TRABAJO DE PEDIATRIA

PRESENTADO A: GRACIELLA MARTINEZ

PRESENTADO POR: AIKMAN CHARRIS ESCORCIA

MEDICINA PEDIATRIA

UNIVERSIDAD METROPOLITANA CIENCIAS DE LA SALUD

2017
PEDIATRIC CLINICAL HISTORY

Identification card

Family history

Non-pathological personal history

Pathological personal history

Current condition

Interrogation by apparatus and systems

Physical examination

Laboratories

Diagnosis: general characteristics

Name

Age

Sex

Date of birth

Place of residence

Religion

Schooling

IDENTIFICATION FILE

Informant: kinship and schooling

HEREDOFAMILIARY BACKGROUND
 Of the Father

Of the mother

Of the brothers

From grandparents, uncles and cousins

Family economic history

Classification of the family

Father: Idem.

Brothers: age, sex, health status.

Grandparents: Uncles, cousins who present with a major illness.

Mother: age, marital status, schooling, work, income / month, hours of work, health status, drug
addiction.

Background of family actions

FAMILY DIAGNOSIS

Type of Family:

Nuclear, extensive, reconstituted or single-parent.

Functionality: functional or dysfunctional, depending on whether each family member plays the
role that corresponds to him.

Family dynamics; Who is the provider, who cares for the child.

NON-PATHOLOGICAL PERSONAL BACKGROUND

Pre-natal history

Perinatal history

Immediate neonatal history

Psychomotor development
 Teething

Food

Immunizations

Habitat and personal higiene

Prenatal: Mother pregnancy, for cesarean sections, abortions, pregnancy age, pregnancy weeks,
prenatal control, by whom, periodicity, complications during pregnancy, feeding during pregnancy,
trauma during pregnancy.

Perinatal: characteristics of labor, duration of labor, weeks of gestation, where it was attended,
how the product was obtained, where it was attended, complications during extraction, forceps,
amniotic fluid characteristics and The placenta.

Breathed and cried the product at birth

What was the Apgar score

What was Silverman's rating?

Amerized special resuscitation maneuvers such as:

a) oxygen bag

b) assisted ventilation with ambu

c) intubation

d) Medications

Postnatal:

Amerized to be in incubator, how much time and why.

GYNECOLOGICAL BACKGROUND In girls:

At School and Adolescent stages, include

Age of onset of Telarca

Age of onset of Pubarca

age of Adrenarca

Age of Menarca
 Gynecological age (time elapsed between menarche and time of evaluation)

Menstrual Cycles: Frequency

Duration

Amount (average number of towels / day)

Dysmenorrhoea Yes / No

In children:

In males it would be convenient to include:

Pubarca Home

Home of Adrenarca

Age of sperm

PSYCHOMOTOR DEVELOPMENT

Psychomotor Development:

a) Thin motor

b) Thick motor

c) Language

d) social adaptive

FINE MOTOR DEVELOPMENT examples

Fine clip

To make stripes

make a cross

make a triangle

make a square

make a rectangle

To make a break
 Write words

DEVELOPMENT OF THICK ENGINE

Cephalic support 3 months

Bearing 5 months

Sedestation with aid 5 months

Sedation only 6 months

Crawling 8-10 months

Standing 12-15 months

Go up and down stairs without alternating feet 2 years

Play in two feet 2 years

Up and down alternating feet 4 years

Jumping on a foot 4-5 years

LANGUAGE

Guttural sounds

Monosyllables

Bisyllabic

3 word phrases

Fluent language of more than 3 words

Understanding of abstract things

Pronunciation of the R and S

SOCIAL-ADAPTIVE

1st. Agustia of separation

2nd separation anxiety

 Parallel play

Group play

Relationship with family and friends

FEEDING

Maternal breast: how long

Agglutination: how it started

Family diet integration

Food groups in quantity and quality per week (meat, milk, egg, fruits, vegetables, cereals and
legumes)

DENTITION

Start of the dentition

When does partial anodontics begin, the first or second?

How many teeth do you have?

Have you had caries previously?

Have you used any orthodontic appliance?

HABITAT

Room conditions,

Type of construction, how many rooms it consists of.

Do you have services? , Where it is located.

How many people live there?

Living with animals

HYGIENE

When do you bathe?

Every time you change clothes

Tooth washing

PATHOLOGICAL PERSONAL HISTORY

Age of illness

Type of illness

Evolution

Complications

Ejm: At 3 years. Chickenpox that course with Pneumonia, merited hospitalization for 2 weeks,
after which satisfactory evolution.

Traumatic, allergic and transfusion

CURRENT ACKNOWLEDGMENT

Break down signs and symptoms chronologically. Example:

Started 2 months ago with:

Edema ........... 2 months

Dyspnea ........... 1 week

Cough ------------ 2 days

Subsequently, make a detailed semiology of each of the signs and symptoms, including the
medications you received and the response you had with them.

PHYSICAL EXPLORATION
 Anthropometric measurements: weight, height, PC, PT, SI, CB, CP, plicometry, measurement of
anterior fontanelle.

Calculation of fat area and muscle area, BMI.

vital signs: TA, FC, FR and temperature

GENERAL INSPECTION

Sex, apparent age, conformity, apparent nutritional status, alertness, facial expression, gait,
spontaneous movements, crying characteristics, breathing type, cooperation, language
characteristics, and whether the patient is accompanied.

LEATHER AND FOOTWEAR

Coloration, moisture, sensitivity

local and generalized temperature

rashes, scaling, ulcerations

scars, edema, nodules, ecchymosis

hemangiomas, petechiae, scratch marks, hyperchromic and hypochromic mongolic spots

O Head, axillary, pubic hair characteristics. O Coloring of the nails, shape, fragility of the nails.
Abnormal distribution of lymphatic tissue

Or (size, confluence, coloration, mobility and increase of local temperature,

Pain on palpation

General inspection

Sex, apparent age, conformity, apparent nutritional status, alertness, facial expression, gait,
spontaneous movements, crying characteristics, type of breathing, cooperation, language
characteristics and whether the patient is accompanied.
LEATHER AND FOOTWEAR

Color, moisture, sensitivity

local and generalized temperature

Eruptions, scaling, ulcerations

scars, edema, nodules, ecchymosis

hemangiomas, petechiae, scratch marks, hyperchromic and hypochromic mongolian spots

O Head, axillary, characteristics of pubic hair. O Coloring of the nails, shape, fragility of the nails.
Abnormal Distribution of Lymphatic Tissue

O (size, confluence, coloration, mobility and increase of local temperature,

Pain on palpation

HEAD

Skull shape, hair implantation, fragility, opacity, ringworm, impetigo, boils, parasites. Size and
tension of the fontanelles. Sutures open, closed, punctiform, roundabouts. Craniotubes, other
bony anomalies.

Facial asymmetry, muscle weakness

Cefalohematoma

Sub Subgaleal hematoma

Par Parietal fracture with collapse

Eyes

Visual acuity, nystagmus, paralysis.

Eyelids (tearing, blepharospasm, ptosis, cellulitis, chaliazion).

Conjunctiva and cornea (keratitis, conjunctivitis, jaundice, etc.).

Students (symmetry, reaction to light, accommodation, photophobia).

Fundus of the eye (papilledema, papilla atrophy, vessels.

Ears

Auditory acuity

External auditory canal and tympanic membrane (integrity, coloration, congestion, bulging or
retraction, presence of dryness or foreign body).

Nose: Mucosa (coloration, ulceration, hemostatic crusts, secretion (characteristics).

NOSE

Obstruction: deviation of the septum, polyps, psuedomembranes, foreign body and hypertrophy
of turbinates.

Mouth and pharynx: lips (malformations, ulcerous lesions, fissures, queilosis, etc.).

Mouth: integrity and appearance.

Teeth: hygiene and number of pieces, caries, spots and malocclusion.

Mouth of mouth

Color

Humidity

Ulcerous lesions

Petequias

Language

Size

Inflammation

Coated

Bridle

Tumors

Tonsils

Hyperemia

Hypertrophic
Edema

Ulcers

Exuded

Pseudomemebranas

Abscesses

NECK

Shape and size

Edema

Tenderness of palpation

Flexibility

position of the trachea

Thyroid (size, consistency, and displacement)

Size

Shape

Symmetry

CHEST

Movements

Type of breath

FR

percussion and VV

FC
Location of heart beat

Card Heart sounds

Hits

Cardiomegaly

Arrhythmia etc

Paralysis of the diaphragm

HEART

Skin reflexes

Hernias

Um umbilical scar.

Volume

Form

Peristalsis

Location

Direction of movement

Hyperesthesia

Muscular tone

ABDOMEN
 superficial or deep pressure pain

Liver

Size

Consistency

Pain

Spleen

Kidney

Bladder

Tumors: location, size, shape, consistency, mobility and pain

EXTREMITIES

Con Congenital deformities: (dislocation of the hip, abnormalities of the phalanges, foot bott,
equine varus, achondroplasia, etc.)

Acquired: rickets, syphilis, tuberculosis. Rheumatoid arthritis.

Joints: increase in size, sensitivity, temperature, color and mobility

GENITALS

Deformities

Hernias

Penis: phimosis, preputial adhesions hypospadias).

Testicles: size, hydrocele, cryptorchidia, transillumination, tumors, spermatic cord, varicocele.

Vulva: hymen, adhesions, secretion, clitoris, integrity.

Evaluate Tanner
Atresia

Cracks

Condiments

Rectal prolapse

Erythema perianal

Per perianal abscess

Look

RECTAL YEAR

PERIPHERAL VASCULAR

Pulse characteristics

Variation from one extremity to another

Changes in skin color

Pulse

Blood pressure (appropriate bracelet

Cap capillary filling

Mental state

Level of consciousness

Cooperation

NEUROLOGICAL
 orientation (time, place and person)

Abnormal attitudes or movements

Memory

Moorish reflection

Irritability

Cephalic scream

Looking for reflexes, grasping, sucking and swallowing

Language

head circumference

Memory

Moorish reflection

Irritability

Cephalic scream

Looking for reflexes, grasping, sucking and swallowing

Language

head circumference

NEUROLOGICAL

orientation (time, place and person)

Abnormal attitudes or movements

Memory

Reflection of moro

Irritability

cephalic scream

Search reflexes, grasping, sucking and swallowing

Language

Cephalic perimeter
 Memory

Reflection of moro

Irritability

cephalic scream

Search reflexes, grasping, sucking and swallowing

Language

Cephalic perimeter

CRANIAL PAIRS

I Olfactory: explored in special cases

II Optical: visual fields, fundus.

III, IV, V. Pupils: size, symmetry, light response, accommodation, consensual reflex. Ocular
movements, nystagmus, strabismus, ptosis and paralysis

VI Motor, converging strabismus

VII Facial asymmetry, taste perception2 / 3 previous language

VIII Auditory acuity, air conduction, ataxia

IX, X Deviation of the uvula. Nauseous reflex, accumulation of secretions.

XI Exploration of sternocleidomastoid and trapezius

XII Protrusion of the tongue, atrophy, tremor and fibrillation.

REFLEXES

Osteotendinous: bicipital, tricipital, radial, patellar, aquiliano, patellar clonus, aquiliano clonus.

Superficial: abs, patellar cremaster, hoffman, oppenheim, chadock.

Nose test

Fast alternating movements

Heel knee test

COORDINATION
 Patient's foot at examiner's index

tremors and dissimetry

Areas of dryness

hypersufficient

AUTONOMIC PHENOMENA

Temperature uniformity

Ciliapinal reflex

SENSOR MOTOR SYSTEM

Muscle development: limitation to passive movement.

Volunteer movements

Weakness

rigidity

Muscle tone

Muscle strength

MUSCULAR

Spasticity

involuntary movements

myoclonus,

Athetotic movements

fasciculations

Core

Tics, convulsions

pain, temperature and touch

SPINE
 Meningeal signs

Stiff neck

kernig

Cephalic and contralateral brudzinski

normal curves

Muscle spasms

Push-ups

opisthotonos

Myelomeningocele

Scoliosis

Xifosis

pilonidal cyst

Mental state

Level of consciousness

Cooperation

NEUROLOGICAL

orientation (time, place and person)

Abnormal attitudes or movements

Memory

Reflection of moro

Irritability

cephalic scream

Search reflexes, grasping, sucking and swallowing

Language

Cephalic perimeter

Memory

Reflection of moro

Irritability
 cephalic scream

Search reflexes, grasping, sucking and swallowing

Language

Cephalic perimeter

CRANIAL PAIRS

I Olfactory: explored in special cases

II Optical: visual fields, fundus.

III, IV, V. Pupils: size, symmetry, light response, accommodation, consensual reflex. Ocular
movements, nystagmus, strabismus, ptosis and paralysis

VI Motor, converging strabismus

VII Facial asymmetry, taste perception2 / 3 previous language

VIII Auditory acuity, air conduction, ataxia

IX, X Deviation of the uvula. Nauseous reflex, accumulation of secretions.

XI Exploration of sternocleidomastoid and trapezius

XII Protrusion of the tongue, atrophy, tremor and fibrillation.

REFLEXES

Osteotendinous: bicipital, tricipital, radial, patellar, aquiliano, patellar clonus, aquiliano clonus.

Superficial: abs, patellar cremaster, hoffman, oppenheim, chadock.

Nose test

Fast alternating movements

Heel knee test

COORDINATION

Patient's foot at examiner's index

tremors and dissimetry

 Areas of dryness

hypersufficient

AUTONOMIC PHENOMENA

Temperature uniformity

Ciliapinal reflex

SENSOR MOTOR SYSTEM

Muscle development: limitation to passive movement.

Volunteer movements

Weakness

rigidity

Muscle tone

Muscle strength

MUSCULAR

Spasticity

involuntary movements

myoclonus,

Athetotic movements

fasciculations

Core

Tics, convulsions

pain, temperature and touch

SPINE

Meningeal signs

Stiff neck

kernig

Cephalic and contralateral brudzinski

normal curves

Muscle spasms

Push-ups

opisthotonos

Myelomeningocele

Scoliosis

Xifosis

pilonidal cyst
HISTORIA CLINICA PEDIATRICA

Ficha de Identificacin

Antecedentes heredofamiliares

Antecedentes personales no patolgicos

Antecedentes personales patolgicos

Padecimiento actual

Interrogatorio por aparatos y sistemas

Exploracin fsica

Laboratorios realizados

Diagnstico: caractersticas generales

Nombre

Edad

Sexo

Fecha de nacimiento

Lugar de residencia

Religin

Escolaridad

FICHA DE IDENTIFICACION

Informante : parentesco y escolaridad

ANTECEDENTES HEREDOFAMILIARES

Del Padre

De la Madre

De los hermanos

De los abuelos, tos y primos

Historia econmica familiar

Clasificacin de la familia

Padre: dem.

Hermanos: edad, sexo, estado de salud.

Abuelos: tos, primos que presenten alguna enfermedad de importancia.

Madre: edad, estado civil, escolaridad, trabajo, ingreso/mes, horas de trabajo, estado de
salud, toxicomanas.

Antecedentes de atpias familiares

DIAGNOSTICO DE FAMILIA

Tipo de Familia:

Nuclear, extensa, reconstituida o de un solo padre.

Funcionalidad: funcional o disfuncional, dependiendo si cada miembro de la familiar juega

el rol que le corresponde.

Dinmica familiar; quin es el proveedor, quin cuida al nio.

ANTECEDENTES PERSONALES NO PATOLGICOS

Antecedentes prenatales

Antecedentes perinatales
 Antecedentes neonatales inmediatos

Desarrollo psicomotor

Denticin

Alimentacin

Inmunizaciones

Habitat e higiene personal

Prenatales: Madre gesta, para, cesreas, abortos, edad a la que se embarazo del paciente,
semanas de gestacin, control prenatal, por quin, periodicidad, complicaciones durante el
embarazo, alimentacin durante el embarazo, traumatismos durante el mismo.

Perinatales : caractersticas del trabajo de parto, duracin del trabajo de parto, semanas de
gestacin, dnde fue atendida, como fue obtenido el producto, en dnde se atendi, hubo
complicaciones durante la extraccin, se utiliz frceps, caractersticas del lquido amnitico y de la
placenta.

Respir y llor el producto al nacer

Cual fue la calificacin de Apgar

Cual fue la calificacin de Silverman

Amerit maniobras de reanimacin especiales tales como:

a) bolsa de oxgeno

b) ventilacin asistida con amb

c) intubacin

d) Medicamentos

Posnatales:

Amerit estar en incubadora, cuanto tiempo y porqu.

ANTECEDENTES GINECOLOGICOS En nias:

En etapa Escolar y Adolescente, incluir

Edad de inicio de Telarca

Edad de inicio de Pubarca

 edad de inIcio de Adrenarca

Edad de Menarca

Edad Ginecolgica (Tiempo transcurrido entre la menarca y el momento de evaluacin)

Ciclos Menstruales: Frecuencia

Duracin

Cantidad ( num. toallas promedio/ da)

Dismenorrea Si/ No

En nios:

En varones sera conveniente incluir:

Inicio de Pubarca

Inicio de Adrenarca

Edad de espermaquia

DESARROLLO PSICOMOTOR

Desarrollo Psicomotor:

a) Motor fino

b) Motor grueso

c) Lenguaje

d) social adaptativo

DESARROLLO MOTOR FINO ejemplos

Pinza fina

hacer rayas

hacer una cruz

hacer un tringulo

hacer un cuadrado
 hacer un rectngulo

hacer un rombo

Escribe palabras

DESARROLLO MOTOR GRUESO

Sostn ceflico 3 meses

Rodamiento 5 meses

Sedestacin con ayuda 5 meses

Sedestacin solo 6 meses

Gateo 8-10 meses

Bipedestacin 12-15 meses

Subir y bajar escaleras sin alternar los pies 2 aos

Brincar en dos pies 2 aos

Subir y bajar alternando los pies 4 aos

Brincar en un pie 4-5 aos

LENGUAJE

Sonidos guturales

Monoslabos

Bislabos

Frases de 3 palabras

Lenguaje fluido de ms de 3 palabras

Comprensin de cosas abstractas

Pronunciacin de la R y S

SOCIAL-ADAPTATIVO
 1ra. Agustia de separacin

2da angustia de separacin

Juego en paralelo

Juego en grupo

Relacin con sus compaeros y familares

ALIMENTACION

Seno materno: cuanto tiempo

Aglactacin: como se inici

Integracin dieta familiar

Grupos de alimentos en cantidad y calidad por semana ( carne, leche, huevo, frutas,
verduras, cereales y leguminosas)

DENTICIN

Inicio de la denticin

Cundo inicia la anodoncia parcial, la primera o segunda?

Cuntas piezas dentarias tiene?

Ha tenido caries previamente?

Ha usado algn aparato de ortodoncia?

HABITAT

Condiciones de la habitacin,

Tipo de construccin, de cuntos cuartos consta.

Cuenta con servicios? , en dnde esta localizada.

Cuntas personas viven ah?

 Convivencia con animales

HIGIENE

Cada cundo se baa?

Cada cuando se cambia de ropa

Lavado de dientes

ANTECEDENTES PERSONALES PATOLGICOS

Edad del padecimiento

Tipo de padecimiento

Evolucin

Complicaciones

Ejm: A los 3 aos. Varicela que curso con Neumona, amerit hospitalizacin 2 semanas,
posteriormente evolucin satisfactoria.

Traumticos, alrgicos y transfusionales

PADECIMIENTO ACTUAL

Desglosar signos y sntomas de manera cronolgica. Ejm:

Inicia hace 2 meses con:

Edema...........2meses

Disnea...........1 semana

Tos------------2 das

Posteriormente hacer la semiologa detallada de cada uno de los signos y sntomas,

incluyendo los medicamentos que recibi y la respuesta que tuvo con ellos.

EXPLORACIN FSICA
 Medidas antropomtrica: peso, talla, PC, PT, SI, CB, CP, plicometra, medicin de fontanela
anterior.

Clculo del rea de grasa y rea muscular, IMC.

signos vitales: TA, FC, FR y temperatura

INSPECCIN GENERAL

Sexo, edad aparente, conformidad, estado nutricional aparente, estado de alerta,

expresin facial, marcha, movimientos espontneos, caractersticas del llanto, tipo de respiracin,
cooperacin, caractersticas del lenguaje, y si el paciente esta acompaado.

PIEL Y FANERAS

Coloracin, humedad, sensibilidad

temperatura local y generalizada

erupciones, descamaciones, ulceraciones

cicatrices, edema, ndulos, equimosis

hemangiomas, petequias, huellas de rascado, manchas monglicas hipercrmicas e

hipocrmicas

o Caractersticas del pelo de cabeza, axilar, pubiano. o Coloracin de la uas, forma, fragilidad de
las uas. o Distribucin anormal del tejido linftico

o ( tamao, confluencia, coloracin, movilidad y aumento de la temperatura local,

dolor a la palpacin

CABEZA

Forma del crneo, implantacin del pelo, fragilidad, opacidad, tia, imptigo, fornculos,
parsitos. Tamao y tensin de las fontanelas. Suturas abiertas, cerradas, puntifrmes, cabalgadas.
Craneotbes, anomalas seas otras.

Asimetra facial, debilidad muscular

 Cefalohematoma

Hematoma Subgaleal

Fractura parietal con hundimiento

OJOS

Agudeza visual, nistgmus, parlisis.

Prpados (lagrimeo, bleforoespsmo, ptosis, celulitis, chaliazin).

Conjuntiva y crnea (queratitis, conjuntivitis, ictericia etc).

Pupilas(simetra, reaccin a la luz, acomodamiento, fotofobia).

Fondo de ojo (papiledema, atrofia de papila, vasos.

OIDOS

Agudeza auditiva

Conducto auditivo externo y membrana timpnica(integridad, coloracin, congestin,

abombamiento o retraccin, presencia de secresin o cuerpo extrao).

Narz: Mucosa ( coloracin, ulceracin, costras hemticas. Secrecin (caracteristicas).

NARIZ

Obstruccin: desviacin del tabique, plipos, psuedomembranas, cuerpo extrao e hipertrofia de

cornetes.

Boca y Faringe: Labios (malformaciones, lesiones ulcerosas, fisuras, queilosis etc).

Paladar: integridad y aspecto.

Dientes: higiene y nmero de piezas, caries, manchas y mala oclusin.

BOCA Mucosa bucal

color

humedad
 lesiones ulcerosas

petequias

Lengua

tamao

inflamacin

saburral

frenillo

tumoraciones

Amgdalas

hiperemia

hipertrficas

edema

lceras

exudado

pseudomemebranas

abscesos

CUELLO

Forma y tamao

edema

dolor a la palpacin

flexibilidad

posicin de la trquea

tiroides( tamao, consistencia y desplazamiento)

Tamao
 forma

simetra

TORAX

movimientos

tipo de respiracin

FR

percusin y VV

CORAZN

FC

localizacin de latido

Ruidos cardiacos

soplos

cardiomegalia

arritmia etc

parlisis del diafragma

reflejos cutneos

hernias

cicatriz umbilical.

volumen

Forma

Peristalsis

localizacin

direccin del moviendo

Hiperestesia

tono muscular
ABDOMEN

dolor superficial o profundo a la presin

Hgado

tamao

consistencia

dolor

Bazo

rin

vejiga

tumoraciones : localizacin, tamao, forma, consistencia, movilidad y dolor

EXTREMIDADES

Deformidades congnita: (luxacin de cadera, anomalas de las falanges, pi bott, equino

varo, acondroplsia etc.)

Adquiridas: raquitismo, sfilis, tuberculosis. Artritis reumatoide.

Articulaciones: aumento de tamao, sensibilidad, temperatura, color y movilidad

GENITALES

Deformidades

hernias

Pene: fimosis, adherencias prepuciales hipospadias).

Testculos: tamao, hidrocele, criptorqudea, transiluminacin , tumores, cordn espermtico,

varicocele.

Vulva: himen, adherencias, secrecin, clitris, integridad.

Evaluar Tanner

Atresia

Fsuras

condilomas

prolapso rectal

eritema perianal

absceso perianal
 aspecto

ANO RECTAL

VASCULAR PERIFRICO

Caractersticas del pulso

Variacin de una extremidad a otra

Cambios de coloracin de la piel

Pulso

Tensin arterial (brazalete apropiado

Llenado capilar

NEUROLGICO

Estado mental

Nivel de conciencia

cooperacin

orientacin (tiempo, lugar y persona)

Actitudes o movimientos anormales

Memoria

reflejo de moro

irritabilidad

grito ceflico

reflejos de bsqueda, prensin , succin y deglucin

Lenguaje

Permetro ceflico

Memoria

reflejo de moro

irritabilidad
 grito ceflico

reflejos de bsqueda, prensin , succin y deglucin

Lenguaje

Permetro ceflico

PARES CRANEALES

I Olfatorio: se explora en casos especiales

II Optico: campos visuales, fondo de ojo.

III, IV, V. Pupilas: tamao, simetra, respuesta de la luz, acomodacin, reflejo consensual.
Movimientos oculares, nistagmus, estrabismo, ptosis y parlisis

VI Motor, estrabismo convergente

VII Asimetra facial, percepcin gustativa2/3 anteriores lengua

VIII Agudeza auditiva, conduccin area, ataxia

IX, X Desviacin de la vula. Reflejo nauseoso, acumulo de secreciones.

XI Exploracin de esternocleidomastoideo y trapecio

XII Protrusin de la lengua, atrofia, temblor y fibrilacin.

REFLEJOS

Osteotendinosos: bicipital, tricipital, radial, patelar, aquiliano, clonus patelar, clonus

aquiliano.

Superficiales: abdominales, cremasteriano patelar, hoffman, oppenheim, chadock.

Prueba dedo nariz

Movimientos alternos rpidos

Prueba taln rodilla tibia

COORDINACIN

Pie del paciente a ndice del examinador

temblores y disimetra
 reas de resequedad

hipersudoracin

FENOMENOS AUTONMICOS

Uniformidad de temperatura

Reflejo cilioespinal

SISTEMA MOTOR SENSORIAL

Desarrollo muscular: limitacin al movimiento pasivo.

Movimientos voluntarios

debilidad

rigidez

tono muscular

fuerzo muscular

MUSCULAR

Espasticidad

movimientos involuntarios

mioclonias,

movimientos atetsicos

fasciculaciones

coreicos

tics, convulsiones

dolor , temperatura y tacto

COLUMNA VERTEBRAL
 Signos menngeos

rigidz de nuca

kernig

brudzinski ceflico y contralateral

curvas normales

espasmos musculares

Flexiones

opisttonos

mielomeningocele

escoliosis

xifosis

quiste pilonidal
SIMBOLOGIA FAMILIOGRAMA

LACTANCIA MATERNA HISTORIA CLINICA