ANAMNESE

IDENTIFICAO:
Nome: ____________________________________________________________
Data de Nascimento: ________________________Idade: __________________
Sexo: F ( ) M ( )
Naturalidade:_____________________________________
Profisso: _______________________ Ocupao: ________________________
Cor: ______________________________________________________________
Estado civil______________________________ Filhos: ___________________
Endereo: _________________________________________________________
Religio: __________________________________________________________

QUEIXA PRINCIPAL: (Sintoma(s) referido(s) pelo paciente - mximo de 3 queixas

- registrado(s) com seus prprios termos e h quanto tempo.)
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HISTRIA DA DOENA ATUAL: (Determine o sintoma-guia; poca e modo de

incio da doena; Intercorrncia de outros sintomas: fenmenos que melhoram, pioram ou
simplesmente acompanham os sintomas emoes, esforo fsico, alimentao,
posies, gestao, drogas, etc)
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HISTRIA PATOLGICA PREGRESSA (ANTECEDENTES PESSOAIS):
Estado habitual de sade;
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Infeces, infestaes, doenas degenerativas e outras, clinicamente importantes;
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Alergias asma, eczemas, urticria, medicamentosas e alimentares, etc.;
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Imunizaes varola, hepatite B, ttano, febre amarela, poliomielite, difteria,

tuberculose;
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Intervenes cirrgicas tipo, poca, transfuses, complicaes e resultados;
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Traumatismos fraturas, TCE, outros; poca e conseqncias; tempo de
cicatrizao
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Medicamentos
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Doenas venreas gonorria, sfilis, cancro, condiloma, linfogranuloma, herpes,

etc.;
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Problemas obsttricos abortos, prematuros, etc.;
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Doenas psquicas aparecimento, evoluo e tratamentos.
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ANTECEDENTES FAMILIARES: (Estado habitual de sade, causas de morte,

idade ao falecer, doenas hereditrias, familiares e infecto-contagiosas. )
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HISTRIA SOCIAL E HBITOS DE VIDA:
Situao scio-econmica Renda Familiar.
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Quantas pessoas na casa, n de cmodos.
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Condies de habitao (moradia) - gua encanada, energia eltrica, esgoto

sanitrio e coleta de lixo;
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Estrutura familiar equilibrada, brigas freqentes, desestruturada;
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Grau de sociabilidade - divertimentos e atividades sociais;
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Dieta habitual (hbitos de alimentao) - alimentao quantitativa e

qualitativamente equilibrada; dficit calrico global; insuficiente consumo protico;
alimentao a base de carboidratos/ com alto teor lipdico/ exclusivamente vegetariana/
lctea exclusiva; etc;
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Hbitos de higiene;
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Sono - n. de horas a cada 24 horas e qualidade;

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Tipo de trabalho - ocupao atual;
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Tabagista - n. de cigarros por dia; incio e quando parou;
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Atividade sexual e uso de preservativos;
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Etilismo - n. de doses, tipo de bebida, incio e quando parou;
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Uso de drogas txicas.
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SINAIS VITAIS
T: _____________
P: _____________
R: _____________
PA: ____________
GLICEMIA CAPILAR (Ps-prandial ou em jejum)
Resultado: ________________
NDICE DE MASSA CORPREA (IMC):
Peso: _____________
Altura: ____________
Resultado IMC: __________
Exame fsico Geral:
1.
Sintomas preocupantes
2.
Nvel de conscincia (Lucidez, sonolncia, torpor, coma)
3.
Fcies
4.
Atitude/ postura/atividade motora/marcha
5.
Veias perifricas
6.
Edema
7.
Fala/linguagem
8.
Desenvolvimento fsico (bitipo)/hbito grcil
9.
Estado de nutrio e hidratao
10.
Higiene Pessoal
11.
Pele e anexos

Anotaes Gerais:

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EXAME FSICO

CABEA E PESCOO
Crnio:
Forma:
( ) normoceflico
( ) macroceflico
( ) microceflico
Superfcie
( ) depresses
( ) abaulamentos
( ) solues de continuidade
( ) Sem alteraes
Couro cabeludo:
( ) sem alteraes.( ) dermatite ( ) seborria ( ) pediculose ( ) foliculite ( ) alopcia;
( ) outro: __________________________________________________________________
Estruturas faciais e funes sensoriais
Globo ocular
Implantao e Simetria________________________________________________________
( ) encovados
( ) protudos
Sobrancelhas
( ) Alopcia
( ) Processos inflamatrios
Plpebras
Pele: ______________________________________________________________________
( ) Edema palpebral;
( ) xantelasma (indica acmulos de gordura);
( ) blefarite (inflamao das bordas das plpebras);
( ) ptose palpebral (queda da plpebra superior por leso nervosa caem as duas);
( ) blefaroespasmo (tique convulsivo das plpebras);
( )logoftalmia ( fechamento incompleto das plpebras);
Conjuntivas
( ) normocorada
( ) hipocorada
( ) hipercorada
Clios
( ) invertido
( ) em condies normais
Esclera:
( ) sem anormalidades. ( ) conjuntivite; ( ) ictercia; ( ) ptergio
Outros ________________________________________________________________________
Crnea
( ) opacificao
ris / pupila: Teste de reao pupilar luz (fotorreagncia)
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Movimentos oculares

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1. BOCA E FARINGE
Lbios
Simetria:_______________________________________________________________________
Colorao: _____________________________________________________________________
Umidade: ______________________________________________________________________
Leses: ( ) herpes viral; ( ) rachaduras; ( ) queilite (falta de vitamina, fissura com processo
inflamatrio); ( ) Lbio leporino.
Outro: _________________________________________________________________________
Inspeo dinmica: verificar a capacidade de abrir a boca: _______________________________
Inspecionar frnulo Labial inferior e superior ___________________________________________
Odor bucal ____________________________________________________________________
Mucosa Oral
Umidade, colorao, presena de ulceraes, aftas:_____________________________________
Inspecione o stio dos ductos parotdeos e sub-linguais__________________________________
Outro: _________________________________________________________________________
Gengivas
Colorao, edema, sangramentos, leses, retrao_____________________________________.
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Lngua
( ) Presena de leses
( ) Lngua saburrosa
( ) Lngua lisa
( ) Lngua geogrfica
( ) sem anormalidades
Funcionalidade do Frnulo lingual
Outros: ________________________________________________________________________
Dentes
Estado de conservao___________________________________________________________
N. de dentes___________________________________________________________________
Prteses / Estado de conservao __________________________________________________
Palato duro
( ) Ulceraes ( ) Perfuraes ( ) Fenda Palatina ( ) Outras Leses

Orofaringe [palato mole, amgdalas (tonsilas), parede posterior, vula].

Colorao______________________________________________________________________
Leses ________________________________________________________________________
Outros_________________________________________________________________________

EXAME FSICO DO PESCOO

Simetria, massas, abaulamentos, leses, gnglios linfticos visveis________________________
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Turgncia da Jugular_____________________________________________________________
Traquia _______________________________________________________________________
Glndula tireide_________________________________________________________________
Movimentao do Pescoo (rigidez de nuca, torcicolo)
Pulso carotdeo__________________________________________________________________

Outros_________________________________________________________________________

2. EXAME FSICO DO OUVIDO

Simetria________________________________________________________________________
Colorao ______________________________________________________________________
Edema ________________________________________________________________________
Pelos _________________________________________________________________________
Higiene ________________________________________________________________________
Mobilidade _____________________________________________________________________
Cerume _______________________________________________________________________
Obstruo:
( ) corpo estranho
( ) secreo
Outros ________________________________________________________________________
( ) Ndulos
( ) Feridas
( ) Fissuras
Sensibilidade____________________________________________________________________
Membrana Timpnica_____________________________________________________________
Acuidade Auditiva________________________________________________________________

3. EXAME FSICO DO NARIZ

Simetria
Traumatismo
Secrees: aquosa ( ), mucide ( ), purulenta( ), sanguinolenta( );
Uni ( ), bilateral ( );
Quantidade
Colorao da mucosa_____________________________________________________________
Umidade_______________________________________________________________________
Tumefaes ____________________________________________________________________
Leses ________________________________________________________________________
Permeabilidade nasal ____________________________________________________________
Sensibilidade ___________________________________________________________________
Transilumine ___________________________________________________________________

4. EXAME FSICO DO TRAX

Pele___________________________________________________________________________
Colorao ______________________________________________________________________
Cicatriz ________________________________________________________________________
Leses ________________________________________________________________________
Abaulamentos __________________________________________________________________
Depresses ____________________________________________________________________
Forma do trax __________________________________________________________________
Hipersensibilidade _______________________________________________________________
Expansibilidade _________________________________________________________________
Frmito Ttil ____________________________________________________________________
Percusso: ( ) Timpnico (som claro pulmonar). ( ) Macio
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Ausculta:
( )Som brnquico ou tubular: audvel sobre a traquia
( )Som brnquico-vesicular: audvel sobre os brnquios, abaixo das clavculas e entre as
escpulas
( )Murmrios vesiculares: audvel na rea pulmonar, sobre os alvolos
Rudos adventcios:
6

( )Estertores: anormalidades nos pulmes

( )Sibilos: estreitamento das vias respiratrias
( )Roncos: secrees nas vias respiratrias

EXAME FSICO CARDIOVASCULAR

Ausculta:
Foco artico: 2 espao intercostal direito
Foco pulmonar: 2 espao intercostal esquerdo
Foco tricspide: 4 espao intercostal, borda esternal esquerda.
Foco mitral: 5 espao intercostal (ictus cordis)

5.

EXAME FSICO ABDOMINAL

Alinhamento corporal e expresso facial (sensibilidade) __________________________________
Contorno Abdominal:
( ) plano
( ) escavado ou escafide
( ) globoso
( ) protuberante (gravidez, obesidade, ascite, tumor)
Simetria _______________________________________________________________________
Massas, abaulamentos ___________________________________________________________
Pulsao artica ________________________________________________________________
Pele:
( ) cicatrizes (anotar ou desenhar o local) _____________________________________________
( ) estrias
( ) veias dilatadas
( ) erupes e leses
( ) flacidez
Outros_________________________________________________________________________
Ausculta:
Sons intestinais _________________________________________________________________
Freqncia _____________________________________________________________________
Caracterstica dos rudos (audveis ou normais, ausentes, hiperativos ou hipoativos)
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Sopros ________________________________________________________________________
Sons de atrito ___________________________________________________________________
Percusso:
Presena de gases (flatulncia) _____________________________________________________
Fgado ________________________________________________________________________
Bao __________________________________________________________________________
Palpao:
Superficial
Sensibilidade ___________________________________________________________________
Massas superficiais ______________________________________________________________
Resistncia muscular ____________________________________________________________
Profunda
Sensibilidade ___________________________________________________________________
Massas:
Localizao ____________________________________________________________________
Tamanho ______________________________________________________________________
Formato _______________________________________________________________________
Consistncia ___________________________________________________________________
Sensibilidade ___________________________________________________________________
Pulsao ______________________________________________________________________
Mobilidade _____________________________________________________________________
Sensibilidade de rebote ___________________________________________________________

Palpao do fgado ______________________________________________________________

Palpao do bao _______________________________________________________________
Palpao dos rins _______________________________________________________________
Palpao da aorta _______________________________________________________________

6. EXAME FSICO MSCULO ESQUELTICO

Marcha
Alinhamento postural _____________________________________________________________
Coluna vertebral:
( ) Cifose
( ) Lordose
( ) Escoliose
Membros: tamanho, deformidades, atrofias musculares _________________________________
Sensibilidade ___________________________________________________________________
Massas ________________________________________________________________________
Amplitude de movimentos articulares:
( )Movimentos ativos _____________________________________________________________
( )Movimentos passivos ___________________________________________________________
( )Fora muscular ________________________________________________________________

Observaes:
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Acadmico de Enfermagem: __________________________________ N. MAT: ____________

Turno: ___________Perodo: ________________Professor (a): __________________________