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Curso de Medicina do

Campus de Sobral

LOGBOOK
Módulo de Abordagem ao Paciente e
Bases Fisiopatológicas e Terapêuticas
dos Principais Sinais e Sintomas

Aluno:

“A vida é breve, a arte é longa, o julgamento, difícil, e a ocasião, fugidia”

Hipócrates, 460 aC

Sobral, 2022.2
# Registro das notas da anamnese

O professor registrar no formulário abaixo a avaliação da ananmese 1 que você coletar,


após a discussão da mesma, no Módulo de Abordagem ao Paciente e Bases
2
Fisiopatológicas e Terapêuticas dos Principais Sinais e Sintomas. Não esqueça de obter a o
preenchimento do formulário pelo professor. Ele não irá preencher o formulário
retroativamente, mesmo em situações de esquecimento do Logbook em casa. O registro
deve ser feito à mão, em caneta azul ou preta.
ANAMNESE 1 Data:
Local: Preceptor:

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Formulário de Avaliação de Anamnese
* Por favor, marque os quadrados abaixo com um "X": 

Nome do NOTA
estudante
8
Nome do Data da
avaliador anamnese ___/___/___

SIM PARCIALMENT NÃO NÃO ESCORE


CRITÉRIO Escore=2 E
Escore=0 AVALIADO OBTIDO
Escore=1
1. Identificou adequadamente o paciente?
☐ ☐ ☐ ☐
2. Identificou a queixa principal e sua duração
☐ ☐ ☐ ☐
de forma adequada?
3. Usou o sintoma-guia como fio condutor da
☐ ☐ ☐ ☐
história?
4. Analisou o sintoma-guia quanto ao início e ao
☐ ☐ ☐ ☐
modo de início?
5. Analisou o sintoma-guia quanto à localização
☐ ☐ ☐ ☐
e à irradiação?
6. Analisou o sintoma-guia quanto à
☐ ☐ ☐ ☐
periodicidade e à duração?
7. Analisou o sintoma-guia quanto à qualidade?
☐ ☐ ☐ ☐
8. Analisou o sintoma-guia quanto à
intensidade? ☐ ☐ ☐ ☐

9. Analisou o sintoma-guia quanto a fatores


☐ ☐ ☐ ☐
desencadeantes, agravantes e atenuantes?
10. Descreveu adequadamente os sintomas e os
☐ ☐ ☐ ☐
sinais associados ao sintoma-guia?
11. Estabeleceu a relação cronológica do
sintoma-guia com sintomas e sinais ☐ ☐ ☐ ☐
associados?
12. Analisou o sintoma-guia quanto à evolução e
☐ ☐ ☐ ☐
à situação no momento atual?
13. Sistematizou a história da doença atual com
☐ ☐ ☐ ☐
começo, meio e fim?
14. Descreveu adequadamente o interrogatório
☐ ☐ ☐ ☐
por órgãos e aparelhos?
15. Descreveu adequadamente as medicações
☐ ☐ ☐ ☐
em uso?
16. Descreveu adequadamente os antecedentes
☐ ☐ ☐ ☐
pessoais fisiológicos e patológicos?
17. Descreveu adequadamente os antecedentes
☐ ☐ ☐ ☐
familiares?
18. Relatou adequadamente os hábitos de vida?
☐ ☐ ☐ ☐
19. Redigiu o relatório da anamnese com
☐ ☐ ☐ ☐
caligrafia legível?
20. Utilizou adequadamente o vocabulário
médico? ☐ ☐ ☐ ☐

Σ=

PONTUAÇÂO MÀXIMA: 40 NOTA = Σ dos escores obtidos/4

OBSERVAÇÕES:

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# Registro das monitorias

Registre nos quadros abaixo sua frequência nas 7 monitorias do Módulo de Abordagem ao
Paciente e Bases Fisiopatológicas e Terapêuticas dos Principais Sinais e Sintomas. Não
9
esqueça de obter a validação do registro por meio da assinatura do monitor em cada
estação. O monitor não irá validar registros retroativamente, mesmo em situações de
esquecimento do Logbook em casa.

Simulação 1 # Sinais vitais, medidas antropométricas e somatoscopia


Data: Assinatura do monitor:

Simulação 2 # Exame da cabeça e do pescoço


Data: Assinatura do monitor:

Simulação 3 # Exame do tórax e do sistema respiratório


Data: Assinatura do monitor:

Simulação 4 # Exame do precórdio e do sistema cardiovascular


Data: Assinatura do monitor:

Simulação 5 # Exame do abdome


Data: Assinatura do monitor:

Simulação 6 # Exame do sistema locomotor


Data: Assinatura do monitor:

Simulação 7 # Exame neurológico


Data: Assinatura do monitor:

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