Anamnese + Exame Clínico - Carol Maldonado modelo

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Modelo por Carol Maldonado @carolfmaldonado 
Semiologia do Adulto II:​ ​ATIVIDADE __ 
Docentes:______________________________________________________________ 
Discente: ______________________________________________________________ 
 
Data da consulta: ​____ de __________________ de _______ 
Local da consulta:​_______________________________________________________________________ 
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IDENTIFICAÇÃO (ID): 
Nome:​ _________________________________________________________________________________ 
Idade:​ ______________________________________ 
Sexo:​ ________________________________________ 
Nome social:​ ___________________________________________________________________________ 
Gênero: ​_______________________________________________________________________________ 
Cor:​ [ ] branco [ ] negro [ ] pardo [ ] amarelo [ ] vermelho 
Negro: classificação do IBGE para pessoas pretas. 
Amarelo: classificação do IBGE para pessoas de descendência/origens asiáticas. 
Vermelho: classificação do IBGE para pessoas indígenas. 
Estado civil: ​[ ] Solteiro/a [ ] Casado/a [ ] Divorciado/a [ ] Viúvo/a [ ] União Estável 
Profissão:​ _____________________________________________________________ 
Naturalidade e Procedência:​ _____________________________________________ 
Religião:​ ______________________________________________________________ 
Escolaridade:​ __________________________________________________________ 
Fonte das informações: __________________________________________________________________ 
Confiabilidade da fonte:​ _________________________________________________ 
 
QUEIXA PRINCIPAL (QD): 
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HISTÓRIA DA DOENÇA ATUAL (HDA): 
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Modelo por Carol Maldonado @carolfmaldonado 
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INTERROGATÓRIO DOS DIVERSOS APARELHOS (IDA): 
Sintomas gerais:​ ________________________________________________________________________ 
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Pele e fâneros:​ __________________________________________________________________________ 
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Cabeça e pescoço: ​______________________________________________________________________ 
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Olhos e Ouvidos:​ ________________________________________________________________________ 
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Nariz e cavidades nasais:​ _________________________________________________________________ 
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Cavidade bucal e faringe:​ ________________________________________________________________ 
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Sistema Gastrointestinal: ​_________________________________________________________________ 
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Modelo por Carol Maldonado @carolfmaldonado 
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Sistema Circulatório:​ ____________________________________________________________________ 
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Sistema respiratório:​ ____________________________________________________________________ 
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Sistema Urogenital:​ _____________________________________________________________________ 
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Sistema Musculoesquelético:​ ______________________________________________________________ 
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Sistema Endócrino:​ _____________________________________________________________________ 
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SistemaNervoso:​ _______________________________________________________________________ 
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Sintomas neuropsicológicos: ​______________________________________________________________ 
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ANTECEDENTES PESSOAIS: 
Comorbidades:​_________________________________________________________________________ 
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Modelo por Carol Maldonado @carolfmaldonado 
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Medicações em uso:​ _____________________________________________________________________ 
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Cirurgias:​ _____________________________________________________________________________ 
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Internações:​ ____________________________________________________________________________ 
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Alergias a medicamentos:​ ________________________________________________________________ 
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Alergias a alimentos:​ ____________________________________________________________________ 
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Alergias a animais:​ ______________________________________________________________________ 
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Outros alérgenos:​ _______________________________________________________________________ 
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Tipo sanguíneo: ​_____________ 
Doador de sangue​ [ ] sim [ ] não 
Doador de medula óssea:​ [ ] sim [ ] não 
Doador de órgãos:​ [ ] sim [ ] não 
Já passou por algum tipo de transplante?​ [ ] sim [ ] não 
Se sim, qual?​___________________________________________________________________________ 
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Diagnóstico prévio pessoal de neoplasias ou síndromes de relevância? ​___________________________ 
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Modelo por Carol Maldonado @carolfmaldonado 
 
Transfusões sanguíneas: 
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Filhos:​ ___ 
G__P__C__A__ 
Vacinação:​ _____________________________________________________________________________ 
ANTECEDENTES FAMILIARES:  
Pai:​ ___________________________________________________________________________________ 
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Mãe:​ __________________________________________________________________________________ 
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Avós:​ _________________________________________________________________________________ 
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Filhos:​ ________________________________________________________________________________ 
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Irmãos:​ _______________________________________________________________________________ 
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Tios de 1° grau:​ _________________________________________________________________________ 
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HÁBITOS DE VIDA: 
Tabagismo e carga tabágica:​ ______________________________________________________________ 
Cálculo da carga tabágica: n° de maços/dia X tempo em anos = CT maços-ano 
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Modelo por Carol Maldonado @carolfmaldonado 
Etilismo:​ ______________________________________________________________________________ 
Uso de drogas:​ __________________________________________________________________________ 
Como é a residência:​ ____________________________________________________________________ 
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Viagens: ​_______________________________________________________________________________ 
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Com o que trabalha e onde trabalha:​ _______________________________________________________ 
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Como é a alimentação:​ ___________________________________________________________________ 
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Atividades físicas: ​_______________________________________________________________________ 
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Animais de estimação:​ ___________________________________________________________________ 
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Vida sexual ativa​: [ ] Sim [ ] Não ___________________________________________________________ 
Quantos parceiros: ​______________________________________________________________________ 
Riscos:​ ________________________________________________________________________________ 
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Problemas para dormir:​ _________________________________________________________________ 
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EXAME FÍSICO GERAL: 
Estado geral do paciente:​ [ ] Bom [ ] Regular [ ] Mau 
Nível de consciência:​ ____________________________________________________________________ 
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Orientação têmporo-espacial: ​_____________________________________________________________ 
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Modelo por Carol Maldonado @carolfmaldonado 
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Fácies:​ ________________________________________________________________________________ 
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Peso:​ __________________ Kg 
Altura:​ ___________________ 
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Escala de coma de Glasgow: 
Resposta Obtida Pontuação 
ABERTURA OCULAR 
Espontânea 4 
Ao estímulo sonoro 3 
Ao estímulo de pressão 2 
Nenhuma 1 
RESPOSTA VERBAL 
Orientada 5 
Confusa 4 
Verbaliza palavras soltas 3 
Verbaliza sons 2 
Nenhuma 1 
RESPOSTA MOTORA 
Obedece a comandos 6 
Localiza estímulos 5 
Flexão normal 4 
Flexão anormal 3 
Extensão anormal 2 
Nenhuma 1 
REATIVIDADE PUPILAR 
Inexistente -2 
Unilateral -1 
Bilateral 0 
TOTAL DO PACIENTE: 
Modelo por Carol Maldonado @carolfmaldonado 
IMC:​ _____________________ 
Biotipo:​ [ ] Longilíneo [ ] Normolíneo [ ] Brevilíneo 
Frequência respiratória: ​_____________ irpm 
Saturação O2: ​__________________________________________________________________________ 
Frequência cardíaca: ​_____________ bpm 
Circunferência braquial:​ _____________ cm 
Cintura:​ ________________ cm 
Circunferência abdominal:​ ______________ cm 
Circunferência do quadril:​ _____________________ cm 
Pregas subcutâneas:​ _____________________________________________________________________ 
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O paciente adota alguma atitude/decúbito?​ __________________________________________________ 
[ ] voluntária [ ] involuntária 
Temperatura corporal​: ____________°C 
Local da aferição:​ _______________________________________________________________________ 
Pressão arterial: ​_____________ sistólica​ /​ _____________ diastólica → ______​/​______ 
Grau de hidratação:​ _____________________________________________________________________ 
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Coloração:​ _____________________________________________________________________________ 
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Tempo de enchimento capilar:​ ____________________ segundos 
Presença de lesões?​ ______________________________________________________________________ 
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Descreva as lesões:​ ______________________________________________________________________ 
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Modelo por Carol Maldonado @carolfmaldonado 
Unhas:​ ________________________________________________________________________________ 
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Pelos:​ _________________________________________________________________________________ 
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EXAME FÍSICO SISTEMÁTICO: 
 
Sistema Circulatório:​ ____________________________________________________________________ 
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Sistema Respiratório:​ ____________________________________________________________________ 
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Abdome:​ ______________________________________________________________________________ 
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Modelo por Carol Maldonado @carolfmaldonado 
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OBSERVAÇÕES: 
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