7/23/2019 Historia Clnica Todo
1/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
HISTORIA CLNICA DE FISIOTERAPIA
ESPECIALIDAD: LESIN DE LOS PARES OCULOMOTORES
ANAMNESIS
FILIACIN
__________________________________________________________________
Apellido paterno Apellido materno Nombre
Fe!a de naimiento: __________________________Edad:_________________
E"tado i#il: ________________________________ $%nero: M & ' F & '
Pro(e"i)n *+o o,pai)n: ______________________________________________
Domiilio: _______________________________Tel%(ono:___________________
Fe!a de on",lta: ______________________________________
Fe!a de e#al,ai)n iniial: _______________________________
Fe!a de e#al,ai)n (inal: _________________________________
Dato" obtenido" del: Paiente & ' Padre & ' Madre & ' Apoderado & '
Otro"____________________________
Nombre del Padre:
_________________________________________________________________
Nombre de la madre:
_________________________________________________________________
MOTIVO DE CONSULTA:
__________________________________________________________________
__________________________________________________________________
GRUPO JENOPIPA
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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
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ENFERMEDAD ACTUAL:
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ANTECEDENTES FAMILIARES:
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ANTECEDENTES PATOLGICOS:
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ANTECEDENTES NO PATOLGICOS:
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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
SIGNOS VITALES
Pe"o: ________________Talla:_____________ Temperat,ra:________________
Pre"i)n Arterial: ________________ Fre,enia Re"piratoria: ________________
Fre,enia Cardiaa: ____________________ P,l"o:_______________________
DESVIACIONES DEL GLOBO OCULAR
Ojo derecho Ojo i!"ierdoEndode"#iai)nE-ode"#iai)n.iperde"#iai)n.ipode"#iai)nDe"#iai)n dia/onal !aia arribaDe"#iai)n dia/onal !aia aba0o
FUER#A MUSCULAR
M"$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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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
DIAGNOSTICO CLNICO:
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DIAGNOSTICO ,INESICO:
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OB)ETIVOS DE TRATAMIENTO
CORTO PLA2O
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MEDIANO PLA2O
GRUPO JENOPIPA
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5/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
__________________________________________________________________
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LAR$O PLA2O
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ABORDA)E TERAPEUTICO
CORTO PLA2O
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MEDIANO PLA2O
GRUPO JENOPIPA
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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
__________________________________________________________________
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LAR$O PLA2O
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PRONSTICO
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OBSERVACIONES
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GRUPO JENOPIPA
7/23/2019 Historia Clnica Todo
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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
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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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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
FILIACIN
__________________________________________________________________
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:
_________________________________________________________________
Nombre de la madre:
__________________________________________________________________
MOTIVO DE CONSULTA:
__________________________________________________________________
____________________________________________________________________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ENFERMEDAD ACTUAL:
GRUPO JENOPIPA
7/23/2019 Historia Clnica Todo
9/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
__________________________________________________________________
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ANTECEDENTES FAMILIARES:
__________________________________________________________________
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__________________________________________________________________
ANTECEDENTES PATOLGICOS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ANTECEDENTES NO PATOLGICOS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SIGNOS VITALES
Pe"o: ________________Talla:_____________ Temperat,ra:________________
Pre"i)n Arterial: ________________ Fre,enia Re"piratoria: ________________
GRUPO JENOPIPA
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10/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
Fre,enia Cardiaa: ____________________ P,l"o:_______________________
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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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
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:
$RAD
O
TONO RESP
89 Normal87 .ipotona Li/era
GRUPO JENOPIPA
7/23/2019 Historia Clnica Todo
12/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
8? .ipotona F,erte7 .ipertona Li/era? .ipertona F,erte
EBALUACION DE SENCIILIDAD:
TERMICA: Frio Calor
TACTIL: Li"o "pero Simple tato
DOLOROSA: P,n3ante Pre"i)n
DIAGNOSTICO CLNICO:
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DIAGNOSTICO ,INESICO:
__________________________________________________________________
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__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
OB)ETIVOS DE TRATAMIENTO
GRUPO JENOPIPA
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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
CORTO PLA2O
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MEDIANO PLA2O
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__________________________________________________________________
LAR$O PLA2O
__________________________________________________________________
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__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
____________________________________________________________________________________________________________________________________
ABORDA)E TERAPEUTICO
CORTO PLA2O
GRUPO JENOPIPA
7/23/2019 Historia Clnica Todo
14/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
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MEDIANO PLA2O
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LAR$O PLA2O
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PRONSTICO
GRUPO JENOPIPA
7/23/2019 Historia Clnica Todo
15/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
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OBSERVACIONES
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CONCLUSIN
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RECOMENDACIONES
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GRUPO JENOPIPA
7/23/2019 Historia Clnica Todo
16/26
7/23/2019 Historia Clnica Todo
17/26
UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
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:
_________________________________________________________________
Nombre de la madre:
_________________________________________________________________
MOTIVO DE CONSULTA:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
____________________________________________________________________________________________________________________________________
ENFERMEDAD ACTUAL:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ANTECEDENTES FAMILIARES:
GRUPO JENOPIPA
7/23/2019 Historia Clnica Todo
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UNIVERSIDAD DE AQUINO BOLIVIACARRERA DE FISIOTERAPIA Y KINESIOLOGIA
__________________________________________________________________
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ANTECEDENTES PATOLGICOS:
__________________________________________________________________
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ANTECEDENTES NO PATOLGICOS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SIGNOS VITALES
Pe"o: ________________Talla:_____________ Temperat,ra:________________
Pre"i)n Arterial: ________________ Fre,enia Re"piratoria: ________________
Fre,enia Cardiaa: ____________________ P,l"o:_______________________
EVALUACION DE PARALISIS FACIAL
ESCALA DE HOUSE BRAC,MAN
$RADO 7
&NORMAL'
$RADO ?
&DISFUNCION
LEBE'
$RADO ;
&DISFUNCION
MODERADA'
$RADO G
&DISFUNCION
MODERADAMENTE
$RADO