VALORACION FISICA - ANAMNESIS

DATOS DE IDENTIFICACIN:
NOMBRE: _____________________________________________________
EDAD: _____________ aos
ESTADO CIVIL: ____________________
EDUCACIN: ________________________
OCUPACIN: ________________________
PROCEDENCIA: ______________________
RESIDENCIA: ________________________
FECHA: _____________________________
INFORMANTE: _______________________
CAUSA DE CONSULTA: __________________________________________
PROBLEMA ACTUAL: ____________________________________________

_______________________________________________________________
____________________________________________________________________________________
__________________________________________
PERFIL DEL PACIENTE
ANTECEDENTES FAMILIARES:____________________________________
_______________________________________________________________
ANTECEDENTES PERSONALES:
GINECOLGICOS:_______________________________________________
OBSTTRICOS: ________________________________________________

TEMBLORES:___________________________________________________
PRESENTACIN PERSONAL: _____________________________________
_______________________________________________________________
GRADO DE COOPERACIN: ______________________________________
EVIDENCIA DE ENFERMEDAD: ____________________________________

REVISIN POR SISTEMAS:

CABEZA: El paciente refiere___________________________________
CUELLO: El paciente refiere___________________________________
OJOS: El paciente refiere___________________________________
NARIZ: El paciente refiere___________________________________
BOCA: El paciente refiere___________________________________
ODOS: El paciente refiere___________________________________
TORX: El paciente refiere___________________________________
CORAZN: El paciente refiere___________________________________
MAMAS: El paciente refiere___________________________________
MIEMBROS SUPERIORES: El paciente refiere_______________________
ABDOMEN: El paciente refiere___________________________________
SISTEMA URINARIO: El paciente refiere____________________________
GENITALES: El paciente refiere___________________________________
MIEMBROS INFERIORES: El paciente refiere________________________
EXAMEN FSICO:
SIGNOS VITALES:

PESO

TALLA

PRESIN ARTERIAL

PULSO

RESPIRACIN

TEMPERATURA

CABEZA:
INSPECCIN:
Simetra: ____________________________________________________
Forma y Tamao: _____________________________________________
Implantacin del Cabello: ______________________________________
Presencia de Parsitos: _______________________________________
Cabello y cuero cabelludo: _____________________________________
PALPACIN:
Caractersticas del cabello: _____________________________________
Sensibilidad: _________________________________________________
Masas: ______________________________________________________
Depresin o Hundimientos: _____________________________________
Estado de Fontanelas: _________________________________________

CARA
INSPECCIN:
Forma: ______________________________________________________
Volumen: ____________________________________________________
Simetra: _____________________________________________________
Facies: ______________________________________________________
Xantomas: ___________________________________________________
Piel: ________________________________________________________
Movimientos Involuntarios: _____________________________________
Edema: ______________________________________________________
Vello: _______________________________________________________
PALPACIN:
Temperatura: _________________________________________________
Sensibilidad: ________________________________________________
Presencia de Masas: __________________________________________
Dolor: ______________________________________________________
Consistencia y movilidad: _____________________________________
OJOS
INSPECCIN:
Cejas: _______________________________________________________
Prpados: ___________________________________________________
Pestaas: ____________________________________________________
Aparato Lacrimal: _____________________________________________
Conjuntiva: __________________________________________________
Esclera: _____________________________________________________
Crnea: _____________________________________________________
Iris: _________________________________________________________
Cristalino: ___________________________________________________
Pupilas: _____________________________________________________
Reflejo directo y Consensual: ___________________________________
Movimientos Oculares: ________________________________________

PALPACIN:
Masas: ______________________________________________________
Dolor:_______________________________________________________
Tono Ocular: _________________________________________________
PRUEBAS:
Paralelismo: _________________________________________________
Agudeza Visual: ______________________________________________
O.I.

O.D.

A.O.

ODOS
INSPECCIN:
Pabelln Auricular: ___________________________________________
Implantacin: ________________________________________________
Integridad: ___________________________________________________
Simetra: ____________________________________________________
Tamao: ____________________________________________________
PALPACIN:
Pabelln Auricular: ____________________________________________
Consistencia: ________________________________________________
Sensibilidad: _________________________________________________
Movilidad: ___________________________________________________
Temperatura: ________________________________________________
NARIZ
INSPECCIN:
Forma: ______________________________________________________
Tamao:_____________________________________________________Posicin
_________________________________________
Simetra: ____________________________________________________
Caractersticas: ______________________________________________
Aleteo Nasal: ________________________________________________
Permeabilidad de las Fosas Nasales: _____________________________
Fracturas: ___________________________________________________
Masas: ______________________________________________________

del Tabique:

RINOSCOPIA ANTERIOR
Vestbulo Nasal: ______________________________________________
Mucosa Nasal: _______________________________________________
Tabique Nasal: ______________________________________________
Pared Lateral: _______________________________________________

SENOS PARANASALES.
INSPECCIN: ________________________________________________
____________________________________________________________
PALPACIN: _________________________________________________

TRANSILUMINACIN: _________________________________________
_________________________________________________________________________________
_________________________________________
EXAMEN FISICO DE OROFARINGE
INSPECCIN:
Aspecto facial; __________________________________________________
Forma de Respiracin: ___________________________________________
Estado de las Maxilas: ___________________________________________
LABIOS:
Simetria: ______________________________________________________
Tamao: _______________________________________________________
Color:__________________________________________________________
Humedad: ______________________________________________________
Integridad: _____________________________________________________
Sensibilidad: ___________________________________________________
MUCOSA BUCAL O DE LOS CARRILLOS
Color: _________________________________________________________
Humedad: ______________________________________________________
Integridad: _____________________________________________________
Conducto: _____________________________________________________

DIENTES Y ENCIAS
Integridad: _____________________________________________________
Presencia de caries: _____________________________________________
LENGUA:
Color Dorsal
Simetra: _______________________________________________________
Tamao: _______________________________________________________
Movimientos involuntarios: _______________________________________
Humedad: _____________________________________________________
Integridad: _____________________________________________________
Cara Ventral
Integridad: _____________________________________________________
Frenillo: _______________________________________________________
Orificios: ______________________________________________________
PALADAR DURO Y BLANDO
Color: _________________________________________________________
Integridad: _____________________________________________________
Movimientos: ___________________________________________________
VULA
Integridad: _____________________________________________________
Movilidad: _____________________________________________________
ARCOS PALATOGLOSOS y PALATOFARNGEOS
Color: _________________________________________________________
Integridad: _____________________________________________________
TONSILAS PALATINAS Y FARNGEAS
Tamao: _______________________________________________________
Color: _________________________________________________________
Integridad: _____________________________________________________
PARED POSTERIOR DE LA FARINGE
Color: _________________________________________________________
Integridad: _____________________________________________________

Reflejo Nauseoso: SI _____

NO_______

Reflejo De Deglucin:

NO ______

SI _______

EXAMEN FSICO DE CUELLO

INSPECCIN
Piel: ___________________________________________________________
Simetra: _______________________________________________________
Desarrollo Muscular: _____________________________________________
Pulsaciones: ____________________________________________________
Masas: _________________________________________________________
Movimientos: ___________________________________________________
PALPACIN
Temperatura: ___________________________________________________
Cadenas Ganglionares: __________________________________________
Masas: ________________________________________________________
Pulso: ________________________________________________________
Glndulas: _____________________________________________________
Trquea: ______________________________________________________
AUSCULTACIN
Arterias Cartidas: _______________________________________________
EXAMEN FSICO DE PULMONES
INSPECCIN
Estado Nutricional y Desarrollo Musculoesqueltico:
____________________________________________________________________________________
____________________________________________________________________________________
_____________________
Estado de la Piel: ________________________________________________
Contextura: ____________________________________________________
Distribucin del Vello: ____________________________________________
Color: _________________________________________________________
Integridad: _____________________________________________________
Forma del Trax: ________________________________________________
SIMETRA:
Escpulas: _____________________________________________________

Clavculas: _____________________________________________________
Hemitorax: _____________________________________________________
Hombros: ______________________________________________________
DIMETROS
Anteroposterior: ________________________________________________
Transverso: ____________________________________________________
NGULOS COSTALES
Trax Posterior: _________________________________________________
Trax Anterior: _________________________________________________
Retraccin

Abombamientos

de

Espacios

Intercostales:

____________________________________________________________________________________
__________________________________________
RESPIRACIN
Tipo: __________________________________________________________
Frecuencia: _____________________________________________________
Ritmo: _________________________________________________________
Profundidad: ____________________________________________________
COLUMNA
Cifosis: ________________________________________________________
Lordosis: ______________________________________________________
Escoliosis: _____________________________________________________
Espina Rgida: __________________________________________________
PALPACIN
Sensibilidad: ___________________________________________________
Presencia de Masas: _____________________________________________
Temperatura: ___________________________________________________
Pulsaciones: ____________________________________________________
Contextura de la piel: ____________________________________________
Expansin Torcica: _____________________________________________
Frmito Vocal:
Presente: _______________________________________________________
Aumentado: ____________________________________________________

Disminuido: ____________________________________________________
Ausente: ______________________________________________________
PERCUSIN
Resonancia: ____________________________________________________
Matidez: ________________________________________________________
AUSCULTACIN
Ruidos normales: ________________________________________________
Murmullo Vesicular: ______________________________________________
Murmullo Broncovesicular: _______________________________________
EXAMEN FSICO DE CORAZN
INSPECCIN
Caractersticas del trax: _________________________________________
Contorno: _____________________________________________________
Depresin del Esternn: _________________________________________
Cifosis: _______________________________________________________
Escoliosis: ____________________________________________________
Otras deformidades: ____________________________________________
PULSACIONES
Artica: _______________________________________________________
Pulmonar: _____________________________________________________
Ventricular Derecha: ____________________________________________
Ventricular Izquierda: ___________________________________________
Epigstrica: ___________________________________________________
Localizacin

Caractersticas:

____________________________________________________________________________________
__________________________________________
Punto de Mximo Impulso (PMI)
Localizacin: ___________________________________________________
Visible: _______________ Palpable: _________________
Preciso: ______________ Difuso: ___________________
AUSCULTACIN
Frecuencia Cardiaca
Caractersticas: _________________________________________________

Frecuencia: ____________________________________________________
Ritmo: _________________________________________________________
Intensidad: _____________________________________________________
Auscultacin del rea Cardiaca
Artica: ________________________________________________________
Pulmonar: ______________________________________________________
Tricspide: _____________________________________________________
Mitral: _________________________________________________________
Caractersticas de los Ruidos Cardiacos:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
EXAMEN FSICO DE MAMAS
INSPECCIN
Forma: _________________________________________________________
Tamao: _______________________________________________________
Nmero: ____________________

Tipo: _____________________________

Simetra: _______________________________________________________
Estado de la Piel: ________________________________________________
Estado y Caractersticas de la Areola y el Pezn:
____________________________________________________________________________________
____________________________________________________________________________________
_____________________
Tono muscular: _________________________________________________
PALPACIN
Consistencia: ___________________________________________________
Sensibilidad: ___________________________________________________
Temperatura: ___________________________________________________
Secreciones: ___________________________________________________
Tono: _________________________________________________________
EXAMEN FSICO DE ABDOMEN
INSPECCIN
Forma: _______________________________________________________
Volumen o Tamao: ____________________________________________

Caractersticas de la Piel: _______________________________________

Alteraciones Comunes:
Estras: ________

Ndulos: ________ Equimosis: ________

Cambios de Color: ________ Cicatrices: _________ Masas: ________

Red Venosa Visible: ________ Petequias: ________ Edema: ________
Simetra: ___________________________________________________
MOVIMIENTOS
Respiratorios: _________________________________________________
Pulsaciones: __________________________________________________
Peristaltismo: _________________________________________________
AUSCULTACIN: ________________________________________________

PALPACIN
Superficial:
____________________________________________________________________________________
__________________________________________
Profunda:
____________________________________________________________________________________
__________________________________________
PERCUCIN:
____________________________________________________________________________________
____________________________________________________________________________________
_____________________
VALORACIN DE HERNIAS:
Inspeccin en Regin Inguinal:
Forma: _________________________________________________________
Localizacin: ___________________________________________________
Tamao: _______________________________________________________
Inspeccin en Regin Interna del Muslo:
Forma: _________________________________________________________

Localizacin: ___________________________________________________
Tamao: _______________________________________________________
Inspeccin en Regin Umbilical:
Forma: ________________________________________________________
Localizacin: ___________________________________________________
Tamao: _______________________________________________________
PALPACIN
Forma: _________________________________________________________
Tamao: _______________________________________________________
Anillo Herniario: _________________________________________________
Consistencia: ___________________________________________________
Sensibilidad: ____________________________________________________
Reduccin Sin Dificultad: _________________________________________
AUSCULTACIN
____________________________________________________________________________________
____________________________________________________________________________________
_____________________

EXAMEN FSICO DEL SISTEMA MUSCULOESQUELTICO

INSPECCIN
Cefalocaudal: ___________________________________________________
Posicin Esttica: _______________________________________________
Posicin Dinmica: ______________________________________________
Marcha
Fase de Apoyo: _________________________________________________
Fase de Propulsin: _____________________________________________
Fase de Balanceo: ______________________________________________
Marchas Anormales
Cojera Antlgica: ________________________________________________
Cojera por Acortamiento: _________________________________________
Cojera por Contractura: __________________________________________
Cojera por Diferencia Muscular: ____________________________________
Marcha Cerebelosa: ______________________________________________
Marcha Tabtica: ________________________________________________

Marcha Espstica: _______________________________________________

Marcha Festonante: ______________________________________________
Marcha Parkinsoniana: ___________________________________________
Marcha de Balanceo: _____________________________________________
PALPACIN
Superficial: _____________________________________________________
Caractersticas de la Piel: _________________________________________
Dolor: _________________________________________________________
Edema: ________________________________________________________
Pulso: _________________________________________________________
Profunda: ______________________________________________________
Zonas Dolorosas: ________________________________________________
Tono Muscular: _________________________________________________
Tumoraciones: _________________________________________________
Funcin: _______________________________________________________
Movilidad: ______________________________________________________
Activa: _________________________________________________________
Pasiva: ________________________________________________________
Amplitud del Movimiento: _________________________________________
Simetra: _______________________________________________________
Desarrollo Muscular y Fuerza: _____________________________________
Medicin de la Fuerza: ___________________________________________
MEDICIN
Circunferencial: _________________________________________________
Longitudinal: ___________________________________________________
MANIOBRAS
Thomas: _______________________________________________________
Lassegue: ______________________________________________________
Trendelemburg: _________________________________________________
Ortatons: _______________________________________________________

EXAMEN FSICO DEL SISTEMA NERVIOSO

CONCIENCIA:________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

ORIENTACIN
En Tiempo: _____________________________________________________
Lugar: _________________________________________________________
Persona: _______________________________________________________
JUICIO:______________________________________________________________________________
____________________________________________________________________________________
_____________________
MEMORIA: _____________________________________________________
PERCEPCIN:
Visual: _________________________________________________________
Auditiva: _______________________________________________________
Tctil: _________________________________________________________
PENSAMIENTO: _________________________________________________
____________________________________________________________________________________
__________________________________________
AFECTO: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
REA PSICOMOTORA: ___________________________________________
_______________________________________________________________
_______________________________________________________________

PARES CRANEALES.
I Par Nervio Olfatorio: ____________________________________________
II Par Nervio ptico: _____________________________________________
III Par Nervio Oculomotor o Motor Ocular Comn: ____________________
_______________________________________________________________
IV Par Nervio Troclear o Pattico : __________________________________
_______________________________________________________________
V Par Nervio Trigmino:
Rama Oftlmica: _________________________________________________
Rama maxilar Superior: ___________________________________________
Rama Maxilar Inferior: ____________________________________________
VI Par Nervio Motor Ocular Externo : ________________________________
VII Par Nervio Facial: _____________________________________________
VIII Par Nervio Auditivo: _________________________________________
IX Par Nervio Glosofarngeo: ______________________________________
X Par Nervio Neumogstrico: ______________________________________
XI Par Nervio Accesorio: __________________________________________
XII Par Nervio Hipogloso: _________________________________________
PLAN ENFERMERO
ACTIVIDADES DEL CUIDADO