Historia sara

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ESTUDIO ORTOPODOLÓGICO

Nº Hª:____________________ 1 FECHA: 9/4/14 __________________

ANAMNESIS FECHA 1ª CONSULTA:___________________________ 9/4/14 HARO LILES SARA APELLIDOS:________________________________________NOMBRE:________________________ 78 60 157 cm F.NAC:_____________________EDAD:___________PESO:_______________TALLA:_____________ 17/1/1954 COCINERA PROFESIÓN:_____________________________ACT.DEPORTIVA:____________________________ PÓLEM, ÁCAROS DEL POLVO ALERGIAS?__________________________________________________________________________ DIABETES?___________________________________________________________________________ VACUNA DE LA ALERGIA: AERUS MEDICACIÓN HABITUAL?____________________________________________________________ DOLOR MUY INTENSO EN EL TALÓN MOTIVO 1ª CONSULTA:_______________________________________________________________ ____________________________________________________________________________________ EN EL APOYO, AL ANDAR DOLOR?_____________________________________________________________________________ NS/NC PROCEDENCIA: ______________________________________________________________________ OBSERVACIONES:____________________________________________________________________ ANTEC.FISIOLÓGICOS: -Parto____________________________________________________________________________ -Gateo___________________________________________________________________________ -Andador/Taca-Taca________________________________________________________________ -Inicio Deambulación_______________________________________________________________ - Habitos Posturales ________________________________________________________________ ENCORVADURA -Cambios Ponderales_______________________________________________________________ -Zurdo /Diestro X /Ambidiestro /__________________________________________________ -Otros___________________________________________________________________________ ANTEC.PATOLÓGICOS: UÑA INFECTADA, CULEBRINA -Patologías Previas_________________________________________________________________ _______________________________________________________________________________ -Enferm. Infantiles_________________________________________________________________ ZAPATO ORTOPODOLÓGICO IZQUIERDO -Ant. Traumáticos _________________________________________________________________ -Hª anterior de: -Distensión/Esguines ___________________________________________________ -Tendinitis/Contracturas_________________________________________________ X -Bursitis______________________________________________________________ -Capsulitis_____________________________________________________________ -Luxación/Subluxación___________________________________________________ X -Fisura/Fractura_________________________________________________________ -Enf.Reumáticas(gota, fibromialgia…)_______________________________________ X HIPERLAXITUD ARTERIAL -Ciática: ______________________________________________________________ X -Otras_________________________________________________________________ ANTEC.FAMILIARES: -Dismetrías________________________________________________________________________ X MADRE -Escoliosis_________________________________________________________________________ X MADRE -Genu varo/valgo___________________________________________________________________ MADRE -Tibias varas_______________________________________________________________________ X -Pies Planos_______________________________________________________________________ -Pies Cavos_______________________________________________________________________ X -Pies Valgos______________________________________________________________________ -Pies Zambos_____________________________________________________________________ -Metatarsus Aductus/Varus__________________________________________________________ -H.V_____________________________________________________________________________ -Dedos Garra______________________________________________________________________ 5º, 4º IZQ. -Otros____________________________________________________________________________ ____________________________________________________________________________ 1

ANTEC. PODOLÓGICOS Y TTOS PREVIOS:_____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ PLANO (38) CALZADO UTILIZA HABITUALMENTE (Nº)____________________________________________ ______________________________________________________________________________________ EXPLORACIÓN DECÚBITO SUPINO

DCHO

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IZQDO

-MEDICIÓN DE MM.II (Dismetrías):______________________________________________________ DISMETRÍA DE LA TIBIA 86/83 ______________________________________________________ ______________________________________________________ -PATRÓN ROTADOR(predominio int/ext):_________________________________________________ INTERNO -Goniómetro Pendular: (Fem/Tib.): Rot.Int.: _______________________________________ Rot.Ext. _______________________________________ -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): ___________________________________________________ -Rótulas convergentes?:______________________________________________________________ X -Rótulas divergentes?: ______________________________________________________________ -Rótulas paralelas?: ________________________________________________________________ -Angulo Q(N:15º):__________________________________________________________________ 13º ________________________________________________________________________________

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DCHO

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IZQDO

-TPA: (Movilidad Articular) 46º/43º -FP(N:40º-50º): ____________________________________________________________ -FD(N:20º-30º): ____________________________________________________________ 25º/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): __________________________________________________________ -FD(N:20º-30º): __________________________________________________________ -ASA:

-Eversión(N:30º): ________________________________________________________ -Inversión(N:60º): ________________________________________________________

-ART.MEDIOTARSIANA: -Pronación(N:15º): __________________________________________ -Supinación(N:35º): ________________________________________ *ANTEPIE -POSICIÓN O ÁNGULO DE ANTEPIE: ______________________________________________ -1º RADIO: -AMTF: -FP(N:45º) _____________________________________________________ 45º/45º -FD(N:70º): ___________________________________________________ 66º/68º -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): __________________________________________________ 39º /40º -FD(N:60º-80º): ______________________________________________ 68º/70º -IF Prox.: -FP(N:35º): ________________________________________________ -FD(N:0º): _________________________________________________ -IF Dist.: -FP(N:60º): _________________________________________________ . –FD(N:30º): _________________________________________________ 5º Meta Corto?: ______________________________________________________________ 5ºd Varo?: __________________________________________________________________ X 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: ______________________________________________________________________ NORMAL Tibial Post: __________________________________________________________________ BAJO -EXPLORACIÓN MORFOLÓGICA: -Fórm.Metatarsal: _______________________________________________________________ -Fórm.Digital: __________________________________________________________________ -Fórm. Podal: ___________________________________________________________________ -Antepie Triangular?: _____________________________________________________________ -Otros: ________________________________________________________________________ _________________________________________________________________________ 4

_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

BIPEDESTACIÓN Visión Ant: ______________________________________ _______________________________________ _______________________________________ ________________________________________ Visión Post: _______________________________________ ________________________________________ ________________________________________ ________________________________________ Visión Lateral: _____________________________________ ________________________________________ ________________________________________ ________________________________________ __________________________________________________ __________________________________________________

-Simetría/Asimetría Postural?:_____________________________________________________________ SIMETRÍA -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?:______________________________ DIM:______________________________ -G.Varo?: ______________________________ X DIC:______________________________ TIBIAS: -T.Fisiológicas?: __________________________ X -T. Valgas: _______________________________ -T.Varas: _________________________________ DCHO / IZQDO 1º VARO/ 4º VARO PIES: -Retropie: _____________________________________________________________________ -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: ___________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: VISITAS POSTERIORES: FECHA:_______________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 8

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