SAP - SISTEMATIZAÇÃO DA ASSISTÊNCIA DE PODOLOGIA

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QUEIXA PRINCIPAL:
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TIPO DE
NÚMERO DO CALÇADO
CALÇADO

TIPO DE FAZ ALGUMA ATIVIDADE

MEIA FÍSICA? SE SIM QUAL?

TABAGISTA SIM( ) HÁ QUANTO TEMPO? NÃO ( )

ETILISTA SIM( ) HÁ QUANTO TEMPO? NÃO ( )

TEM ALGUMA ALIMENTO PRODUTO QUÍMICO MEDICAMENTO

ALERGIA?

DOENÇAS:_________________________________________________________________________________________________
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MEDICAMENTOS E DOSAGEM:
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HISTÓRICO FAMILIAR:
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 AVALIAÇÃO UNGUEAL:
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AVALIAÇÃO PLANTAR:
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LEDS: LESÕES ELEMENTARES DERMATOLÓGICAS.

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OBSERVAÇÃO BIOMECÂNICA:
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TIPO DE UNHA PD PE

COMPRIMENTOO DOS
PD PE
METARTARSOS

COMPRIMENTO DOS
PD PE
DEDOS

HIDRATAÇÃO

PD - ANIDROSE PE - ANIDROSE

PD - HIPERIDROSE PE - HIPERIDROSE

PD - BROMIDOSE PE- BROMIDOSE

 TESTES DE VITAIS:

PA: mm/Hg FC: bpm FR; mr/pm Glicemia capilar: mg/dl

Altura: Peso: IMC : peso/altura ² =

IMC= 18,5 (MAGREZA) 18,5 A 24,9 (SAUDÁVEL) 25,0 – 29,9 (SOBREPESO) 30,0 – 34,9 (OBESIDADE
MODERADA) 35,0 – 39,9 (OBESIDADE ) 40,0 (OBESIDADE MÓRBIDA)

Índice ,Tornozelo e Braço-ITB

Pulso AD/PD Cheio Fraco Filiforme Ausente

PS:

II:

Pulso: TP /PD Cheio Fraco Filiforme Ausente

PS:

II:

Pulso AD/PE Cheio Fraco Filiforme Ausente

PS:

II:

Pulso TP/PE Cheio Fraco Filiforme Ausente

PS:

II:

TESTES DE SENSIBILIDADE:

Tátil pressória Vibratória Térmica Dolorosa

PD

PE
 Digito Pressão PD
Hálux 2º 3º 4º 5º Planta
(2s)

Digito Pressão PE
Hálux 2º 3º 4º 5º
(2s) Planta

Cor da Pele - PD normal Pálida Cianótica Rubor

Cor da Pele - PE normal Pálida Cianótica Rubor

CIRCUNFERÊNCIA MMII DIREITO: MMII ESQUERDO:

EDEMA PD MOLE DURO DURO MALEÁVEL MALEÁVEL

EDEMA PE MOLE DURO DURO MALEÁVEL MALEÁVEL

SINAL DE
GODET + ++ +++ ++++
PD

SINAL DE
GODET + ++ +++ ++++
PE

ALGIA
PD

ALGIA
PE

TURGOR: PD-NORMAL PD- DIMINUÍDO

TURGOR: PD-NORMAL PD- DIMINUÍDO

OUTRAS OBSERVAÇÕES:
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 DIAGNÓSTICO DE PODOLOGIA
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PRESCRIÇÃO DE PODOLOGIA
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EVOLUÇÃO
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