MODELO DE HISTORIA CLINICA PEDIATRICA

MARÍA C. ROSADO VARGAS

1. IDENTIFICACION DEL PACIENTE:

 NOMBRE COMPLETO___________________________________________________
 EDAD: ______________
 SEXO: F/M/REASIGNADO
 ESTADO CIVIL: ____________________
 OCUPACIÓN: __________________________________________________________
 RAZA: MESTIZA/BLANCA/NEGRA/OTRA ________________________
 RELIGIÓN: CATÓLICA/PROTESTANTE/JUDÍA/ISLÁMICA/ATEO/OTRAS_______________
 NATURAL DE: _________________________________
 RESIDENTE: ___________________________________
 PROCEDENCIA: ________________________________
 DIRECCIÓN: ___________________________________
 TELÉFONO: FIJO/MÓVIL __________________________
 RÉGIMEN DE SEGURIDAD SOCIAL: EPS/SISBEN/PREPAGADA/PARTICULAR/OTRA_________
 FUENTE DE LA HISTORIA: DIRECTA /INDIRECTA
 FECHA DE INGRESO: ________/________/_______
 FECHA DE REALIZACIÓN DE LA HISTORIA: ________/_________/_______
 CONFIABILIDAD DE LA HISTORIA: BUENA /MALA/ REGULAR

2. MOTIVO DE CONSULTA: ________________________________________________________

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3. ENFERMEDAD ACTUAL: ________________________________________________________

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4. ANTECEDENTES PERSONALES PATOLÓGICOS

 HOSPITALIZACIONES:________________________________________________________
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 QUIRÚRGICOS:_____________________________________________________________
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 TRAUMATICOS:(FX, QUEMADURAS, TCE)
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 TÓXICOS: (ABUSO DE DROGAS/INTOXICACIÓN ALIMENTARIA)
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 ALÉRGICOS:________________________________________________________________
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 TRANSFUSIONALES: (FACTORES DE COAGULACIÓN /SANGRE TOTAL/PLASMA)
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 INMUNIZACIONES: (PAI)
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 FARMACOLÓGICOS:_________________________________________________________
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 PERINATALES: (DESARROLLO PSICOMOTOR) _____________________________________
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5. ANTECEDENTES PERSONALES NO PATOLÓGICO:

 GINECO-OBSTETRICO
o MENARCA: ________________
o MENSTRUAL: ________________
o # DE COMPAÑEROS SEXUAL_____
o MÉTODO ANTICONCEPTIVO: ____
 HEREDOFAMILIARES
o TBC _________________________________________________________________________
o DBT__________________________________________________________________________
o HTA _________________________________________________________________________
o IAM _________________________________________________________________________
o ALERGIAS _____________________________________________________________________
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o PSIQUIATRICAS________________________________________________________________
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o CANCER______________________________________________________________________
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6. REVISIÓN POR SISTEMA

 PIEL Y FANERAS
o RESECA
o DESCAMATIVA
o ERITEMA.

 OJOS
o LAGRIMEO
o SECRECIONES
o ENROJECIMIENTO.

 NARIZ
o SANGRADO
o SECRECIONES

 OÍDOS
o DOLOR
o SECRECIÓN
o ENROJECIMIENTO
 OROFARINGES
o HUMEDAD
o SEQUEDAD
o MUGUET
o AUMENTO DE LAS AMIGDALAS.

 CUELLO
o MOVILIDAD
o MASA

 RESPIRATORIO
o TOS
o EXPECTORACIÓN
o DISNEA
o DOLOR PUNTA DE COSTADO.

 CARDIOVASCULAR
o DISNEA DE ESFUERZO
o ORTOPNEA
o DISNEA PAROXÍSTICA
o EDEMA DOLOR PRECORDIAL

 DIGESTIVO
o APETITO
o NAUSEAS
o VOMITO
o TRANSITO INTESTINAL
o DIARREA
o ESTREÑIMIENTO.

 ENDOCRINO
o CAMBIO EN EL PESO
o TALLA
o INTOLERANCIA AL FRIO
 o TEMBLOR
o SOMNOLIENCIA.
o
 GENITOURINARIO:
o ALTERACIÓN DEL CHORRO
o HEMATURIA
o DISURIA
o POLAQUIURIA

 NEUROLÓGICO:
o MAREOS
o CEFALEA
o COORDINACIÓN.

7. EXAMEN FÍSICO GENERAL: ________________________________________________________

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 EXAMEN FISICO GENERAL PIEL Y FANERAS

 COLOR: ROSADA – PÁLIDA - CIANOTICA

 CARACTERISTICAS: SECA-HÚMEDA- ERUPCIONES- DESCAMACIÓN- ULCERACIONES-

CICATRICES- HERIDAS- NODULOS- PETEQUIAS- EQUIMOSIS- HEMATOMA- HIPOCROMICA-
HIPERCROMICA-HUELLAS DE RASCADO- MANCHAS MONGOLICAS.

 TEMPERATURA: FRIA – CALIENTE.

 CIRCULACIÓN VENOSA – TELANGESTACIA- NEVOS.

 FANERAS (PELOS Y UÑAS) INSPECCIÓN _________________________________________

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PALPACIÓN __________________________________________________________________
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PELOS CANTIDAD_________________________________________________________________

DISTRIBUCIÓN E IMPLANTACIÓN ____________________________________________________

COLOR _________________________________________________________________________
RESISTENCIA ____________________________________________________________________
LARGO__________________________________________________________________________

 UÑAS: COLOR_________________________
TEXTURA_____________________________
FORMA ______________________________

 EXAMEN FISICO REGIONAL CABEZA

 FORMA: NORMOCEFALO – BRAQUICÉFALO - DOLICOCÉFALO
 TUMEFACCIONES: CAPUT SUCCEDANEUM - CEFALOHEMATOMA.
 ACABALGAMIENTO.
 FONTANELA ANTERIOR, FORMA_______________________________________________
MEDIDA __________________________________________________________________
CIERRE ___________________________________________________________________
 FONTANELA POSTERIOR, FORMA ______________________________________________
 NORMOTENSA – ABOMBADA - DEPRIMIDO.
 FACIE: ____________________________________________________________________

 EXAMEN FISICO REGIONAL OJOS (PRESENTA O NO PRESENTA)

 COLOR _________________________________________
 REACCIÓN A LA LUZ _______________________________
 TINTE ICTÉRICO EN ESCLERAS _______________________
 AUMENTO DE BILIRRUBINA _________________________
 TINTE AZULADO __________________________________
 HEMORRAGIA SUBCONJUNTIVAL ____________________
 EPIFORA ________________________________________
 ESTRABISMO __________________________DE QUE TIPO (CONVERGENTE- DIVERGENTE)
 PTOSIS PALPEBRAL ________________________________

 EXAMEN FISICO REGIONAL NARIZ (PRESENTA O NO PRESENTA)

 PERMEABILIDAD __________________________________
 ATRESIA DE COANAS ______________________________
 COLORACIÓN DE LA PIEL ____________________________
 EDEMA __________________________________________
 HIPOPLASIA DEL PUENTE NASAL ______________________
  CUERPO EXTRAÑO _________________________________
 PÓLIPO NASAL ____________________________________

 EXAMEN FISICO REGIONAL – BOCA (PRESENTA O NO PRESENTA)

 SIMÉTRIA DEL LABIO___________________________________
 LEPORINO ___________________________________________
 FISURA PALATINA _____________________________________
 FRENILLO LINGUAL ____________________________________
 RÁNULA _____________________________________________
 PERLAS DE EPSTEIN ____________________________________
 MUCOCELE ___________________________________________
 DIENTE NEONATAL _____________________________________
 MACROGLOSIA ________________________________________
 LENGUA GEOGRÁFICA ___________________________________
 AMÍGDALA-COMPOSICIÓN _______________________________

 EXAMEN REGIONAL DE OREJAS

 FORMA _______________________________________________
 TAMAÑO ______________________________________________
 IMPLANTACIÓN _________________________________________
 PREAURICULAR _________________________________________
 RETROAURICULAR _______________________________________
 HERIDA ________________________________________________
 GANGLIOS ______________________________________________
 EDEMA _________________________________________________
 RUBOR _________________________________________________

 EXAMEN REGIONAL-CUELLO (HALLAZGOS)

 SUBMAXILAR ______________________________________________________________
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 CADENA GANGLIONAR _______________________________________________________
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 SUPRACLAVICULAR
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 ESTERNOCLEIDOMASTOIDEO
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 TIROIDE ___________________________________________________________________
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 SUBMAXILAR ______________________________________________________________
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 CADENA GANGLIONAR _______________________________________________________
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 SUPRACLAVICULAR
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 ESTERNOCLEIDOMASTOIDEO
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 EXAMEN REGIONAL CARDIORESPIRATORIO

 INSPECCIÓN (PRESENTA O NO PRESENTA)
o TIRAJES: _____________________TIPO: INTERCOSTAL – SUBCOSTAL- SUPRACLAVICULAR.
o ALTERACIÓN ESTRUCTURAL DE LOS CARTÍLAGOS COSTALES: ________________________
o PECTUS EXCAVATUM O HUNDIDO _____________________________________________

 AUSCULTACIÓN PULMONAR (PRESENTA O NO PRESENTA)

o RUIDOS RESPIRATORIOS ____________________________________________________
o SIBILANCIAS (ESPIRATORIAS) _________________________________________________
o CREPITOS O ESTERTORES (INSPIRATORIOS) ______________________________________
o RONCUS (ESPIRACIÓN) MOV SECRECIONES _____________________________________
o ESTRIDOR (INSPIRATORIO) ___________________________________________________
o HIPOVENTILACIÓN__________________________________________________________

 PALPACIÓN (PRESENTA O NO PRESENTA)

o AIRE (VIBRACIÓN DÉBIL) _____________________________________________________
o LIQUIDO (VIBRACIÓN AUSENTE) _______________________________________________
o CONDENSACIÓN (VIBRACIÓN AUMENTADA O FRÉMITO) ___________________________
o EXPANSIÓN DEL TÓRAX (MOVIMIENTO SIMÉTRICO DE LAS MANOS) __________________

o PERCUSIÓN (PRESENTA O NO PRESENTA)

o SONIDO MATE (CONDENSACIÓN) ______________________________________________
EJ: DERRAME PLEURAL
o SONIDO SONORO (AIRE)
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o EJ: NEUMOTORAX – ASMA - BRONQUIOLITIS

 EXAMEN REGIONAL: AUSCULTACIÓN CARDIACOS (HALLAZGOS)

o RITMO ____________________________________________________________________
o FOCO AORTICO_____________________________________________________________
o FOCO PULMONAR __________________________________________________________
o FOCO TRICUSPIDEO _________________________________________________________
o FOCO MITRAL ______________________________________________________________
o FOCO ACCESORIO ___________________________________________________________
 EXAMEN REGIONAL _ABDOMEN (PRESENTA O NO PRESENTA)
o SINDROME DE EDWARDS, CORDÓN UMBILICAL 2 A 1V
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o GASTROSQUISIS ____________________________________________________________
o ONFALOCELE ______________________________________________________________
o SÍNDROME PRUNE BELLY _____________________________________________________

 EXAMEN REGIONAL DE GENITALES- MASCULINOS (PRESENTA O NO PRESEMTA)

o HIPOSPADIAS _________________________________
o EPISPADIAS ___________________________________
o FIMOSIS ______________________________________
o HIDROCELES ___________________________________
o HERNIAS INGUINALES ____________________________

 EXAMEN REGIONAL DE GENITALES- FEMENINOS (HALLAZGOS)

o LABIOS ________________________________________
o CLÍTORIS _______________________________________
o HIMEN _________________________________________

 ANO (PRESENTA O NO PRESENTA)

o PERMEABILIDAD _________________________________
o FISURA _________________________________________
o PÓLIPO _________________________________________

 EXAMEN REGIONAL DE EXTREMIDADES (PRESENTA O NO PRESENTA)

o SINDACTILIA _____________________________________
o POLIDACTILIA ____________________________________
o PLIEGUE SIMIANO _________________________________
o PIE EQUINO VARO _________________________________

 EXAMEN REGIONAL DE TRONCO Y COLUMNA (PRESENTA O NO PRESENTA)

o MENINGOCELE: __________________________________________
o MIELOMENINGOCELE: _________________________ESPINA BIFIDA__________________

 EXAMEN REGIONAL DE CADERA (PRESENTA O NO PRESENTA)

o LUXACIÓN_________________________________________________________________
o HALLAZGOS DE LA MANIOBRA DE ORTOLANI _____________________________________
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 o HALLAZHOS DE LA MANIOBRA DE BARLOW
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 SNC PRIMITIVO (PRESENTE O AUSENTE)

o REFLEJO DE BÚSQUEDA _____________________________________
o REFLEJO DE MORO _________________________________________
o REFLEJO DE PRENSIÓN (PALMAR- PLANTAR______________________
o REFLEJO DE LA MARCHA AUTOMÁTICA) _________________________
o REFLEJO TÓNICO DEL CUELLO _________________________________
o REFLEJO DE GALANT _________________________________________

8. IMPRESIÓN DIAGNOSTICA ______________________________________________________

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9. DIAGNOSTICO DIFERENCIALES ____________________________________________________

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10. PLAN DIAGNOSTICO Y PARACLINICOS _____________________________________________

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11. PLAN TERAPÉUTICO – FÓRMULA

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12. FIRMA Y SELLO DEL MEDICO

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