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: ______

Estado civil: ____________

Sexo : ___________

Raza: ___________

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

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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
N Controles Prenatales
Historia de Hemorragias
Diagnstico de Hemorragia
Historia de ITUs
Tratamiento para ITUs
HTA inducida por Gestacin

(S)
(NO)
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(S)
(NO)
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(S)
(NO)
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(S)
(NO)

Natales:

Tipo de Parto
Causa de Parto Distcico
Edad Gestacional
Peso al Nacer
Llanto Inmediato

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(S)
(NO)

UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA

FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

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:
- Motor Grueso: ______________________________________
- Motor Fino: _________________________________________
- Lenguaje: __________________________________________
- Social: ____________________________________________
- Escolaridad: ________________________________________
- Desarrollo Sexual: ___________________________________

Vacunas
BCG
Dosis
1 Dosis
2 Dosis
3 Dosis

Antipolio

Dosis
1 Dosis
2 Dosis
3 Dosis

RN
Hepatitis B

Pentavalente

SPR

Neumococo

Antiamarlica

Rotavirus

Influenza

DPT

3) Antecedentes Personales Patolgicos: _________________________________________

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4) Antecedentes Personales Quirrgicos: _________________________________________
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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 Obsttricos: ___________________________________________
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7) Antecedentes Epidemiolgicos: _______________________________________________
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8) Antecedentes Familiares: ___________________________________________________
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9) Antecedentes Socioeconmicos:
Propia
Luz

VIVIENDA
Alquiler
Otros
SERVICIOS BSICOS
Agua
Desage

Material
Otros

ELIMINACIN DE BASURA
N DE PERSONAS
INGRESO MENSUAL
Funciones Biolgicas
1) Sueo: __________________________________________________________________
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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) 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
P.A.:____/___mmHg

Pulso: ___ pulsos/min

F.C.: ____ latidos/min

F.R.: ___respiraciones/min
SO2: ___ %

3) Antropometra:
Peso: ____kg
Talla: _____m
PC: ____cm
2
IMC: ____kg/m
Circunf. Cintura: ____ cm
SC: ____m2
P/E: ____
P/T: _____
T/E: _____
Tanner: ______________________________________________________________
Piel, Faneras y Tejido Celular Subcutneo
1) Piel: ____________________________________________________________________

UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA

FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

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2) Uas: ___________________________________________________________________
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3) Tejido Celular Subcutneo: __________________________________________________
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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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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) Odos: __________________________________________________________________
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8) Boca y Faringe: ___________________________________________________________
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Cuello
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Trax 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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EXMENES DE LABORATORIO
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UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA

FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

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

UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA

FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

EVOLUCIN MDICA
Fech
a

Hora

Evolucin

UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA

FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA

INDICACIONES MDICAS
Fech
a

Hora

Indicaciones

UNIVERSIDAD PRIVADA ANTERIOR ORREGO PIURA

FACULTAD DE MEDICINA HUMANA ESCUELA DE MEDICINA HUMANA