Universitatea de Stat de Medicin i Farmacie

Nicolae Testemianu

Catedra__________________________________________________
ef.catedrei_________________________________
Conductor gr.______________________________
Curator____________________________________
Grupa_______________ anul__________________
Facultatea__________________________________

FI DE OBSERVAIE

Data currii__________________

- Chiinu 2012 -

EXAMENUL CLINIC
I. DATE PAAPORTALE
Nume,prenume____________________________________________________________________________
_
Vrsta____________________________________________________________________________________
Sexul
____________________________________________________________________________________
Adresa ___________________________________________________________________________________
Ocupatia__________________________________________________________________________________
Data internrii______________________________ Ora___________________________________________
Institutia care a trimis bolnavul________________________________________________________________
Diagnosticul la internare_____________________________________________________________________

DIAGNOSTICUL CLINIC.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

II. Acuzele
La ziua curatiei:
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
La internare:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
III. Anamneza

bolii

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

IV. ANAMNEZA VIEII

1.Date biografice
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2.Anamneza sexual
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3.Antecedente patologice
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4.Deprinderi duntoare
5.Antecedente familiale.
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
6. Anamneza alergologic
Intolerana la
medicamente____________________________________________________________________
Vaccinuri_________________________________________________________________________________
Alimente_________________________________________________________________________________
_
3

V. STAREA GENERAL.
1. INSPECIE.
Stare
general_____________________________________________________________________________
Contiina________________________________________________________________________________
Poziia___________________________________________________________________________________
Faciesul
__________________________________________________________________________________
Constituia___________________ talia________________ masa
corpului__________________________________________________________________________________
_________________________________________________________________________________________
_
Tegumentele, mucoasele i anexele pielii
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
umeditatea i
turgorul________________________________________________________________________
esutul
celuloadipos________________________________________________________________________
Edeme___________________________________________________________________________________
Ganglionii
limfatici_________________________________________________________________________
Capul____________________________________________________________________________________
Gtul____________________________________________________________________________________
_
Pulsarea patologic a carotidelor_______________________________________________________________
Muchii: nivelul de dezvoltare, tonusul
_________________________________________________________________________________________
_________________________________________________________________________________________
Dureri la
palpare____________________________________________________________________________
Oasele: prezena deformaiilor, dureri. Modificarea oaselor
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Articulaiile: schimbarea conturului, edeme, hiperemie,
durere.___________________________________________________________________________________
4

_________________________________________________________________________________________
_
limitarea
micrilor_________________________________________________________________________________
_________________________________________________________________________________________
2.SISTEMUL RESPIRATOR.
ACUZE.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
INSPECIE.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PALPARE.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PERCUIE.
Comparativ:.____________________________________________________________________________
_
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Topografic:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
5

AUSCULTAIE.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

3. APARATUL CARDIOVASCULAR.
ACUZE.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PALPARE.
Caracteristica ocului apexian
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PERCUIE.

Limita relativ a cordului

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Limita absolut a cordului
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
AUSCULTAIE.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
FCC n minut______________
Pulsul_____________________
TA :_______________________

4. TRACTUL GASTROINTESTINAL
ACUZE.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________
INSPECIE.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PALPARE.
Palpare superficial_______________________________________________________________________________
_________________________________________________________________________________________________
Palparea dup Obrasov-Strjescu____________________________________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PERCUIE.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Ficatul i vezica biliara
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Splina

___________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
5. SISTEMUL URINAR.
ACUZE.
_________________________________________________________________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________
Palparea:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Percutia:
_________________________________________________________________________________________
_________________________________________________________________________________________

6. SISTEMUL HEMATOPOETIC.
ACUZE.
_________________________________________________________________________________________________
_________________________________________________________________________________________________

PALPAREA

Oaselor (regiuni dureroase)

_________________________________________________________________________________________
_________________________________________________________________________________________

7. SISTEMUL ENDOCRIN.
_________________________________________________________________________________________________
________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________

8. STAREA NEUROPSIHIC.
Contiina: clar, difuz, com, sopor, stupor, delir, halucinaii
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Dispoziia: indiferent, indispoziie, apatie, obinuit,iritabilitate

_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. ORGANELE DE SIM.
Sensibilitatea____________________________________________________________________________________
_

Vzul___________________________________________________________________________________________
_

Auzul___________________________________________________________________________________________
_

VI. CLINICA DERMATOLOGIC (status localis)

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
8

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
VII. INDIVIDUALIZAREA DERMATOZEI LA BOLNAVUL CONCRET.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
VIII. DIAGNOSTIC PREZUMPTIV
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
9

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
IX. PLANUL DE INVESTIGAIE.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

X. REZULTATELE ANALIZELOR DE LABORATOR I A ALTOR

INVESTIGAII EFECTUATE.

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
10

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
11

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
___________________________________________________________
XI. DIAGNOSTIC DIFERENIAL.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
12

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

XII. DIAGNOSTICUL CLINIC, ARGUMENTAREA

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
13

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

XIII. Evolutia zilnic

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
14

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_______________________________
XIV. RECOMANDRI I PROGNOSTIC
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

XVI. EPICRIZA
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
15

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
____________________

16