Professional Documents
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IDENTIFICAÇÃO:
Nome: __________________________________________________________Data: _____/______/______ Hora: _____:______
Idade: ________________ _______ Sexo: □ F □ M Internação: _______/______/________ Hora: _____:______
Endereço:______________________________________________________________ Zona: □ Rural □ Urbana
Cidade: _____________________________________ Raça/Cor:____________________________
Profissão: ________________________________________________________________ Enfermaria/Leito:_________________
Estado Civil: □ Solteiro □ Casado □ Divorciado □ Viuvo Instrução: _____________________________________________
Médico: _______________________Diagnóstico médico:__________________________________________________________
Queixa Principal:
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HPP: _____________________________________________________________________________________________________
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EXAME FÍSICO
Tipo de Tórax:
( ) Chato ( ) Tonel/Barril ( ) Pectus scavatum (dentro) ( ) Sino ( ) Cifoescoliótico
( ) Pectus carinatum (fora) ( ) Escoliótico ( ) Paralítico ( ) Cifótico
□ Cianose □Sudorese □Atrofia visivel □Tosse □Secreção □Hemoptise □Edema MMII/MMSS □Cifose □Cifoescoliose
□MM acessória □Tiragem esternal □Tiragem intercostal □Baqueteamento digital
□BAN □ICTUS CORDIS_______________________________________________________________________________
Padrão Respiratorio: □Normal □Apical □Abdominal □Misto □Resp. Kussmaul □Resp. Cheyne- Stoke
□Resp. Paradoxal □Musc Acessoria: __________________________________________________________________
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Suporte Ventilatório
□Oxigenoterapia/Litros: __________Tempo:___________ □ Vent. Não Invasiva: __________________________
□ Ventilador Mecânico: Modelo: _________________________
□ Ventilação Mecânica: Modo: _____________TOT ( ), TQT ( ) Numero: _____Posição: ___________ Cuff:_________
Parâmetros: VC _____________ FR ___________ Fluxo _______________Peep___________ FiO 2______________
Sens: _________________ SatPO2______________________
Avaliação Neurológica
Nível de Consciência: ___________________________________________________________________________________
Pupilas: _______________________________________ Face: _______________________________________________
Fala: _________________________________________Mobilidade: □ Ativa □ Passiva
Tônus muscular: ________________________________________________________________________________________
ADM: _________________________________________________________________________________________________
Sensibilidade: _______________________________________
Outras:
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Conduta: ______________________________________________________________________________________________
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Professor: ___________________________________
Acadêmicos: _______________________________________
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