Universitatea Transilvania -Brasov

Facultatea de Medicina
Judeul ..................

Specializare: MG
Anul: III

ntocmit de: ...............................................................

Grupa: ...............................................................

Localitatea .....................................................
Spitalul ............................................................

Nr. nregistrare SC

Secia ................................................................

CNP pacient

FOAIE DE OBSERVAIE CLINIC GENERAL

NUMELE ......................................... PRENUMELE ........................................................ Sexul M/F
lun

an

Domiciliul legal: judeul

Sect.

Mediul U/R

Grup sangvin: A/B/AB/0; Rh + / -

Localitatea .......................................................... Alergic la: ..............................................................

Str. ....................................................................... Nr. ...... Data internrii:

Reedina: judeul

Localitatea .........................................................................

zi

Sect.

Str. ....................................................................... Nr. ......

Data externrii:

Mediul U/R

Cetenie:

Romn

Strin

Greutatea la natere (nou nscui)

ora

NT

Data naterii: zi

lun

an

ora

....
grame

zi

Ocupaia: fr ocupaie (1); salariat (2); lucrtor pe cont propriu (3);

patron (4); agricultor (5); elev/ student (6); omer (7); pensionar (8)

lun

an

Nr. zile spitalizare .........................................

Nr. zile c.m. la externare .........................

Locul de munc ..............................................................................
Nivel de instruire: fr studii (1); ciclu primar (2); ciclu gimnazial (3); coal profesional (4); liceu (5)
coal postliceal (6); studii superioare de scurt durat (7); studii superioare (8); nespecificat (9)
Nr.

Certificat natere (copil) seria

UD
E

C.I / B.I. seria

Statut asigurat:

Asigurat CNAS

Asig. oblig. CAS

Nr.

Asigurare voluntar

Asig. facultativ CAS

Eurocard

Neasigurat

Acorduri internaionale

Categ. asig. CNAS: salariat (1); coasig. (2); pensionar (3); copil<18 ani (4); elev/ucenic/student 18-26 ani (5);
gravid (6) veteran (7); revoluionar (8); handicap (9); PNS (10); ajutor social (11); omaj (12); alte (13)

Tipul internrii: urgen (1); trimit. MF (2); trimit. ambulatoriu (3); transfer interspit. (4); la cerere (5); alte (9)
Criteriu internare: urgen (1); diagnostic (2); tratament (3); nedeplasabil (4) epidemiologic (5); medic ef (6)
Diagnosticul de trimitere: .................................................................................................................................

................................ .......................................... ................................ ................................ ...........................

Diagnosticul la internare: .................................................................................................................................

................................ ................................ ....................... ........ ..............................................

Semntura i parafa medicului

................................................

Diagnosticul la 72 de ore: .............................. ................................ ................................ ................................ ................................ ..............................

.................................................................................................................................................................................................................................................................

ST

Diagnosticul principal la externare:................................ ................................ ..................... ...............................................

................................ ................................ ........................................ ................................ ................................ ...........................................

Diagnostice secundare la externare (complicaii / comorbiditi):

1. ................................ ................................ ........................................ ................................ ................................ ...........................................

2. ................................ ................................ ........................................ ................................ ................................ ...........................................
3. ................................ ................................ ........................................ ................................ ................................ ...........................................
4. ................................ ................................ ........................................ ................................ ................................ ...........................................
5. ................................ ................................ ........................................ ................................ ................................ ...........................................
6. ................................ ................................ ........................................ ................................ ................................ ...........................................
Semntura i parafa medicului ef
...............................................

Semntura i parafa medicului curant

.......................................................

23.3 A4 t2

Intervenia chirurgical principal: .....................................................................................................................................................................

..................................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................

Consimmntul pentru intervenie: ...........................................................................................................................................................................

medic operator principal ............................................................................................................................................
Echipa operatorie:

medic operator II

medic operator III

Data interveniei chirurgicale: zi

...........................................................

medic ATI

..........................................................

asistent/

luna

..........................................................

..............................................................

an

Intervenii chirurgicale concomitente (cu cea principal):

1........................................................................................................................................

medic operator principal ............................................................................................................................................

Echipa operatorie:

medic operator II

...........................................................

medic operator III

..........................................................

medic ATI

asistent/

..........................................................

..............................................................

EN

2........................................................................................................................................

medic operator principal ............................................................................................................................................

Echipa operatorie:

medic operator II

...........................................................

medic ATI

medic operator III

..........................................................

asistent/

..........................................................

..............................................................

Alte intervenii chirurgicale:

1........................................................................................................................................

medic operator principal ............................................................................................................................................

medic operator II

...........................................................

medic ATI

medic operator III

..........................................................

asistent/

UD

Echipa operatorie:

..........................................................

..............................................................

Data interveniei chirurgicale: zi

luna
an
2........................................................................................................................................
medic operator principal ............................................................................................................................................

Echipa operatorie:

medic operator II

medic operator III

Data interveniei chirurgicale: zi

...........................................................

medic ATI

..........................................................

asistent/

luna

..........................................................

..............................................................

an

Examen citologic ..................................................................................................... ................................................................................................................

Examen extemporaneu ..................................................................................................... ...................................................................................................
Examen histopatologic (biopsie pies operatorie) .....................................................................................................
...................................

ST

Transfer ntre seciile spitalului:

Secia

Diagnostic

Data intrrii (ora) Data ieirii (ora)

Starea la externare: vindecat (1); ameliorat (2); staionar (3); agravat (4); decedat (5)
Tipul externrii: externat (1); externat la cerere (2); transfer interspitalicesc (3); decedat (4)
Deces: intraoperator (1); postoperator: 0 23 ore (2); 24 47 ore (3); > 48 ore (4)
Data i ora decesului:

zi

luna

an

ora
2

Nr. zile
spitalizare

Diagnostic n caz de deces:

a. Cauza direct (imediat) .............................................................. .............................................................. ..........................................
b. Cauza antecedent .............................................................. .............................................................. .........................................................
I
Stri morbide iniiale:
c. .............................................................. .............................................................. .......................................................................................................
d. .............................................................. .............................................................. .......................................................................................................
II

Alte stri morbide importante .............................................................. .............................................................. ........................................

.............................................................. ..................................................................................................................... .........................................................

Diagnostic anatomo-patologic (autopsie), macroscopic: ...........................................................................................................................

.............................................................. ..................................................................................................................... .............................................................................

.............................................................. ..................................................................................................................... .............................................................................

.............................................................. ..................................................................................................................... .............................................................................

Microscopic: .............................................................. ..................................................................................................................... ...........................................

EN

.............................................................. ..................................................................................................................... .............................................................................

.............................................................. ..................................................................................................................... .............................................................................

.............................................................. ..................................................................................................................... .............................................................................

Codul morfologic (n caz de cancer)

Explorri funcionale:

Denumirea

Codul

Nr.

Codul

Nr.

Codul

Nr.

1. .............................................................. ....................................................................................................
2. .............................................................. ....................................................................................................

3. .............................................................. ....................................................................................................

UD

4. .............................................................. ....................................................................................................
5. .............................................................. ....................................................................................................
6. .............................................................. ....................................................................................................

Investigaii radiologice:

Denumirea

7. .............................................................. ....................................................................................................
8. ............................................................. ....................................................................................................
9. ............................................................. ....................................................................................................
10. ............................................................. ....................................................................................................

ST

11. ............................................................. ....................................................................................................

12. ............................................................. ....................................................................................................

Alte proceduri terapeutice:

Denumirea

13. ............................................................. ....................................................................................................

14. ............................................................. ....................................................................................................
15. ............................................................. ....................................................................................................
16. ............................................................. ....................................................................................................
17. ............................................................. ....................................................................................................
18. ............................................................. ....................................................................................................

ALTE OBSERVAII:
1

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

MOTIVELE INTERNRII: .............................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

ANAMNEZA: ...........................................................................................................................................................................................................................

NT

a) Antecedente heredo-colaterale ..........................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

b) Antecedente personale, fiziologice i patologice ................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

UD
E

c) Condiii de via i munc .....................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

d) Comportamente (fumat, alcool etc.)

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

e) Medicaie de fond administrat naintea internrii (inclusiv preparate hormonale i imunosupresoare

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

ISTORICUL BOLII: ..............................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

ST

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

EXAMENUL CLINIC GENERAL .............................................................................................................................................................................

EXAMEN OBIECTIV .........................................................................................................................................................................................................

Starea general ...................................................................................................... Talie ....................................... Greutate ...............................

Starea de nutriie .................................................................................. Starea de contien ............................................................................
Facies .............................................................................................................................................................................................................................................
Tegumente .................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

Mucoase ......................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

NT

Fanere ............................................................................................................................................................................................................................................
esut conjunctiv-adipos ..................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

Sistem ganglionar ................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

Sistem muscular ....................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

Sistem osteo-articular .......................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

UD
E

.............................................................................................................................................................................................................................................................

APARAT RESPIRATOR ...................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

APARAT CARDIOVASCULAR ..................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

APARAT DIGESTIV ...................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

FICAT, CI BILIARE, SPLINA ...................................................................................................................................................................................

ST

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

APARAT URO-GENITAL ...............................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

SISTEM NERVOS, ENDOCRIN, ORGANE DE SIM .................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

EXAMEN ONCOLOGIC: .................................................................................................................................................................................................

1. Cavitatea bucal ............................................................................... ............................................................................... ...............................................
2. Tegumente ............................................................................... ............................................................................................ ..............................................
3. Grupe ganglioni palpabile ............................................................................... ............................................................................... ........................
4. Sn ............................................................................... ............................................................................................................. ...............................................
5. Organe genitale feminine ............................................................................... ............................................................................... .........................
6. Citologia secreiei vaginale ............................................................................... ............................................................................... .........................
7. Prostat i Rect ....................................................................................................... ............................................................................... .........................
8. Alte ............................................................................... .................................................................................................................................. .........................

NT

................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

ALTE EXAMENE DE SPECIALITATE ..................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

UD
E

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

EXAMENE DE LABORATOR ......................................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

EXAMENE RADIOLOGICE (rezultate) .................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

ST

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

EXAMENE ECOGRAFICE (rezultate) ...................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

INTERVENII CHIRURGICALE (numrul interveniei chirurgicale, protocol operator):

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

NT

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

UD
E

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

EXAMENE ANATOMO-PATOLOGICE: .............................................................................................................................................................

ST

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

SUSINEREA DIAGNOSTICULUI I TRATAMENTULUI:

CLINIC: ..................................................................................... ............................................................................... ..................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

NT

PARACLINIC: ....................................................................... ............................................................................... ...................................................

.................................................. ............................................................................. ............................................................................... ............................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

UD
E

EPICRIZA: ...................................................................................... ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

ST

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

Semntura i parafa medicului,

......................................................

FOAIE DE TEMPERATUR ADULI

ST

CNP

Numele . Prenumele ....

Anul luna Nr. foii de observaie Nr. salon .. Nr. pat ..

T.A.

Puls

Temp

30

160

41O

30

25

140

40O

25

20

120

39O

20

15

100

38O

15

10

80

37O

10

60

36O

Lichide ingerate
Diurez
Scaune
Diet

D S

D S

D S

D S D S

D S

D S

D S D S D S D S

D S D S D S D S

D S D S D S D S

D S D S D S D S

EN

35

D S

UD

Resp.

Ziua
Zile de boal

D S D S D S

FOAIE DE EVOLUIE I TRATAMENT

EVOLUIE

TRATAMENT

ST

UD
E

NT

DATA

10