Hitoria Clinica

ABDOMEN:
Epigastric pain: Positive
INDIGESTION: Casual, Rumbling: Denied, bloating: Casual, flatulence: Casual, INTESTINAL HABIT: Evacuations 1 time per day, defecation: No changes
YEAR: Noalterations, STOOLS: From nutritional content, color, smell, shape and normal consistency.

LIVER AND BILIARY TRACT:
JAUNDICE: Denied, choluria: Denied, PAIN: Denied, ITCHING: Denied
Haemolymph:Pallor: Denied, petechiae: Denied, BLEEDING: Denied, lymphadenopathy: Denied

ENDOCRINE:
WEIGHT: 85 KG, GOITER: Denied, nervousness: Denied
Secondary sexual characteristics: A facial hair distribution,voice unchanged (according to genre), obese, hot flashes only at very high temperatures.

NERVOUS:
HEADACHE: Occasional (stress), Syncope: Denied, SEIZURES: Denied. Sleep-wake cycle: Noalterations, gait and balance: No changes

PSYCHIATRIC:
CONDUCT: No alterations, THOUGHTS: No alterations, NEUROSIS: Denied, HALLUCINATIONS: Denied, DRUG: Denied
MUSCLE-SKELETAL:
MUSCLE: No alterations,JOINTS: Joint pain to climate change

PHYSICAL EXAMINATION:
VITAL SIGNS:
BLOOD PRESSURE: 145/90
HEART RATE: 90
RESPIRATORY FREQUENCY: 19
TEMPERATURE: 36.5 ° C

Habitus EXTERIOR: SOMATIC AREA:SEX: Female
APPARENT AGE: According to the timeline.
Facies: Normal
ATTITUDE: Freely chosen
INTEGRITY: Complete
CONSTITUTION: Robust
NUTRITIONAL STATUS: No changes
TIME: Normal
SOMATOTYPE:Normal

PSYCHIC SPHERE: Targeted, conscious, cooperative, emotional state unchanged.
SOCIOCULTURAL SPHERE:
SOCIO-ECONOMIC LEVEL-CULTURAL: Medium

Somatometry:
CURRENT WEIGHT: 85 KG
HEIGHT: 156 CMBODY MASS INDEX: 34.93
DEGREE OF OBESITY: Obesity grade I
IDEAL WEIGHT: 52.3 KG

HEAD:
INSPECTION: Normocefalo, normal volume, without changes in movement.
PALPATION:
Normal consistency,painless, normal subsidence.
HAMMER: No changes.
Auscultation: No changes

FACE: Fascies, shape and volume unchanged.
PALPATION: No changes
EYES: Eyebrows, eyelashes normally distributed unaltered...