ficha de avaliação neuro_adulto_2006
TRANSCRIPT
SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
TERMO DE RESPONSABILIDADE
Eu,__________________________________________________________
R.G.:__________________________, responsável por
______________________________________________________ ,comprometo-me
a comparecer nos dias agendados para o atendimento fisioterapêutico na Clínica de
Fisioterapia da UNIP - Universidade Paulista/ Assis , tendo ciência de que com uma
falta sem justificativa perderei sua vaga.
A falta poderá ocorrer uma vez justificada por motivo pertinente ( consulta
médica, óbito na família ou viagem a trabalho). A falta justificada deverá ser notificada
com pelo menos 24 horas de antecedência, junto à Secretaria da Clínica. No caso de
consulta médica, o atestado deverá ser apresentado no próximo dia de atendimento, e
ser entregue na secretaria da Clínica.
Estando ciente, concordo.
_____________________________________________data:______/_____/_____Nome do paciente/ responsável
_____________________________________________data:______/_____/_____Nome do(a) estagiário(a)
SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
UNIVERSIDADE PAULISTA – UNIP – ASSIS
ESTAGIO SUPERVISIONADO DE FISIOTERAPIA NEUROLÓGICA
FICHA DE AVALIAÇÃO
Nº____________________ DATA DA AVALIAÇÃO:___________/__________/___________
NOME DO AVALIADOR:________________________________________________________________________
I. IDENTIFICAÇÃO
NOME:
D. N. :____/____/____ IDADE:_________ SEXO:___________ ESTADO CIVIL:_______________________
ENDEREÇO:__________________________________________________BAIRRO _______
CIDADE/UF:______________________________________ CEP:_______________________-_____________
TEL. RES.:__________________ TEL. COM.:___________________ CEL:________________________
PROFISSÃO:__________________________ ( ) ATUANTE ( ) AFASTADO ( ) APOSENTADO
DIAGNOSTICO CLINICO:______________________________________________________________________
MEDICO RESPONSAVEL:_________________________________________TEL.:________________________
ACOMPANHANTE:___________________________________________________________________________
GRAU DE PARENTESCO:_____________________________________________________________________
II. ANAMNESE:
1. Q.P. (MOTIVO DA CONSULTA):
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2. H.M.P/ H.M.A:
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3. PATOLOGIAS CONCOMITANTES:______________________________________________________________
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4. ANTECEDENTES FAMILIARES:
SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
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5. TRATAMENTOS ANTERIORES:
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6. EXAMES COMPLEMENTARES/CIRURGIAS:
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7. MEDICAÇÃO ATUAL:
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8. HÁBITOS/VÍCIOS:
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9. IMPRESSÃO INICIAL DO PACIENTE:
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III. EXAME FÍSICO1 . SINAIS VITAIS:
P.A.: _______________ F.C.: _______________ F.R.: _______________ TEMPERATURA:____________
2. INSPEÇÃO (escoriações, cicatrizes, escaras):
3. AUDIÇAO
DIREITA ESQUERDA
4. VISÃODIREITA ESQUERDA
SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
5. PADRÃO POSTURAL____________________________________________________________________________________________
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6. TROFISMO MUSCULAR
D E
MMSS
MMII
7. PALPAÇÃO – TÔNUS MUSCULAR
D E
MMSS
MMII
8. SENSIBILIDADE PROFUNDA: cinético/ postural (placing)
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9. MOBILIDADE
- TÔNUS MUSCULAR:
MSD ( ) AUSENTE ( ) PRESENTE ( ) NORMAL ( ) ESPÁSTICO ( ) HIPERTÔNICO ( ) ATÁXICO
MSE ( ) AUSENTE ( ) PRESENTE ( ) NORMAL ( ) ESPÁSTICO ( ) HIPERTÔNICO ( ) ATÁXICO
MID ( ) AUSENTE ( ) PRESENTE ( ) NORMAL ( ) ESPÁSTICO ( ) HIPERTÔNICO ( ) ATÁXICO
MIE ( ) AUSENTE ( ) PRESENTE ( ) NORMAL ( ) ESPÁSTICO ( ) HIPERTÔNICO ( ) ATÁXICO
( ) ATETÓIDE ( ) HIPOTÔNICO ( ) OUTROS
OBS________________________________________________________________________________________
10. ADM – RETRAÇÕES/ ENCURTAMENTOS
- MMSS:_____________________________________________________________________________________
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- MMII:______________________________________________________________________________________
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- TRONCO:__________________________________________________________________________________
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11. TESTE NEUROLÓGICO
- BABINSKI: ( ) AUSENTE ( ) PRESENTE ( ) UNILATERAL MI______________ ( ) BILATERAL
- REFLEXOS PROFUNDOS:
TESTE DIREITO ESQUERDO OBSERVAÇÃO
BICIPITAL
TRICIPITAL
SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
PATELAR
AQUILEU
- PROVA DE ROMBERG: ( ) OLHO ABERTO ( ) OLHO FECHADO OBS.:________________________________
( ) MI LATERAL/ FRENTE ( ) MI TOTALMENTE A FRENTE
- PROVA DOS BRAÇOS ESTENDIDOS:____________________________________________________________
- INDEX/NARIZ:_________________________________ INDEX/INDEX:_______________________________
- NISTAGMO: ( ) AUSENTE ( ) PRESENTE ( ) UNILATERAL ( ) BILATERAL TIPO:_____________________
- OUTROS:___________________________________________________________________________________
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12. ATIVIDADE FUNCIONAL
EQUILIBRIO
- DEITADO:__________________________________________________________________________________
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- SENTADO:_________________________________________________________________________________
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- EM PÉ:_____________________________________________________________________________________
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- ROLAR:____________________________________________________________________________________
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- SENTAR:___________________________________________________________________________________
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- GATO:_____________________________________________________________________________________
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- AJOELHADO:_______________________________________________________________________________
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- SEMI – AJOELHADO ( D/E): __________________________________________________________________
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- ORTOSTASE (como o paciente fica em pé ):______________________________________________________
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13. MARCHA:
( ) INDEPENDENTE ( ) ANDA COM APOIO ( ) BENGALA ( ) MULETAS ( ) ANDADOR ( ) NÃO ANDA
OUTROS:____________________________________________________________________________________
- COMO O PACIENTE ANDA (análise da marcha):____________________________________________________
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14. OBSERVAÇÃO/AVALIAÇÃO POSTURAL:
- FRENTE:__________________________________________________________________________________
SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
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- COSTAS:__________________________________________________________________________________
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- PERFIL:___________________________________________________________________________________
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15. AVD/AVP:
DEPENDENTE SEMI-DEPENDENTE INDEPENDENTE OUTROS
ALIMENTAÇÃO
HIGIENE
VESTUÁRIO
TRANSFERÊNCIAS
OBS.:_______________________________________________________________________________________
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ESTADO EMOCIONAL: -
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ESTADO MENTAL: ____________________________________________________________________________
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17. OBSERVAÇÕES GERAIS:___________________________________________________________________
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18. CONCLUSÕES:
DIAGNÓSTICO FISIOTERAPÊUTICO: ____________________________________________________________
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PROGNÓSTICO: _____________________________________________________________________________
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OBJETIVOS DO TRATAMENTO: _________________________________________________________________
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PROGRAMAÇÃO DO TRATAMENTO: ____________________________________________________________
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SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
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ALUNO RESPONSÁVEL
PROFESSOR RESPONSÁVEL
DATA:_____/_____/_____
DATA:______/_____/_____
19.SENSIBILIDADE SUPERFICIAL
( ) COM ALTERAÇÕES
( ) SEM ALTERAÇÕES
( ) OUTROS
SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
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20. EVOLUÇÃO:
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SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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SETOR NEUROLOGIA (ADULTO) _________________________________________________________________________________________
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SUPERVISORA DOCENTE: PROFa CÁSSIA R. SAADE PACHECOSUPERVISORA FISIOTERAPEUTA: BETHANIA R. DE SOUZA TANGERINO
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