UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA

FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA

HISTORIA CLÍNICA PEDIÁTRICA 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: ____________ Ocupación:____________ Fecha de Nacimiento: __________
Lugar de Nacimiento: _________ Grado de Instrucción: ___________ Idioma: _________
Residencia Actual: ___________________________________________________________
Residencia Anterior: __________________________________________________________
Teléfono: ________ Religión: _________________ Grupo Sanguíneo 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 Cronológico: ________________________________________________________

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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
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6) DNP: ___________________________________________________________________
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7) Tratamiento Previo: Líquidos _________________________________________________

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Medicamentos ______________________________________________________________
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Antecedentes

1) Hábitos Nocivos: __________________________________________________________

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2) Antecedentes Personales Fisiológicos:

 Prenatales: Gestación Controlada (SÍ) (NO)

N° Controles Prenatales _______________
Historia de Hemorragias (SÍ) (NO)
Diagnóstico de Hemorragia _______________
Historia de ITUs (SÍ) (NO)
Tratamiento para ITUs _______________
HTA inducida por Gestación (SÍ) (NO)

 Natales: Tipo de Parto _______________

Causa de Parto Distócico _______________
Edad Gestacional _______________
Peso al Nacer _______________
Llanto Inmediato (SÍ) (NO)
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
Cianosis (SÍ) (NO)
Apgar 1’ ( ) 5’ ( )
Otros: _____________________________________

 Posnatales LME (SÍ) (NO) Hasta los ___ meses

Inicio de la ablactancia a los ____ meses de vida.
Dieta actual: ___________________________________________
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Crecimiento y Desarrollo:
- 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 Antiamarílica DPT

1° Dosis
2° Dosis
3° Dosis

3) Antecedentes Personales Patológicos: _________________________________________

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4) Antecedentes Personales Quirúrgicos: _________________________________________

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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
5) Alergias: _________________________________________________________________
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6) Antecedentes Gineco – Obstétricos: ___________________________________________

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7) Antecedentes Epidemiológicos: _______________________________________________

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8) Antecedentes Familiares: ___________________________________________________

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9) Antecedentes Socioeconómicos:

VIVIENDA
Propia Alquiler Otros Material

SERVICIOS BÁSICOS
Luz Agua Desagüe Otros

ELIMINACIÓN DE BASURA
N° DE PERSONAS
INGRESO MENSUAL

Funciones Biológicas

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

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EXAMEN FÍSICO

1) Impresión 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) Antropometría:

Peso: ____kg Talla: _____m PC: ____cm

IMC: ____kg/m2 Circunf. Cintura: ____ cm SC: ____m2
P/E: ____ P/T: _____ T/E: _____
Tanner: ______________________________________________________________

Piel, Faneras y Tejido Celular Subcutáneo

1) Piel: ____________________________________________________________________
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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
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2) Uñas: ___________________________________________________________________
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3) Tejido Celular Subcutáneo: __________________________________________________

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4) Cabellos: ________________________________________________________________
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Ganglios Linfáticos
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Cabeza

1) Cráneo: _________________________________________________________________
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2) Cara: ___________________________________________________________________
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3) Párpados: _______________________________________________________________
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4) Globos oculares: __________________________________________________________

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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
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5) Pupilas: _________________________________________________________________
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6) Nariz: ___________________________________________________________________
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7) Oídos: __________________________________________________________________
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8) Boca y Faringe: ___________________________________________________________

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Cuello
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Tórax y Pulmones
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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
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Cardiovascular
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Abdomen
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Genitourinario
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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
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Osteomioarticular
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Sistema Nervioso
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EXÁMENES DE LABORATORIO
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 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
DIÁGNOSTICO
1) Signos y Síntomas

2) Problema de Salud

3) Diagnóstico
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
PLAN DIAGNÓSTICO

PLAN TERAPEÚTICO
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
EVOLUCIÓN MÉDICA
Fecha Hora Evolución
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA
INDICACIONES MÉDICAS
Fecha Hora Indicaciones
 UNIVERSIDAD PRIVADA ANTERIOR ORREGO – PIURA
FACULTAD DE MEDICINA HUMANA – ESCUELA DE MEDICINA HUMANA