Dr.

Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762

Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança

PRONTUÁRIO DE NEUROCIRURGIA - RETORNO

DATA:_____/____/__________

A- Identificação (mudança de dados):

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B- Queixas:

1.____________________________________________________________________________
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2.____________________________________________________________________________
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3.____________________________________________________________________________
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C- Checar objetivos prévios:

1.____________________________________________________________________________
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2.____________________________________________________________________________
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3.____________________________________________________________________________
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4.____________________________________________________________________________
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D- Mudança de hábitos e controle de comorbidades:

1.____________________________________________________________________________
_____________________________________________________________________________

2.____________________________________________________________________________
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3.____________________________________________________________________________
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Dr. Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762
Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança

A- História da doença atual:

1.____________________________________________________________________________
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2.____________________________________________________________________________
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3.____________________________________________________________________________
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A- Exame físico:

Geral:________________________________________________________________________
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SN:

Funções superiores, hemisféricas e de pares cranianos:

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Coordenação motora, marcha e equilíbrio:

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Funções motora e sensitiva:

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Reflexos profundos:_____________________________________________________________

SN (outros):

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Palpação do escalpe/cervical(gráfico na próxima página):

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Palpação do dorso, lombar/nádegas e pernas:

_____________________________________________________________________________
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SCV:_________________________________________________________________________

Abdômen:_____________________________________________________________________
Dr. Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762
Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança
Dr. Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762
Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança
B- Exames complementares:

1._____________ (___/___/_____):
_____________________________________________________________________________
_____________________________________________________________________________

2. ._____________ (___/___/_____):
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_____________________________________________________________________________

3._____________ (___/___/_____):
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_____________________________________________________________________________

C- Hipótese diagnóstica:

1. ___________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

D- Condutas e orientações:

1.
_____________________________________________________________________________
_____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

6.____________________________________________________________________________