FICHA DE EVALUACION TRAUMATOLOGICA

ANAMNESIS:

NOMBRE…………………………………………………………………………………………………………………………….………
EDAD………………………….SEXO……………………………..OCUPACION………………………………………..………….
FECHA DE EVALUACION …………………………………………………………………………………………….................
DIAGNOSTICO MEDICO……………………………………………………………………………………………………………..
PROCEDENCIA…………………………………………………………………………………………………………………………….
DIRECCION…………………………………………………………………………………………………………………………………
TELEFONO…………………………………………ESTADO CIVIL………………………………………………………………….
RELEGION………………………………………N.SOCIO ECONOMICO………………………………………………………

PR. INTERROGATORIO

1. MOTIVO DE LA CONSULTA
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2. MECANISMO DE LA LESIÓN
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3. INTERVENCIÓN QUIRÚRGICA
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4. COMO FUE LA UNMOVILIZACION
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5. ZONA DEL MALESTAR SEÑALE EN DONDE CON TODA LA MANO Y CON UN DEDO
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6. CUANDO APARECE LA MOLESTIA
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7. QUE HISO CUANDO APARECIO EL DOLOR
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8. DONDE LE DUELE AHORA
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 EVALUACION CLINICA

1. EV. DE LA PIEL
 COLORACION_____________________________________________________
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 TURGENCIA______________________________________________________
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 HIDRATACION____________________________________________________
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 HEMATOMAS SI ____________________NO____________________________
 ELASTICIDAD_____________________________________________________
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 TEMPERATURA____________________________________________________
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2. EV. SENSEBILIDAD
 DERMATOMAS

RECEPTORES TACTILES
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SUPERFIAL _____________________________________________________________
TEXTURAS
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 PROFUNDA
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DISCRIMINACION DE :
 UN PUNTO _______________________________________________________
 DOS PUNTOS_____________________________________________________
 GRAFICA ________________________________________________________
PROPIOCEPCION

3. EV.INFLAMACION
TETRADA DE CELSIUS
DOLOR________________________________________________________________
RUBOR_________________________________________________________________
CALOR_________________________________________________________________
TUMOR________________________________________________________________
IMPOTENCIA FUNCIONAL _________________________________________________
EDEMA:
SIGNO FOBEA:

4. EV DOLOR
LOCALIZACION
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TIPO:
 PROYECTADO_____________________________________________________
 PUNZANTE_______________________________________________________
 IRRADIADO_______________________________________________________
 SINTOMAS ACOMPAÑADOS
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 DURACION_______________________________________________________
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EV. A LA PALPACION
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EV.AL MOVIMIENTO

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 ESCALAS:

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5. EV. DE LA ACTITUD POSTURAL

-SUPINO ( ) PRONO ( ) LATERAL ( ) SEDENTE ( ) BIPEDO ( )
-ANATOMICO ( ) FISILOGICO ( )
OBS:___________________________________________________________________
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DESCRIPCION POSTURAL
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EVALUACION POSTURAL ESTATICA
VISTA ANTERIOR
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VISTA POSTERIOR
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 VISTA LATERAL
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6. EV.ARTICULAR
7. GONIOMETRICO
IZQUIERDA MOVIMIENTO DERECHA
HOMBRO
FLEXION
EXTENSION
ABDUCCION
ADUCCION
ROTACION INTERNA
ROTACION EXTERNA
CODO
FLEXION
EXTENSION
ANTEBRAZO
PRONACION
SUPINACION
MUÑECA
FLEXION
EXTENSION
DESVIACION RADIAL
DESVIACION CUBITAL
DEDOS
FLEXION
EXTENCION
ABDUCCION
ADUCCION
OPOSICION
CADERA
FLEXION
EXTENSION
ABDUCCION
ADUCCION
ROTACION INTERNA
ROTACION EXTERNA
RODILLA
FLEXION
EXTENSION
TOBILLO
PLANTIFLEXION
DORSIFLEXION
PIE
SUPINACION
PRONACION
EVERCION
 INVERCION
DEDOS
FLEXION
EXTENCION
ABDUCCION
ADUCCION

8. EV. MUSCULAR
TONO__________________________________________________________________
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TROFISMO _____________________________________________________________
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ELASTICIDAD
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ACCION DE FUERZA MUSCULAR
0 1 2 3 4 5
MMSS
HOMBRO________________________________________________
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CODO___________________________________________________
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ANTEBRAZO______________________________________________
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MUÑECA________________________________________________
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DEDOS__________________________________________________
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MMII
CADERA_________________________________________________
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RODILLA_________________________________________________
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TOBILLLO________________________________________________
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9. EV. FISICO-FUNCIONAL
-CAMBIOS EN DECUBITO:
 SUPINO – PRONO__________________________________________________
 PRONO-SEDENTE__________________________________________________
 SEDENTE- BIPEDO_________________________________________________
-COORDINACION
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-EQUILIBRIO
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VELOCIDAD
-AVD
Elegir una activad ________________________________________________________
VESTIRCE:
 SI( ) NO ( )
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ALCANCES

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-PINSAS

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-MARCHA

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10. DIAGNOSTICO FISIOTERAPEUTICO

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11. PLAN DE TRATAMIENTO
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META
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OBJETIVOS
 GENERALES
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 ESPECIFICOS
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12. ESTATEGIAS

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