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Syllabus of Internal Medicine I Last
Syllabus of Internal Medicine I Last
CONTENT:
1. GENERAL DATA
2. SUMILLA
3. COURSE COMPETENCES
4. CONTENT
5. SPECIFIC COMPETENCES OF THE DIDACTIC UNITS .
6. PROGRAMMING BY UNITS
7. TEACHING METHODOLOGY
8. AUXILIARY TEACHING MEDIA
9. EVALUATION SYSTEM
10. BIBLIOGRAPHY
11. ANNEX (EVALUATION INSTRUMENTS, MODULE)
Chief coordinator :
Med. Jimmy Curo Niquén AXTP – 20 hrs.
2.- SUMILLA .
The subject of Internal Medicine aims to train a GENERAL PHYSICIAN, the subject being of
a THEORETICAL-PRACTICAL nature: with the purpose of achieving a professional-medical
profile in the skills:
Cognitive: The processes for acquiring knowledge of Peruvian and world pathology, with its
phases, which begin with the preparation of the clinical history until the diagnosis and
therapeutic management.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
The subject of Internal Medicine I has a value of 15 credits, lasting 18 weeks, with seven
teaching units: Toxicology, Medical Oncology and Introduction to the aging process,
Neurology, Gastroenterology, Dermatology, Hematology and Rheumatology-Immunology.
The subject of Internal Medicine trains students of the 4th year of EAP Studies of Human
Medicine in the basic competencies that include: COGNITIVE – PROCEDIMENTAL AND
ATTITUDINAL field, using SEVEN UNITS, which make up this subject, so that your
performance as a 1st level doctor is satisfactory.
The subject, whose course is THEORETICAL – PRACTICAL, is developed in TWO
healthcare teaching centers: Hospital II ESSALUD Huánuco and Hospital Hermilio Valdizán
Medrano, in addition to a rotation at the Carlos Showin Hospital.
Based on the learning of the Introduction to Clinical subject, detects and extracts the
symptoms and performs the comprehensive physical examination, describing the
normal or pathological findings.
- Of the symptoms and signs detected, forms SYNDROMES OR PROBLEMS, of which the
most important will be selected, based on severity, or on its location, strategy for the
reasoned elaboration that leads to the PRESUMPTIVE DIAGNOSIS.
- Based on the knowledge previously acquired in the basic subjects of Clinical Laboratory
and Imaging. A WORK PLAN will be scheduled requesting diagnostic support tests to
confirm or rule out the presumptive clinical diagnosis.
PRESCRIBE medications rationally, taking into account adverse or collateral effects.
- Locate the nosological entity in the epidemiological spectrum of Peru and the world,
recommending PREVENTION measures.
- Recognize the critical patient and reference and/or counter-reference criteria for patients.
- Request informed consent from the patient in your care.
- Know and apply biosafety standards, to protect your health and the people around you.
4.- CONTENTS .
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
UNIT: GASTRENTEROLOGY
(Duration: 03 weeks)
CONTENTS
CONCEPTUAL PROCEDURAL ATTITUDINAL
Learn about gastroenterological Preparation of clinical history of outpatient consultation, Supportive and respectful of the sick.
pathology: hospitalization and emergency service.
Inflammatory–infectious, Explains his illness while maintaining
Inflammatory, neoplastic-metabolic, Correctly execute the comprehensive physical examination. discretion
degenerative, congenital, common in
Peru and the world. Appropriately request diagnostic aid tests. Request informed consent, if the
case requires it.
Identify risk factors and epidemiologicalApplication of the knowledge and skills acquired in:
aspects. Biochemistry, physiology, pathophysiology, microbiology, Demonstrates discipline, interest,
clinical laboratory, imaging, for the interpretation of diagnostic and excitement for learning.
Observe and follow the teachings aid tests.
regarding endoscopic examinations As a consequence, instructions will
and biopsies of the digestive system. Integrating the symptoms, signs and findings of diagnostic be given on how to start the
help, it forms the Syndromes or Problems. INVESTIGATION.
Indicates the appropriate medication,
knowing its indications and Select the most important Syndrome or Problem, based on Solidarity and respect for their
contraindications. severity, or location, to begin diagnostic reasoning. teachers, classmates and medical
staff.
Recognizes critical patients through the Prescribe appropriate medications.
detection of symptoms and signs. Locate the frequency and incidence of the entity in Peru.
Apply prevention measures.
Establishes the prognosis of diseases and their
complications.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
UNIT: NEUROLOGY
(Duration: 03 weeks)
CONTENTS
CONCEPTUAL PROCEDURAL ATTITUDINAL
Synthetic knowledge of diseases of Preparation of clinical history in outpatient consultation, Shows discipline, interest and
the NERVOUS SYSTEM, of etiology: hospitalization and Emergency service. excitement in learning
infectious, parasitic, traumatic,
cerebrovascular, neoplastic, Application of the knowledge acquired in anatomy, As a consequence, you will be
metabolic, degenerative, congenital, biochemistry, physiology-pathophysiology, microbiology, INSTRUCTED how to START the
frequent and uncommon in Peru and clinical laboratory, imaging, for the request and INVESTIGATION
in the world interpretation of diagnostic aid tests.
Supportive and respectful of the sick.
Observe and pay attention to the By applying the knowledge acquired in the Introduction to
teachings regarding the indications Clinical subject, the syndromes are formed, selecting the Explains his illness while maintaining
and contraindications of the most important one, based on its severity, or strategic discretion
procedures. location, and the diagnostic reasoning begins.
Request informed consent, if the
Identify risk factors and They prescribe the appropriate medications. case requires it.
epidemiological aspects.
Recognize critical patients through Locate the frequency of the Entity in Peru. Refers the patient in a timely and
symptoms and signs. effective manner
Apply prevention measures.
Supportive relationship and respect
Establishes the prognosis of diseases of the nervous for their teachers, classmates and
system and their complications paramedical staff.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
UNIT: DERMATOLOGY
(Duration: 02 weeks)
CONTENTS
CONCEPTUAL PROCEDURAL ATTITUDINAL
Synthetic knowledge of common and Preparation of the Clinical History in outpatient Shows discipline, interest and excitement in
uncommon dermatological diseases in consultation, hospitalization and Emergency learning.
Peru and the World: service.
* Of the skin As a consequence, you will be
* From the annexes Correctly perform the comprehensive physical INSTRUCTED how to START the
* Sexually transmitted examination, preferably of the skin. INVESTIGATION.
* Systematic diseases
with dermatological lesion Application of the knowledge acquired in anatomy Supportive and respectful of the sick.
and physiology, and introduction to the clinic, for
Observe and pay attention to the the detection of signs and consequently, formation Explains his illness while maintaining
teachings regarding invasive of Dermatological SYNDROMES that, through discretion
examinations: biopsies, therapy, surgery. clinical reasoning, makes the final diagnosis
possible. Request informed consent, if the case
Defines what are the indications and requires it.
against indications of the procedures. Request diagnostic aid procedures - Interpret - the
results of the requested diagnostic aid tests. Refers the patient in a timely and effective
Identify risk factors and epidemiological manner
aspects. They prescribe the appropriate medications.
Supportive relationship and respect for their
List emergencies, recognizing alarm Locate the frequency and incidence of teachers, classmates and paramedical
manifestations. dermatological disease in Peru. staff.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
RHEUMATOLOGY
(Duration: 02 weeks)
CONTENTS
CONCEPTUAL PROCEDURAL ATTITUDINAL
Knowledge of the most frequent diseases Development of clinical records that meet Maintaining interest and constant motivation
that compromise the device the characteristics of clarity and towards the study and research on
Locomotor caused by immunological, readability; chronology in the description rheumatic ailments.
degenerative, metabolic and infectious and execution of systematic physical
alterations. examination. Adequate knowledge of rheumatic diseases
that allows you to have a human approach
Training in the rational request for auxiliary Adequate interpretation of all the auxiliary to the patient, respecting their beliefs and
examinations that help us diagnose and elements used in the nosographic values.
monitor diseases that compromise the diagnosis.
musculoskeletal system. They provide emotional support that
Participation in the procedures used for facilitates a better relationship between
Knowledge of the therapeutic schemes the diagnosis and/or treatment of health personnel and the patient and their
appropriate to each particular situation, musculoskeletal diseases. families.
taking into account the different socio-
economic realities Choosing the most appropriate therapeutic Supportive relationship and respect for their
scheme for the rheumatic patient teachers, classmates and paramedical staff.
according to his medical condition and
socio-economic situation.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
HEMATOLOGY
(Duration: 03 weeks)
CONTENTS
CONCEPTUAL PROCEDURAL ATTITUDINAL
Knowledge of frequent and uncommon Preparation of clinical history of Shows discipline, interest and excitement
hematological diseases: diagnosis, therapy outpatient consultation, hospitalization in learning.
and prevention of deficiency anemias, and emergency service.
anemias due to bone marrow disease and As a consequence, instructions will be
hemolytic diseases. Correctly execute the anamnesis, given on how to start the
comprehensive physical examination INVESTIGATION.
Diagnosis, therapy and prevention of
hemostasis disorders. Application of the knowledge and skills The relationship with the patient must be
acquired in Physiology, pathophysiology warm. Recognize your rights to information
Recognizes, diagnoses and treats and Clinical Laboratory, for the and informed consent.
hematological neoplasms: leukemia - interpretation of requested diagnostic aid
lymphomas - myeloma. tests. Refer the patient in a timely and effective
manner.
Observe and pay attention to the teachings Appropriately request diagnostic aid
regarding invasive bone marrow tests. Solidarity and respect for their teachers,
examinations. classmates and paramedical staff.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
TOXICOLOGY.
Coordinator: Méd. Carlos Navarro Manchego
1. Toxicology. Intoxications. Syndromes in toxicology and their identification in the
Emergency.
2. Intoxication by organophosphates , coumarins and household agents . Mèd Luis
Bracamonte F.
3. Intoxication by caustics, corrosives , industrial solvents.
4. Oxygen, carbon monoxide , lead and iron poisoning . . Mèd Luis Bracamonte F.
5. Salicylate poisoning . Opiate poisoning .
6. Adverse reactions from the use of antibiotics.
7. poisoning by benzodiazepines , alcohol . Botulism. . Mèd Luis Bracamonte F.
MEDICAL ONCOLOGY.
Coordinator: Méd. Rosa Guzmán Díaz
1. Cancer epidemiology. Molecular biology and genetic relationship with cancer.
2. Drugs for cancer treatment.
3. Role of surgery in cancer treatment . Dr Helard Romàn.
4. Cancer treatment with radiotherapy.
5. Oncological emergencies.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
NEUROLOGY .
Coordinator: Méd. Hector Rodriguez Arroyo
1. Headache, Migraine and other craniofacial pain.
2. Epilepsy.
3. Neuroinfections: acute and chronic meningitis, granulomas and abscesses, viral
encephalitis.
4. NeuroInfections in the patient with HIV.
5. Ischemic cerebral vascular diseases.
6. Hemorrhagic cerebral vascular diseases.
7. Demyelinating diseases. Multiple sclerosis. Encephalomyelitis, myelinolysis.
8. Movement Disorders
9. Tumors of the central nervous system. Brain tumors. Med. Mauro Mollepaza Tito
10. Diseases of the Spinal Cord: Spinal cord compression, Myelopathy due to
spondylosis, Transverse myelitis, PET, ALS, etc. Med. Mauro Mollepaza Tito
11. Degenerative and Hereditary Diseases. Med. Mauro Mollepaza Tito
12. Peripheral neuropathies. Med. Mauro Mollepaza Tito
13. Myopathies. Neuromuscular transmission disorders. Myasthenia. Botulism. Med.
Mauro Mollepaza Tito
14. Vertigo Med. Mauro Mollepaza Tito
15. Dementias Med. Mauro Mollepaza Tito
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
GASTROENTEROLOGY .
Coordinator: Méd. Heriberto Hidalgo Carrasco
1. Gastroesophageal reflux disease and complications.
2. Motor disorders of the esophagus. Doctor Jaime Quispe M.
3. Dyspepsia.
4. Peptic ulcer and complications. Helicobacter pylori infection.
5. Intestinal and Peritoneal Tuberculosis.
6. Acute and chronic diarrhea.
7. Inflammatory Bowel Disease: Crohn's Disease, Ulcerative Rectocolitis. Doctor
Jaime Quispe M.
8. Cholecystitis, gallbladder lithiasis. Choledocholithiasis. Acute cholangitis.
9. Acute and Chronic Pancreatitis. Doctor Jaime Quispe M.
10 . Irritable bowel syndrome. Irritable Colon. Colon diverticular disease.
11.Anorectal pathology. Méd Jaime Quispe M.
12.Viral Hepatitis: A - G. Chronic Hepatitis.
13.Liver Cirrhosis and Complications.
14.Autoimmune hepatitis. Primary biliary cirrhosis. Sclerosing cholangitis. Doctor
Jaime Quispe M.
15. Liver abscess.
16. Esophageal Cancer. Gastric cancer.
17. Pancreatic Cancer. Bile duct tumors. Doctor Jaime Quispe M.
18. Intestinal Lymphoma. Adenocarcinoma of the Small Intestine. Doctor Jaime
Quispe M.
19. Colorectal cancer. Doctor Jaime Quispe M.
20. Liver Tumors. Hepatocarcinoma. Liver Cyst.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
SEMINARS:
DIDACTIC UNIT 1: Electrolyte and Acid Base Disorder.
DIDACTIC UNIT 2: Cardiorespiratory Arrest and CardioPulmonary Resuscitation.
DIDACTIC UNIT 3: Emergency Management of Ischemic and Hemorrhagic VCD
DIDACTIC UNIT 4: Neuroimaging.
DIDACTIC UNIT 5: Septic Shock.
DIDACTIC UNIT 6: Management of the jaundiced patient
DIDACTIC UNIT 7: Transfusion therapy.
ACADEMIC ACTIVITIES
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Theoretical Classes.
Hospital clinical practice.
Hospital guards.
Clinical-Pathological Conversation.
Clinical-Therapeutic Conversation.
magazine magazine
Seminars.
The student will enter clinical practice, with the minimum necessary instruments
and a clean white apron with the respective card - credential.
At the end of each rotation, the student must present his or her booklet within a
period of no more than 2 days after the end of the rotation.
In the case of Emergency practice, the student is required to attend TWO guards
in each rotation, outside the usual Practice hours. Attendance and qualification
must be corroborated in the respective format to be taken into account when
grading practices.
THEORETICAL CLASSES.
The dictation of the 7 didactic units must be synthetic, schematic and updated.
Teachers will be able to develop teaching strategies and techniques to develop the
respective competencies in the student. The active intervention of students must
be encouraged, seeking to integrate knowledge of basic sciences with that
provided by clinical sciences. THE STUDENT SHOULD MAKE A
BIBLIOGRAPHICAL CONSULTATION BEFORE AND AFTER in order to improve
their understanding of the topic to be presented.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Based Medicine and other options, taking into consideration the concepts of
effectiveness, safety, risk, cost-benefit, drug interactions and side effects.
MAGAZINE OF MAGAZINES .
A review of magazines will be presented in two sessions per unit (total 14), where
the Course Coordinator will be the facilitator. Each student will prepare, using some
audiovisual means, a critical synthesis of an ORIGINAL ARTICLE, analyzing the
methodology used and the clinical value of the article. They will take no more than
10 minutes per student. There are at least eight students per session CHOSEN AT
RANDOM, the rest will present their analysis in writing on the scheduled day.
SEMINARS
A seminar to be developed per unit (total 7). The 6 designated students under the
supervision of the teacher will prepare the seminar, on frequent situations in the
Emergency. Each seminar will be graded with each student having a grade at the
end of it.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
The teacher and students have at their disposal an overhead projector, multimedia
equipment and a slide projector, to carry out all academic activities, in the facilities of the
EAP of Human Medicine.
PARTIAL AVERAGE:
45% Theory exam
05% Clinical Discussions
05% Seminars
40% Clinical practice (proper)
05% Magazine of Magazines
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
the clinical discussion grade (5%). %). An average (40%) is extracted from the
actual practice and guard notes.
l. Attendance at clinical practices and related activities is mandatory. Unjustified
absence from 30% or more of them (each one of them) invalidates the right to have
the practice grade and take the theoretical exam (art. 30°). The evaluation of the
practices is continuous throughout the entire course. In the evaluation of the
practices, the teacher will take into consideration punctuality, responsibility, active
participation, cooperation, the student's initiative and the quality of the preparation
of the clinical history.
m. Students who have not shown up at any time to class or to any scheduled
evaluation during the course of the subject will be recorded in the Promotional
Record NO SHOW (NSP), equivalent to a grade of ZERO.
n. Practice starts at 08:00 am and ends at 1:00 p.m. Attendance will be signed by the
respective internship teacher.
10.- BIBLIOGRAPHY
INTERNAL MEDICINE:
HARRISON, ANTHONY Principles of Internal Medicine Ed. McGraw Hill
FAUCI AND OTHERS
WILLIAM N. KELLEY Textbook of Internal Medicine, Ed. JB: Lippinctott,
New York.
ALLEN R. MYERS NMS National Medical Serves for Independent Study,
Medicine. 3rd Edition. Ed. Williams & Willkins.
WEB PAGES (free access for Latin America):
www.nejm.org
www.bmjjournals.com
EXOGENOUS INTOXICATIONS:
AGG from FERNÍCOLA;
JAUGE, Pedro. “Basic Notions of Toxicology.” Pan American Center
for Human Ecology and Health. PAHO.WHO.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
GASTROENTEROLOGY:
HARRISON Principles of Internal Medicine.- Ed. in Spanish KJ
Isseelbacher, E. Braunwald, JD Wilson, EDS. 14th Ed.
Inter-American. Mc. Graw-Hill, New York.
HEMATOLOGY:
WILLIAMS Hematology.
NEUROLOGY:
ADAMS, R.D. and VICTOR . “Principles of Neurology” Mc. Graw Hill, New York.
DERMATOLOGY:
FITZPATRICKA “Dermatology in Medicine”. Edit Panamericana.
11.- ANNEX
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
ROTATION SCHEDULE
GROUP 1
Acosta Sobrado, Roy Edson
Allazo Bejar, Ingrid A1 Med. Jimmy Curo Niquén
Bazán Álvarez, Johannes Kendall
Calero Huamalí, Jhenny
Chávez García, Abel Yefferson B1 Med. Bernardo Damaso Mata
Cori Valverde, Victor Rossini
Espinoza Dávila, Samantha Noelia
Gonzales Amancio, Gemeneza Lidia C1 Med. Luis Chuquihuanga Chambilla
Guerra Alvarado, Liliana Jackeline
Hilario Barreto, Katherin Luz
Meza Villaneda, Xi-Omara Wilda D1 Med. Jaime Quispe Marocho
Panduro Arroyo, Ivan Yhersino
Pollo Briceño, Leidith Darmelly
Ramos Pando, Wilfredo E1 Med. Hector Rodriguez Arroyo
Raraz Vidal, Harvis
Rubio Degrees, Dumer Gary
Sarmiento Ponciano, Cati F1 Med. Patricia Paucar Lescano
Sullca Ccopa, Franklin
Tolentino Hinojosa, Lennin José
Velasquez Pimentel, Vanesa Tatiana G1 Med. Luis Bracamonte Ferrel
Zárate Casachahua, Yojhaida Catty
*Med. Hugo Sánchez Cerna (Free for replacement)
GROUP 2
Agüero Vega, Ader
Baldeón Chávez, Ivan A2 Med. Rosa Guzmán Díaz
Agurto Boxes, Fabio
Campos Gonzales, Roel K.
Condor Cisneros, Julio B2 Med. Daniel Delgado Cornejo
Diaz Rivera, Wilmer
Figueroa Arquiñigo, José R.
Grandes Graus, Juan Carlos C2 Med. Abel Ponce Hurtado
Gutiérrez Cariga, Myriam
Meza Copello, Williams
Med. Heriberto Hidalgo
Ospino Martin, Luis D2
Carrasco
Santiago Tweezers, Michael
Ramos Bermúdez, Gerson
Ramos Velásquez, Fredy E2 Med. Mauro Molleapaza Tito
Rivera Illatopa, Gean Carlos N.
Salazar Borja, Juan Carlos
Solorzano Gómez, Diana
F2 Med. José Velit Besada
Tarazona Luna, Gaby
Trinidad Guzmán, Heiddy J.
Med. Carlos Navarro Manchego
*Med. Juan C. Najera Gómez (Free for replacement)
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
NOTE
DOCTOR
No. PLACE DATE (Number and
(Signature and stamp)
Letters)
1
10
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
NOTE
No. DOCTOR
PLACE DATE (Number and
(Signature and stamp)
Letters)
11
12
13
14
15
16
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student: ____________________________________________________________
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PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
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PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
STUDENT (A):
____________________________________________________
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PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
STUDENT
(A):______________________________________________________________
___
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PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
STUDENT
(A):_______________________________________________________
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
CONOCIMIENTOS
Cumplimiento de las tareas solicitadas 1 0
Respuesta de conocimiento a las preguntas durante la visita medica, consultorio externo y emergencia. 1 0
Juicio adecuado respecto a los diagnósticos 1 0
Juicio adecuado respecto a la terapéutica 1 0
Conocimiento del uso e interpretación de los exámenes auxiliares ( EKG, Radiografías y de laboratorio ). 1 0
PROCEDIMIENTOS
Técnica adecuada para el examen físico 1 0
Toma de funciones vitales con las técnicas adecuadas 1 0
Observación por los detalles durante el examen fisico 1 0
Emplea con el paciente un tono confiado y cortez 1 0
Explica al paciente los procedimientos antes de realizarlos, en forma clara 1 0
Escucha atentamente al paciente 1 0
Aplica medidas de bio-seguridad ( lavado de manos, uso de guantes, uso de mandil, uso de anteojos, uso de mascarillas ). 1 0
ACTITUD
Puntualidad a sus prácticas 2 1 0
Trae sus materiales para el examen ( estetoscopio, tensiómetro, linterna, martillo ) 2 1 0
Entrega oportuna de sus historias clínicas 1 0
Tiene iniciativas durante la evaluación medica 1 0
Trae bibliografía relacionada a su paciente 1 0
Uso de libreta de anotaciones y de resumen 1 0
NOTA DE PRACTICA :
Responsible Teacher
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
CONOCIMIENTOS
Diagnostico sindromico coherente y justificado (evaluar comentarios) 2 0
Diagnostico etiologico coherente y justificado (evaluar comentarios) 2 0
Plan de Trabajo coherente y justificado (evaluar comentarios) 2 0
Tratamiento coherente y justificado (evaluar comentarios) 2 0
Pronostico y medidas preventivas coherentes y justificadas (evaluar comentarios) 1 0
PROCEDIMIENTOS
Historia Clinica escrita manualmente con letra legible 2 0
Cumple con todas las partes de la Historia Clinica Modelo. 2 0
Cumple con todas las partes de la Evolucion diaria 1 0
Anexa los resultados de la evaluacion del Mini-mental test de Folstein 1 0
ACTITUD
Entrega PUNTUAL de acuerdo a lo programado (no hay prorrogas) 2 0
Anexa cuatro bibliografias de los cuatro ultimos años (de preferencia idioma extranjero). 2 1 0
Explica cada una de las bibliografias 1 0
Importante : El alumno cuenta con dos semanas para confeccionar la historia clinica, con la evaluacion geriatrica y evaluacion mental al ingreso y alta (o ultimo dia de la rotacion) del paciente.
La entrega de la Historia Clinica es el ultimo de rotacion al coordinador general y al docente de practica.
La nota de calificacion es realizado por el docente de practica.
Responsible Teacher
Delegate
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Issue:
Rotation No.: ________________________________________________
Date:
Responsible professor:
CONOCIMIENTOS
Diagnostico sindromico coherente y justificado (evaluar comentarios) 2 0
Diagnostico etiologico coherente y justificado (evaluar comentarios) 2 0
Diagnostico diferencial coherente y justificado (evaluar comentarios) 2 0
Pruebas auxiliares coherente y justificado (evaluar comentarios) 2 0
Tratamientos coherentes y justificadas (evaluar comentarios) 1 0
PROCEDIMIENTOS
Cuadernillo escrito manualmente con letra legible 3 0
Cumple con todas las partes de lo solicitado 3 0
ACTITUD
Entrega PUNTUAL de acuerdo a lo programado (no hay prorrogas) 2 0
Anexa cuatro bibliografias de los cuatro ultimos años (de preferencia idioma extranjero). 2 1 0
Explica cada una de las bibliografias 1 0
NO TA DE CUADERNILLO
Responsible Teacher
Delegate
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student: ___________________________________________________________
Rotation No.: _____________________________________________________
Date: __________________________________________________________
Responsible professor: ______________________________________________
KNOWLEDGE
(9 points)
Appropriate judgment regarding diagnosis
Substantiate with valid arguments regarding the suggested therapy.
Substantiate the request for auxiliary examinations with valid arguments.
PROCEDURES
(6 points)
You have an order for the resolution of the interconsultation
Thoroughly reviews the medical history and ancillary imaging examinations.
Preparation of the appropriate anamnesis
Preparation of the appropriate clinical examination
ATTITUDE
(5 points)
Explain to the patient the reason for the requested interconsultation
Has initiative for the resolution of the interconsultation
Appropriate behavior towards patients.
NOTE:
__________________
Responsible Teacher
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
Appropriat inappropriat
e e
Supports diagnosis and treatment
Supports differential diagnoses
Justify the reason for the reference
Justify the destination service of the reference
Justify the destination hospital of the referral
Fill out the reference form
Initiative to make the reference
Explain to the patient or family the reason for
referral
___________________
Responsible teacher
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
Adecuado Inadecuado
Diagnóstico
Nombre genérico del producto (denominación común internacional, DCI)
Nombre (s) comercial del producto
Presentacion (forma farmacéutica)
Posología (dosis total por día)
Dosis fraccionada por día
Vias de administración
Periodo total de administración
Fecha de expedición de la receta
Fecha de la próxima cita
Nota: al termino de la rotacion de practica, el alumno debe realizar todos los indicadores del instrumento, SIN
EXCEPCION. Ante la carencia de uno de ellos, el alumno no aprobara la rotacion de practica, sin excepcion.
El docente de practica debe asegurar que el alumno cumpla con la COMPETENCIA.
Responsible Teacher
Delegate
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
Adecuado Inadecuado
Informa el diagnóstico mas probable al paciente
Explica acerca de otros probables diagnósticos al paciente
Explica la evolución a corto y/o largo plazo del diagnóstico probable
Explica la evolución a corto y/o largo plazo de otros diagnósticos probables
Explica el pronóstico del diagnóstico probable
Explica el pronóstico de otros diagnósticos probables
Explica el tratamiento del diagnóstico probable
Explica el tratamiento de otros diagnósticos probables
Explica tratamientos alternativos del diagnóstico probable
Explica tratamientos alternativos de los otros diagnósticos probables
Nota: al termino de la rotacion de practica, el alumno debe realizar todos los indicadores del instru-
mento, SIN EXCEPCION. Ante la carencia de uno de ellos, el alumno no aprobara la rotacion de
practica, sin excepcion.
El docente de practica debe asegurar que el alumno cumpla con la COMPETENCIA.
Responsible Teacher
Delegate
36
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
Adecuado Inadecuado
Informa el diagnóstico mas probable al paciente
Explica la via de administración de los medicamentos a ser empleados
Explica la posología de administración de los medicamentos a ser empleados
Explica el tiempo de administración de los medicamentos a ser empleados
Explica los riesgos a corto y/o largo plazo durante la administración de los medicamentos
Explica las contraindicaciones absolutas y relativas de la medicación elegida
Explica las reacciones adversas que se pueden presentar durante la administración
Explica las principales interacciones farmacológicas
Realiza una demostración, frente al paciente, de la administración del medicamento
Observa y corrige el procedimiento de administración por el paciente
Nota: al termino de la rotacion de practica, el alumno debe realizar todos los indicadores del instrumento, SIN
EXCEPCION. Ante la carencia de uno de ellos, el alumno no aprobara la rotacion de practica, sin excepcion.
El docente de practica debe asegurar que el alumno cumpla con la COMPETENCIA.
Responsible Teacher
37
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
Adecuado Inadecuado
Saluda cordialmente al paciente
Se identifica adecuada y completamente
Explica el motivo de la entrevista, solicitándole permiso
Informa el diagnóstico al paciente
Explica las posibilidades diagnósticas probables
Explica las ventajas de elegir un tratamiento médico o quirúrgico
Explica los efectos colaterales a corto y largo plazo del tratamiento médico o quirúrgico
Explica las interacciones medicamentosas que se pueden presentar
Explica los beneficios y riesgos al elegir un tratamiento médico o quirúrgico
Conjuntamente con el paciente, elijen una opcion terapeutica
Nota: al termino de la rotacion de practica, el alumno debe realizar todos los indicadores del instrumento, SIN
EXCEPCION. Ante la carencia de uno de ellos, el alumno no aprobara la rotacion de practica, sin excepcion.
El docente de practica debe asegurar que el alumno cumpla con la COMPETENCIA.
Responsible Teacher
38
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
Adecuado Inadecuado
Saluda cordialmente al paciente
Se identifica adecuada y completamente
Explica el motivo de la entrevista, solicitándole permiso
Informa el diagnóstico al paciente
No emite juicios de valor frente al paciente, respecto a la decisión terapéutica
Adopta una actitud expectante ante las respuestas del paciente
Explica los procedimientos del examen físico, antes de realizarlo (EN PRIVADO)
Explica los procedimientos de los examenes auxiliares, antes de su realizacion
No interrumpe cuando el paciente explica su dolencia
Se despide cordialmente, agradecido por la entrevista ofrecida
Nota: al termino de la rotacion de practica, el alumno debe realizar todos los indicadores del instrumento, SIN
EXCEPCION. Ante la carencia de uno de ellos, el alumno no aprobara la rotacion de practica, sin excepcion.
El docente de practica debe asegurar que el alumno cumpla con la COMPETENCIA.
Responsible Teacher
39
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Student:
Rotation No.:
Date:
Responsible professor:
Adecuado Inadecuado
Saluda cordialmente al paciente
Se identifica adecuada y completamente
Explica el motivo de la entrevista, solicitándole permiso
Informa al paciente la confidencialidad de la entrevista y el examen físico
Elaboración de la Historia Clínica, con códigos (NO NOMBRES)
Realiza el examen físico en forma confidencial
Mantiene en forma reservada sus apuntes respecto a la Historia Clínica
Los hallazgos son comunicados directamente al médico tratante y el docente
No comentar los hallazgos con personal no autorizado por el paciente
Recalcar al paciente sobre la confidencialidad de la entrevistas, al término de la misma
Nota: al termino de la rotacion de practica, el alumno debe realizar todos los indicadores del instrumento, SIN
EXCEPCION. Ante la carencia de uno de ellos, el alumno no aprobara la rotacion de practica, sin excepcion.
El docente de practica debe asegurar que el alumno cumpla con la COMPETENCIA.
Responsible Teacher
40
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Issue:
Date:
Responsible professor:
CRITERIOS
Uso de materiales Presentacion de Conocimiento Desenvolmiento Empleo del tiempo
Nota
Alumno Audiovisuales Revisiones actualizadas del Tema programado
(0-5) (0-5) (0-4) (0-4) (0-2)
1.-
2.-
3.-
4.-
5.-
Responsible Teacher
41
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Docente :
Fecha :
Alumno :
Fecha de Rotacion :
L M M J V S L M M J V S
Fecha
P : presente Guardia :
F : falta
T : tarde
Fecha
Establecimiento
Docente Delegado
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
CRITERIOS
Uso de materiales Presentacion de Conocimiento Desenvolmiento Empleo del tiempo
Nota
Alumno Audiovisuales Revisiones actualizadas del Tema programado
(0-5) (0-5) (0-4) (0-4) (0-2)
1.-
2.-
3.-
4.-
5.-
Responsible Teacher
43
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Y
Criterion 0 1 2 3 4 score o
44
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
Criterion 0 1 2 3 4 score
45
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
MAGAZINE OF MAGAZINES
CHAPTER: …………………………………………DATE:…………………….
STUDENT:……………………………………………………………………………
SECTION A
SECTION B
Appreciation of the clinical contribution of the article (attach article).
46
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
47
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
CURRENT ILLNESS.
Sick Time
Start Form
Course of the disease
Main Symptoms
Story
RASA
HEAD: headache, trauma
EYES: vision, lenses, diplopia, scotomas, pain and inflammation
EARS: hearing, tinnitus, pain, secretions
NOSE: olfaction, anterior or posterior discharge, epistaxis, obstruction, itching, sneezing
MOUTH: taste disorders, symptoms and signs referring to lips, teeth, gums and tongue
PHARYNX – LARYNX: pain, swallowing disorders, hoarse voice, laryngeal stridor. Tonsils
NECK: pain, stiffness, goiter and tumors
MAMMARY GLANDS: lumps, pain, secretions and retractions
RESPIRATORY SYSTEM: cough, expectoration, hemoptysis, dyspnea, chest pain,
pleurisy, bronchial asthma and vomiting
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
SKIN AND ANNEXES: rashes, changes in color and temperature, itching, ecchymosis,
petechiae. Seborrhea and dry skin. Hair system: hair loss, dryness and fragility,
hypertrichosis and hirsutism. Nails: fragility and deformation
BIOLOGICAL FUNCTIONS
Appetite
Thirst
Urine
Deposition
Dream
Weight
BACKGROUND
GENERAL PERSONAL BACKGROUND
living place
Feeding
Outfit
Bad Habits
Socio-economic situation
Trips
Previous Residences
Occupation and Previous Occupations
Immunizations
Allergies
Blood Transfusions
a: number of pregnancies
b: number of births at term
c: number of premature births
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
d: number of abortions
e: number of children currently alive
Menopause
FAMILY BACKGROUND
Parents
Wife or Partner
Children
Siblings
Coworkers
Neighbors
PHYSICAL EXAM
VITAL FUNCTIONS (Temperature, Heart Rate, Pulse Rate, Respiratory Rate, Blood
Pressure, Weight, Height, Body Mass Index).
FACIE
OVERALL STATUS
NUTRITIONAL CONDITION
HYDRATION STATUS
MORPHOLOGICAL TYPE
ATTITUDE
MARCH
LYMPHATIC TISSUE
Ganglia (location, number, size, pain, degree of fixation to deep planes, consistency),
axillary, cervical, supraclavicular, occipital, inguinal, epitrocheal, popliteal regions.
MAMMARY REGION
Inspection-Palpation.
Moms.
Areola.
Nipple.
Axillary and supraclavicular lymph nodes.
Tanner scale.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
MUSCULAR SYSTEM
Tone, Trophism, Muscle Contractures, Muscle Strength.
REGIONAL EXAM
HEAD
SKULL: position, movements, shape, size.
ORBITAL REGION: Superciliary region, eyelids, eyeballs (FUNDO DE EYE), cornea,
anterior chamber, iris.
AURICULAR AND MASTOID REGION: Pinnae, external auditory canal, tympanic
membrane, preauricular area, mastoid region.
NASAL REGION: Nasal pyramid, nasal mucosa, inferior turbinates.
ORAL REGION: lips, buccal mucosa, gums, teeth, sublingual mucosa, tongue, hard palate,
soft palate.
OROPHARYNX REGION: soft palate, uvula, pillars, tonsils.
NECK
Cervical spine
Trachea and Thyroid Cartilage
Thyroid gland
Blood vessels
Ganglia
CARDIOVASCULAR SYSTEM
EXTREMITIES: Presence of Cyanosis, edema. Pulse . Blood pressure.
NECK: Jugular venous pulse, Carotid pulse
PRECORDIAL REGION:
INSPECTION
PALPATION: apical region, left sternal border, pulmonary area, aortic area.
Left and right ventricular impulse. Fremito.
PERCUSSION: cardiac dullness.
AUSCULTATION: mitral focus, tricuspid focus, pulmonary focus, aortic focus.
Heart rate, first, second, third and fourth sounds, murmur, pericardial rub.
EPIGASTRIUM: right ventricular beat, aortic beat. Hepatojugular reflux.
ABDOMEN EXAMINATION
INSPECTION
AUSCULTATION: Hydroaerial sounds, murmurs, borborygmi, gastric bazuqueo.
PERCUSSION: dullness, subdullness or tympany. Liver, spleen, bladder
Superficial and deep PALPATION. Painful points, retro abdominal or peritoneal masses.
Liver, Spleen.
INGUINAL REGION: nodes, neurovascular bundle, hernias.
RECTAL TOUCH:
Anal and Perianal INSPECTION.
PALPATION: anal sphincter, rectum, prostate."Glove finger"
GENITOURINARY SYSTEM
URINARY SYSTEM
INSPECTION
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
MALE GENITALS
Axillary and Pubic Hair.
Penis. Scrotum. Testicles. Epididymis. spermatic cord.
Prostate. Size, consistency, mobility.
Tanner scale (penis, pubic hair).
FEMALE GENITALS
INSPECTION: Mons venus, vulva, perineum.
PALPATION: Vaginal, adnexa and rectal touch.
Tanner scale (pubic hair).
NEUROLOGICAL EXAM
CONSCIOUSNESS STATE
GLASGOW SCORE SCORE (describe)
CRANIAL PAIRS
I Nasal passages, olfaction.
II Optical. Visual acuity, Campimetry, Color recognition, Fundus of the eye.
III oculomotor (superior rectus, levator palpebrae superioris, medial rectus
inferior rectus, minor oblique), pupils.
IV Pathetic (major oblique muscle).
V Trigeminal (ophthalmic, upper and lower jaw, and motor sensitivity).
VI External ocular motor.
VII Facial (motor, sensitive and sensory)
VIII Cochleovestibular (Clock Test, Weber Test, Rinne Test, Barany Index,
Babinsky Star, Acaloric Test)
IX - X Voice, swallowing, soft palate, uvula, gag reflex, sense of taste
XI Sternocleidomastoid and trapezius muscle.
XII language exam (trophism, movements)
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
WORKPLAN
Auxiliary exams: Hematological
Biochemicals
Serological
Microbiological
Hormonal
Immunological
Ultrasounds (conventional, specialized -cardiological-).
Radiological (conventional radiology, CT, MRI).
Scintigraphy.
Endoscopy
TREATMENT
Diet type
Hydration type
Antibiotic treatment
Etiological treatment
Prophylactic treatment
Treatment suggested by other specialists.
Supportive treatment (oxygen, nursing procedures).
Bibliographic commentary of each one
FORECAST
Short term
Long-term
PRECAUTIONARY MEASURES
Primary
high schools
Tertiary
SUBJECTIVE:
Symptoms related to the disease
Medication compliance
Symptoms not related to the disease
biological functions
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
GOALS:
Vital functions
Diuresis (volume).
General physical examination
Preferential physical examination
APPRECIATION:
Diagnostic impression
New diagnoses
Opinion on diagnoses
WORKPLAN:
Therapeutic proposals
Diagnostic test proposals
Bibliography
54
HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
I. FILIACIÓN
NOMBRE EDAD
ESTADO CIVIL SOLTERO CASADO VIUDO DIVORCIADO SEXO M F
GRADO DE INSTRUCCIÓN ANALFABETO PRIMARIA SECUNDARIA SUPERIOR
DOMICILIO TELEFONO
(REFERENCIA) (paciente)
RESPONSABLE DEL PACIENTE TELEFONO
TIPO DE ANAMNESIS DIRECTA INDIRECTA DIRECTA + INDIRECTA
FECHA DE INGRESO
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
ORIENTACIÓN
5 ( ) ¿Qué (dia) (mes) (estación) (año) (fecha) es ?
5 ( ) ¿Dónde estamos? (provincia ) ( comunidad) ( ciudad) (hospital) ( suelo)
REGISTRO
3 ( ) Nombre tres objetos: 1 segundo para decir cada uno. Pida entonces al paciente que los
vuelva a repetir los 3 después de usted. Déle 1 punto por cada
respuesta correcta. Sígalos repitiendo hasta que el paciente aprenda
los 3. Cuente los intentos y regístrelos
INTENTOS
ATENCIÓN Y CÁLCULO
5 ( ) Serie de 7. 1 punto por cada respuesta correcta. Parar después de 5 respuestas.
Como alternativa, haga que el paciente deletree una palabra al revés
RECUERDO
3 ( ) Pida que repita los tres objetos repetidos anteriormente. Un punto por respuesta correcta
LENGUAJE
9 ( ) Nombre un lápiz y un reloj (2 puntos )
Repita lo siguiente "No usar si condicional, y ni pero" (1 punto)
Realice una orden con tres pasos
"Coja un papel con la mano derecha, dóblelo por la mitady déjelo en el suelo" (3 puntos)
Lea y siga las instrucciones siguientes
Cierre los ojos (1 punto)
Escriba una frase (1 punto)
Copie una figura (1 punto)
INSTRUCCIONES PARA LA REALIZACIÓN DEL EXAMEN DEL ESTADO MENTAL MINI- MENTAL
ORIENTACIÓN
(1) Pregunte la fecha. Después pregunte algo omitido, p. ej: "Puede decirme además la estación en
la que estámos". Un punto por cada respuesta correcta
(2) Pregunte por orden datos sobre el hospital (ciudad, distriti, barrio). Un punto por cada respuesta correcta.
REGISTRO
Pregunte al paciente si puede comprobar su memoria. Diga entonces en nombre de tres objetos sin relación
clara y lentamente (emplee aproximadamente 1 segundo por cada uno). Una vez dichos, pida al paciente que
los repita. La primera repetición determina su puntiación (0 a 3 ), pero haga que los repita 6 veces.
Si no se ha aprendido bien los tres objetos, el recuerdo no es valorable.
ATENCIÓN Y CÁLCULO
Pida al paciente que, comenzando en el 100, vaya restando de 7 en 7. Deténgase despues de las 5
primeras restas (93, 86, 79, 65). Puntúe el núemro de respuestas correctas.
Si el paciente no puede realizar esta prueba, pídale que deletree una palabra al revés (p. ej. PABLO).
La puntuación es el número de letras en el orden solicitado: OLBAP = 5 puntos; OBLAP = 3 puntos.
RECUERDO
Pregunte al paciente las tres palabras que repitió anteriormente.
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HERMILIO VALDIZAN NATIONAL UNIVERSITY
PROFESSIONAL ACADEMIC SCHOOL OF HUMAN MEDICINE
LENGUAJE
NOMBRAR: Muestre al paciente un reloj de pulsera y pregúntele qué es. Repítalo con un lápiz. Puntos 0 a 2
REPETIR: Pida al paciente que repita un frase después de decirla usted. Sólo un intento. Puntos 0 a1.
ÓRDENES: En tres frases, entrege al paciente un papel blanco y repita la orden. U punto por
cada fase ejecutada correctamente.
LEER: Escriba en un paple: "CIERRE LOS OJOS", en letras lo suficientemente grandes como para que el
paciente pueda leerlos. Pidale que haga lo que se indica en el papel. Puntúe un punto solo
si el paciente cierra realmente los ojos.
ESCRIBIR: Entrege al paciente un papel en blanco y haga que escriba un frase. No le dicte, que
la escriba espontáneamente. Debe tener al menos u sujeto y un verbo. No es necesaria una correcta gramática.
COPIAR: En un papel en blanco, dibuje dos pentágonos que se crúzan, cada uno de unos 3 cm de lado, y pida
al paciente que los copie exáctamente como están. Para obtener un punto debe dibujar los 10 ánguolos y la
intersección de dos de ellos. No cuenta el temblor ni la rotación,
Estime el nivel sensorial del paciente mostrado durante el examen d froma continua : desde aleta (a la izquierda)
hasta el como (a la derecha).
Subjective:
Symptoms related to the disease
Medication compliance
Symptoms not related to the disease
biological functions
Goals:
Vital functions
Diuresis (volume).
General physical examination
Preferential physical examination
Appreciation:
Diagnostic impression
New diagnoses
Opinion on diagnoses
Workplan:
Therapeutic proposal
Proposal for diagnostic tests
Bibliography
57