAMIENTOHA+%#-B# ')#p/'%*#H / )&/+'# +/g( 0 %'%) + 0%#g-(&'%*(#?/+#'()%( $(&p%'#+%B#*%9-; < / ?/&*# +# (),# ( */)#*%9- 0 +#-)0#0 ( 0%#g-(&'%*(

• Tratamiento curativo ra!ica"#: 0&'%-#0( # ))#0%*#) +#

-)0#0 p() *(p+'(.• Tratamiento activo: 0%)%g%0( *(-')# +# *#/&# / p)(=(*# +#

-)0#0 p/0 &) */)#'%=( ( p#+%#'%=(;.• Tratamiento $a"iativo: & + / %-'-'# #+%=%#) / ()*) + á%(

?%-&'#) #+ p#*%-' <# / -( & p/0 #+*#-B#) + ')#'#%-'(*/)#'%=(.

• Tratamiento %intom&tico: & + / *#+# ( #+%=%# +(& &,-'(#& -#/++#& -)0#0& / & 0&*(-(*- ( / -( '%--')#'#%-'( 8*#B.

6. EVOLUCION

Sg/%%-'( 0+ p#*%-' (),#7 =(+/*%9- &'#?+ ( '9)p%0#;. FIRMA DEL MEDICO TRATANTEE- &' *#&( 0+ &'/0%#-' < =%&'( ?/-( 0+ 0(*-'

MODELO DE EVOLUCION>#< /*$(& &/#& p)( /- &/# p)#*'%*( / *(-'%- +(& 0#'(&)+=#-'& 0+ p#*%-' & + / '%- p() &%g+#& P.S.O.A.P.

F*$#P@ p#*%-';E0#07 S(7 &'#-*%# $(&p%'#+#)%#D%#g-(&'%*( 0 %-g)&(





S@ &/?'%=(;)= %-'))(g#'()%( #+ p#*%-' #*)*# 0 +(& &,-'(#& #& %p()'#-'&)*%-'-'O@ (?'%=(;S%g-(& =%'#+&7 p)&%9- #)')%#+7 )*/-*%# )&p%)#'()%#7 F)*/-*%# *#)0%#*#

E#- ,&%*( 0%)%g%0( #+ ( +(& &%&'#& #*'#0(.A@ #-á+%&%&;S #-#+%B# +(& &,-'(#& < &%g-(& -*(-')#0(& #+ (-'( 0 +# =(+/*%9-#&, *(( p#)#*+%-%*(& ()0-#0(& < )#+%B#0(& p)=%#-' < &/ )+#*%9- *(-+ &'#0( #*'/#+ 0+ p#*%-'.P@ p+#-;D #*/)0( # +(& $#++#Bg(& %-')p)'#*%9- *+,-%*# < p#)#*+%-%*# & 0?#0(p'#) /- p+#- + */#+ 0? &) *(-&%g-#0( - +#& ()0-& 0%*#&*())&p(-0%-'& # & 0%#. D? p#)'%) 0+ #-á+%&%& )#+%B#0( < 0?#-('#)& &% / )=%&#0( - )(-0# 0%*# *(- &p*%#+%&'# ( 0%*( g-)#+.

!. EPICRISIS

E& + p),(0( p(&')%() # +# *)%&%& 0 /-# -)0#0. S )8) # +#

&g/-0# *)%&%& ( *)%&%& /+')%() - + ')#-&*/)&( 0 /-# -)0#0W < #+

#-á+%&%& ( /%*%( *),'%*( 0 /- *#&( *+,-%*(7 /-# =B *(p+'#0(. 1

E- g-)#+7 & /- -9-( %p()'#-' #*#*%0( 0&p/& 0 +# *)%&%& %-%*%#+

0 /-# -)0#0 < / +# *(p+'#7 < p/0 (?+%g#) # )p+#-'#) + /%*%(

*+,-%*( &(?) + p)(?+# 0 &#+/0 / &/) + p#*%-'


http://es.wikipedia.org/wiki/Epicrisis#cite_note-1

http://es.wikipedia.org/wiki/Epicrisis#cite_note-1

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