Faculdade Pitgoras Betim

AVALIAO FISIOTERAPUTICA DE RESPIRATRIA

AMBULATORIAL
1 - Dados Pessoais:
Nome:_________________________________________________________
Data Nascimento.:__/__/____

Idade:____

Estado Civil:__________Peso:____kgAltura:_____m

Raa: __________
IMC:_______

Naturalidade:________________ Profisso/ocupao:_________________
Endereo:______________________________________ CEP:_______-____
Telefones: (__)_____-______ / (__)_____-______ / (__)_____-______
Mdico Resp.:__________________ Diagnstico mdico:______________
Diagnstico Fisioteraputico:______________________________
Data avaliao atual: ____/____/____
2 - Anamnese:
Queixa
Principal:_________________________________________________
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Histria da Molstia Atual:________________________________________
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Grau de Dispneia de acordo com a Escala de Dispneia de MRC:_______________

Medicamentos em uso
Medicamento

Dosagem

Posologia

Histria da Molstia Pregressa:____________________________________

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Histria Familiar:________________________________________________
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Histria Psicossocial: ____________________________________________
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5 Manifestaes Respiratrias Primrias:
Tosse:_________________________________________________________
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Expectorao:____________________________________________________
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Hemoptise:______________________________________________________
Dor Torcica:____________________________________________________
Chieira Torcica:_________________________________________________
Cianose:________________________________________________________
Dispneia:_______________________________________________________
Outros:_________________________________________________________
5.1 Manifestaes Respiratrias Secundrias:
Gerais:_________________________________________________________
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Extratorcica:____________________________________________________
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3 - Exame Fsico:
Sinais Vitais: FC:____bpmPA:____X___mmHg FR:____irpm SpO 2:____%
3.1 Inspeo:
InspeoGeral:______________________________________________
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Medida cintura___________________

Medida Quadril:________________

ndice cintura-quadril:______________________
Inspeo Esttica:
Torx:__________________________________________________________
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Inspeo Dinmica:
Padro Respiratrio:______________________________________________
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Ritmo:__________________________________________________________
Amplitude:_______________________________________________________
Esforo:_________________________________________________________
3.2 Palpao
Sensibilidade:____________________________________________________
Flexibilidade:_____________________________________________________
Expansibilidade:__________________________________________________
Percusso:______________________________________________________
3.3 Fora Musculatura Respiratria:
PEmx: __________ Valor predito:_________ % predito:__________
PImx: ___________ Valor predito:_________ % predito:__________
3.4 Pico de Fluxo Expiratrio:_______ Valor predito:_____ %predito:______
3.5 Ausculta Respiratria: _________________________________________
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4 - Exames Complementares:
4.1 Gasometria arterial:
pH(7,35 a

PaCO2(35 a

PaO2(80 a 100

HCO3(22 a 26

7,45)

45 mmHg)

mmHg)

mmHg)

SpO2(>92%)

BE(-2 a
+2)

Data do exame: __/__/____

4.2 Radiografia:_________________________________________________
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Data do exame: __/__/____
4.3
Espirometria:_________________________________________________
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Data do exame: __/__/____
4.4 Outros:______________________________________________________
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Data do exame: __/__/____
6 - Objetivos do tratamento: _______________________________________
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7 - Conduta Fisioteraputica:
Curto Prazo:_____________________________________________________
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Mdio Prazo:____________________________________________________
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Longo Prazo:_____________________________________________________
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Avaliao Postural:
Vista Anterior:

Vista Posterior:

Vista Lateral Esquerda:

Vista Lateral Direita:

Expansibilidade Torcica:
Lobos Superiores:

Lobo Mdio e lngula:

Lobos Inferiores:

Exames Complementares:

Tomografia Computadorizada