Comprehensive Medical History Overview
Uploaded by
ScribdTranslationsComprehensive Medical History Overview
Uploaded by
ScribdTranslationsNORMAL MEDICAL HISTORY
1. PATIENT DATA
2. ANAMNESIS
3. PERSONAL BACKGROUND
4. FAMILY BACKGROUND
5. GYNECOOBSTETRIC BACKGROUND
6. PEDIATRIC BACKGROUND
7. HABITS AND CUSTOMS
8. REVIEW BY SYSTEMS
9. PHYSICAL EXAMINATION
-GENERAL PHYSICAL EXAMINATION: The biotype, the face, the attitude or posture, the gait or
ambulation, weight, height and the condition of the skin, mucous membranes and any abnormalities
observable.
Lucid patient, oriented temporospatially. In active decubitus, normal ambulation.
Afebrile, without characteristic facial features. Mesomorphic constitution. Skin with elasticity and turgor.
stored, hydrated mucous membranes.
HEAD: Inspection: Position, shape, and proportion of the head.
-EYES: Inspection: eyebrows, eyelids and eyelashes, shape of the eyes and symmetry
EYES: eyes and pupils are isocoric, photoreactive.
Intact eyebrows and eyelashes, normocolored palpebral and bulbar conjunctiva
Nose
NOSE: With good implantation, pyramidal shape, without anatomical alterations, without discharge.
secretions, without palpable or visible masses, translucent and non-painful paranasal sinuses
by touch (both nostrils permeable)
-EARS: Inspection: Integrity of the skin, shape, size, symmetry, and position of the
ears. Palpation: Sensitivity.
EARS: Symmetrical auricular pavilion, well implanted, without discharge of secretions, no
painful to the traction, without palpable or visible masses.
-Oropharynx:
Oropharynx:
-NECK- THYROID: Shape, volume, position, mobility, beats and presence or absence of
tumors
# Exploración de la glándula tiroides, #Examen de los ganglios linfáticos,#Examen
of the neck vessels, Exploration of the rest of the structures: Larynx and trachea.
NECK: Symmetrical in length and width preserved. Absence of tumors, without
jugular regurgitation, without adenopathies. Carotid pulse is observed and palpated, it is observed
venous pulse.
TORACOPULMONARY: (Inspections, palpation, percussion, and auscultation)
Inspection: Skin condition, Shape and Symmetry, musculoskeletal structure,
expandability of the thoracic cavity.
Palpation: Sensitivity, thoracic expansibility and intensity of vocal vibrations or
shiver.
Percussion: digit-digital of the thorax produces two types of sensations:
The auditory, which is due to the soundness of the lung. The tactile, which is due to the elasticity of the
lung
Auscultation:
Glottal stop.
Vesicular murmur.
Bronchovesicular breathing.
THORAX: Normolinear, symmetrical, expandable with good elasticity. HR of 16 x min with good
amplitude, rhythm, and symmetry.
LUNG FIELDS: Well-ventilated lung fields, audible vesicular breath sounds
without added noises (snoring, sibilant, crackling).
-MOTHERS:
Breasts: Symmetrical, prominent nipples, normal colored, not painful to palpation.
without palpable or visible masses, absence of secretions.
-HEART:
HEART: rhythmic, r1-r2 audible with good tone, absence of heart murmurs.
Sequence: Inspection, Auscultation, Percussion, Superficial Palpation
Deep palpation.
Inspection: contour, symmetry, respiratory movements, pulses, peristalsis,
skin integrity, masses.
Auscultation: intestinal sounds (hydroaeric noises), vascular sounds
Percussion: tone, limits of the abdominal organs.
Palpation: muscle tone, characteristics of the organs, sensitivity, masses, pulsations,
liquid accumulation
Flat, soft, not tense, good coloration and pigmentation, intact skin
painless on palpation, absence of visible and palpable masses, audible peristaltic sounds
normal (35xmin), without signs of peritoneal irritation.
-RECTOPERINEAL: (RENAL TOUCH)
RECTOPERINEAL: Intact anus, no lesions, no scars. No presence of visible masses nor
palpable. Absence of unusual secretions.
-GENITALS:
GENITALS: Intact bulbous region, intact normal colored labia majora, normal
tense. Absence of unusual secretions
State of consciousness, Vital functions, Activity
,Orientación(tiempo, espacio, persona) ,Memoria, Signos meníngeos, Fuerza y tono
muscular, coordination, sensitivity, reflexes.
NEUROLOGICAL: Patient conscious, with good vital functions, active, oriented
temporally and spatially, with good memory, without meningeal alterations, with good tone and
good muscular strength, good coordination, good sensitivity to palpation, with good
reflections.
-EXTREMITIES (OSTEOARTICULAR-VASCULAR-LYMPHATIC) inspection and palpation
EXTREMITIES: Skin intact, good coloration and pigmentation, symmetrical, mobile, no
sensitive to palpation, without pathological alterations (edema, atrophy, etc.)
Patient with good gait, coordinated and symmetrical. Healthy bones without alterations.
SKIN AND APPENDAGES :
Through inspection: Color and pigmentation, Hygiene and lesions
Through palpation: Humidity, Temperature, Texture and thickness, Turgor and mobility
Skin normocolored, normothermic, normohydric, normal elasticity, thickness, and mobility.
with good hygiene and without injury.
[Link] DIAGNOSIS
