• Author / Uploaded
• Clenor Junior

Citation preview

HISTORIA CLINICA PEDIATRICA AFILIACIÓN Nombre completo______________________________________________________________ Edad _______________________fecha de nacimiento_______________________________ Sexo_________________________ Dirección ________________________________________ Datos obtenidos de__________________________Confiabilidad_________________________ MOTIVO DE CONSULTA _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ HISTORIA DE LA ENFERMEDAD ACTUAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES PATOLÓGICOS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES NO PATOLÓGICOS Hábitos personales _____________________________________________________________ Lactancia Materna Artificial Mixta Ablactación ___________________________________________________________________ Alimentación__________________________________________________________________ Alergias ______________________________________________________________________ Grupo y factor Sanguíneo________________________________________________________ Otros ________________________________________________________________________ _____________________________________________________________________________ Desarrollo Psicomotor Sonrió Sostuvo cabeza Se sentó Se paró Camino solo Control de esfínter vesical anal Escolaridad actual______________________________________________________________ Otros_________________________________________________________________________ _____________________________________________________________________________ Inmunización BCG__________________________________ Polio_______________________________ Pentavalente___________________________ Rotavirus____________________________ Antineumococica________________________ Influenza estacional___________________ SRP Antiamarillica Otras ______________________________________________________________________

ANTECEDENTES PERINATALES Producto de embarazo Nº_____________ de ________________ semanas de gestación Sitio de nacimiento _________________________________________________________ Tipo de Parto Vaginal / Cesárea por que________________________________________ Datos al nacimiento: Peso ____________ Talla_____________ PC___________________ APGAR_____________________________ Problemas al nacimiento_________________________________________________________ _____________________________________________________________________________ ANTECEDENTES FAMILIARES Nombre completo madre_______________________________________________________ Edad Hábitos Grupo sanguíneo G P C A Gineco-obstetricos_____________________________________________________________ _____________________________________________________________________________ Ant. Patológicos________________________________________________________________ _____________________________________________________________________________ Nombre completo Padre_________________________________________________________ Edad Hábitos Grupo sanguineo Ant.Patológicos________________________________________________________________ _____________________________________________________________________________ Otros_familiares________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANAMNESIS POR SISTEMAS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

EXAMEN FISICO EXAMEN FISICO GENERAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FC PESO

FR TALLA

EXAMEN FISICO SEGMENTARIO

Tº IMC

PA

Cabeza_______________________________________________________________________ _____________________________________________________________________________ ojos__________________________________________________________________________ orejas________________________________________________________________________ nariz_________________________________________________________________________ Boca_________________________________________________________________________ _____________________________________________________________________________ Cuello________________________________________________________________________ _____________________________________________________________________________ Torax_________________________________________________________________________ _____________________________________________________________________________ Corazón_______________________________________________________________________ ____________________________________________________________________________ Pulmones_____________________________________________________________________ _____________________________________________________________________________ Abdomen_____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Extremidades _________________________________________________________________ _____________________________________________________________________________ Genitourinario_________________________________________________________________ _____________________________________________________________________________ Neurológico___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ DIAGNOSTICO PRESUNTIVO 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ 4. _______________________________________________________________________ 5. _______________________________________________________________________

Elaborado por: ______________________ HISTORIA CLINICA PEDIATRICA

AFILIACIÓN Nombre completo______________________________________________________________ Edad _______________________fecha de nacimiento_______________________________ Sexo_________________________ Dirección ________________________________________ Datos obtenidos de__________________________Confiabilidad_________________________ MOTIVO DE CONSULTA _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ HISTORIA DE LA ENFERMEDAD ACTUAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES PATOLÓGICOS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES NO PATOLÓGICOS Hábitos personales _____________________________________________________________ Lactancia Materna Artificial Mixta Ablactación ___________________________________________________________________ Alimentación__________________________________________________________________ Alergias ______________________________________________________________________ Grupo y factor Sanguíneo________________________________________________________ Otros ________________________________________________________________________ _____________________________________________________________________________ Desarrollo Psicomotor Sonrió Sostuvo cabeza Se sentó Se paró Camino solo Control de esfínter vesical anal Escolaridad actual______________________________________________________________ Otros_________________________________________________________________________ _____________________________________________________________________________ Inmunización BCG__________________________________ Polio_______________________________ Pentavalente___________________________ Rotavirus____________________________ Antineumococica________________________ Influenza estacional___________________ SRP Antiamarillica Otras ______________________________________________________________________ ANTECEDENTES PERINATALES Producto de embarazo Nº_____________ de ________________ semanas de gestación

Sitio de nacimiento _________________________________________________________ Tipo de Parto Vaginal / Cesárea por que________________________________________ Datos al nacimiento: Peso ____________ Talla_____________ PC___________________ APGAR_____________________________ Problemas al nacimiento_________________________________________________________ _____________________________________________________________________________ ANTECEDENTES FAMILIARES Nombre completo madre_______________________________________________________ Edad Hábitos Grupo sanguíneo G P C A Gineco-obstetricos_____________________________________________________________ _____________________________________________________________________________ Ant. Patológicos________________________________________________________________ _____________________________________________________________________________ Nombre completo Padre_________________________________________________________ Edad Hábitos Grupo sanguineo Ant.Patológicos________________________________________________________________ _____________________________________________________________________________ Otros_familiares________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANAMNESIS POR SISTEMAS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

EXAMEN FISICO EXAMEN FISICO GENERAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FC PESO

FR TALLA

Tº IMC

PA

EXAMEN FISICO SEGMENTARIO Cabeza_______________________________________________________________________ _____________________________________________________________________________

ojos__________________________________________________________________________ orejas________________________________________________________________________ nariz_________________________________________________________________________ Boca_________________________________________________________________________ _____________________________________________________________________________ Cuello________________________________________________________________________ _____________________________________________________________________________ Torax_________________________________________________________________________ _____________________________________________________________________________ Corazón_______________________________________________________________________ ____________________________________________________________________________ Pulmones_____________________________________________________________________ _____________________________________________________________________________ Abdomen_____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Extremidades _________________________________________________________________ _____________________________________________________________________________ Genitourinario_________________________________________________________________ _____________________________________________________________________________ Neurológico___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ DIAGNOSTICO PRESUNTIVO 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ 4. _______________________________________________________________________ 5. _______________________________________________________________________

Elaborado por: ______________________ HISTORIA CLINICA PEDIATRICA AFILIACIÓN Nombre completo______________________________________________________________

Edad _______________________fecha de nacimiento_______________________________ Sexo_________________________ Dirección ________________________________________ Datos obtenidos de__________________________Confiabilidad_________________________ MOTIVO DE CONSULTA _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ HISTORIA DE LA ENFERMEDAD ACTUAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES PATOLÓGICOS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES NO PATOLÓGICOS Hábitos personales _____________________________________________________________ Lactancia Materna Artificial Mixta Ablactación ___________________________________________________________________ Alimentación__________________________________________________________________ Alergias ______________________________________________________________________ Grupo y factor Sanguíneo________________________________________________________ Otros ________________________________________________________________________ _____________________________________________________________________________ Desarrollo Psicomotor Sonrió Sostuvo cabeza Se sentó Se paró Camino solo Control de esfínter vesical anal Escolaridad actual______________________________________________________________ Otros_________________________________________________________________________ _____________________________________________________________________________ Inmunización BCG__________________________________ Polio_______________________________ Pentavalente___________________________ Rotavirus____________________________ Antineumococica________________________ Influenza estacional___________________ SRP Antiamarillica Otras ______________________________________________________________________ ANTECEDENTES PERINATALES Producto de embarazo Nº_____________ de ________________ semanas de gestación Sitio de nacimiento _________________________________________________________ Tipo de Parto Vaginal / Cesárea por que________________________________________

Datos al nacimiento: Peso ____________ Talla_____________ PC___________________ APGAR_____________________________ Problemas al nacimiento_________________________________________________________ _____________________________________________________________________________ ANTECEDENTES FAMILIARES Nombre completo madre_______________________________________________________ Edad Hábitos Grupo sanguíneo G P C A Gineco-obstetricos_____________________________________________________________ _____________________________________________________________________________ Ant. Patológicos________________________________________________________________ _____________________________________________________________________________ Nombre completo Padre_________________________________________________________ Edad Hábitos Grupo sanguineo Ant.Patológicos________________________________________________________________ _____________________________________________________________________________ Otros_familiares________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANAMNESIS POR SISTEMAS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

EXAMEN FISICO EXAMEN FISICO GENERAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FC PESO

FR TALLA

Tº IMC

PA

EXAMEN FISICO SEGMENTARIO Cabeza_______________________________________________________________________ _____________________________________________________________________________ ojos__________________________________________________________________________

orejas________________________________________________________________________ nariz_________________________________________________________________________ Boca_________________________________________________________________________ _____________________________________________________________________________ Cuello________________________________________________________________________ _____________________________________________________________________________ Torax_________________________________________________________________________ _____________________________________________________________________________ Corazón_______________________________________________________________________ ____________________________________________________________________________ Pulmones_____________________________________________________________________ _____________________________________________________________________________ Abdomen_____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Extremidades _________________________________________________________________ _____________________________________________________________________________ Genitourinario_________________________________________________________________ _____________________________________________________________________________ Neurológico___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ DIAGNOSTICO PRESUNTIVO 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ 4. _______________________________________________________________________ 5. _______________________________________________________________________

Elaborado por: ______________________ HISTORIA CLINICA PEDIATRICA AFILIACIÓN Nombre completo______________________________________________________________ Edad _______________________fecha de nacimiento_______________________________ Sexo_________________________ Dirección ________________________________________

Datos obtenidos de__________________________Confiabilidad_________________________ MOTIVO DE CONSULTA _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ HISTORIA DE LA ENFERMEDAD ACTUAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES PATOLÓGICOS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES NO PATOLÓGICOS Hábitos personales _____________________________________________________________ Lactancia Materna Artificial Mixta Ablactación ___________________________________________________________________ Alimentación__________________________________________________________________ Alergias ______________________________________________________________________ Grupo y factor Sanguíneo________________________________________________________ Otros ________________________________________________________________________ _____________________________________________________________________________ Desarrollo Psicomotor Sonrió Sostuvo cabeza Se sentó Se paró Camino solo Control de esfínter vesical anal Escolaridad actual______________________________________________________________ Otros_________________________________________________________________________ _____________________________________________________________________________ Inmunización BCG__________________________________ Polio_______________________________ Pentavalente___________________________ Rotavirus____________________________ Antineumococica________________________ Influenza estacional___________________ SRP Antiamarillica Otras ______________________________________________________________________ ANTECEDENTES PERINATALES Producto de embarazo Nº_____________ de ________________ semanas de gestación Sitio de nacimiento _________________________________________________________ Tipo de Parto Vaginal / Cesárea por que________________________________________ Datos al nacimiento: Peso ____________ Talla_____________ PC___________________ APGAR_____________________________

Problemas al nacimiento_________________________________________________________ _____________________________________________________________________________ ANTECEDENTES FAMILIARES Nombre completo madre_______________________________________________________ Edad Hábitos Grupo sanguíneo G P C A Gineco-obstetricos_____________________________________________________________ _____________________________________________________________________________ Ant. Patológicos________________________________________________________________ _____________________________________________________________________________ Nombre completo Padre_________________________________________________________ Edad Hábitos Grupo sanguineo Ant.Patológicos________________________________________________________________ _____________________________________________________________________________ Otros_familiares________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANAMNESIS POR SISTEMAS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

EXAMEN FISICO EXAMEN FISICO GENERAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FC PESO

FR TALLA

Tº IMC

PA

EXAMEN FISICO SEGMENTARIO Cabeza_______________________________________________________________________ _____________________________________________________________________________ ojos__________________________________________________________________________ orejas________________________________________________________________________

nariz_________________________________________________________________________ Boca_________________________________________________________________________ _____________________________________________________________________________ Cuello________________________________________________________________________ _____________________________________________________________________________ Torax_________________________________________________________________________ _____________________________________________________________________________ Corazón_______________________________________________________________________ ____________________________________________________________________________ Pulmones_____________________________________________________________________ _____________________________________________________________________________ Abdomen_____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Extremidades _________________________________________________________________ _____________________________________________________________________________ Genitourinario_________________________________________________________________ _____________________________________________________________________________ Neurológico___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ DIAGNOSTICO PRESUNTIVO 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ 4. _______________________________________________________________________ 5. _______________________________________________________________________

Elaborado por: ______________________ HISTORIA CLINICA PEDIATRICA AFILIACIÓN Nombre completo______________________________________________________________ Edad _______________________fecha de nacimiento_______________________________ Sexo_________________________ Dirección ________________________________________ Datos obtenidos de__________________________Confiabilidad_________________________

MOTIVO DE CONSULTA _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ HISTORIA DE LA ENFERMEDAD ACTUAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES PATOLÓGICOS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANTECEDENTES PERSONALES NO PATOLÓGICOS Hábitos personales _____________________________________________________________ Lactancia Materna Artificial Mixta Ablactación ___________________________________________________________________ Alimentación__________________________________________________________________ Alergias ______________________________________________________________________ Grupo y factor Sanguíneo________________________________________________________ Otros ________________________________________________________________________ _____________________________________________________________________________ Desarrollo Psicomotor Sonrió Sostuvo cabeza Se sentó Se paró Camino solo Control de esfínter vesical anal Escolaridad actual______________________________________________________________ Otros_________________________________________________________________________ _____________________________________________________________________________ Inmunización BCG__________________________________ Polio_______________________________ Pentavalente___________________________ Rotavirus____________________________ Antineumococica________________________ Influenza estacional___________________ SRP Antiamarillica Otras ______________________________________________________________________ ANTECEDENTES PERINATALES Producto de embarazo Nº_____________ de ________________ semanas de gestación Sitio de nacimiento _________________________________________________________ Tipo de Parto Vaginal / Cesárea por que________________________________________ Datos al nacimiento: Peso ____________ Talla_____________ PC___________________ APGAR_____________________________ Problemas al nacimiento_________________________________________________________ _____________________________________________________________________________

ANTECEDENTES FAMILIARES Nombre completo madre_______________________________________________________ Edad Hábitos Grupo sanguíneo G P C A Gineco-obstetricos_____________________________________________________________ _____________________________________________________________________________ Ant. Patológicos________________________________________________________________ _____________________________________________________________________________ Nombre completo Padre_________________________________________________________ Edad Hábitos Grupo sanguineo Ant.Patológicos________________________________________________________________ _____________________________________________________________________________ Otros_familiares________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ANAMNESIS POR SISTEMAS _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

EXAMEN FISICO EXAMEN FISICO GENERAL _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FC PESO

FR TALLA

Tº IMC

PA

EXAMEN FISICO SEGMENTARIO Cabeza_______________________________________________________________________ _____________________________________________________________________________ ojos__________________________________________________________________________ orejas________________________________________________________________________ nariz_________________________________________________________________________

Boca_________________________________________________________________________ _____________________________________________________________________________ Cuello________________________________________________________________________ _____________________________________________________________________________ Torax_________________________________________________________________________ _____________________________________________________________________________ Corazón_______________________________________________________________________ ____________________________________________________________________________ Pulmones_____________________________________________________________________ _____________________________________________________________________________ Abdomen_____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Extremidades _________________________________________________________________ _____________________________________________________________________________ Genitourinario_________________________________________________________________ _____________________________________________________________________________ Neurológico___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ DIAGNOSTICO PRESUNTIVO 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ 4. _______________________________________________________________________ 5. _______________________________________________________________________

Elaborado por: ______________________