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Modelo para anamnese

Modelo para anamnese

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Publicado por_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
Direitos Autorais:Attribution Non-commercial

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1.

IDENTIFICAÇÃO
NOME:___________________________________________
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SEXO:___________________________________________
IDADE:__________ COR: branca/parda/preta
ESTADO CIVI:__________________________________
!ROFISSÃO:______________________________________
NAT"RA DE:____________________________________
!ROCEDENTE ____________________________________
#. $"EIXA !RINCI!A E D"RAÇÃO
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%. &IST'RIA DA DOENÇA AT"A (&DA)
(d*ra+,- t-ta./ 0n1c0-/ c*r2-/ caracter12t0ca2/
20nt-3a2 a22-c0ad-2/ e4e0t-2 de trata3ent-2/
pr-5re22,-/ reperc*226e2 2-bre a 70da d- pac0ente/
-rde3 cr-n-.850ca/ 20nt-3a2 a22-c0ad-2)
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9. INTERRO:AT'RIO SINTOMATO':ICO
S0nt-3a2 5era02: a.tera+6e2 d- pe2- (e3 ;*ant- te3p-)/
4ebre/ ca.a4r0-2/ a2ten0a/ 2*d-re2e n-t*rna / an-re<0a
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!e.e e 4=ner-2: pr*r0d-/ .e26e2 c*t=nea2 (.-ca.0>a+,-)/
a.-pec0a/ a.tera+6e2 da p053enta+,-/ an-r3a.0dade2 n-2 p?.-2
e na apar?nc0a *n5*ea.
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Cabe+a e pe2c-+-: ce4a.@0a/ cer70ca.50a/ .030ta+,- da
3-703enta+,- d- pe2c-+-/ t*3-ra+6e2 cer70ca02
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O.A-2: d-r -c*.ar/ ac*0dade 702*a./ d0p.-p0a/ 4-t-4-b0a/
.acr03eBa3ent-/ 2ecre+,- c-nB*nt07a./ e2c-t-3a2 702*a02/
702,- t*r7a/ c-rre+,- c-3 8c*.-2 -* .ente2 de c-ntat-
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O*70d-2/ nar0> e 2e0-2 da 4ace: -ta.50a/ a.50a2 4ac0a02/
c-n5e2t,- per0-rb0tCr0a/ ep02ta<e/ -t-rr@0a/ r0n-rr@0a/
-b2tr*+,- na2a./ e2p0rr-2 4re;Dente2/ 5-ta p82Ena2a./
>*3b0d-2/ ac*0dade a*d0t07a/ 7ert05e3
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Ca70dade Ora.: -d-nta.50a/ 5en507-rra50a2/ *.cera+6e2 da
3*c-2a/ ;*e03a+,- -* ard?nc0a da .1n5*a/ -d0n-4a50a/
20a.-2e/ d-r e3 ATM
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Ma3a2: 3a2ta.50a/ de2car5a 3a30.ar/ n8d*.-2 pa.pC7e02.
:0nec-3a2t0a n- A-3e3
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Re2p0rat8r0-: t-22e/ e<pect-ra+,- (a2pect- e ;*ant0dade)/
r-*;*0d,-/ Ae3-pt02e/ d-r t-rCc0ca/ d02pn@0a/ cA0ad- n- t8ra<
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Card0-7a2c*.ar: prec-rd0a.50a/ pa.p0ta+6e2/ d02pn@0a de
e24-r+-/ n-t*rna e de decFb0t-/ 21nc-pe/ ede3a/ c0an-2e/
c.a*d0ca+,- 0nter30tente/ 7e0a2 7ar0c-2a2/ F.cera2 de perna
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:a2tr0nte2t0na.: d024a50a/ p0r-2e/ 0nt-.er=nc0a a.03entar/
er*cta+6e2/ e3pacAa3ent-/ re5*r50ta+,-/ ep05a2tra.50a/
c8.0ca2/ 0cter1c0a/ nC*2ea2 e 7G30t-2/ Ae3at?3e2e/ ACb0t-
0nte2t0na. (n
H
de e7ac*a+6e2 d0Cr0a2/ a2pect- da2 4e>e2 E c-r e
c-n202t?nc0a E/ pre2en+a e.e3ent-2 an-r3a02 E 2an5*e/ 3*c-
e/-* p*2)/ tene23- e7ac*at8r0-/ d-r e pr*r0d- reta./
enter-rra50a/ 3e.ena/ 3ete-r023-/ c8.0ca2/ 4.at*.?nc0a/
-b2t0pa+,- 0nte2t0na.
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"r0nCr0-: d-r (.-3bar/ n- 4.anc-/ 7e20ca.)/ d02Fr0a/ a.tera+6e2
30cc0-na02/ e2tran5Fr0a/ p-.ac0Fr0a/ a.tera+6e2 da c-r e -d-r
da *r0na/ n0ctFr0a/ en*re2e/ -.05Fr0a/ p-.0Fr0a/ 0nc-nt0n?nc0a
*r0nCr0a de e24-r+- (3*.Aer)/ 5-teBa3ent- ter30na. e 4-r+a d-
Bat- *r0nCr0- (A-3e3)/ e.030na+,- de cC.c*.-2 d*rante a
30c+,-
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:en0ta.: A-3e3 (c-rr03ent- *retra./ .e26e2 5en0ta02/
d024*n+6e2 2e<*a02)I 3*.Aer (.e*c-rr@0a/ pr*r0d-
7*.7-7a50na./ 2an5ra3ent- 0nter3en2tr*a./ d-r p@.70ca/
d02pare*n0a)
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O2te-art0c*.ar: artra.50a2/ r050de> 3at0na./ ede3a art0c*.ar/
.030ta+,- de 3-703ent-2/ de4-r30dade2/ .-3ba.50a
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&e3at-p-0@t0c-: pa.0de>/ tend?nc0a2 Ae3-rrC50ca2/
.0n4aden-3e5a.0a2/ e2p.en-3e5a.0a/ Aepat-3e5a.0a
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End8cr0n-: 0nt-.er=nc0a a- 4r0- -* a- ca.-r/ p-.0Fr0a/ p-.04a50a
e p-.0d0p20a/ A0r2*t023-
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Ner7-2-: pare20a2 (para.020a 3-derada)/ para.020a2/
pare2te20a2/ atr-40a2 3*2c*.are2/ tre3-re2/ c-n7*.26e2/
a*2?nc0a2/ pert*rba+6e2 da 3e38r0a (a3n@20a tran20t8r0a -*
per3anente)
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!20;*023-: 0n2Gn0a/ ner7-2023-/ cA-r- 4re;Dente/
0rr0tab0.0dade/ tr02te>a/ 2ent03ent- de c*.pa/ perda de 0ntere22e
e pra>er n- traba.A- e n- .a>er
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J. ANTECEDENTES !ESSOAIS FISIO':ICOS
C-nd0+6e2 de 5e2ta+,- e na2c03ent-:__________________
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De2en7-.703ent- ne*r-p20c-3-t-r: __________________
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I3*n0>a+6e2 (KC:/ DT!/ ant0Ep-.0-/ Aepat0te 70ra./ ant0E
tetan0ca/ 5r0pe ) ____________________________________
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Ad-.e2c?nc0a: (p*berdade/ 2*r503ent-2 d-2 caractere2
2ec*ndCr0-2)_______________________________________
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At070dade 2e<*a. e 70da repr-d*t07a (pr03e0r- c-ntat-/
parce0r-2/ 4re;D?nc0a de re.a+6e2/ ca3020nAa/
e3n2tr*a+,-(4.*<-/ c0c.-)/ 5e2ta+6e2/ part-2)
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C.03at@r0-: (0dade da 3enn-pa*2a/ -nda2 de ca.-r/
re22eca3ent- 7a50na.) _______________________________
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Senect*de: ( c-3- - pac0ente 2e 2ente n- a3b0ente 4a30.0ar/
2-.0d,-/ 70*7e>/ pen2,-/ ap-2entad-r0a/ at070dade2 d0Cr0a2)
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L. ANTECEDENTES !ESSOAIS !ATO':ICOS
D-en+a2 da 0n4=nc0a (2ara3p-/ catap-ra/ r*b@-.a/
ca<*3ba):_________________________________________
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D-en+a2 apre2entada2 na 70da ad*.ta ( t*berc*.-2e/ DST/
Aepat0te/ d0abete2/ A0eprten2,- arter0a./ card0-pat0a2/
ep0.ep20a2/ 4ebre re*3Ct0ca/ a23a/ ab-rt- e2p-nt=ne- -* n,-/
d024*n+,- 2e<*a.) : ___________________
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Antecedente2 de a.er50a: ____________________________
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C0r*r50a2:_________________________________________
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&-2p0ta.0>a+6e2:____________________________________
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Tra*3at023-2:_____________________________________
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&e3-tran24*26e2:___________________________________
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"2- de dr-5a2 0nBetC7e02:____________________________
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Med0ca+6e2 de *2- pr-.-n5ad-:______________________
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M. ANTECEDENTES FAMIIARES
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N. ANTECEDENTES SOCIAIS
C-nd0+6e2 de Aab0ta+,- e A050ene: ____________________
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C-nd0+6e2 de a.03enta+,-: __________________________
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N17e. de 0n2tr*+,-: ________________________________
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&02t8r0a Oc*pac0-na.: ______________________________
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Re.050,-: _________________________________________
Renda 4a30.0ar 3en2a.: ____________________________
Re.a+6e2 0nterpe22-a02: ( 2e e<02te pr-b.e3a de
re.ac0-na3ent- na 4a31.0a O 2e - pac0ente te3 a305-2 O 2ente
2-.0d,- E te3 re22ent03ent- )
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!r-b.e3a2 p20c-22-c0a02: ( 3a0-r pre-c*pa+,- d- pac0ente E-
;*e .Ae e2tre22a7a ante2 da 0nterna+,- E 2-4re* a.5*3a perda
03p-rtante n- pa22ad- E 2enteE2e rea.0>ad- O 2e A-*7e
e<pectat07a2 4r*2trada2)_____________________________
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&Cb0t-2 e c-2t*3e2: taba5023- (d*ra+,-/ t0p- de c05arr-/ nP
de c05arr-2 c-n2*30d-2 p-r d0a)/ c-n2*3- de C.c--.
(d*ra+,-/ t0p- de beb0da/ ;*ant0dade c-n2*30da)/ banA-2 de
r0-2 a+*de2 e .a5-a2 (.-ca.0dade e @p-ca)/ c-ntat- c-3 -
tr0at-31ne-/ c-ntat- c-3 an03a02 d-3@2t0c-2/ prCt0ca re5*.ar
de e<erc1c0-2 4120c-2 (t0p- e 4re;D?nc0a)/ 2-n-/ .a>er/ 70a5en2/
*2- de dr-5a2 0.1c0ta2
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