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Ouvidos, nariz e seios da face: otalgia, algias faciais, congestão periorbitária, epistaxe, otorréia, rinorréia, obstrução nasal, espirros freqüentes, gota pós-nasal, zumbidos, acuidade auditiva, vertigem
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Cavidade Oral: odontalgia, gengivorragias, ulcerações da mucosa, queimação ou ardência da língua, odinofagia, sialose, dor em ATM
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Mamas: mastalgia, descarga mamilar, nódulos palpáveis.
Ginecomastia no homem
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Respiratório: tosse, expectoração (aspecto e quantidade),
rouquidão, hemoptise, dor torácica, dispnéia, chiado no tórax
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Cardiovascular: precordialgia, palpitações, dispnéia de esforço, noturna e de decúbito, síncope, edema, cianose, claudicação intermitente, veias varicosas, úlceras de perna
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Gastrintestinal: disfagia, pirose, intolerância alimentar, eructações, empachamento, regurgitação, epigastralgia, cólicas, icterícia, náuseas e vômitos, hematêmese, hábito
intestinal (n0 de evacuações diárias, aspecto das fezes - cor e consistência -, presença elementos anormais - sangue, muco e/ou pus), tenesmo evacuatório, dor e prurido retal, enterorragia, melena, meteorismo, cólicas, flatulência, obstipação intestinal
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Urinário: dor (lombar, no flanco, vesical), disúria, alterações miccionais, estrangúria, polaciúria, alterações da cor e odor da urina, nictúria, enurese, oligúria, poliúria, incontinência urinária de esforço (mulher), gotejamento terminal e força do jato urinário (homem), eliminação de cálculos durante a micção
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Genital: homem (corrimento uretral, lesões genitais, disfunções sexuais); mulher (leucorréia, prurido vulvovaginal, sangramento intermenstrual, dor pélvica, dispareunia)
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Osteoarticular: artralgias, rigidez matinal, edema articular,
limitação de movimentos, deformidades, lombalgia
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Hematopoiético: palidez, tendências hemorrágicas,
linfadenomegalias, esplenomegalia, hepatomegalia
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Endócrino: intolerância ao frio ou ao calor, poliúria, polifagia
e polidipsia, hirsutismo
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Nervoso: paresias (paralisia moderada), paralisias, parestesias, atrofias musculares, tremores, convulsões, ausências, perturbações da memória (amnésia transitória ou permanente)
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Psiquismo: insônia, nervosismo, choro freqüente, irritabilidade, tristeza, sentimento de culpa, perda de interesse e prazer no trabalho e no lazer
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5.ANTECEDENTES PESSOAIS FISIOLÓGICOS
Condições de gestação e nascimento:__________________
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Desenvolvimento neuropsicomotor:__________________
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Imunizações (BCG, DTP, anti-polio, hepatite viral, anti-
tetanica, gripe )____________________________________
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Adolescência: (puberdade, surgimentos dos caracteres
secundários)_______________________________________
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Atividade sexual e vida reprodutiva (primeiro contato,
parceiros,
freqüência
de
relações,
camisinha,
emnstruação(fluxo,
ciclo),
gestações,
partos)
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Climatério: (idade da mennopausa, ondas de calor,
ressecamento vaginal)_______________________________
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Senectude: ( como o paciente se sente no ambiente familiar,
solidão, viuvez, pensão, aposentadoria, atividades diárias)
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6. ANTECEDENTES PESSOAIS PATOLÓGICOS
Doenças da infância (sarampo, catapora, rubéola,
caxumba):_________________________________________
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Doenças apresentadas na vida adulta ( tuberculose, DST, hepatite, diabetes, hieprtensão arterial, cardiopatias, epilepsias, febre reumática, asma, aborto espontâneo ou não, disfunção
sexual)
:
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Antecedentes de alergia:____________________________
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Cirurgias:_________________________________________
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Hospitalizações:____________________________________
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Traumatismos:_____________________________________
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Hemotransfusões:___________________________________
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Uso de drogas injetáveis:____________________________
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Medicações de uso prolongado:______________________
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7. ANTECEDENTES FAMILIARES
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8. ANTECEDENTES SOCIAIS
Condições de habitação e higiene:____________________
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Condições de alimentação:__________________________
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Nível de instrução:________________________________
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História Ocupacional:______________________________
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_________________________________________________ Religião:_________________________________________ Renda familiar mensal:____________________________ Relações interpessoais:
( se existe problema de relacionamento na família – se o paciente tem amigos – sente solidão
-
tem
ressentimento
)
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Problemas psicossociais: ( maior preocupação do paciente -o que lhe estressava antes da internação - sofreu alguma perda importante no passado - sente-se realizado – se houve expectativas frustradas)_____________________________
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Hábitos e costumes: tabagismo (duração, tipo de cigarro, nº de cigarros consumidos por dia), consumo de álcool (duração, tipo de bebida, quantidade consumida), banhos de rios açudes e lagoas (localidade e época), contato com o triatomíneo, contato com animais domésticos, prática regular de exercícios físicos (tipo e freqüência), sono, lazer, viagens,
uso de drogas ilícitas
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