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UNIVERSIDAD DE SAN CARLOS DE GUATEMALA FACULTAD DE CIENCIAS MÉDICAS UNIDAD DIDACTICA DE CIENCIAS CLINICAS SEGUNDO AÑO AÑO 2019

Apellidos y Nombres completos del Estudiante: _____________________________________________________________________________ Carnet: __________________Historia clínica No. _______ HISTORIA CLÍNICA PEDIÁTRICA FECHA: _________________ Hora: ______________ Servicio: ____________________

HISTORIA CLINICA PEDIÁTRICA DATOS GENERALES Nombres y Apellidos del paciente:________________________________________________ Fecha de Nacimiento:__________________________________ Edad: __________________ Sexo:_______ Estado civil:_______________________ Religión:_____________________ Procedencia:_____________________________________ Residencia: __________________ Profesión:___________________________ Ocupación:_______________________________ Etnia: ________________________ Alfabeta:_____ Escolaridad: ______________________ Teléfono: _______________ Informante: __________________________________________________________________

Motivo de consulta: _____________________________________________________________________________

Historia de la enfermedad actual: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

UNIVERSIDAD DE SAN CARLOS DE GUATEMALA FACULTAD DE CIENCIAS MÉDICAS UNIDAD DIDACTICA DE CIENCIAS CLINICAS SEGUNDO AÑO AÑO 2019

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Antecedentes Fisiológicos: Prenatales:___________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________ Natales:____________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Post natales:________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Desarrollo:___________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Inmunizaciones: _____________________________________________________________ ___________________________________________________________________________ Alimentación:_______________________________________________________________ ___________________________________________________________________________ Hábitos y manías:_____________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Antecedentes Patológicos: Médicos:_______________________________________________________________________ ______________________________________________________________________________ Quirúrgicos: ____________________________________________________________________ ______________________________________________________________________________ Traumáticos:____________________________________________________________________ ______________________________________________________________________________ Alérgicos:______________________________________________________________________ ______________________________________________________________________________ Familiares: _____________________________________________________________________ ______________________________________________________________________________

UNIVERSIDAD DE SAN CARLOS DE GUATEMALA FACULTAD DE CIENCIAS MÉDICAS UNIDAD DIDACTICA DE CIENCIAS CLINICAS SEGUNDO AÑO AÑO 2019

Hereditarios: ___________________________________________________________________ ______________________________________________________________________________

Revisión por Sistemas: Síntomas generales:____________________________________________________________ Piel y faneras:_________________________________________________________________ Cabeza:______________________________________________________________________ Ojos:________________________________________________________________________ Oídos, nariz y garganta (senos paranasales):__________________________________________________________________ ____________________________________________________________________________ Boca y garganta:_______________________________________________________________ ____________________________________________________________________________ Cuello:______________________________________________________________________ Mamas:______________________________________________________________________ S. Linfático:__________________________________________________________________ S. Respiratorio:________________________________________________________________ S. Cardiovascular:_____________________________________________________________ S. Digestivo:_________________________________________________________________ S. Genito-urinario:_____________________________________________________________ S. Endocrino:_________________________________________________________________ S. Músculo esquelético:_________________________________________________________ S. Nervioso:__________________________________________________________________

UNIVERSIDAD DE SAN CARLOS DE GUATEMALA FACULTAD DE CIENCIAS MÉDICAS UNIDAD DIDACTICA DE CIENCIAS CLINICAS SEGUNDO AÑO AÑO 2019

Perfil Social: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

EXAMEN FÍSICO: PESO:___________

TALLA:________

Adecuaciones: P/T: ____________

CC:_____________

IMC:_____________

T/E: ____________________ P/E: ______________

S/V: Temp.: _____________ FR:_______

Pulso:___________FC:________P/A:________

Aspecto general: _______________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Piel y anexos:_________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Cabeza:______________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ORL:________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

UNIVERSIDAD DE SAN CARLOS DE GUATEMALA FACULTAD DE CIENCIAS MÉDICAS UNIDAD DIDACTICA DE CIENCIAS CLINICAS SEGUNDO AÑO AÑO 2019

____________________________________________________________________________ Cuello:______________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Tórax:_______________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Abdomen:____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Extremidades:_________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Genitales:____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Neurológico:_________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

UNIVERSIDAD DE SAN CARLOS DE GUATEMALA FACULTAD DE CIENCIAS MÉDICAS UNIDAD DIDACTICA DE CIENCIAS CLINICAS SEGUNDO AÑO AÑO 2019

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Firma y sello:________________________________