Aluna: Brbara Vasconcelos da Silva

Enfermaria de Pediatria HUPE

Anamnese de Internao
Data___/___/___
Nome
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DN___/___/___Idade____Sexo___Cor______Naturalidade________________________
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Informante__________________________________________________________________
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Queixa
Principal________________________________________________________________
HDA________________________________________________________________________
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_________HPP(doenas exantemticas, alergias, asma, transfuso,
convulso, ITU, anemia, infeces, cirurgias, internaes, acidentes, outros)
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Histria gestacional, Parto e Neonatal
Gesta___Para___Abortos___Ordem na prole___PrNatal___Incio___Consultas____________
Intercorrncias(sangramento, HAS, DM,
medicamentos)________________________________
Sorologias___________________________________________________________________
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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_____________________
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Histria Familiar(TB,DM, neoplasias, hipercolesterolemia, HA, doenas
cardiovasculares, atopia/asma, epilepsia, nefropatia, transfuso, doena
mental, DST, consaguinidade, tabagismo, uso de drogas, outras)
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Histria Social Condies de
moradia_______________________________________________
Moradores da casa_____Ncleo familiar_____Escolaridade
Pais___________Animais________

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

ECTOSCOPIA

Estado
Geral__________Atividade/postura___________Mucosa_________________________
Pele/fneros______________Hidratao______________Linfonodos_______________
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2)

CABEA E PESCOO

Crnio___________Fontanelas_____________Fcies_________Olhos/Nariz_________
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Boca/OF_____________Orelha/Otoscopia_______________________________________
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Linfonodos/Massas
cervicais______________________________________________________
3)

SISTEMA NERVOSO e APARELHO LOCOMOTOR

NO APLICADO

4)

TRAX E APARELHO RESPIRATRIO

Inspeo/Percusso/Ausculta________________________________________________
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5)

APARELHO CIRCULATRIO

Inspeo/Palpao/Ausculta_________________________________________________
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Pulsos_______________________________________________________________________
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6)

ABDOME

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

Genitlia_____________________________nus/Mamas/Testiculos________________
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Impresso e Hipteses Diagnsticas
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Conduta
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EVOLUO
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