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Es el documento Medico Legal en el que se
registra los datos de identificacion y de
los procesos relacionados con la atenc...
¿Qué es una Historia Clinica
Pediatrica?
Es un documento o instrumento
Medico Legal, en el que se registran
los antecedent...
Compilación de
información obtenida de:
Entrevistas y
Cuestionarios
Observacione
s directas
Historiales
médicos
La primera...
¿Cuál es la Importancia de la
Historia Clinica Pediatrica?
Es imprescindible para
el control de la salud y
seguimiento de ...
Relacion Medico-Paciente
6
Los componentes de la Historia Clinica
Pediatrica son:
0 Datos de Identificacion
0 Fuente de la Historia
0 Motivo de Consu...
Datos de identificación
 Nombre
 Direccion
 Fecha y Hora de Ingreso
 Fecha y Hora de Historia
 Fecha de Nacimiento
 ...
Motivo de Consulta
o Consulta por
En este apartado se
debe anotar
textualmente lo que
dicen los padres o el
paciente.
Fuen...
Presente enfermedad o
Enfermedad actual
Narración clara y cronológica del problema.
Aparición, entorno, manifestaciones , ...
6. Factores que han aliviado o agravado
síntomas
7. Manifestaciones asociadas.
Hallazgos negativos
Ausencia de ciertos s...
Antecedentes personales
Historia
Prenatal
Historia
del
nacimiento
Historia
Natal.
Historia
Neonatal
Fuente: Bickley LS, Ho...
Historia Prenatal
0 Patrones nutricionales,
enfermedades gestacionales,
infecciones.
0 Dosis y duración de
medicamentos.
0...
Historia del nacimiento
0 Evaluar 2 primeros años
de vida (Problemas
neurológicos y
desarrollo)
0 Dificultades antes ,
dur...
Historia Natal.
Naturaleza del trabajo de parto y periodo
expulsivo :
0 Grado de dificultad
0 Analgesia materna
0 Parto Mu...
Historia Neonatal
0 Comienzo de las respiraciones
0 Necesidad de Reanimación
0 Apgar
0 Edad gestacional
0 Vinculo afectivo...
Historia de la alimentacion
2 primeros años de vida
Lactancia materna: Nº tomas y frecuencia
Alimentación con formula : ...
Historia del crecimiento
y desarrollo
0 Evaluar periodo de
lactancia e infancia
0 Retraso del crecimiento
físico
0 Retraso...
Crecimiento y desarrollo
0 Sostiene la cabeza
0 Se da vuelta
0 Sonrisa social
0 Agarra cosas con la mano
0 Se sienta solo
...
Desarrollo Social
0 Patrones de sueño
0 Control de esfínteres
0 Lenguaje
0 Hábitos
0 Disciplina
0 Escolaridad
0 Sexualidad...
Enfermedades de la
infancia
0 Determinar enfermedades especificas
0 Exposición reciente a enfermedades transmisibles.
Fuen...
Inmunizaciones
0 Fechas especificas de
administración
0 Refuerzos en infancia y
adolescencia
0 Efectos adversos (post-
vac...
Procedimientos de
deteccion
0 Prueba de Cribado:
visión, audición, EGO, Hematocrito, T4 y TSH
0 Screenning neonatal (Trast...
Antecedentes quirurgicos
0Hernias
0Apendicitis
0Fracturas
0Prevención de
accidentes
Fuente: Bickley LS, Hoekelman RA: Inte...
Alergias
0 Durante la lactancia e infancia
0 Hipersensibilidad.
0 Intolerancia a los alimentos.
0 Alergia a los medicament...
Medicamentos actuales
0 Remedios caseros
0 Medicina alternativa
0 Medicamentos de venta
libre
0 Nombre, cantidad,
frecuenc...
Antecedentes familiares
0 Nivel educativo de padres
0 Historia laboral de padres
0 Salud mental
0 Ecológico social
0 Consa...
Historia Psicosocial
0 Descripcion narrativa que capta la información
relevante sobre el paciente como persona.
Examen Fis...
29
Historia clinica pediatrica. Iris Guevara
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Historia clinica pediatrica. Iris Guevara

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  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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Historia clinica pediatrica. Iris Guevara

  1. 1. Es el documento Medico Legal en el que se registra los datos de identificacion y de los procesos relacionados con la atención del paciente en forma ordenada, integrada, secuencial e inmediata de la atención que el medico u otros profesionales de salud brindan al paciente. Fuente: Norma Tecnica de Salud para la Gestion de la Historia Clinica NT No 022 (Lima – Peru) 20072
  2. 2. ¿Qué es una Historia Clinica Pediatrica? Es un documento o instrumento Medico Legal, en el que se registran los antecedentes biólogicos, patológicos y evolutivos del niño. Fuente: Revista Gastrohnup Año 2011 Vol 13 No 1 Suplemento 1: S283
  3. 3. Compilación de información obtenida de: Entrevistas y Cuestionarios Observacione s directas Historiales médicos La primera parte de la intervención del médico con un paciente radica en la obtención de información que conduzca al análisis del problema clínico Es el punto de partida del razonamiento médico para definir el diagnóstico y tratamiento del paciente. Es el instrumento utilizado por todos los profesionales de la salud y sirve de nexo entre las diferentes disciplinas. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Bate´s guide to physical examination and history taking, ed. 7. 19994
  4. 4. ¿Cuál es la Importancia de la Historia Clinica Pediatrica? Es imprescindible para el control de la salud y seguimiento de la enfermedad. Detección precoz de problemas relacionados con Crecimiento, desarrollo y nutrición Exploración del estilo de vida y ambiente del niño y su familia. Prevención de futuras dificultades Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Bate´s guide to physical examination and history taking, ed. 7. 19995
  5. 5. Relacion Medico-Paciente 6
  6. 6. Los componentes de la Historia Clinica Pediatrica son: 0 Datos de Identificacion 0 Fuente de la Historia 0 Motivo de Consulta 0 Enfermedad actual 0 Antecedentes Medicos 0 Historia de Nacimiento 0 Historia Prenatal 0 Historia Natal 0 Historia Neonatal 0 Historia de Alimentación 0 Lactancia 0 Infancia 0 Historia de Crecimiento y Desarrollo. 0 Enfermedades de la Infancia. 0 Inmunizaciones. 0 Procedimientos de deteccion. 0 Alergias. Y Medicamentos Actuales. 0 Historia Familiar. 0 Revision por Sistemas. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history.7
  7. 7. Datos de identificación  Nombre  Direccion  Fecha y Hora de Ingreso  Fecha y Hora de Historia  Fecha de Nacimiento  Sexo  Religión de padres  Teléfono  Datos por  Parentesco  Confiabilidad Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido. 8
  8. 8. Motivo de Consulta o Consulta por En este apartado se debe anotar textualmente lo que dicen los padres o el paciente. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.9
  9. 9. Presente enfermedad o Enfermedad actual Narración clara y cronológica del problema. Aparición, entorno, manifestaciones , tratamientos. Describir los síntomas 1. Localización 2. Calidad 3. Cantidad o gravedad 4. Cronología ( inicio, duración y frecuencia) 5. Situación Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.10
  10. 10. 6. Factores que han aliviado o agravado síntomas 7. Manifestaciones asociadas. Hallazgos negativos Ausencia de ciertos síntomas (Lo que facilita el diagnostico diferencial) Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.11
  11. 11. Antecedentes personales Historia Prenatal Historia del nacimiento Historia Natal. Historia Neonatal Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.12
  12. 12. Historia Prenatal 0 Patrones nutricionales, enfermedades gestacionales, infecciones. 0 Dosis y duración de medicamentos. 0 Consumo alcohol y tabaco 0 Aumento de peso, sangrado transvaginal, edad gestacional. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.13
  13. 13. Historia del nacimiento 0 Evaluar 2 primeros años de vida (Problemas neurológicos y desarrollo) 0 Dificultades antes , durante y después del parto Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.14
  14. 14. Historia Natal. Naturaleza del trabajo de parto y periodo expulsivo : 0 Grado de dificultad 0 Analgesia materna 0 Parto Multiple o Unico 0 Peso al nacimiento Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.15
  15. 15. Historia Neonatal 0 Comienzo de las respiraciones 0 Necesidad de Reanimación 0 Apgar 0 Edad gestacional 0 Vinculo afectivo 0 Patrones de sueño 0 Micción y Defecación Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.16
  16. 16. Historia de la alimentacion 2 primeros años de vida Lactancia materna: Nº tomas y frecuencia Alimentación con formula : tipo , dilución, Nº tomas y frecuencia. Ablactación Vitaminas y Hierro Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.17
  17. 17. Historia del crecimiento y desarrollo 0 Evaluar periodo de lactancia e infancia 0 Retraso del crecimiento físico 0 Retraso psicomotor e intelectual 0 Trastornos del comportamiento Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.18
  18. 18. Crecimiento y desarrollo 0 Sostiene la cabeza 0 Se da vuelta 0 Sonrisa social 0 Agarra cosas con la mano 0 Se sienta solo 0 Se mantiene de pie 0 Camina Solo o con ayuda 0 Primeras palabras Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.19
  19. 19. Desarrollo Social 0 Patrones de sueño 0 Control de esfínteres 0 Lenguaje 0 Hábitos 0 Disciplina 0 Escolaridad 0 Sexualidad 0 Personalidad Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.20
  20. 20. Enfermedades de la infancia 0 Determinar enfermedades especificas 0 Exposición reciente a enfermedades transmisibles. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.21
  21. 21. Inmunizaciones 0 Fechas especificas de administración 0 Refuerzos en infancia y adolescencia 0 Efectos adversos (post- vacuna) 0 Carnet de vacunación. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.22
  22. 22. Procedimientos de deteccion 0 Prueba de Cribado: visión, audición, EGO, Hematocrito, T4 y TSH 0 Screenning neonatal (Trastornos metabólicos genéticos) 0 Prueba de tuberculina, Falciformismo 0 VIH , Plomo, Colesterol 0 Deficiencia de alfa 1 antitripsina Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.23
  23. 23. Antecedentes quirurgicos 0Hernias 0Apendicitis 0Fracturas 0Prevención de accidentes Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.24
  24. 24. Alergias 0 Durante la lactancia e infancia 0 Hipersensibilidad. 0 Intolerancia a los alimentos. 0 Alergia a los medicamentos. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.25
  25. 25. Medicamentos actuales 0 Remedios caseros 0 Medicina alternativa 0 Medicamentos de venta libre 0 Nombre, cantidad, frecuencia , indicación 0 Medicamentos múltiples. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.26
  26. 26. Antecedentes familiares 0 Nivel educativo de padres 0 Historia laboral de padres 0 Salud mental 0 Ecológico social 0 Consanguinidad 0 Diabetes, Tb, Enfermedades cardiacas, HTA, ECV, Enfermedad renal, Cáncer, Artritis , Anemia, Migraña. Fuente: Bickley LS, Hoekelman RA: Interviewing and the health history. Manual traducido.27
  27. 27. Historia Psicosocial 0 Descripcion narrativa que capta la información relevante sobre el paciente como persona. Examen Fisico Diagnostico 28
  28. 28. 29

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