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Modelo para anamnese

Modelo para anamnese

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Published by _belle_
Roteiro para anamnese. Útil para quem está começando a aprender a semiologia médica.
Roteiro para anamnese. Útil para quem está começando a aprender a semiologia médica.

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Categories:Types, Resumes & CVs
Published by: _belle_ on Jul 05, 2009
Copyright:Attribution Non-commercial

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05/19/2014

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1. IDENTIFICAÇÃO NOME:___________________________________________  _________________________________________________ SEXO:___________________________________________ IDADE:__________ COR: branca/parda/pretaESTADO CIVIL:__________________________________ PROFISSÃO:______________________________________  NATURAL DE:____________________________________ PROCEDENTE ____________________________________ 2. QUEIXA PRINCIPAL E DURAÇÃO _________________________________________________  _________________________________________________  _________________________________________________ 
3.
HISTÓRIA DA DOENÇA ATUAL (HDA)(duração total, início, curso, características,sintomas associados, efeitos de tratamentos, progressão, repercussões sobre a vida do paciente,ordem cronológica, sintomas associados) _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ 4. INTERROGATÓRIO SINTOMATOLÓGICOSintomas gerais: alterações do peso (em quanto tempo),febre, calafrios, astenia, sudorese noturna , anorexia _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Pele e fâneros: prurido, lesões cutâneas (localização),alopecia, alterações da pigmentação, anormalidades nos pêlose na aparência ungueal _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Cabeça e pescoço: cefaléia, cervicalgia, limitação damovimentação do pescoço, tumorações cervicais _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Olhos: dor ocular, acuidade visual, diplopia, fotofobia,lacrimejamento, secreção conjuntival, escotomas visuais,visão turva, correção com óculos ou lentes de contato _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ 
 
 _________________________________________________  _________________________________________________ Ouvidos, nariz e seios da face: otalgia, algias faciais,congestão periorbitária, epistaxe, otorréia, rinorréia,obstrução nasal, espirros freqüentes, gota pós-nasal,zumbidos, acuidade auditiva, vertigem _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Cavidade Oral: odontalgia, gengivorragias, ulcerações damucosa, queimação ou ardência da língua, odinofagia,sialose, dor em ATM _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Mamas: mastalgia, descarga mamilar, nódulos palpáveis.Ginecomastia no homem _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Respiratório: tosse, expectoração (aspecto e quantidade),rouquidão, hemoptise, dor torácica, dispnéia, chiado no tórax _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Cardiovascular: precordialgia, palpitações, dispnéia deesforço, noturna e de decúbito, síncope, edema, cianose,claudicação intermitente, veias varicosas, úlceras de perna _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Gastrintestinal: disfagia, pirose, intolerância alimentar,eructações, empachamento, regurgitação, epigastralgia,cólicas, icterícia, náuseas e vômitos, hematêmese, hábitointestinal (n
0
de evacuações diárias, aspecto das fezes - cor econsistência -, presença elementos anormais - sangue, mucoe/ou pus), tenesmo evacuatório, dor e prurido retal,enterorragia, melena, meteorismo, cólicas, flatulência,obstipação intestinal _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Urinário: dor (lombar, no flanco, vesical), disúria, alteraçõesmiccionais, estrangúria, polaciúria, alterações da cor e odor da urina, nictúria, enurese, oligúria, poliúria, incontinênciaurinária de esforço (mulher), gotejamento terminal e força do jato urinário (homem), eliminação de cálculos durante amicção _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Genital: homem (corrimento uretral, lesões genitais,disfunções sexuais); mulher (leucorréia, pruridovulvovaginal, sangramento intermenstrual, dor pélvica,dispareunia) _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Osteoarticular: artralgias, rigidez matinal, edema articular,limitação de movimentos, deformidades, lombalgia _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Hematopoiético: palidez, tendências hemorrágicas,linfadenomegalias, esplenomegalia, hepatomegalia
 
 _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Endócrino: intolerância ao frio ou ao calor, poliúria, polifagiae polidipsia, hirsutismo _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  Nervoso: paresias (paralisia moderada), paralisias, parestesias, atrofias musculares, tremores, convulsões,ausências, perturbações da memória (amnésia transitória ou permanente) _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Psiquismo: insônia, nervosismo, choro freqüente,irritabilidade, tristeza, sentimento de culpa, perda de interessee prazer no trabalho e no lazer  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ 
5.
ANTECEDENTES PESSOAIS FISIOLÓGICOSCondições de gestação e nascimento:__________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Desenvolvimento neuropsicomotor: __________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Imunizações (BCG, DTP, anti-polio, hepatite viral, anti-tetanica, gripe ) ____________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Adolescência: (puberdade, surgimentos dos caracteressecundários)_______________________________________  _________________________________________________  _________________________________________________  _________________________________________________  ________________________________________________ Atividade sexual e vida reprodutiva (primeiro contato, parceiros, freqüência de relações, camisinha,emnstruação(fluxo, ciclo), gestações, partos) _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Climatério: (idade da mennopausa, ondas de calor,ressecamento vaginal) _______________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Senectude: ( como o paciente se sente no ambiente familiar,solidão, viuvez, pensão, aposentadoria, atividades diárias) _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ 6. ANTECEDENTES PESSOAIS PATOLÓGICOSDoenças da infância (sarampo, catapora, rubéola,caxumba):_________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Doenças apresentadas na vida adulta ( tuberculose, DST,hepatite, diabetes, hieprtensão arterial, cardiopatias,epilepsias, febre reumática, asma, aborto espontâneo ou não,disfunção sexual) : __________________ _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Antecedentes de alergia: ___________________________ _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Cirurgias:_________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  ________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________  _________________________________________________ Hospitalizações:____________________________________  _________________________________________________ 

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