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FOAIE DE OBSERVATIE CLINICA


I. DATELE DE PAAPORT
Numele de familie, prenumele_______________________________________________
Vrsta
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sexul_____________________________________
Profesiunea i specialitatea
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Domiciliul
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Diagnosticul de internare
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Diagnosticul clinic
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Diagnosticul la externare
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a)de baza______________________________________________________________
b)complicatii___________________________________________________________
c) afeciunile asociate
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II. ACUZELE BOLNAVULUI


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III. ISTORICUL ACTUALEI BOLI
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IV. ANAMNEZA (ISTORICUL) VIEII


1.Date succinte biografice-_________________________________________________________________
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2.Conditii de munc.______________________________________________________________________
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3..Antecedentele personale fiziologice -_______________________________________________________
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4.Deprinderile nocive _____________________________________________________________________
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5.Antecendentele personale patologice _______________________________________________________
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6.Anamneza alergologic _________________________________________________________________
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7.Anamneza de asigurare social __________________________________________________________
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8.Antecendentele eredocolaterale _________________________________________________________
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V. STAREA PREZENT A BOLNAVULUI


1Inspecia general.
Starea general a bolnavului:_________________________________________________________
Contiina bolnavului: ______________________________________________________________
Poziia bolnavului__________________________________________________________________
Facies___________________________________________________________________________
Tipul constituional: _________________________________________________________________
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Tegumentele i mucoasele vizibile_____________________________________________________
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Fanere:.__________________________________________________________________________
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esutul adipos :_______________________________________________________________________
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Edeme:__________________________________________________________________________
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Ganglioni limfatici: _________________________________________________________________
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Capul:___________________________________________________________________________
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Gtul:_____________________________________________________________________________
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Muchii: ____________________________________________________________________________
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Oasele:_________________________________________________________________________________
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Articulaiil: _______________________________________________________________________
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2.APARATUL RESPIRATOR
Acuzele_______________________________________________________________________________________
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Inspecia
Nasul:__________________________________________________________________________________
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Vocea: __________________________________________________________________________
Cutia toracic___________________________________________________________________________
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Tipul respiraiei :__________________________________________________________________
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Excursia respiratorie a cutiei toracice: _________________________________________________
Palpaia
Palparea simetricitatii_______________________________________________________________
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Determinarea elesticitatii________________________________________________________________
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Evidentierea punctelor dureroase_________________________________________________________
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Trasmiterea vibratiei vocale__________________________________________________________
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Percuia
Percuia comparativ: ___________________________________________________________________
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Percuia topografic:
nlimea apexelor plmnilor din partea
Anterior
Posterior
Limea benzilor Kroning
Limita inferioar a plmnilor
lin. parasternal
lin. medioclavicular
lin. axilar anterioar

Dreapta

stnga

lin. axilar medie


lin. axilar posterioar
lin. Scapular
lin. paravertebral
Mobilitatea maximal a limitei inferioare a plmnului
Pe linia axilar medie
Limea hilului pulmonar

Auscultaia
Caracterul respiraiei:__________________________________________________________________
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Zgomotele respiratorii supraadugate: _____________________________________________________
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3.APARATUL CARDIO- VASCULAR


Acuzele_______________________________________________________________________________________
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Inspecia______________________________________________________________________________________
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Palpaia_______________________________________________________________________________________
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Percuia______________________________________________________________________________________
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Auscultaia____________________________________________________________________________________
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Examinarea vaselor sanguine___________________________________________________________________
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