UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA

FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

HISTORIA CLNICA PEDITRICA N 000___
ANAMNESIS
Tipo: ___________________ Fecha y Hora de Entrevista: _______________
Fuente: __________________ Fecha y Hora de Ingreso: _________________

Datos Filiatorios

Apellidos y Nombres: _________________________________________________________

DNI: ______ Edad: ______ Sexo : ___________ Raza: ___________
Estado civil: ____________ Ocupacin:____________ Fecha de Nacimiento: __________
Lugar de Nacimiento: _________ Grado de Instruccin: ___________ Idioma: _________
Residencia Actual: ___________________________________________________________
Residencia Anterior: __________________________________________________________
Telfono: ________ Religin: _________________ Grupo Sanguneo y Factor: ________
Responsable y parentesco: ____________________________________________________
DNI del responsable : ____________________________________________________
Residencia (responsable) : ____________________________________________________

Enfermedad Actual

1) Motivo de Consulta: ________________________________________________________

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2) TE: _____ 3) FI: _______________ 4) C: ____________

5) Relato Cronolgico: ________________________________________________________

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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

6) DNP: ___________________________________________________________________
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7) Tratamiento Previo: Lquidos _________________________________________________

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Medicamentos ______________________________________________________________
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Antecedentes

1) Hbitos Nocivos: __________________________________________________________

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2) Antecedentes Personales Fisiolgicos:

Prenatales: Gestacin Controlada (S) (NO)

N Controles Prenatales _______________
Historia de Hemorragias (S) (NO)
Diagnstico de Hemorragia _______________
Historia de ITUs (S) (NO)
Tratamiento para ITUs _______________
HTA inducida por Gestacin (S) (NO)

Natales: Tipo de Parto _______________

Causa de Parto Distcico _______________
Edad Gestacional _______________
Peso al Nacer _______________
Llanto Inmediato (S) (NO)
Cianosis (S) (NO)
Apgar 1 ( ) 5 ( )
Otros: _____________________________________

Posnatales LME (S) (NO) Hasta los ___ meses

Inicio de la ablactancia a los ____ meses de vida.
Dieta actual: ___________________________________________
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Crecimiento y Desarrollo:
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA
- Motor Grueso: ______________________________________
- Motor Fino: _________________________________________
- Lenguaje: __________________________________________
- Social: ____________________________________________
- Escolaridad: ________________________________________
- Desarrollo Sexual: ___________________________________

Vacunas

RN
BCG Hepatitis B

Dosis Antipolio Pentavalente Neumococo Rotavirus Influenza

1 Dosis
2 Dosis
3 Dosis

Dosis SPR Antiamarlica DPT

1 Dosis
2 Dosis
3 Dosis

3) Antecedentes Personales Patolgicos: _________________________________________

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4) Antecedentes Personales Quirrgicos: _________________________________________

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5) Alergias: _________________________________________________________________
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6) Antecedentes Gineco Obsttricos: ___________________________________________

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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA
7) Antecedentes Epidemiolgicos: _______________________________________________
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8) Antecedentes Familiares: ___________________________________________________

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9) Antecedentes Socioeconmicos:

VIVIENDA
Propia Alquiler Otros Material

SERVICIOS BSICOS
Luz Agua Desage Otros

ELIMINACIN DE BASURA
N DE PERSONAS
INGRESO MENSUAL

Funciones Biolgicas

1) Sueo: __________________________________________________________________
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2) Sed: ____________________________________________________________________
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3) Apetito: __________________________________________________________________
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4) Orina: ___________________________________________________________________
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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA
5) Deposiciones: ____________________________________________________________
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6) Sudoracin: ______________________________________________________________
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7) Estado Anmico: ___________________________________________________________

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EXAMEN FSICO

1) Impresin General: ________________________________________________________

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2) Signos Vitales:

T: ______C Pulso: ___ pulsos/min F.R.: ___respiraciones/min

P.A.:____/___mmHg F.C.: ____ latidos/min SO2: ___ %

3) Antropometra:

Peso: ____kg Talla: _____m PC: ____cm

IMC: ____kg/m 2 Circunf. Cintura: ____ cm SC: ____m2
P/E: ____ P/T: _____ T/E: _____
Tanner: ______________________________________________________________

Piel, Faneras y Tejido Celular Subcutneo

1) Piel: ____________________________________________________________________
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2) Uas: ___________________________________________________________________
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3) Tejido Celular Subcutneo: __________________________________________________

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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA
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4) Cabellos: ________________________________________________________________
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Ganglios Linfticos
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Cabeza

1) Crneo: _________________________________________________________________
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2) Cara: ___________________________________________________________________
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3) Prpados: _______________________________________________________________
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4) Globos oculares: __________________________________________________________

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5) Pupilas: _________________________________________________________________
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6) Nariz: ___________________________________________________________________
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7) Odos: __________________________________________________________________
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8) Boca y Faringe: ___________________________________________________________

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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA
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Cuello
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Trax y Pulmones
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Cardiovascular
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Abdomen
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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA
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Genitourinario
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Osteomioarticular
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Sistema Nervioso
Pares Craneales
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA
I Olfatorio: normal
II Optico: agudeza visual de cerca y lejos.
III, IV, V. Pupilas: isocoricas, estrabismo ojo derecho, respuesta de la luz + reflejo de
acomodacin +, reflejo consensual ++. No nistagmus, estrabismo, ptosis y parlisis
VII simetra facial
VIII Agudeza auditiva +
IX, X no hay desviacin de la vula. Si Reflejo nauseoso, no acumulo de secreciones.
XI Exploracin de esternocleidomastoideo y trapecio normal
XII Protrusin de la lengua, No atrofia ni temblor

REFLEJOS
Osteotendinosos: bicipital +, radial +, patelar +, aquiliano +,
COORDINACIN
Prueba dedo nariz +
Movimientos alternos rpidos +
DIGNOSTICO
1) Signos y Sntomas

2) Problema de Salud

3) Diagnstico
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

PLAN DIAGNSTICO

PLAN TERAPETICO

EVOLUCIN MDICA
Fecha Hora Evolucin
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

INDICACIONES MDICAS
Fecha Hora Indicaciones
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA
FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA