Ficha de Avaliação - Úlceras

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FICHA DE AVALIAÇÃO – FISIOTERAPIA VASCULAR
ÚLCERAS
ANAMNESE:
IDENTIFICAÇÃO:
Nome: ___________________________________________________ Idade: _________
Sexo: ________ Cor: _______ Peso: __________ Altura: ___________ IMC: _________
Estado Civil: _____________________ Grau de Instrução: ______________________
Profissão atual: ______________________ Profissão anterior: _____________________
Endereço: _______________________________________________________________
Cidade: ________________________ Estado: _____ CEP: __________ - _______
Telefone.: ( ) ___________________________________
Médico acompanhante: ____________________________________________________
Diagnóstico médico: _______________________________________________________
Diagnóstico Fisioterapêutico: ________________________________________________
Fisioterapeuta: ___________________________________________________________
Data da avaliação: _______/_____/_______
Data do início do tratamento: ________/_____/________
HISTÓRIA CLÍNICA:
QP: ______________________________________________________________
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HDA: ____________________________________________________________
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SINAIS E SINTOMAS: ______________________________________________
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ATECEDENTES PESSOAIS: _________________________________________
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ANTECEDENTES FAMILIARES: ______________________________________
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HÁBITOS SOCIAIS: ________________________________________________
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TRATAMENTOS ANTERIORES: ______________________________________
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USO DE MEDICAMENTOS: 		( sim			( não
Quais: ______________________________________
EXAME FÍSICO:
SINAIS VITAIS:
PA: __________________
FC: __________________
FR: __________________
T (°C): ________________
INSPEÇÃO:
*Estática:
( Varizes: Morfologia/Localização ________________________________
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( Edema		( Dermatites		( Infecções
( Úlceras: Localização/Tamanho/Característica _____________________
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( Secreção: Odor/Coloração/Reações adjacentes ____________________
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( Alterações tróficas: Quais? ____________________________________
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*Dinâmica:
Marcha: _____________________________________________________
Equilíbrio: ____________________________________________________
Coordenação: ________________________________________________
Postura: _____________________________________________________
Deformidades: ________________________________________________
PALPAÇÃO:
*Temperatura: 	( aumentada	( diminuída		( normal
Local: ____________________________________________
*Aspecto da pele:
Turgor: ______________________________________________________
	Elasticidade: _________________________________________________
	Umidade: ____________________________________________________
	Aderências: __________________________________________________
	Cicatriz: _____________________________________________________
	Hiperpigmentação: ____________________________________________
*Edema:
	Cacifo: 		( sim				( não
	Localização/Grau: _____________________________________________
*Consistência da parede venosa: ______________________________________
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*Pulsos periféricos: 		( presentes			( ausentes
				( diminuídos		( aumentado
Quais:____________________________________________
*Pontos dolorosos: _________________________________________________
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*Sensibilidade:
			( térmica			( vibratória
( tátil				( dolorosa
Local: ____________________________________________
PERCURSÃO:
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AUSCULTA:
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PROVAS FUNCIONAIS:
*Força muscular: __________________________________________________
*Amplitude de movimento (goniometria): ________________________________
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*Perimetria: _______________________________________________________
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*Análise da marcha: ________________________________________________
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*AVDs:
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TESTES ESPECIAIS:
*Prova de Trendelenburg:
	( positivo		( negativo		( duplamente positivo
*Prova de Adams
	( positivo		( negativo
*Manobra de Isquemia Provocada
	Alteração: Palidez		( sim		( não
*Manobra de Hiperemia Reativa:
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REGISTRO FOTOGRÁFICO:
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EXAMES COMPLEMENTARES:
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PROPOSTA DE TRATAMENTO FISIOTERAPÊUTICO:
Objetivos:
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_______________________________________________________________________Tratamento Fisioterapêutico:
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Recife, _______/___________________/__________
__________________________________________�FISIOTERAPEUTA