Ficha de exame teorico-prático de clinica médica

Curso:_____________ Turma:_________ Semestre:_______

Local de Exame:___________________________________ Data:____/____/______

Nome do Aluno:_______________________________________________________
Caso Avaliado: _________________________________________________________

Passo nota valor

Anamnese
1 Identificou os dados básicos do doente 0.25
2 Pesquisou a queixa(s) principal(is) 1.0
3 Pesquisou a história da doença actual 0.5
4 Fez a avaliação funcional 0.25
5 Pesquisou a história médica pregressa 0.25
6 Pesquisou a história familiar 0.25
7 Pesquisou a história pessoal – social 0.25
8 Revisou os sistemas e aparelhos 0.25
9 Registou os achados correctamente 1.0
Exame físico
10 Fez o exame físico geral 1.5
11 Fez os exame físico por aparelho / sistema direccionado à(s) queixa(s) 1.5
principal(is) apresentada(s)
17 Registou os achados do exame físico correctamente 1.0
Diagnóstico
18 Chegou ao diagnóstico mais provável 2.0
19 Listou um diagnóstico diferencial adequado 1.5
20 Argumentou / Justificou o seu diagnóstico correctamente 1.5
Meios Auxiliares de Diagnóstico
21 Identificou os exames auxiliares essenciais 2.0
Conduta Terapêutica
22 Aplicou a conduta terapêutica correcta 5.0
TOTAL /20

Aluno: Júri:

Nome: ______________________________ ___________________________

Assinatura: __________________________ ___________________________

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 Formulário para a Apresentação de Casos

Curso:______________ Turma:_____ Exame de:________________________

Semestre:______
Local de exame:_____________________________________________ Data:____/_____/______
Nome do Aluno:__________________________________________________________________
Caso Avaliado: __________________________________________________________________

Instruções para o Estagiário: Preencher os itens abaixo com base num caso observado durante o estágio.
Caso não tenha acesso a toda a informação proposta abaixo preencher deve preencher o máximo possível.

Identificação do paciente:

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Motivo pelo qual o paciente está na clínica (queixa/s principais):

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História da doença actual:

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História patológica pregressa:

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História familiar, pessoal e social:

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Revisão por aparelhos ou sistemas:

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Achados do exame físico:

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Exames diagnósticos auxiliares solicitados e resultados:

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Hipóteses de diagnóstico, incluindo diagnósticos diferenciais: (explique o diagnóstico do clínico e a razão
pela qual você acha que esse diagnóstico está correcto)
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Conduta (terapêutica e não terapêutica):

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Resumo do caso (Lista os achados chaves da história clínica e os resultados chave dos meios diagnósticos
que lhe levou ao diagnóstico, o diagnóstico e a conduta):

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Nota(valores)___________ Data___/_____/______

Assinatura do Júri___________________ __________________ ____________________