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FACULDADE DE CINCIAS HUMANAS, EXATAS E DA SADE DO PIAU

INSTITUTO DE EDUCAO SUPERIOR DO VALE DO PARNABA


CURSO DE GRADUAO EM MEDICINA

ALUNO(S):
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FICHA DE ANAMNESE
1. IDENTIFICAO

NOME:_____________________________________________________________________________________________
SEXO: __________________________________________
DATA DE NASCIMENTO: ____/____/______ IDADE ______________ COR: branca/parda/preta
TIPO SANGUNEO: _______________________________
ESTADO CIVIL:____________________________________ ESCOLARIDADE: ___________________________________
PROFISSO:______________________________________ RELIGIO: ________________________________________
NATURAL DE:_____________________________________ PROCEDENTE _____________________________________

2. QUEIXA PRINCIPAL E DURAO


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3. HISTRIA DA DOENA ATUAL (HDA) (durao total, incio, curso, caractersticas, sintomas
associados, efeitos de tratamentos, progresso, repercusses sobre a vida do paciente, ordem
cronolgica, sintomas associados)
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4. INTERROGATRIO SINTOMATOLGICO

Sintomas gerais: alteraes do peso (em quanto tempo), febre, calafrios, astenia, sudorese noturna, anorexia
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Pele e fneros: prurido, leses cutneas (localizao), alopecia, alteraes da pigmentao, anormalidades
nos plos e na aparncia ungueal
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Cabea e pescoo: cefalia, cervicalgia, limitao da movimentao do pescoo, tumoraes cervicais


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Olhos: dor ocular, acuidade visual, diplopia, fotofobia, lacrimejamento, secreo conjuntival, escotomas
visuais, viso turva, correo com culos ou lentes de contato
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Ouvidos, nariz e seios da face: otalgia, algias faciais, congesto periorbitria, epistaxe, otorria, rinorria,
obstruo nasal, espirros freqentes, gota ps-nasal, zumbidos, acuidade auditiva, vertigem
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Cavidade Oral: odontalgia, gengivorragias, ulceraes da mucosa, queimao ou ardncia da lngua,


odinofagia, sialose, dor em ATM
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Mamas: mastalgia, descarga mamilar, ndulos palpveis. Ginecomastia no homem


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Respiratrio: tosse, expectorao (aspecto e quantidade), rouquido, hemoptise, dor torcica, dispnia,
chiado no trax
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Cardiovascular: precordialgia, palpitaes, dispnia de esforo, noturna e de decbito, sncope, edema,


cianose, claudicao intermitente, veias varicosas, lceras de perna
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Gastrintestinal: disfagia, pirose, intolerncia alimentar, eructaes, empachamento, regurgitao,


epigastralgia, clicas, ictercia, nuseas e vmitos, hematmese, hbito intestinal (n 0 de evacuaes dirias,
aspecto das fezes - cor e consistncia -, presena elementos anormais - sangue, muco e/ou pus), tenesmo
evacuatrio, dor e prurido retal, enterorragia, melena, meteorismo, clicas, flatulncia, obstipao intestinal
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Urinrio: dor (lombar, no flanco, vesical), disria, alteraes miccionais, estrangria, polaciria, alteraes da
cor e odor da urina, nictria, enurese, oligria, poliria, incontinncia urinria de esforo (mulher), gotejamento
terminal e fora do jato urinrio (homem), eliminao de clculos durante a mico
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Genital: homem (corrimento uretral, leses genitais, disfunes sexuais); mulher (leucorria, prurido
vulvovaginal, sangramento intermenstrual, dor plvica, dispareunia)
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Osteoarticular: artralgias, rigidez matinal, edema articular, limitao de movimentos, deformidades, lombalgia
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Hematopoitico: palidez, tendncias hemorrgicas, linfadenomegalias, esplenomegalia, hepatomegalia


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Endcrino: intolerncia ao frio ou ao calor, poliria, polifagia e polidipsia, hirsutismo


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Nervoso: paresias (paralisia moderada), paralisias, parestesias, atrofias musculares, tremores, convulses,
ausncias, perturbaes da memria (amnsia transitria ou permanente)
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Psiquismo: insnia, nervosismo, choro freqente, irritabilidade, tristeza, sentimento de culpa, perda de interesse
e prazer no trabalho e no lazer
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5. ANTECEDENTES PESSOAIS FISIOLGICOS

Condies de gestao e nascimento


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Desenvolvimento neuropsicomotor:
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Imunizaes (BCG, DTP, anti-polio, hepatite viral, anti-tetanica, gripe)


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Adolescncia: (puberdade, surgimentos dos caracteressecundrios)


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Atividade sexual e vida reprodutiva (primeiro contato, parceiros, freqncia de relaes, camisinha,
menstruao(fluxo, ciclo), gestaes, partos)
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6. HISTRIA PATOLGICA PREGRESSA (HPP)

Doenas da infncia (sarampo, catapora, rubola, caxumba):


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Doenas apresentadas na vida adulta ( tuberculose, DST, hepatite, diabetes, hipertenso arterial,
cardiopatias, epilepsias, febre reumtica, asma, aborto espontneo ou no, disfuno sexual):
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Antecedentes de alergia:
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Cirurgias:
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Hospitalizaes:____________________________________________________________________________________________
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Traumatismos:______________________________________________________________________________________________
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Hemotransfuses:___________________________________________________________________________________________
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Uso de drogas injetveis:____________________________________________________________________________________


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Medicaes de uso prolongado


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7. ANTECEDENTES FAMILIARES
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8. ANTECEDENTES SOCIAIS

Condies de habitao e higiene:


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Condies de alimentao:
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Histria Ocupacional:
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Renda familiar mensal: ______________________________________________________

Relaes interpessoais: ( se existe problema de relacionamento na famlia se o paciente tem amigos sente
solido - tem ressentimento )
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Problemas psicossociais: (maior preocupao do paciente -o que lhe estressava antes da internao - sofreu
alguma perda importante no passado - sente-se realizado se houve expectativas frustradas)
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Hbitos e costumes: tabagismo (durao, tipo de cigarro, n de cigarros consumidos por dia), consumo de
lcool (durao, tipo de bebida, quantidade consumida), banhos de rios audes e lagoas (localidade e
poca), contato com o triatomneo, contato com animais domsticos, prtica regular de exerccios fsicos
(tipo e freqncia), sono, lazer, viagens, uso de drogas ilcitas
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Exame fsico
Altura _______ Peso__________ Circunferncia abdominal__________ IMC___________

Presso arterial sentada____________. Deitada____________

Exame do olho __________________________________________________________________________________________

Exame da cavidade oral _________________________________________________________________________________

Frequncia cardaca________________. Frequncia respiratria __________________


Ausculta cardiopulmonar ___________________________________________________________________________________
Avaliao da pele quanto a sua integridade, turgor, colorao e manchas.
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Membros inferiores: unhas, dor, edema, pulsos pediosos e leses; articulaes (capacidade de flexo,
extenso, limitaes de mobilidade, edemas); ps (bolhas, sensibilidade, ferimentos, calosidades e corte das
unhas).
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Abordar/orientar sobre:

Sinais de hipoglicemia e hiperglicemia e orientaes sobre como agir diante dessas situaes;
Motivao para modificar hbitos de vida no saudveis (fumo, estresse, bebida alcolica e
sedentarismo);
Avaliar com a pessoa e a famlia o quanto as metas de cuidados foram alcanadas e o seu grau de
satisfao em relao ao tratamento.
Percepo de presena de complicaes; A doena e o processo de envelhecimento;
Insulina:30 minutos antes das refeies 1 3x/dia. A aplicao subcutnea pode ser realizada nos
braos, abdmen, coxas e ndegas.
recomendada a monitorizao da glicemia capilar trs ou mais vezes ao dia a todas as pessoas
com DM tipo 1 ou tipo 2 em uso de insulina em doses mltiplas
Estabelecer metas de controle de peso e sobre exerccio fsico.
Avaliar o conhecimento sobre os cuidados com os ps e as unhas (complicaes agudas e crnicas
de fcil identificao);Avaliar o comportamento do paciente com relao aos seus ps; Avaliar o
cuidado executado pela pessoa;
Realize 5 a 6 refeies dirias, evitando beliscar alimentos entre as refeies e permanecer longos
perodos sem se alimentar. Evite o consumo de alimentos ricos em acar.
Consuma frutas diariamente. O ideal so trs pores dirias (uma poro = 1 ma mdia ou 1
banana ou 1 fatia mdia de mamo ou 1 laranja mdia). Para evitar o aumento da glicemia, prefira
consumir as frutas acompanhadas com leite, aveia, linhaa, granola diet ou como sobremesa aps as
refeies, sendo preferencialmente com casca ou bagao, por possurem maiores quantidades de
fibras.
Evite consumir alimentos ricos em sal como embutidos. Diminua o consumo de alimentos ricos em
gordura.

Preparao e aplicao da insulina:


lavar as mos com gua e sabo antes da preparao da insulina; o frasco de insulina deve ser
rolado gentilmente entre as mos para mistur-la,antes de aspirar seu contedo;
no necessrio limpar o local de aplicao com lcool; o local deve ser pinado levemente entre
dois dedos e a agulha deve ser introduzida completamente, em ngulo de 90 graus;no necessrio
puxar o mbolo para verificar a presena de sangue; esperar cinco segundos aps a aplicao antes
de se retirar a agulha do subcutneo, para garantir injeo de toda a dose de insulina;
importante mudar sistematicamente o local de aplicao de insulina de modo a manter uma
distncia mnima de 1,5 cm entre cada injeo. Orientar a pessoa a organizar um esquema de
administrao que previna reaplicao no mesmo local em menos de 15 a 20 dias, para preveno
da ocorrncia de lipodistrofia.

Exames a serem solicitados:

Glicemia de jejum e HbA1C.


Colesterol total (CT), HDL, LDL e triglicerdeos (TG).
Creatinina srica.
Exame de urina tipo 1 e, se necessrio, microalbuminria ou relao albumina/creatinina.
Fundoscopia
Eletrocardiograma