Universidade Federal de Pernambuco

Hospital das Clínicas da UFPE

DISCIPLINA DE INICIAÇÃO AO EXAME

CLÍNICO
Roteiro de Anamnese e Exame Físico
 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO

Data: _________________ Registro: _______

Identificação (ID)

N o m e C o m p l e t o : ______________________________________
Idade: _____________Data de nascimento: ____/_____/______
Residência atual: ___________________________________________
Contatos: Telefone: ( ) ________________________________
email: ______________________________
Sexo: M( ) F ( ) Outro ( )

Estado civil: Casado ( )Solteiro( ) separado/divorciado( )

Viúvo(a) ( )
Naturalidade: _____________Procedência:__________________

I-Queixa Principal (QP)

(Sintomas do paciente e tempo)

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II- História da Doença Atual (HDA):
Começoda doença e quanto tempo está doente, sintomas relacionados a QPD)

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 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO

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III- Interrogatório Sintomatológico:
(série de perguntas para todos os sistemas)

1. Sintomas Gerais:
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2. Cabeça a e Pescoço: PERGUNTAS AMPLAS
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3. Sistema Cardiovascular: PERGUNTAS AMPLAS

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4. Sistema Respiratório: PERGUNTAS AMPLAS

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5. Sistema Gastrointetinal: PERGUNTAS AMPLAS
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 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO

6.Rins e Vias urinárias:

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7. Órgãos genitais masculinos:

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8. Feminino:
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9.Osteoarticular:________________________________________________
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11.Sistema nervoso:
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 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO

IV- Antecedentes Pessoais Patológicos (APP)

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Tabagismo ( ) carga tabágica ____________________________________

Etilismo ( ) ______________________Drogas ilícitas ( ) _____________
At física ( ) ___________________________________________________
Vacinação:_____________________________________________________
Alergias: ______________________________________________________
V-Antecedentes Pessoais Familiares:
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VI-Histórico Fisiológico e Social

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VII- Medicaçõ es em uso:

Droga Dose Tempo de uso

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 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO

Motivo da descontinuação:
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VIII-Roteiro para Exame Físico

1.Sinais Vitais:Peso: _____________ Altura ____________ IMC _______________

PA: ___________mmHg (sentado) PA: ___________mmHg (deitado)
FC _____ bpm FR : ______ irpm Temperatura axilar _______ C'
2.Geral:
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3.Exame
Respiratório:____________________________________________________________________________
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4.Exame cardiovascular:
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 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO

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5. Exame do abdome: e aparelho genitourinário:

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6.Músculo esquelético:
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7. Exame Neurológico:
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8. Outras alterações do exame físico:

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 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO

IX- Lista de problemas:

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X- Plano terapêutico:
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Professor:

Alunos:

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 HOSPITAL DAS CLÍNICAS
INICIAÇÃ O AO EXAME CLÍNICO