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HOSPITAL ESCUELA
FACULTAD DE CIENCIAS MDICAS
DEPARTAMENTO DE PEDIATRIA
HISTORIA CLINICA PEDIATRICA
I.
DATOS GENERALES
III.
SINTOMA PRINCIPAL
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IV.FOG
Disminuido
Estable
Aumentado
Apetito
Sed
Sueo
Defecacin
Miccin
V.-
VI.-
A.
ANTECEDENTES PRENATALES
1.
DATOS MATERNOS
CONTROL DE EMBARAZO
ANTECEDENTES NATALES
C.
ANTECEDENTES NEONATALES
Se investiga Antecedentes que ocurrieron desde el Primer da hasta los 28 das (anotar datos
Relevantes como vmitos, fiebre, ictericia, cirugas, hospitalizaciones)
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D.
E.
DESARROLLO
HITOS
Motor grueso
Logro :
Edad en
Meses
HITOS
Motor fino
Logro :
Edad en
Meses
Control ceflico
Coge el sonajero
Sigue la mirada
Responde a ruidos
Garabatea
Se para solo
HITOS
comunicacin y lenguaje
Corre
Balbuceo
Inhibe en respuesta a no
Se alimenta solo
Se viste solo
Control de la defecacin
Control de la miccin
Monta un triciclo
Conoce su nombre
Utiliza tijeras
Otros:
F.
VACUNACION
VACUNA
BCG
Hepatitis B
Sabin
Rotavirus:
FECHA
FECHA
FECHA
Pentavalente
Neumococo
SRP
Refuerzos
Otras
VII.
ENFERMEDADES ANTERIORES
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B.
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C.
D.
TRAUMATICOS
QUIRURGICOS
ANTECENDENTES INMUNOALERGICOS
Cuales:________________________________________________
VIII.
DATOS SOCIOECONOMICOS
Nombre de la Madre
Edad
Edad
Grado de
Educacin(especifico)
Profesin u
Oficio(actuales y
anteriores)
Ingreso Mensual
(de todos los que
laboran)Padre y madre
Estado civil de Padres
Grado de Educacin
Hermanos
Profesin u Oficio
Ingreso Mensual
Total:
Casados:
unin libre:
separados:
CARACTERISTICAS DE LA VIVIENDA:
Letrinas ( )
Al aire libre ( ).
IX.
HABITOS Y PERSONALIDAD
ANTECEDENTES EPIDEMIOLOGICOS
XII.
EXAMEN FSICO
ANTROPOMETRIA:
CABEZA:
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OJOS:________________________________________________________________________________________________
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ODOS:_______________________________________________________________________________________________
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NARIZ________________________________________________________________________________________________
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BOCA ________________________________________________________________________________________________
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CUELLO______________________________________________________________________________________________
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TORAX
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CORAZN_____________________________________________________________________________________________
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PULMONES____________________________________________________________________________________________
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ABDOMEN
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GENITALES____________________________________________________________________________________________
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ANO, RECTO Y
PERINE_______________________________________________________________________________________________
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COLUMNA VERTEBRAL
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EXTREMIDADES_______________________________________________________________________________________
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PIEL Y FANERAS
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EXAMEN NEUROLOGICO
GLASGOW:
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I Par: ________________________________________________________________________________________
II Par: _______________________________________________________________________________________
III, IV, VI: _____________________________________________________________________________________
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V Par: _______________________________________________________________________________________
VII Par:______________________________________________________________________________________
VIII Par: _____________________________________________________________________________________
IX Par: ______________________________________________________________________________________
X Par: _______________________________________________________________________________________
XI Par: ______________________________________________________________________________________
XII Par: ______________________________________________________________________________________
XIII.
DIAGNSTICOS
1. DIAGNOSTICO ETARIO:_________________________________________________________
2. DIAGNOSTICO NUTRICIONAL:___________________________________________________
3. DIAGNOSTICO INMUNOBIOLOGICO:_______________________________________________
4. DIAGNOSTICO SOCIOECONOMICO:______________________________________________
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5. DIAGNOSTICO PATOLOGICO: a.__________________________________________________
b._________________________________________________
c._________________________________________________
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COMENTARIO: PLAN:_________________________________________________________________
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