ESTUDIO ORTOPODOLÓGICO
Nº Hª:____________________ 3 FECHA: __________________ 11/4/2014
ANAMNESIS FECHA 1ª CONSULTA:___________________________ 11/4/14 APELLIDOS:________________________________________NOMBRE:________________________ CRISTINA ORTEGA RUIZ F.NAC:_____________________EDAD:___________PESO:_______________TALLA:_____________ 166cm 6/6/1989 26 68 MAESTRA PROFESIÓN:_____________________________ACT.DEPORTIVA:____________________________ NATACIÓN ALERGIAS?__________________________________________________________________________ DIABETES?___________________________________________________________________________ MEDICACIÓN HABITUAL?____________________________________________________________ MOTIVO 1ª CONSULTA:_______________________________________________________________ ALTERACIÓN UÑAS PIES ____________________________________________________________________________________ DOLOR?_____________________________________________________________________________ PROCEDENCIA: ______________________________________________________________________ 2-3 MESES OBSERVACIONES:____________________________________________________________________ ANTEC.FISIOLÓGICOS: -Parto____________________________________________________________________________ -Gateo___________________________________________________________________________ -Andador/Taca-Taca________________________________________________________________ X -Inicio Deambulación_______________________________________________________________ 2 AÑOS - Habitos Posturales ________________________________________________________________ GATEO ARRASTRANDO PIERNAS ROTADAS EXTERNAMENTE -Cambios Ponderales_______________________________________________________________ -Zurdo /Diestro X /Ambidiestro /__________________________________________________ -Otros___________________________________________________________________________ ANTEC.PATOLÓGICOS: -Patologías Previas_________________________________________________________________ ONICOLISIS _______________________________________________________________________________ -Enferm. Infantiles_________________________________________________________________ -Ant. Traumáticos _________________________________________________________________ -Hª anterior de: -Distensión/Esguines ___________________________________________________ -Tendinitis/Contracturas_________________________________________________ X POSTERIOR MUSLO -Bursitis______________________________________________________________ -Capsulitis_____________________________________________________________ -Luxación/Subluxación___________________________________________________ -Fisura/Fractura_________________________________________________________ -Enf.Reumáticas(gota, fibromialgia…)_______________________________________ -Ciática: ______________________________________________________________ -Otras_________________________________________________________________ ANTEC.FAMILIARES: -Dismetrías________________________________________________________________________ -Escoliosis_________________________________________________________________________ -Genu varo/valgo___________________________________________________________________ -Tibias varas_______________________________________________________________________ -Pies Planos_______________________________________________________________________ -Pies Cavos_______________________________________________________________________ -Pies Valgos______________________________________________________________________ -Pies Zambos_____________________________________________________________________ -Metatarsus Aductus/Varus__________________________________________________________ MUY LEVE -H.V_____________________________________________________________________________ -Dedos Garra______________________________________________________________________ X -Otros____________________________________________________________________________ ____________________________________________________________________________ 1
ANTEC. PODOLÓGICOS Y TTOS PREVIOS:_____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ CALZADO UTILIZA HABITUALMENTE (Nº)____________________________________________ ______________________________________________________________________________________ EXPLORACIÓN DECÚBITO SUPINO
DCHO
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IZQDO
86/86 -MEDICIÓN DE MM.II (Dismetrías):______________________________________________________
______________________________________________________ ______________________________________________________ -PATRÓN ROTADOR(predominio int/ext):_________________________________________________ IGUAL -Goniómetro Pendular: (Fem/Tib.): Rot.Int.: _______________________________________ 40 Rot.Ext. _______________________________________ 40 -CADERA: (Movilidad Articular) -Flexión(N:130º-140º): _______________________________________________________ -Extensión(N:0º):___________________________________________________________ -Hiperextensión(N:10º-12º):___________________________________________________ -Abducción(N:30º-50º): ______________________________________________________ -Aducción(N:20º-30º): _______________________________________________________ -Rot.Int.(N:30º-45º): _________________________________________________________ -Rot.Ext.(N:40º-50º): ________________________________________________________ __________________________________________________________________________ -RODILLA: (Movilidad Articular) -Flexión(N:120º-150º): ________________________________________________________ -Extensión(N:0º)____________________________________________________________ -Hiperextensión(N:5º-10º)_____________________________________________________ _________________________________________________________________________ X -Genu-valgo(Reductible/Irreductible): __________________________________________________ -Genu-varo(Reductible/Irreductible): ___________________________________________________ X -Rótulas convergentes?:______________________________________________________________ -Rótulas divergentes?: ______________________________________________________________ -Rótulas paralelas?: ________________________________________________________________ 14º -Angulo Q(N:15º):__________________________________________________________________ ________________________________________________________________________________
2
DCHO
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IZQDO
-TPA: (Movilidad Articular) -FP(N:40º-50º): ____________________________________________________________ 44º/43º -FD(N:20º-30º): ____________________________________________________________ 23º/23º DECÚBITO PRONO -CADERA(Movilidad Articular) -R.Int.(N:30º): _____________________________________________________________ -R.Ext.(N:60º): ______________________________________________________________ -TORSIÓN FEMORAL(N:45º) -T.Fem.Int. o Ant: __________________________________________________________ -T.Fem.Ext. o Post: __________________________________________________________ -TORSIÓN TIBIAL(N:15º-20º) -T.T.I: ____________________________________________________________________ -T.T.E: ____________________________________________________________________ SEDESTACIÓN -ANTEVERSIÓN FEMORAL ? (N:8º-10ºadulto/N:12ºniño): ___________________________________ -ÁNG. TORSIÓN BIMALEOLAR(N:15º-20º): ______________________________________________ -MANIOBRA DE ROTES(Hiperlaxitud Articular): ___________________________________________ -EXPLORACIÓN ARTICULAR: *RETROPIE -TPA: -FP(N:40º-50º): __________________________________________________________ 49º/47º -FD(N:20º-30º): __________________________________________________________ 26º/26º -ASA:
-Eversión(N:30º): ________________________________________________________ 30º/30º -Inversión(N:60º): ________________________________________________________ 58º/60º
-ART.MEDIOTARSIANA: -Pronación(N:15º): __________________________________________ -Supinación(N:35º): ________________________________________ X *ANTEPIE -POSICIÓN O ÁNGULO DE ANTEPIE: ______________________________________________ 42º/45º -1º RADIO: -AMTF: -FP(N:45º) _____________________________________________________ -FD(N:70º): 70º/70º ___________________________________________________ -Falange Distal: -FP(N:80º):_______________________________________________ -FD(N:0º): ______________________________________________ Longitud 1º meta (Maniobra Doble Pinza): ________________________________________ Hallux Límitus?: ____________________________________________________________ Hallux Rígidus?:____________________________________________________________ Hallux Flexus?: ____________________________________________________________ Hallux Hiperextensus?: ______________________________________________________ H.V?: ____________________________________________________________________ Otros: ____________________________________________________________________ -2º-5º RADIO: -AMTF: -FP(N:40º): __________________________________________________ 38º/40º -FD(N:60º-80º): ______________________________________________ 66º/68º -IF Prox.: -FP(N:35º): ________________________________________________ -FD(N:0º): _________________________________________________ -IF Dist.: -FP(N:60º): _________________________________________________ . –FD(N:30º): _________________________________________________ 5º Meta Corto?: ______________________________________________________________ 5ºd Varo?: __________________________________________________________________ 5º Hipermóvil?: ______________________________________________________________ Juanete de Sastre?: ____________________________________________________________ Metatarsus Laxus?(Test de Kellikian):_____________________________________________ Dedos Garra(reductible/irreductible)?: ____________________________________________ Otros: _____________________________________________________________________ 3
DCHO
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IZQDO
-EXPLORACIÓN MUSCULAR: Aductores Cadera…………………… ________________________________________________ Cuadriceps Femoral…………………._________________________________________________ Isquiotibiales…………………………_________________________________________________ Triceps………………………………._________________________________________________ Soleo…………………………………_________________________________________________ Tibial Posterior………………………_________________________________________________ Flex.Prop.1ºd y Flex. Común dedos…_________________________________________________ PLC Y PLL…………………………._________________________________________________ Tibial Anterior y Ext.Prop.1ºd………_________________________________________________ Ext.Común dedos y Peroneo Ant……_________________________________________________ T.A……………………………… Ext.Prop.1ºd……………………. Ext.Común dedos ……………… P.Ant.…………………………… T.P……………………………… Flex.Prop.1ºd…………………… Flex.Común dedos……………... Triceps Sural…………………… Plantar Delgado………………… PLL…………………………….. PLC……………………………. PLL……………………………... PLC…………………………….. P.Ant……………………………. Ext.Común dedos………………. T.A…………………………….. Ext.Prop.1ºd…………………… T.P…………………………….. Flex.Común dedos……………. Flex.Prop.1ºd…………………. Triceps Sural………………….
F.D.: ___________________________________________
F.P.: ____________________________________________
Pronación: _______________________________________
Supinación: ______________________________________
-Simetrías/Asimetrías de masas musculares? ______________________________________________ -Otros: ____________________________________________________________________________ -PALPACIÓN PTOS DOLOROSOS: _______________________________________________________ _______________________________________________________ -PULSOS : Pedio: ______________________________________________________________________ Tibial Post: __________________________________________________________________ -EXPLORACIÓN MORFOLÓGICA: -Fórm.Metatarsal: _______________________________________________________________ -Fórm.Digital: __________________________________________________________________ -Fórm. Podal: ___________________________________________________________________ -Antepie Triangular?: _____________________________________________________________ -Otros: ________________________________________________________________________ _________________________________________________________________________ 4
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
BIPEDESTACIÓN Visión Ant: ______________________________________ _______________________________________ _______________________________________ ________________________________________ Visión Post: _______________________________________ ________________________________________ ________________________________________ ________________________________________ Visión Lateral: _____________________________________ ________________________________________ ________________________________________ ________________________________________ __________________________________________________ __________________________________________________
-Simetría/Asimetría Postural?:_____________________________________________________________ ASIMETRÍA -Báscula Escapular?: ____________________________________________________________________ -Báscula Pélvica(dismetría,mm)?: __________________________________________________________ -Posición Escoliótica?: __________________________________________________________________ -Test de Adams(gibosidad)?: _____________________________________________________________ -Simetría/Asimetría Pliegues Subglúteos?: __________________________________________________ -Simetría/Asimetría Huecos Poplíteos?: ____________________________________________________ -Pruebas de Isquiotibiales Cortos?: ________________________________________________________ 5
GENU: -G.Fisiológico?:___________________________ -G. Valgo?:______________________________ X DIM:______________________________ -G.Varo?: ______________________________ DIC:______________________________ TIBIAS: -T.Fisiológicas?: __________________________ -T. Valgas: _______________________________ -T.Varas: _________________________________ X DCHO / IZQDO PIES: -Retropie: _____________________________________________________________________ 6º VARO/ 2º VARO -Antepie: ______________________________________________________________________ -Algún Radio Insuficiente? ________________________________________________________ -Sobrecarga de algún Meta? _______________________________________________________ LÍNEA DE HELBING: ________________________________________________________________ LÍNEA DE FEISS: ____________________________________________________________________ LÍNEA DE MEYER: __________________________________________________________________ IMAGEN PODOSCOPIO(Huella): _______________________________________________________ _______________________________________________________ ANÁLISIS EN DINÁMICA BANCO DE MARCHA: Visión Ant.: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Visión Post.: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Ángulo de Fick(N:15º) ________________________________________________________ Desarrollo del Paso: -Choque de Talón: ____________________________________________________________ -Apoyo Total del Pie: _________________________________________________________ -Despegue Dedos: ____________________________________________________________ Otros: _________________________________________________________________________ ESTUDIO DE PRESIONES(PODOBIT): En Estática: _________________________________________________________________ _________________________________________________________________ En Dinámica: _______________________________________________________________ _________________________________________________________________ Otros: ___________________________________________________________________________ ___________________________________________________________________________ DEAMBULACIÓN CON CALZADO: ____________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 6
ESTUDIO DEL CALZADO DESGASTE/DEFORMIDAD (Escarpología):___________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ PRUEBAS COMPLEMENTARIAS PEDIGRAFÍA: ______________________________________________________________ RX: _______________________________________________________________________ _______________________________________________________________________ ANÁLISIS SANGUÍNEO: _____________________________________________________ CULTIVO: _________________________________________________________________ DOPPLER: _________________________________________________________________ OTRAS: ____________________________________________________________________ _____________________________________________________________________ FOTOS (fecha): ______________________________________________________________ _______________________________________________________________ ______________________________________________________________ DIAGNÓSTICO _____________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ TRATAMIENTO FÍSICO: _______________________________________________________________________ EJERCICIOS PROPIOCEPTIVOS: _________________________________________________ ______________________________________________________________________________ FARMACOLÓGICO: ___________________________________________________________ QUIROPODOLÓGICO: _________________________________________________________ ORTOSIS DIGITAL: ___________________________________________________________ _____________________________________________________________________________ SOPORTE PLANTAR: _________________________________________________________ TAD:_______________________________________________________ Termomoldeables:_____________________________________________ Resinas: ____________________________________________________ Blandos/Espumas:_____________________________________________ Polipropileno:________________________________________________ Componentes:_______________________________________________ Otros: _____________________________________________________ VENDAJE FUNCIONAL: _______________________________________________________ _____________________________________________________________________________ PREVENTIVO: _______________________________________________________________ CALZADOTERAPIA: __________________________________________________________ _____________________________________________________________________________ OTROS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 7
ATENDIDO POR (fecha): ______________________________________________________________ _____________________________________________________________________ TARIFA ( precio): _____________________________________________________________________ _____________________________________________________________________ OBSERVACIONES: ___________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
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