Roteiro de Anamnese

Prévia do material em texto

�� ,GHQWLILFDU�R�DQLPDO_�4XHL[D�SULQFLSDO
QRPH��HVSpFLH��UDoD��VH[R��LGDGH�&01"*���&$"01¾/&,
$SHWLWH�H�'HJOXWLomR
2�DQLPDO�HVWi�VH�DOLPHQWDQGR�QRUPDO"
1RUPRUH[LD � $SHWLWH�QRUPDO
+LSRUH[LD � $SHWLWH�EDL[R
3ROLIDJLD � $SHWLWH�DQRUPDO�
DXPHQWDGR
3DURUH[LD � $SHWLWH�DQRUPDO��
LQDGHTXDGD
'LVIDJLD�� 'LILFXOGDGH�QD�GHJOXWLomR
$SHWLWH�VHOHWLYR�� &RPHQGR�DTXLOR�TXH�
VHOHFLRQD
ÈPHVH�H�5HJXUJLWDomR
2�DQLPDO�DSUHVHQWRX�Y{PLWR
,QLFLR�� TXDQWLGDGH�� IUHTXrQFLD�� DVSHFWR
'HIHFDomR�H�IH]HV�
2�FRF{�HVWD�QRUPDO"
1RUPRTXHVLD � )H]HV�VHP�DOWHUDomR
'LVTXHVLD � 'LILFXOGDGH�SDUD�GHIHFDU
'LDUUpLD � (OLPLQDomR�GH�IH]HV�
OLTXLGDV
+HPDWRTXHVLD_�PHOHQD � IH]HV�FRP�
VDQJXH
,QLFLR�� IUHTXrQFLD�� DVSHFWR�� YHUPHV
,QJHVWmR�GH�iJXD
1RUPRGLSVLD � LQJHVWmR�QRUPDO
3ROLGLSVLD � VHGH�H[FHVVLYD
2OLJRSVLD � 'LPLQXLomR�GD�LQJHVWmR
$GLSVLD � $XVrQFLD�GH�VHGH
�&01"*�� �/!&,D�"0-&/�1¾/&,�
$�UHVSLUDomR�HVWD�QRUPDO"
'LVSQpLD � 'LILFXOGDGH�HP�UHVSLUDU
7DTXLSQpLD � $XPHQWR�GRV�PUSP
%UDGLSQpLD � 'LPLQXLomR�GRV�PUSP�
7RVVH�H�HVSLUUR
(OH�HQJDVJD"
3HUtRGR� )UHTXrQFLD� SURGXWLYD�RX�QmR�

1RLWH�RX�PDQKm��TXDQWDV�YH]HV�H�VH�
WHP�VHFUHomR�
6HFUHomR�QDVDO_�2FXODU
,QLFLR�� DVSHFWR�� TXDQWLGDGH�
,QWROHUkQFLD�D�H[HUFtFLRV�
&DQVDoR"�
6tQFRSH � 3HUGD�GH�FRQVFLrQFLD�
&LDQRVH � )LFD�FRP�D�OtQJXD�UR[D_�
IDOWD�GH�2�
�&01"*��
·+&1,D�/&+­/&,
;L[L�QRUPDO"
$Q~ULD � $XVrQFLD�GH�XULQD
2OLJXULD � 'LPLQXLomR�GH�XULQD
3ROLXULD � $XPHQWR�GH�XULQD�
'LVXULD � 'LILFXOGDGH�DR�XULQDU
(VWUDQJXULD � 8ULQD�OHQWD��GRORURVD
3RODTXLXULD � $XPHQWR�QR�Q~PHUR�GH
[L[L
&ROXULD� 8ULQD�HVFXUD
,QFRQWLQHQFLD � VHP�FRQWUROH
)rPHDV�
e�FDVWUDGD"
&LRV�� LQWHUYDORV��FUX]DPHQWR��
DQWLFRQFHSFLRQDLV"
3VHXGRFLHVH � *UDYLGH]�SVLFROyJLFD
&RUULPHQWR_�6HFUHomR�
6HURVR��VHUR�VDQJXLQROHQWR��
VDQJXLQROHQWR�RX�SXUXOHQWR
3DUWRV�
1XOtSDUD � QXQFD�WHYH
3ULPtSDUD � 3ULPHLUD�YH]
0XOWtSDUD � PDLV�GH���ILOKRWH�SRU�YH]
3DUWR�QRUPDO"
)LOKRWHV�YLiYHLV��DERUWR"
0DFKRV
/tELGR � GHVHMR�
-i�FUX]RX"
$JUHVVLYLGDGH��SRVWXUD�GH�PLFomR
�&01"*��+"/3,0,����, ,*,1,/
&RQYXOV}HV�RX�DOWHUDo}HV�GH�
FRPSRUWDPHQWR"
,QLFLR��IUHTXrQFLD��WLSR
)DVHV�
3URG{PLFD � LQGLFDWLYR�GH�GRHQoD
'H�DXUD�� HQ[DTXHFD��VLQWRPDV�SUp�
FRQYXOVmR�
,FWXV � 3HUtRGR�TXH�WHPRV�D�FRQYXOVmR
3yV� LFWXV � 3HUtRGR�DSyV�FRQYXOVmR
3RVWXUD�H�PDUFKD
'LILFXOGDGH��GRU"
$WD[LD� SHUGD�RX�LUUHJXODULGDGH�GD�
FRRUGHQDomR�PRWRUD
3DUHVLD � 0RYLPHQWRV�IUDFRV�GHOLPLWDGRV
3DUDOLVLD � 3HUGD�GD�FDSDFLGDGH�GRV�
PRYLPHQWRV
3RVVLELOLGDGHV�GH�LQWR[LFDomR
%DQKRV��,QMHo}HV�FDUUDSDWLFLGDV��
GHGHWL]DomR��iJXD�GH�EDWHULD
�")"�"��+"5,0�
3HOH
3UXULGR�� 'HVFDPDomR�� RGRUHV
2UHOKD
3UXULGR�� 6HFUHomR�� 2GRU�� 0DQHLRV�
FHIiOLFRV�
1RUPRDFXVLD � 'HWHFomR�GH�VRQV�
QRUPDO
$FXVLD � $XVrQFLD�GH�SHUFHSomR�GRV�
VRQV
8QKD
&UHVFLPHQWR�� 4XHGD�� )UDWXUD
��+"',
3UHVHQoD�GH�HFWRSDUDVLWDV"
3XOLFLRVH � 3XOJDV
,[RGLGLRVH � &DUUDSDWRV
3HGLFXORVH � 3LROKRV
$PELHQWH
'RPLFLOLDGR��6HPL� GRPLFLOLDGR��
TXHUHQFLDGR��DFHVVR�D�UXD��SUHVHQoD�
GH�URHGRUHV��GHGHWL]DomR�RX�
SURGXWRV�Wy[LFRV"
'LHWD
&RPH�UDomR��FRPLGD�FDVHLUD��FRPH�
SHWLVFRV��TXDQWLGDGH�H�IUHTXrQFLD
%DQKR
3URGXWR�XWLOL]DGR��FRP�TXDO�
IUHTXrQFLD��TXDO�IRL�R�XOWLPR�EDQKR"
9DFLQDomR
e�YDFLQDGR��TXDO�IRL�D�XOWLPD��RQGH�
Gi"

ROKDU�VHPSUH�D�FDUWHLULQKD
&RQWDFWDQWHV
7HP�SUHVHQoD�GH�RXWURV�DQLPDLV�QD�
FDVD��TXDLV�DQLPDLV�H�TXDQWRV��H�
VDEHU�R�HVWDGR�JHUDO�
$QWHFHGHQWHV�PyUELGRV�
4XDQGR��TXDO�IRL�R�GLDJQRVWLFR��
UHVXOWDGR�GH�H[DPHV��UHVROXomR�GR�
TXDGUR��WUDWDPHQWRV�DQWHULRUHV
3ULQFLSLR�DWLYR�� GRVHV�� IUHTXrQFLD��
SRVVtYHLV�HIHLWRV�FRODWHUDLV�
I J�,1"&/,�!"��+�*+"0"