ROTEIRO DE ANAMNESE / EXAME FÍSICO /DIAGNÓSTICOS / CONDUTAS

NOME:
LEITO / PRONTUÁRIO:
DATA DE NASCIMENTO:
GENERO/ SEXO:
RAÇA/ ETNIA:
RELIGIÃO:
PROFISSÃO:
NATURAL / PROCEDENTE :

QUEIXA PRINCIPAL/ MOTIVO DA CONSULTA:

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HISTÓRICO DA MOLESTIA/PATOLOGIA ATUAL:

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HISTÓRICO PÁTOLOGICO PREGRESSO:

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HISTÓRICO PATOLÓGICO FAMILIAR:

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HISTÓRICO BIOPSICOSSOCIAL / HÁBITOS DE VIDA :

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HISTÓRICO GINECOLÓGICO / OBSTÉTRICO :
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INTERROGATÓRIO SISTEMÁTICO:
PELE E FÂNEROS:
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CABEÇA E PESCOÇO:
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TÓRAX:
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ABDOME:
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TRATO GENITURINÁRIO:
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OSTEOMUSCULAR:
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NEUROLÓGICO:
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EXTREMIDADES:
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EXAME FÍSICO:
SINAIS VITAIS:
FC: FR: T.AXILAR: SPO2:

ESTADO GERAL:
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NEUROLÓGICO:
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CABEÇA E PESCOÇO:
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APARELHO RESPIRATÓRIO:
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APARELHO CARDIOVASCULAR:
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ABDOME:
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TRATO GENITURIÁRIO:
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OSTEOMUSCULAR:
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EXTREMIDADES:
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LISTA DE PROBLEMAS

P1:______________________________________ P6:_________________________________
P2:______________________________________ P7:_________________________________
P3:______________________________________ P8:_________________________________
P4:______________________________________ P9:_________________________________
P5:______________________________________ P10:________________________________

DIAGNÓSTICO SINDRÔMICO
S1:_________________________________________
S2:_________________________________________
S3:_________________________________________

DIAGNÓSTICOS DIFERENCIAIS:
D1:_________________________________
D2:_________________________________
D3:_________________________________
D4:__________________________________
EXAME COMPLEMENTARES:
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DIAGNÓSTICO ETIOLÓGICO:
D1:________________________________________________
D2:________________________________________________
D3:________________________________________________
D4:________________________________________________

PRÓXIMOS PASSOS:

1- EXAMES COMPLEMENTARES A SEREM SOLICITADOS

2- TRATAMENTOS A SEREM ADOTADOS