Escolar Documentos
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Cultura Documentos
I. IDENTIFICAÇÃO
Nome: _____________________________________________________________________
Data de Nascimento: _____/____/________ Idade: ___________ Gênero: ( ) F ( ) M
Naturalidade:_______________________ Religião:________________________________
Endereço:___________________________________________________________________
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Cidade: ______________________________ Bairro: ______________________________
Telefone: ________________ Estado Civil: ( ) Casado(a) ( ) Solteiro(a) ( ) Viúvo(a)
Escolaridade:_____________________________ Profissão: __________________________
QUEIXAPRINCIPAL:_______________________________________________________
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ANTECEDENTES PESSOAIS:
( ) Diabetes ( ) HAS ( ) Cardiopatia ( ) Pneumopatia ( ) Neuropatia ( ) Neoplasia
Outros:_____________________________________________________________________
EXAMES COMPLEMENTARES
( ) Raio – X ( ) Ressonância Magnética ( ) Espirometria
( ) Ex. Laboratoriais ( ) Gasometria Arterial ( ) Cintilografia Pulmonar
( ) Broncografia ( ) Tomografia Computadorizada
( ) Outro(s): ________________________________________________________________
Resultado do(s) exame(s):______________________________________________________
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I. EXAME FÍSICO
SINAIS VITAIS
Pressão Arterial (PA): ___________mm/Hg
Frequência Cardíaca (FC): ___________bpm
Frequência Respiratória (FR): ___________irpm
Saturação Periférica de Oxigênio (SpO2): ________%
Temperatura: _______ºC
( ) Cianose:
( ) Batimento da asa do Nariz:
( ) Uso de Musculatura acessória:
( ) Baqueteamento Digital:
( ) Dispnéia:
( ) Rouquidão:
( ) Edema: Local: ________________________________________
( ) Cicatriz: Local: _______________________________________
( ) Manchas: Local: ______________________________________
( ) Incisões: Local: _______________________________________
( ) Utiliza O2 suplementar: _________________________________
PADRÃO RESPIRATÓRIO
( ) Diafragmático ( ) Costal
( ) Costodiafragmático ( ) Movimento Paradoxal
MORFOLOGIA DO TÓRAX
( ) Normal ( ) Pectus Excavatum – “Peito de Sapateiro”
( ) Tórax em Tonel ( ) Pectus de Carinatum – “ Peito de Pombo”
MOBILIDADE DIAFRAGMÁTICA:
( ) Sim ( ) Não
AUSCULTA PULMONAR:
( ) Normal ( ) Diminuída ( ) Aumentado
Região: ___________________________________________________________
RUÍDOS ADVENTÍCIOS:
( ) Roncos ( ) Sibilios
( )Estertores crepitantes ( ) Atrito pleural
Região: ___________________________________________________________
TOSSE:
( ) Eficaz ( ) Ineficaz ( ) Produtiva ( ) Seca
EXPECTORAÇÃO:
( ) Mucosa ( ) Serosa ( ) Amarelada ou Esverdeada
( ) Purulenta ( ) Hemoptise ( ) Sanguinolenta ou Hemoptóica
QUANTIDADE DA EXPECTORAÇÃO:
( ) Pouco ( ) Médio ( ) Muito
VISCOSIDADE DA EXPECTORAÇÃO:
( ) Fluida ( ) Espessa ( ) Espumosa
ODOR DA EXPECTORAÇÃO:
( ) Fétido ( ) Não Fétido
RITMO RESPIRATÓRIO:
( ) Dispnéia: ( ) Ortopnéia
( ) Taquipnéia ( ) Platipnéia
( )Hiperpnéia ( )Trepopnéia
OBSERVAÇÕES:
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EVOLUÇÃO
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