FICHA CLÍNICA RESPIRATORIO PEDIATRÍA

Nombre: ________________________________________________________________Edad___________

Peso: ____________Talla: ______________

Con quien vive:______________________________________________________________________________________________

Fecha de ingreso: ____________________________________________________________________________________________

Persona responsable: _________________________________________________________________________________________

Otras enfermedades: ___________________________________________________________________________________________

Motivo de consulta hoy:

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Signos:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Síntomas:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Tiempo de evolución: _________________________________________________________________________________________

Factor causal: ________________________________________________________________________________________________

Frecuencia:
__________________________________________________________Localización:_______________________________________
____________________________________________________________________________________________________________

Motivo de hospitalización:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Evolución: __________________________________________________________________________________________________

ANAMNESIS REMOTA
APGAR:

Antecedentes prenatales:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Antecedentes perinatales:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Antecedentes post-natales:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Edad gestacional: ____________________________________________________________________________________________

Medicamentos:_______________________________________________________________________________________________
____________________________________________________________________________________________________________

Vacunas: ____________________________________________________________________________________________________

Tipo de lactancia: ____________________________________________________________________________________________

Alimentación:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Hábitos familiares: ____________________________________________________________________________________________

Factores de riesgo (hermanos, alérgenos, alimentación, calefacción, tabaco, tipo de casa, escolaridad de los padres, otros):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Hospitalizaciones previas:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Cirugías previas:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

EVALUACIÓN FÍSICO TORÁCIO

PAM: ___FC: ____FR: ____ Sat:______T°:____

INSPECCIÓN
Estado de la piel:

Color___________________________Cicatrices____________________________________________________________________
Circulación: _________________________________________________________________________________________________

Estado de la musculatura:
_______________________________________________________________________________________

Conformación del tórax bilateral:

Tonel ______ Paralítico _____ Excavatum ____ Carinatum ____Cifoescolisosis ___

Conformación del tórax unilateral

Retracciones_____________________________________________Abovedamiento_______________________________________

Tórax dinámico:
Ritmo: ________________________________Amplitud: __________________________________ Patrón respiratorio:
_____________________________UMA: _______________________________________________________________

PALPACIÓN
Frémitos: ____________________________________________________________________________ Temperatura:____________

Expansión torácica: _____________________________________________Flexibilidad torácica: _____________________________

Vibraciones vocales: _________________________________________________________________

AUSCULTACIÓN:
Murmullo pulmonar (normal, disminuido o abolido):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Ruidos adventicios (estridor laríngeo, sibilancias, roncus, crepitaciones y/o frotes pleurales):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

CIF
Funciones y estructuras corporales:______________________________________________________________________________

Limitación de la actividad:_____________________________________________________________________________________

IRestricción en la participación:
__________________________________________________________________________________ha