Roteiro de Anamnese e Exame Físico Pediatrico

Prévia do material em texto

FUNORTE 
Faculdades Unidas do Norte de Minas 
INSTITUTO DE CIÊNCIAS DA SAÚDE – ICS 
 
 
ANAMNESE PEDIÁTRICA 
 
Identificação 
 
 
1 – Data da Consulta: ____/____/____ Local: ______________________ Horário: ______ 
2 – Nome da Criança:________________________________________________________ 
3 – Data Nascimento: ____/____/____ 4 – Idade: _____ 5 – Sexo: ______ 
6 – Cor: ________________________ 7 – Procedência: ___________________ 
8 – Naturalidade: _______________ 9 – UF: ______ 10 – Nacionalidade: ____________ 
11 – Filiação: ______________________________________________________________ 
12 – Endereço Completo (Rua, n°, Bairro, Cep, Tel.): ___________________________________ 
__________________________________________________________________________ 
13 – Informante (grau de parentesco): ______________________________________________ 
 Informa: _______________________________________________________________ 
 
QP: ______________________________________________________________________ 
HMA: ____________________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
ISDA: 
Geral: ____________________________________________________________________ 
__________________________________________________________________________
Específico:________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
História Pregressa 
 
HGO: 
História Pré-natal:__________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
História do Nascimento: ____________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
Período Neonatal: __________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________ 
 
HA:_______________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
HV: ______________________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________ 
 
HDNPM: __________________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
HPP: _____________________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
HF: ______________________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
HS: ______________________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
Exame Físico 
 
Antropometria: Peso: _____ Escore Z ____Estatura: ______ Escore Z ____ PC: ______ 
Escore Z ____ 
Dados Vitais: Tax._______Pulso: ______ FC: ______ FR: _____ PA: _______________ 
 
Ectoscopia 
1 – Postura: _______________________________________________________________ 
2 – Estado Geral: ___________________________________________________________ 
3 – Fascies: _______________________________________________________________ 
4 – Estado Psíquico: _________________________________________________________ 
5 – Hidratação: _____________________________________________________________ 
6 – Mucosas: ______________________________________________________________ 
7 – Escleras: _______________________________________________________________ 
8 – Pele:___________________________________________________________________ 
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________ 
9 – Respiração: _____________________________________________________________ 
10 – Extremidades: __________________________________________________________ 
11 – Musculaturas: __________________________________________________________ 
12 – Edemas: ______________________________________________________________ 
13 – Coluna Vertebral: _______________________________________________________ 
14 – Pulsos: _______________________________________________________________ 
15 – Perfusão: _____________________________________________________________ 
16 – Cadeia de linfonodos: ____________________________________________________ 
__________________________________________________________________________ 
17 – C: ___________________________________________________________________ 
 O: ___________________________________________________________________ 
 O: ___________________________________________________________________ 
 N: ___________________________________________________________________ 
 G: ___________________________________________________________________ 
18 – Fâneros: 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
19 – Panículo adiposo: 
__________________________________________________________________________
__________________________________________________________________________ 
20 – Articulações:___________________________________________________________ 
 
 
Exames Aparelhos 
 
ACV 
 Inspeção: ___________________________________________________________ 
 Palpação: ___________________________________________________________ 
 Ausculta: ___________________________________________________________ 
 
AR 
 Inspeção: ___________________________________________________________ 
_________________________________________________________________________ 
 Palpação: 
____________________________________________________________________ 
 Percurssão: _________________________________________________________ 
 Ausculta: ____________________________________________________________ 
__________________________________________________________________________ 
 
AD 
 Inspeção: ___________________________________________________________ 
 Palpação:____________________________________________________________
____________________________________________________________________ 
 Percurssão: __________________________________________________________ 
 Ausculta: ____________________________________________________________ 
OUTROS 
APARELHOS:______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
 
Otoscopia: ________________________________________________________________ 
 
Oroscopia: ________________________________________________________________ 
 
HD: 
Avaliação do Crescimento: __________________________________________________ 
Avaliação do Desenvolvimento: ______________________________________________ 
Vacinação: ________________________________________________________________ 
Alimentação: ______________________________________________________________ 
Diagnóstico Clínico: ________________________________________________________ 
__________________________________________________________________________ 
 
CD: 
Orientações Gerais: ________________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ 
Orientações Específicas: ____________________________________________________ 
__________________________________________________________________________
__________________________________________________________________________