HISTÓRIA CLÍNICA CIRURGIA

I-IDENTIFICAÇAO
Nome:___________________________________________NID:_____/___________________
Sexo:________________ Idade:_______________ Raça:______________________________
Estado civil:______________________ Naturalidade:__________________________________
Residencia:____________________________________________________________________
Profissão:________________________ Local de trabalho:______________________________
Proveniente de:__________________________ Em:________/_________/________________
Historia fornecida por:____________________________ Serviço:________________________
II-ANAMNESE II.1 – MOTIVO DE INTERNAMENTO OU QUEIXA(S) PRINCIPAL(AIS) (usar
termos médicos, não sugerir diagnostico(s))
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II.2 – HISTORIA DA DOENCA ACTUAL (usar termos médicos, caracterizar o inicio e a evolução
dos sintomas e sinais, referir sintomas e sinais negativos importantes para o diagnostico
diferencial, indicar tratamentos já feitos e seus resultados)
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REVISAO POR APARELHOS E SISTEMAS NAO DIRECTAMENTE RELACIONADOS COM A

DOENCA ACTUAL (assinalar apenas os dados positivos)

a)- RESPIRATORIO/CARDIOVASCULAR Tosse__________________

Expetoração____________ Dor torácica_____________ Dispneia________________
DPN/Ortopneia__________ Palpitações_____________ Suores noturnos________
Pieira__________________

b)- SISTEMA NERVOSO Convulsões ______________ Sincope_________________

Cefaleias________________ Distúrbios da sensibilidade__ Fraqueza muscular________

c)- GASTROINTESTINAL Vómitos_________________ Hematémeses____________

Obstipação______________ Melenas________________ Pirose___________________
Enfartamento pós-prandial__ Flatulência_______________ Dor abdominal____________
Icterícia__________________

d)- GENITOURINARIO Disúria_________________ Polaquiuria_____________

Hematúria______________ Incontinência urinaria_____ Dor lombar______________
Corrimento uretral/vaginal__

e)- HEMOLINFOPOETICO Anomalias da coagulação__ Anemias _______________

 f)-CARACTERIZAÇAO DOS SINTOMAS E SINAIS RELEVANTES E OUTROS NAO
ESPECIFICADOS
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– ANTECEDENTES PESSOAIS (doenças anteriores , intervenções cirúrgicas, internamentos

anteriores, historia medicamentosa, transfusões, alergias, antecedentes de DTS)
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II.5 – HISTORIA PESSOAL E SOCIAL (condições de habitação, saneamento, abastecimento de
agua, hábitos alimentares, alcoólicos e tabágicos, profissões e viagens anteriores)
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II.6 – HISTORIA GINECO-OBSTETRICA (se mulher, menarca, menopausa, ultima menstruação,
formulas menstrual e gestacional, alterações da menstruação, metrorragias, anticoncetivos,
idades do 1º e ultimo partos, cesarianas)
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II.7 – HISTORIA FAMILIAR (saúde dos parentes próximos, causas de morte dos parentes
próximos, doenças de tendência familiar)
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III. – EXAME OBJECTIVO

.1- EXAME GERAL Estado geral (impressão

geral):____________________________________________________ Idade
aparente:_______________________ Frequência respiratória:_____________________ Estado
de consciência: O:_____V:_____ M:_____ E.C.G.:_____/_________________________
Peso:____________ Altura:___________ I.M.Corporal:________________________________
Tensão arterial:________________________ Pulso radial:______________________________
Temperatura axilar:_____________________ Pele:____________________________________
Edemas:______________________ Linfadenopatias:__________________________________
Outros:_______________________________________________________________________
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III.2 – Cabeça Fácies:______________________________
Olhos:____________________________________ _____________________________
___________________________________ Nariz:_______________________________
Boca:____________________________________ _______________________________
____________________________________ Orofaringe:__________________________
Ouvidos:__________________________________ __________________________
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1. 4. 4 III.3 – PESCOÇO Forma:___________________________

Dimensões:__________________________________ Mobilidade:_______________________
Posição da traqueia:___________________________ Pressão venosa jugular
(PVJ):_____________________________________________________
Tiroide:_______________________________________________________________________
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Outros:_______________________________________________________________________
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III.4 – TORAX a)-SEMIOLOGIA RESPIRATORIA
Inspecçao:____________________________________________________________________
Palpaçao:_____________________________________________________________________
Percurssao:____________________________________________________________________
Auscultaçao:___________________________________________________________________
b)SEMIOLOGIA CARDIACA
Inspecçao:____________________________________________________________________
Palpaçao:_____________________________________________________________________
Percurssao:____________________________________________________________________
Auscultaçao:___________________________________________________________________
c)MAMAS E AXILAS
Inspecçao:____________________________________________________________________
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Palpaçao:_____________________________________________________________________
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III.5 – ABDOMEN E PERINEO a)-ABDOMEN
Inspecçao:____________________________________________________________________
Palpaçao:_____________________________________________________________________
Percurssao:____________________________________________________________________
Auscultaçao:___________________________________________________________________
Manobras especiais:____________________________________________________________
b)-GENITAIS EXTERNOS
Inspecçao:____________________________________________________________________
Palpaçao:_____________________________________________________________________
Percurssao:____________________________________________________________________
Auscultaçao:___________________________________________________________________
Urina (cor, turvaçao):____________________________________________________________
c)-REGIOES INGUINO-CRURAIS
Inspecçao:____________________________________________________________________
Palpaçao:_____________________________________________________________________
Percurssao:____________________________________________________________________
Auscultaçao:___________________________________________________________________
d)-EXAME PROCTOLOGICO
Posiçao:______________________________________________________________________
Inspecçao:____________________________________________________________________
Palpação (toque rectal):__________________________________________________________
2.
3. 5. 5 e)-EXAME GINECOLOGICO Posição:
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Inspecçao:____________________________________________________________________
Palpação, bimanual (toque vaginal):________________________________________________
III.6-EXTREMIDADES a)-MEMBROS SUPERIORES
Inspecçao:____________________________________________________________________
Palpaçao:_____________________________________________________________________
Auscultaçao:___________________________________________________________________
Manobras especiais:____________________________________________________________
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b)-MEMBROS INFERIORES
Inspecçao:____________________________________________________________________
Palpaçao:_____________________________________________________________________
Auscultaçao:___________________________________________________________________
Manobras especiais:____________________________________________________________
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III.7 – EXAME NEUROLOGICO
Fala:_________________________________________________________________________
Estado mental:_________________________________________________________________
Força muscular:________________________________________________________________
Sensibilidade:__________________________________________________________________
Tonus muscular:________________________________________________________________
Sinais
meningeos:_______________________________________________________________
Reflexos osteotendinosos:________________________________________________________
Nervos cranianos:
4. a)1ºpar:_OPTICO_________________________________________________________
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5. b)-2º
par:_OLTATÓRIO_________________________________________________________
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6. c)-3º, 4º e 6º pares:_
Oculomotor,Troclear,Abducente______________________________________________
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7. d)- 5ºpar:_
TRIGÉMEO_____________________________________________________________
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8. e)- 7º
par:__FACIAL____________________________________________________________
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9. f)- 8º par:_ Vestíbulococlear
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10. 6. 6 g)- 9º e 10º pares:Glossofaríngeo, Vago
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h)-11º par: Acessório
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i)-12º
par:_HIPOGLOSSO_____________________________________________________________
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Coordenaçao motora:___________________________________________________________
Marcha:______________________________________________________________________
Fundoscopia (se necessario):______________________________________________________
Punçao lombar (se necessario):____________________________________________________
11. IV-RESUMO (dados importantes da amnese e do exame fisico)
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-DIAGNOSTICO(S) PROVISORIO (S) (por ordem de importancia)
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VI-MEIOS AUXILIARES E COMPLEMENTARES DE DIAGNOSTICO (por ordem de prioridade,
justificar o motivo do pedido)
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VII-DIAGNOSTICOS DIFERENCIAIS (DISCUSSAO DO DIAGNOSTICO) (justificar)
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12. 7. 7 VIII-DIAGNOSTICO(S) DEFINITIVO(S)
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IX-PROPOSTATERAPEUTICA/CONDUTA (justificar)
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X-PROGNOSTICO (de vida, sequelas,...)
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N.B: Colocar em folha anexa o mapeamento das queimaduras, lesões da mama, tiroide e
períneo se necessário. ELABORADO
POR:______________________________________________________________
ANO:______________
CURSO:____________________________________________________ CORRIGIDA
POR:_______________________________________________________________
COMENTARIOS:_______________________________________________________________
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NOTA:________________ VALORES