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Instituto Superior de Ciências e Tecnologia de Moçambique

Curso de Medicina Geral Disciplina de Cirurgia e Ortopedia

HISTORIA CLÍNICA I-IDENTIFICAÇAO Nome:___________________________________________NID:_____/___________________ Sexo:________________ Idade:_______________ Raça:______________________________ Estado civil:______________________ Naturalidade:__________________________________ Residencia:____________________________________________________________________ Profissao:________________________ Local de trabalho:______________________________ Proveniente de:__________________________ Em:________/_________/________________ Historia fornecida por:____________________________ Serviço:________________________ II-ANAMNESE II.1 – MOTIVO DE INTERNAMENTO OU QUEIXA(S) PRINCIPAL(AIS) (usar termos medicos, nao sugerir diagnostico(s)) __________________________________________________________________________________________________________________________________________________________ II.2 – HISTORIA DA DOENCA ACTUAL (usar termos medicos, caracterizar o inicio e a evolucao dos sintomas e sinais, referir sintomas e sinais negativos importantes para o diagnostico diferencial, indicar tratamentos ja feitos e seus resultados) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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II.3 REVISAO POR APARELHOS E SISTEMAS NAO DIRECTAMENTE RELACIONADOS COM A DOENCA ACTUAL (assinalar apenas os dados positivos) a)- RESPIRATORIO/CARDIOVASCULAR

Tosse__________________ Expectoracao____________ Dor toraxica_____________ Dispneia________________ DPN/Ortopneia__________ Palpitaçoes_____________ Suores nocturnos________ Pieira__________________

b)- SISTEMA NERVOSO Convulçoes ______________ Sincope_________________ Cefaleias________________ Disturbios da sensibilidade__ Fraqueza muscular________

c)- GASTROINTESTINAL Vomitos_________________ Hematemeses____________ Obstipaçao______________ Melenas________________ Pirose___________________ Enfartamento pos-prandial__ Flatulencia_______________ Dor abdominal____________ Ictericia__________________

d)- GENITOURINARIO Disuria_________________ Polaquiuria_____________ Hematuria______________ Incontinencia urinaria_____ Dor lombar______________ Corrimento uretral/vaginal__ e)- HEMOLINFOPOETICO Anomalias da coagulação__ Anemias _______________

f)-CARACTERIZAÇAO DOS SINTOMAS E SINAIS RELEVANTES E OUTROS NAO ESPECIFICADOS

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II.4 – HISTORIA PREGRESSA (doenças anterioes , intervençoes cirurgicas, internamentos anteriores, historia medicamentosa, transfusoes, alergias, antecedentes de DTS) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ II.5 – HISTORIA PESSOAL E SOCIAL (condiçoes de habitaçao, saneamento, abastecimento de agua, habitos alimentares, alcoolicos e tabagicos, profissoes e viagens anteriores) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ II.6 – HISTORIA GINECO-OBSTETRICA (se mulher, menarca, menopausa, ultima menstruaçao, formulas mentrual e gestacional, alteraçoes da menstruaçao, metorragias, anticonceptivos, idades do 1º e ultimo partos, cesarianas) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ II.7 – HISTORIA FAMILIAR (saude dos parentes proximos, causas de morte dos parentes proximos, doenças de tendencia familiar) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ III. – EXAME OBJECTIVO III.1- EXAME GERAL Estado geral (impressao geral):____________________________________________________ Idade aparente:_______________________ Frequencia respiratoria:_____________________ Estado de coinsciencia: O:_____V:_____ M:_____ E.C.G.:_____/_________________________ Peso:____________ Altura:___________ I.M.Corporal:________________________________ Tensao arterial:________________________ Pulso radial:______________________________ Temperatura axilar:_____________________ Pele:____________________________________ Edemas:______________________ Linfadenopatias:__________________________________ Outros:____________________________________________________________________________________________________________________________________________________ III.2 – Cabeça Facies:______________________________ Olhos:____________________________________ _____________________________ ___________________________________ Nariz:_______________________________ Boca:____________________________________ _______________________________ ____________________________________ Orofaringe:__________________________ Ouvidos:__________________________________ __________________________ _________________________________

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III.3 – PESCOÇO Forma:___________________________ Dimensoes:__________________________________ Mobilidade:_______________________ Posiçao da traqueia:___________________________ Pressao venosa jugular (PVJ):_____________________________________________________ Tiroide:____________________________________________________________________________________________________________________________________________________ Outros:____________________________________________________________________________________________________________________________________________________ III.4 – TORAX a)-SEMIOLOGIA RESPIRATORIA Inspecçao:____________________________________________________________________ Palpaçao:_____________________________________________________________________ Percurssao:____________________________________________________________________ Auscultaçao:___________________________________________________________________ b)SEMIOLOGIA CARDIACA Inspecçao:____________________________________________________________________ Palpaçao:_____________________________________________________________________ Percurssao:____________________________________________________________________ Auscultaçao:___________________________________________________________________ c)MAMAS E AXILAS Inspecçao:_________________________________________________________________________________________________________________________________________________ Palpaçao:__________________________________________________________________________________________________________________________________________________ III.5 – ABDOMEN E PERINEO a)-ABDOMEN Inspecçao:____________________________________________________________________ Palpaçao:_____________________________________________________________________ Percurssao:____________________________________________________________________ Auscultaçao:___________________________________________________________________ Manobras especiais:____________________________________________________________ b)-GENITAIS EXTERNOS Inspecçao:____________________________________________________________________ Palpaçao:_____________________________________________________________________ Percurssao:____________________________________________________________________ Auscultaçao:___________________________________________________________________ Urina (cor, turvaçao):____________________________________________________________ c)-REGIOES INGUINO-CRURAIS Inspecçao:____________________________________________________________________ Palpaçao:_____________________________________________________________________ Percurssao:____________________________________________________________________ Auscultaçao:___________________________________________________________________ d)-EXAME PROCTOLOGICO Posiçao:______________________________________________________________________ Inspecçao:____________________________________________________________________ Palpaçao (toque rectal):__________________________________________________________

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e)-EXAME GINECOLOGICO Posiçao: ______________________________________________________________________ Inspecçao:____________________________________________________________________ Palpaçao, bimanual (toque vaginal):________________________________________________ III.6-EXTREMIDADES a)-MEMBROS SUPERIORES Inspecçao:____________________________________________________________________ Palpaçao:_____________________________________________________________________ Auscultaçao:___________________________________________________________________ Manobras especiais:____________________________________________________________ _____________________________________________________________________________ b)-MEMBROS INFERIORES Inspecçao:____________________________________________________________________ Palpaçao:_____________________________________________________________________ Auscultaçao:___________________________________________________________________ Manobras especiais:____________________________________________________________ _____________________________________________________________________________ III.7 – EXAME NEUROLOGICO Fala:_________________________________________________________________________ Estado mental:_________________________________________________________________ Força muscular:________________________________________________________________ Sensibilidade:__________________________________________________________________ Tonus muscular:________________________________________________________________ Sinais meningeos:_______________________________________________________________ Reflexos osteotendinosos:________________________________________________________ Nervos cranianos: a)-1º par:_____________________________________________________________________ _____________________________________________________________________________ b)-2º par:_____________________________________________________________________ _____________________________________________________________________________ c)-3º, 4º e 6º pares:_____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ d)- 5º par:_____________________________________________________________________ _____________________________________________________________________________ e)- 7º par:_____________________________________________________________________ _____________________________________________________________________________ f)- 8º par:_____________________________________________________________________ _____________________________________________________________________________

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g)- 9º e 10º pares:______________________________________________________________ _____________________________________________________________________________ h)-11º par:____________________________________________________________________ _____________________________________________________________________________ i)-12º par:_____________________________________________________________________ _____________________________________________________________________________ Coordenaçao motora:___________________________________________________________ Marcha:______________________________________________________________________ Fundoscopia (se necessario):______________________________________________________ Punçao lombar (se necessario):____________________________________________________ IV-RESUMO (dados importantes da amnese e do exame fisico) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ V-DIAGNOSTICO(S) PROVISORIO (S) (por ordem de importancia) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________ VI-MEIOS AUXILIARES E COMPLEMENTARES DE DIAGNOSTICO (por ordem de prioridade, justificar o motivo do pedido) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ VII-DIAGNOSTICOS DIFERENCIAIS (DISCUSSAO DO DIAGNOSTICO) (justificar) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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VIII-DIAGNOSTICO(S) DEFINITIVO(S) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IX-PROPOSTATERAPEUTICA/CONDUTA (justificar) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ X-PROGNOSTICO (de vida, sequelas,...) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ N.B: Colocar em folha anexa o mapeamento das queimaduras, lesoes da mama, tiroide e perineo se necessario. ELABORADO POR:______________________________________________________________ ANO:______________ CURSO:____________________________________________________ CORRIGIDA POR:_______________________________________________________________ COMENTARIOS:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ NOTA:________________ VALORES