Ficha de avaliação traumato-ortopédica de fisioterapia da faculdade Pitágoras PDF

Preview

Summary

Ficha de avaliação - Ficha de avaliação traumato-ortopédica de fisioterapia da faculdade Pitágoras - Bahia...

Description

Ficha de Avaliação Fisioterapêutica em Traumato-ortopedia Data da avaliação____/_____/______ Fisioterapeuta : ANAMNESE 1.Identificação Nome_______________________________ Data de nascimento____/______/____ sexo : F( )M ( ) Endereço__________________________________________________________________________ Profissão Atual_____________________________________________________________________ Profissão Anterior___________________________________________________________________ Telefone______________Grau de escolaridade_______________Filhos ______________________ Diagnóstico clínico__________________________________________________________________ Médico___________________________________________________________________________

2.Apresentação do paciente

(como chegou ?sozinho ou acompanhado?deambulando sozinho ou

com auxílio?comunicativo?colaborativo?)

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

3.HDA (História da doença atual)

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

4.HP (História pregressa)

___________________________________________________________________ ___________________________________________________________________ ________________________________________________________________

5.HS (História social) ___________________________________________________________________ ___________________________________________________________________ ________________________________________________________________ 6.HF (História familiar) ___________________________________________________________________ ___________________________________________________________________ ________________________________________________________________ 7.QP (queixa principal) ___________________________________________________________________ ___________________________________________________________________ ________________________________________________________________ 8. Medicamentos/Exames complementares ___________________________________________________________________ ___________________________________________________________________ ________________________________________________________________

EXAME FISICO 1.Inspeção (simetria, tônus muscular, aspecto da pele, etc)

VISTA ANTERIOR __________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________________________________

VISTA LATERAL __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________

VISTA POSTERIOR __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________

2.Palpação ___________________________________________________________________ ___________________________________________________________________ ________________________________________________________________ 3.Sinais Vitais PA_____/_____mmHg FC_______bpm FR_______rpm Peso______Kg Altura______m

4. Goniometria Região : MOVIMENTO Flexão Extensão Abdução Adução Rotação medial Rotação lateral

DIREITO

ESQUERDO

5.Perimetria __________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________________________________

6.Força Muscular Flexores: Extensores: Rotadores internos : Rotadores externos : Adutores: Abdutores:

7. Sensibilidade Superficial Grau: Profunda Grau: 8.Reflexos __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

9.Testes Especiais

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

PLANO DE TRATAMENTO __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________...