Professional Documents
Culture Documents
PACIENTE: _____________________________________________________________________________________
Idade: ______ anos Peso _________ Kg LEITO: _____________ DATA DO INTERNAMENTO: ___/___/___
DIAGNSTICOS:
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HMP:
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MEDICAMENTOS EM USO:
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EXAME FSICO NA ADMISSO:
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MEDICAMENTOS EM USO:
ANTIBIOTICOTERAPIA:
(___) emprico (___) emprico, aguarda cultura (___) com cultura positiva (___) amplo espectro
(___) emprico (___) emprico, aguarda cultura (___) com cultura positiva (___) amplo espectro
(___) emprico (___) emprico, aguarda cultura (___) com cultura positiva (___) amplo espectro
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O# EXAME FSICO
Pupilas: (__) isocria / (__) Midrase / (__) Miose (__) Direita . (__) Esquerda. (__) Bilateral.
(__) fotorreagentes / (__) sem fotorreao (__) Direita . (__) Esquerda. (__) Bilateral.
Pulsos: (__) palpveis. (__) difcil palpao / (__) simtricos. (__) assimtricos / (__) cheios. (__) filiforme
Edema: (__) MMII (__) MMSS (__) ANASARCA (__) EDEMA GENERALIZADO
ACESSO VENOSO CENTRAL: (__) no. (__) sim: _________________________________________. Data: ___/___/___
ACESSO VENOSO PERIFRICO: (__) no. (__) sim: _______________________________________. Data: ___/___/___
SONDA VESICAL DE DEMORA: (__) no. (__) sim: _______________________________________. Data: ___/___/___
DERIVAO VENTRICULAR: (__) no. (__) sim: _________________ Drenou: ______________ ml. Data ___/___/___
VENTILAO: (__) ambiente. (__) O2 suplementar. (__) mscara de O2. (__) ventilao mecnica. Data: ___/___/___
GASOMETRIA:
PH: ___________ pO2: __________ pCO2: _________ BIC: ___________ BE: ____________
EXAME FSICO PULMONAR: FR: ____ ipm (__) sinais de esforo respiratrio
MV __________________ / Rudos adventcios: __________________ em (__) HTD / (__) HTE / (__) ambos HT
EXAME FSICO ABDOMINAL: RHA: (__) presente / (__) ausente Dor: __________________________
(__) flcido (__) globoso (__) em tbua/rgido (__) distendido (__) em avental
(__) com visceromegalias (__) massa palpvel (__) sinais de irritao peritoneal
(__) com globo vescical (__) Piparote positivo (__) som timpnico em quadrante ______________________
MEMBROS INFERIORES: (__) edema ausente / (__) edema presente: _____/4+ / (__) com cacifo
Panturrilhas: (__) livres / (__) empastamento / (__) dolorosa palpao / (__) sinais flogsticos
Exame Vascular: (__) sem alteraes / (__) pulsos no palpveis / (__) leso vascular arterial / (__) CEAP _____
EXAME NEUROLGICO: (__) SEM ALTERAES (__) ALTERAES EM:
Mn__________ mn_________
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EXAMES LABORATORIAIS:
CLEARANCE Cr: anterior __________________ atual ____________________ (__) DRC grau _____
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P# PLANO
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CHECKLIST DOS EXAMES A SEREM SOLICITADOS:
(__) HEMOGRAMA / (__) UREIA / (__) CREATININA / (__) POTSSIO / (__) SDIO / (__) BILIRRUBINA
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