CABINET MEDICAL Dr.

DATA ..............................

EPICRIZ DE ETAP DIABET ZAHARAT

DATE PERSONALE : NUME
.................................................................PRENUME ................................................................
......
DIAG. DZ DIN............................ TIP DZ .........................
1. ANAMNEZ
AHC..................................................... FACT.
RISC............................................................................
A. EVALUARE STIL VIA : ALIMENTAIE.........................., ACTIVITATE
FIZIC............................................, SEDENTARISM .................................
B. CONDIII PATOLOGICE ASOCIATE : OBEZITATE GR. .......,
DISLIPIDEMII..................................................., HTA....................................................
C. AUTOMONITORIZARE : DA / NU, VALORI GLICEMICE.........................................................,
GLICOZURIE...............................................................
D. EVALUARE COMPLIAN LA TRATAMENT.........................................................., PROGRAM DE
EDUCAIE.........................................................
2. EXAMEN CLINIC : G ................., T ...................., IMC ...........................,
TA : CLINOSTATISM =
, ORTOSTATISM =
, AV =
EX.
TEGUMENTE .............................................................................................................................
...........................
EX. CARDIOVASCULAR : SUFLURI .................................... PULS
PERIFERIC.......................................................
EX. OFTALMOLOGIC : ACUITATE VIZUAL =
FO =
CATARACT = DA / NU
GLAUCOM = DA / NU
EX. NEUROLOGIC : SENSIBILITATE
TACTIL ........................................................................................................
VIBRATORIE ................................................................................................
REFLEXE : ROT TULBURRI MOTILITATE
DA / NU..
DISFUNCIE ERECTIL DA / NU
SIMPT. SUGESTIVE AIT SAU AVC DA/
NU ...........................................................................
EX. PICIOR : PULS ART. GAMB ............................,
DEFORMRI ........................., ULCERAII ..........................
3. EXP. METABOLISM GLUCIDIC : GLICEMIE BAZAL =
, Hba1c =
,
4. EXP. FUNCIE RENAL : CREATININ =
MICROALBUMINURIE = ,
5. PROFIL LIPIDIC : COLESTEROL =
,

, GLICOZURIE =

, EX. URIN =

, TRIGLICERIDE =

, CETONURIE =

, UROCULTUR =

, HDL =

, LDL =

6. ALTE EXPLORRI :
EKG .........................................................................................................................................
................................

ECOCARDIOGRAFIE
EX. OFTALMOLOGIC
7. CALITATEA VIEII ........................................................................................................
8. MANAGEMENT :
DIET ...............................................................................................
OPTIMIZARE STIL DE VIA .........................................................
COMBATERE SEDENTARISM .......................................................
SCDERE N GREUTATE .............................................................
TRATAMENT CU : HIPOGLICEMIANTE ORALE ..........................
INSULIN DA / NU
ALTELE : HTA .
IC .
CARDIOPATIE ISCHEMIC..
DISLIPIDEMII..
POLINEUROPATIE..
NEFROPATIE