IDENTIFICAÇÃO

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QUEIXA PRINCIPAL
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HISTÓRIA DA DOENÇA ACTUAL

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HISTÓRIA PATOLÓGICA PREGRESSA
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HISTÓRIA FAMILIAR
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HISTÓRIA PSICO-SOCIAL.
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HISTÓRIA GINECOLÓGICA
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REVISÃO POR SISTEMAS

Cardiorespiratório:
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Gastrointestinal:
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Genito-urinário:
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Nervoso:
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Osteomioarticular:
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Hemolinfopoético:
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Endócrino:
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EXAME OBJECTIVO

EXAME GERAL
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Sinais Vitais
FC _____ bpm FR _____cpm T° _____°C
TA _____/____ mmHg SPO2 _____ao ar ambiente IMC _____kg/𝑚2

Pele
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Mucosas
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Hidratação
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Unhas
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Tecido celular subcutâneo

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Linfadenopatias
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EXAME REGIONAL

CRÂNIO
Inspecção:
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Palpação:
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Auscultação:
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FACE (seios perinasais)_____________________________________________

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CABELOS_________________________________________________________
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OLHOS____________________________________________________________
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ORELHAS/ OUVIDOS_____________________________________________
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NARIZ_____________________________________________________________
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BOCA
Lábios______________________________________________________________
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Língua_____________________________________________________________
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Gengivas___________________________________________________________
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Palato duro/ mole __________________________________________________
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Dentes _____________________________________________________________
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Parede posterior da faringe _________________________________________
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Amígdalas__________________________________________________________
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PESCOÇO
Inspecção:
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Palpação:
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Auscultação:
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TÓRAX
Inspecção:
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Palpação:
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Pulsos:
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Percussão:
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Auscultação:
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CARDIOVASCULAR
Inspecção:
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Palpação:
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Percussão:
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Auscultação:
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Manobras Especiais:
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ABDÓMEN
Inspecção:
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Auscultação:
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Palpação:
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Percursão:
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MANOBRAS ESPECIAIS
Gerais: ______________________________________________________________
Rim: ________________________________________________________________
Fígado:
Murphy hepático:___________________________________________________
Refluxo hepatojugular: _______________________________________________
Vesícula Biliar:
Sinal de Couvusier:__________________________________________________
Pâncreas: ___________________________________________________________
Pontos dolorosos: _____________________________________________________
Sinais: ______________________________________________________________

COLUNA VERTEBRAL
Inspecção:
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Palpação:
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MEMBROS SUPERIORES
Inspecção:
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Palpação:____________________________________________________________
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MEMBROS INFERIORES
Inspecção:
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Palpação:____________________________________________________________
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EXAME NEUROLÓGICO

Estado Mental
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Nervos Craneanos

1° par:
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2° par:
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3°, 4° e 6° par:
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5° par:
Sensitiva:
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Motora:
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7° par:
Sensitiva:
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Sensorial:
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Motora:
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8° par:
Coclear:
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Vestibular:
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9° e 10° par:
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11° par:
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12° par:
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Motilidade:
Tónus___________________________________________________________________________
Hipertrofias/ atrofias ______________________________________________________________
Movimentos involuntários___________________________________________________________

Força Muscular:
Segmentar_______________________________________________________________________
Testes___________________________________________________________________________

Sinais meníngeos:
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Kerning:______________________________________________________________
Brudzinsky:____________________________________________________________

Reflexos:
Superficiais cutâneos ______________________________________________________________
Osteotendinosos __________________________________________________________________

Sensibilidade:
Superficial_______________________________________________________________________
Profunda________________________________________________________________________
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Coordenação Motora:
Estática: ________________________________________________________________
Dinâmica: _____________________________________________________________

Marcha:
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RESUMO DA HISTÓRIA

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Exame Físico Geral
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Sinais Vitais
FC _____bpm FR _____cpm IMC _____kg/𝑚2
TA _____/_____ mmHg SPO2 _____% ao ar ambiente T° _____°C

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DIAGNÓSTICO SINDROMÁTICO:
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DIAGNÓSTICO DIFERENCIAL:
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DIAGNÓSTICO PROVISÓRIO:
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EXAMES COMPLEMENTARES:
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