UNIVERSIDAD DE SAN CARLOS DE GUATEMALA

FACULTAD DE CIENCIAS MÉDICAS

UNIDAD DIDACTICA DE CIENCIAS CLINICAS
SEGUNDO AÑO
AÑO 2019

Apellidos y Nombres completos del Estudiante:

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Carnet: __________________Historia clínica No. _______ HISTORIA CLÍNICA PEDIÁTRICA

FECHA: _________________ Hora: ______________ Servicio: ____________________

HISTORIA CLINICA PEDIÁTRICA

DATOS GENERALES
Nombres y Apellidos del paciente:________________________________________________
Fecha de Nacimiento:__________________________________ Edad: __________________
Sexo:_______ Estado civil:_______________________ Religión:_____________________
Procedencia:_____________________________________ Residencia: __________________
Profesión:___________________________ Ocupación:_______________________________
Etnia: ________________________ Alfabeta:_____ Escolaridad: ______________________
Teléfono: _______________
Informante: __________________________________________________________________

Motivo de consulta:
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Historia de la enfermedad actual:

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UNIVERSIDAD DE SAN CARLOS DE GUATEMALA
FACULTAD DE CIENCIAS MÉDICAS
UNIDAD DIDACTICA DE CIENCIAS CLINICAS
SEGUNDO AÑO
AÑO 2019

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Antecedentes Fisiológicos:
Prenatales:___________________________________________________________________
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Natales:____________________________________________________________________
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Post natales:________________________________________________________________
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Desarrollo:___________________________________________________________________
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Inmunizaciones: _____________________________________________________________
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Alimentación:_______________________________________________________________
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Hábitos y manías:_____________________________________________________________
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Antecedentes Patológicos:
Médicos:_______________________________________________________________________
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Quirúrgicos: ____________________________________________________________________
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Traumáticos:____________________________________________________________________
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Alérgicos:______________________________________________________________________
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Familiares: _____________________________________________________________________
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UNIVERSIDAD DE SAN CARLOS DE GUATEMALA
FACULTAD DE CIENCIAS MÉDICAS
UNIDAD DIDACTICA DE CIENCIAS CLINICAS
SEGUNDO AÑO
AÑO 2019

Hereditarios: ___________________________________________________________________
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Revisión por Sistemas:

Síntomas generales:____________________________________________________________

Piel y faneras:_________________________________________________________________

Cabeza:______________________________________________________________________

Ojos:________________________________________________________________________

Oídos, nariz y garganta (senos

paranasales):__________________________________________________________________

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Boca y garganta:_______________________________________________________________

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Cuello:______________________________________________________________________

Mamas:______________________________________________________________________

S. Linfático:__________________________________________________________________

S. Respiratorio:________________________________________________________________

S. Cardiovascular:_____________________________________________________________

S. Digestivo:_________________________________________________________________

S. Genito-urinario:_____________________________________________________________

S. Endocrino:_________________________________________________________________

S. Músculo esquelético:_________________________________________________________

S. Nervioso:__________________________________________________________________
UNIVERSIDAD DE SAN CARLOS DE GUATEMALA
FACULTAD DE CIENCIAS MÉDICAS
UNIDAD DIDACTICA DE CIENCIAS CLINICAS
SEGUNDO AÑO
AÑO 2019

Perfil Social:
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EXAMEN FÍSICO:

PESO:___________ TALLA:________ CC:_____________ IMC:_____________

Adecuaciones: P/T: ____________ T/E: ____________________ P/E: ______________
S/V: Temp.: _____________ FR:_______ Pulso:___________FC:________P/A:________

Aspecto general: _______________________________________________________________

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Piel y anexos:_________________________________________________________________
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Cabeza:______________________________________________________________________
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ORL:________________________________________________________________________
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UNIVERSIDAD DE SAN CARLOS DE GUATEMALA
FACULTAD DE CIENCIAS MÉDICAS
UNIDAD DIDACTICA DE CIENCIAS CLINICAS
SEGUNDO AÑO
AÑO 2019

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Cuello:______________________________________________________________________
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Tórax:_______________________________________________________________________
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Abdomen:____________________________________________________________________
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Extremidades:_________________________________________________________________
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Genitales:____________________________________________________________________
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Neurológico:_________________________________________________________________
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UNIVERSIDAD DE SAN CARLOS DE GUATEMALA
FACULTAD DE CIENCIAS MÉDICAS
UNIDAD DIDACTICA DE CIENCIAS CLINICAS
SEGUNDO AÑO
AÑO 2019

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Firma y sello:________________________________