ANAMNEZA

DATE GENERALE
Numele; prenumele________________________________________
Profesiunea_______________________________________________
Instituia unde lucreaz_____________________________________
Domiciliu_________________________________________________
Etatea____________________________________________________
Studiile ___________________________________________________
Vrsta_____________________________________________________

Grupa 302
Felceri

DIAGNOSTICUL_________________________________________________________________________
ACUZELE LA INTERNARE
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ISTORICUL ACTUALEI BOLI

-debutul bolii: brusc, acut , lent, cronic
-motivele mbolnvirii _______________________________________________________________________________________
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-tratamentul urmat i eficacitatea acestuia_____________________ ___________________________________________________
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Anamneza de asigurare: este sau nu asigurat;

Condiiile de munc____________________________________________________________________
Stajul de munc____________________________
Grupa de invaliditate _________________cnd a fost determinat_______________________________

ANAMNEZA SEXUAL
Pentru femei- cnd a nceput menstruaia___________ ;evoluia ciclului( abundent sau neabundent;
Dureroas sau nedureroas; durata n zile__________; periodicitatea_______________ )
-hipertermie legat de ciclu menstrual(nainte, pa parcurs sau dup)
-vrsta cstoriei______; sarcini_____ ; nateri_____ ; avorturi_______(spontane, provocate terapeutice)
-vrsta climaxului; manifestri (dureri de cap, ameeli , iritabilitate)______________________________
Pentru brbai
-de la ce vrst e cstorit_____ ; a avut sarcini soia ______cte_____ ;ci copii are______ ; Relaiile n
familie_______________________________________________________________________________
Antecedente patologice_____________________________________________________________
Anamneza alergologic _________________________________________________________________
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Deprinderi duntoare_________________________________________________________________

Date obiective
Starea general: (satisfctoare; de graviditate mede; extrem de grav)corespunde vrstei: DA/NU
Cunotina :clar, confuz ,stupoare , supor, delir , halucinaii, com.
Expresia feei: obinuit; cu semne de durere; spaim; bucurie; indiferen; tumefiat; cianotic; tetanic acromegalie; hippocratic
Tipul constituional: astenic; normostenic; hiperstenic. Dezvoltarea fizic: insuficient ; accelerat ;atletic. H- ____ cm. G ___ kg
Tegumentele, mucoasele: CULOAREA___________________ ; Umede sau uscate ; Turgorul cutanat______________________
Reea venoas pronunat local: DA/NU; Integritatea tegumentelor: descuamaii; erupii; excoriaii; ulcere ; fistule ; cicatrice ;
pigmentare ; depigmentare peteie ; xantome ; stelue vasculare.
Prul :tipul pilozitii, ncrunire , hipertrihoz. Starea prului: fragil, cdere n focar , alopeie __________________________
Unghiile: luciu, matitate, striaii transversale, fragile, forma asemntoare cu sticla ceasornicului.
esutul celulo-adipos subcutan: caecsie; nutriie sczut, satisfctoare; exagerat. Grosimea cutei (spaiul Traube
la brbai)___cm. regiunea iliac la femei _____cm Locuri unde predomin depunerile de grsimi___________________________
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Edeme : localizarea ____________________ de origine___________________ rspndirea _____________________
Ganglionii limfatici: suboccipitali______________, submaxilari____________, preuriculari___________, axilari ______________,
inghinali________________, supra- i subclaviculari_________________ consistena ________________, forma_______________
Dureroi sa nu la palpare.
Muchii: bine sau insuficient dezvoltai; atrofie , tonus_________________, induraie_____________________________________
___________________, senzaie dureroas________________________________________________________________________
esutul osos________________________________________________________________________________________________
Articulaiile________________________________________________________________________________________________
P-_______ bti /min ;R- _______ respiraii /min Tensiunea arterial-____________ mm/Hg
Examenul de laborator_______________________________________________________________________________________
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Examenul instrumental______________________________________________________________________________________
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Palparea___________________________________________________________________________________________________
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Auscultaia________________________________________________________________________________________________
Percuia___________________________________________________________________________________________________