Aluna: Brbara Vasconcelos da Silva

Enfermaria de Pediatria HUPE Anamnese de Internao Data___/___/___ Nome ________________________________________________________________________ DN___/___/___Idade____Sexo___Cor______Naturalidade________________________ _____ Informante__________________________________________________________________ __ Queixa Principal________________________________________________________________ HDA________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _________HPP(doenas exantemticas, alergias, asma, transfuso, convulso, ITU, anemia, infeces, cirurgias, internaes, acidentes, outros) _____________________________________________________________________________ _ Histria gestacional, Parto e Neonatal Gesta___Para___Abortos___Ordem na prole___PrNatal___Incio___Consultas____________ Intercorrncias(sangramento, HAS, DM, medicamentos)________________________________ Sorologias___________________________________________________________________ __

Parto________Local__________IG_______Apgar___Peso_______Comprimento____P C______ Intercorrncias Neonatais/ Alta____________________________________________________ Teste do Pezinho/Teste da orelhinhas/Reflexo Vermelho________________________________ Histria Alimentar: LM exclusivo at _____Frmula?_____Misto at______________________ Alimentao atual_______________________________________________________________ Histria do Crescimento e Desenvolvimento Sustentou cabea______Rolou______Sentou______Engatinhou____Andou____Falou____ Controle Esfincteriano________________Creche/Escolaridade___________________________ Desenvolvimento Sexual__________________Psicossocial______________________________ Histria Imunolgica(ver carto-n de doses) BCG(ver marca)___________HepB___DPT/Hib___Plio___Rotavrus___Trplice viral_________ Outras/Especiais______________________________________Ig_____________________ ____ Histria Familiar(TB,DM, neoplasias, hipercolesterolemia, HA, doenas cardiovasculares, atopia/asma, epilepsia, nefropatia, transfuso, doena mental, DST, consaguinidade, tabagismo, uso de drogas, outras) _____________________________________________________________________________ _____________________________________________________________________________ __ Histria Social Condies de moradia_______________________________________________ Moradores da casa_____Ncleo familiar_____Escolaridade Pais___________Animais________

Fumantes________________________Viagens____________________________________ ___ Exame Fsico Peso____________Comp/Est______________PC___________SC__________Estado Nutricional(Escore Z) P/I_____________P/E__________E/I_________IMC__________________ Tax_____________FC_________FR____________PA_____________(p95______________ ___) 1) ECTOSCOPIA

Estado Geral__________Atividade/postura___________Mucosa_________________________ Pele/fneros______________Hidratao______________Linfonodos_______________ ______ 2) CABEA E PESCOO

Crnio___________Fontanelas_____________Fcies_________Olhos/Nariz_________ ______ Boca/OF_____________Orelha/Otoscopia_______________________________________ ____ Linfonodos/Massas cervicais______________________________________________________ 3) SISTEMA NERVOSO e APARELHO LOCOMOTOR

NO APLICADO

4)

TRAX E APARELHO RESPIRATRIO

Inspeo/Percusso/Ausculta________________________________________________ _____________________________________________________________________________ _______ 5) APARELHO CIRCULATRIO

Inspeo/Palpao/Ausculta_________________________________________________ _____________________________________________________________________________ _______ Pulsos_______________________________________________________________________ __ 6) ABDOME

Inspeo/Ausculta/Palpao/Percusso_______________________________________ _____________________________________________________________________________ ________ Hepatimetria____________________Permetro abdominal______________________________ APARELHO GENITO-URINRIO E NUS (Tanner/Malformaes)7)

Genitlia_____________________________nus/Mamas/Testiculos________________ ______ Impresso e Hipteses Diagnsticas _____________________________________________________________________________ _____________________________________________________________________________ __ Conduta _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ___

EVOLUO Data___/___/___ Nome_______________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

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