Sheet Anamnesis

Patient Identification
• Name • Age • Gender • Ethnicity • Marital Status • • Occupation Naturalidad
Nationalist and • • Address • Telephone
Main Complaint (reason for consultation)
Pain; Discomfort; Burns; Paralysis; Tingling; Dry mouth; Bad Breat
h;
This refers to information that the patient generally reports in relation to:
Taste Bad Taste Metallic Bleeding Wound Core Etc. Bubble
Medical History
• Must contain diseases or changes
character reported in major medical semiology.
Family History hereditary and / or diseases of the note character
infectious and report which presents familiar (eg, hypertension Maternal Grandmo
ther).
• Examples of diseases:
Heart disease Hypertension Diabetes Cancer Tuberculosis Syphilis
• Or write on the card:
The patient reported no family members present with hereditary or contagious.
Social history and physiological
These should include:
• Smoking (cigarette
of paper, straw, cigar, pipe, and how often per day) • Alcoholism; Chimarrão •,
• Use of Drugs (oral, inhaled, snorted, injected);
• Hygienic Habits
(Baths per day, oral hygiene how many times a day) • Sexual History (active, ina
ctive, how many partners, condom use) • Date of last menstrual period; • Pregnan
cy (how many children, abortion, etc.).
Systems Review • Skin:
Note changes in color, consistency, patéquias, ecchymosis (patéquias larger),
lesions, itching, skin diseases. • Head: Headache, dizziness, tinnitus. • Nose
and sinus: epistaxis, obstruction, frequent colds, sinusitis. • Respiratory:
Chest Pain, cough, hemoptysis, bronchitis,
• Cardiovascular System:
chest discomfort (pain radiating to the arm), dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea (dyspnea requiring the patient to sit), palpitation
, cyanosis, edema of lower limbs. • Digestive system: Appetite, dysphagia, hea
rtburn, nausea, vomiting, hematemesis (vomiting blood), diarrhea,
• Urinary:
Renal colic, hematuria (bloody urine), oliguria (small amount of urine), dysur
ia (difficult urination), polyuria (urine too), pruritus, metrorréia (corrosion
signs lining of the uterus).
• Nervous System:
Convulsions, tremors, fainting (fainting without loss of consciousness), synco
pe (fainting with loss of consciousness), paresthesia, paralysis.
• System
• System
Immunologic:
To investigate diseases such as pemphigus, herpes, candidiasis, psoriasis, rec
urrent aphthous stomatitis, AIDS,
Hematopoietic:
Bleeding, blood dyscrasias (anemia, hemophilia,
Clinical Examination
• Temperature: arises, the thermometer in the armpit for 3-5 minutes. Reading:
Normal: 36 ° C Below 36 ° C mild hypothermia Fever: 37.2 to 38 Febres mo
derate: 38 to 39 Intense Fever (Hyperpyrexia): Above 41 ° C (may occur
Vital Signs
• Pulse: It is observed
rhythm, amplitude and frequency, making bidigital palpating the radial pulse for
1 minute. Note the following parameters:
Rhythm: Regular or irregular. Amplitude: increased or decreased. Frequency
: Normal 60 to 100 BPM Bradiesfigmia: Below 60 BPM Taquiesfigmia: Above
• Blood pressure: Is
measured using a sphygmomanometer and stethoscope. Standards of Evaluation:
normotensive: 120/80 mmHg Mild Hypertension: 140/90 to 159/99 mmHg Moderat
e Hypertension: 160/100 to 179/109 mmHg Severe hypertension: 180/110 to 209/11
9 Very Severe Hypertension:> 210 / > 120 mmHg
• Breathing: Observe your breathing for one minute, noting that the man is often
abdominal breathing, while the woman's chest. Features:
eupneic: 14-20 rpm (H) and 16-22 rpm (M) Bradypnea: below 14 Rpm Tachypnea
: above 22 Rpm Apnea: Absence or cessation of breathing Dyspnea: Difficulty
Is an assessment of medical and physical conditions of the patient.
• General condition: (BEG,
to suggest diagnoses. REG, PEG), level of consciousness possess great value, bec
ause there is semiological orientation (LOT - lucid and oriented few diseases th
at, in relation to time and as it were, bring the label space), posture (atypica
l on the faces of patients . or typical) feature (Vieira Romeiro). a disease. •
Atypical: Normal characteristics. • Typical: Features a syndrome or disease. • E
xamples: adenoidal: Bite
Ectoscopy
• Facies: "They are useful
• Skin: Evaluation:
Nomocoradas pale pallid (pale) Hydrated Dried Look conjunctival mucosa, nail bed
s, lips, oral mucosa and ear lobe.€ jaundiced (yellow sclera and sublingual car
uncula) anicteric (normal) Clasma pregnancy (after spots on the face and / o
r during
• Breathing:
Evaluation in normal respiration, bradypnea, tachypneic or dyspneic.
Physical Examination Extra-Oral
We should note:
Symmetry of the face • • • • •
(Symmetric or asymmetric) Mimic Musculature (preserved or changed) Permeability
of the Nostrils (permeable or not permeable) Edema Hyperesthesia sinus
• Eyes and eyebrows •
(Normal or altered) linfonodular Palpation of lymph nodes from head and neck (To
uchable, location, consistency, surface smooth or irregular, mobile, painful or
painless).
Physical Examination Intra-Oral
Note:
• Pigmentation • Color (normochromic, • • • Changes such as language
fissured, geographic, crenate, coating, glossitis, Fordyce, double lip. Texture
Modilidade Aspects normal and abnormal
hyperemia, cyanosis, jaundice) Presence of Hearing Examination of the teeth (col
or, number, shape and position)
• • •
Sequence of the Oral Cavity Examination 1. Commissures mucosa
1. Lower lip (zone 2. 3.
red lips and adjacent skin) Upper lip (red zone of the lips and adjacent skin) o
f the lower lip mucosa and sulcus (mouth closed, pull the lip leaving visible ar
ound the bottom of the vestibule). Mucosa of the upper lip and sulcus (mouth clo
sed, pull the lip leaving visible around the bottom of
2. 3. 4. 5. 6. 7.
4.
buccal and sulcus (top and bottom) alveolar ridge alveolar ridge lingual oral Tu
ber: with the help of clinical mirror frontal alveolar ridge, tongue at rest Put
tongue outside the mouth (the examiner to secure gauze. Edge of the tongue, sec
ure with gauze by the
4. Belly of the tongue and
mouth floor
5. Hard and soft palate, mouth
wide open, head tilted back.
7. Oropharynx with tongue
7. Floor of the mouth,
with open mouth (tongue up)
at home, ask the patient to pronounce the vowel "a" and lowering the tongue, the
patient should only stop to pronounce the vowel when the tongue depressor is no
longer positioned. This maneuver allows for more viewing area for q less discom
fort