422184294-FICHA-DE-ATENDIMENTO-CLINICO-pdf

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FICHA DE ATENDIMENTO CLÍNICO DE PEQUENOS ANIMAIS 
DADOS DO RESPONSÁVEL 
Nome CPF 
Endereço Cidade UF 
Telefone fixo ( ) Celular ( ) Celular ( ) 
 
IDENTIFICAÇÃO DO ANIMAL 
Nome 
 
Espécie Raça Sexo Idade Peso 
Pelagem 
 
Procedência 
 
ANAMNESE GERAL 
Queixa principal (evolução do quadro, tratamentos, resultados): __________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________ 
Histórico médico pregresso: ________________________________________________________________________ 
Alimentação: _____________________________________________________________________________ 
Contactantes:_____________________Ambiente em que vive: _____________________________________ 
Vacinação: _____________________________________________________________________________________ 
Vermifugação: __________________________________________________________________________________ 
ANAMNESE ESPECIAL 
Sistema respiratório (secreção, tosse, espirro, cianose, dispnéia, ruído na respiração etc):_______________________ 
_______________________________________________________________________________________________ 
Sistema cardiovascular (intolerância a exercícios, cansaço, síncope, cianose, tosse etc): _______________________ 
_______________________________________________________________________________________________ 
Sistema digestório (apetite, vômito, diarréia): _________________________________________________________ 
_______________________________________________________________________________________________ 
Sistema urinário (ingestão de água, aspecto, volume e frequência da urina, tenesmo vesical, disúria): _____________ 
_______________________________________________________________________________________________ 
Sistema reprodutor: (secreção, cio, anticoncepcional, prenhez, número de filhotes, mamas, alteração de 
comportamento): ________________________________________________________________________________ 
_______________________________________________________________________________________________
Sistema locomotor (claudicação, trauma, aumento de volume, marcha, impotência de membro, frequência e tipo de 
exercícios): _____________________________________________________________________________________ 
_______________________________________________________________________________________________ 
Sistema neurológico (convulsão, síncopes, déficits neurológicos, deambulação, audição, olfato, propriocepção, manias, 
deglutição, alteração latido/miado): __________________________________________________________ 
 
_______________________________________________________________________________________________ 
Pele e anexos (higiene, secreção, alopecia, prurido, lesões, descamação, parasitas, orelha): ____________________ 
_______________________________________________________________________________________________ 
_______________________________________________________________________________________________ 
Olhos (secreção, olho vermelho, olho esbranquiçado, déficit visual, blefaroespasmo, fotofobia, primeiro olho 
afetado):_______________________________________________________________________________________
_______________________________________________________________________________________________ 
 
EXAME FÍSICO 
Postura 
 
Nível de consciência Escore Corporal 
TR: °C FR: mpm FC: bpm TPC: seg Pulso: ppm Hidratação 
Linfonodos Submand. 
 
Linf. Pré-escapulares Linf. Poplíteos Linf. Inguinais: 
Mucosa ocular Mucosa oral Mucosa peniana/vulvar Mucosa anal 
 
RG: _______________ 
DATA: ____/____/____ 
 
 
EXAME FÍSICO ESPECÍFICO 
Sistema respiratório: ____________________________________________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________ 
Sistema cardiovascular: ___________________________________________________________________________ 
_______________________________________________________________________________________________
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Sistema digestório: _______________________________________________________________________________ 
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Sistema genito-urinário: ___________________________________________________________________________ 
_______________________________________________________________________________________________
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Sistema locomotor: _______________________________________________________________________________ 
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Sistema neurológico: _____________________________________________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________ 
Pele e anexos: ___________________________________________________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________ 
Olhos: _________________________________________________________________________________________ 
_______________________________________________________________________________________________
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SUSPEITA(S) CLÍNICA(S) 
_______________________________________________________________________________________________
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EXAME(S) COMPLEMENTAR(ES) 
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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PROGNÓSTICO 
_______________________________________________________________________________________________ 
DIAGNÓSTICO 
_______________________________________________________________________________________________
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TRATAMENTO 
_______________________________________________________________________________________________
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Plantonista(s) discente(s):__________________________________________________________________________ 
Médico(s) Veterinário(s) Responsável(is): ____________________________________________________________