FISA /CPU SPITAL JUNITATE PRIMIRE URGENTE PACIENT STARE PACIENT. Nig Nume: [so-Resusct Diat-crite Dte-Pretaat a Lore: prenume:| LitLitit it drys. urgent : EB aa aa 1 33-Non-urg. 141-0ra prim consult modi \Varsta: |_| | Data nasterit Lt Jom) ae 11112- Grup sanguin: |__| Ora] clul | clv Slo [ees Funefi vital [a preluare: Feros Adus de: Adusdele: | Fis6 decedat [130-Resuscitare a ora: |_| |_| JP Av Drssas Drr-domictu |e cerca Elo-Reugt Puls| eo ae Te7-cumaney. [4t-Nereusitoré deces:|_| | | J] TA -Ailoace prop .0¢ public 7 ae does. incurs Py42-Mothul neinceperi esusctéri S2¥ | Dite.an: Dz0-L0c munca | Somes incre Fisene: LLL 11 1 Bata Ober = rauma ANAMNEZA TRIAJ ANTECEDENTE PATOLOGICE Observatii General Ochi DicaroiAce 14 -Taie(o) enone 1 68-Pierdere ac. a ved IINEUROLOGICE 1 15-Greutate(kg). (67-Tulb. de vedere ORENALE D t6-Febra Doe-comp sirin intraoe. DIPULMONARE D1 17-Astenie Tlee-Alte manit. oculare rec 1 t8-Ametel Dinerarice pe Torace-ospiratio castaice 118-08 resp. s. afectate oe ead DIDIABET ZAHARAT C20Flacsra ite Drones) i801 nF-CONTAGIOASE D2t-sotd C1 1s-Hemoptizie B01! CU TRANSM. SEXUALA Dz2tichia O14 Tuse Dacre Di 23.veportgae Dit eeedomp Di 24.chimic Gastrointestinal ANAMNEZA Psihiatric CO 132-Greata 1126 ores Diiesiont 247-Tub, comporament Fy 34 rus ana 1 248-suicia DD 225-Halucinati a 1 136-Melena O226-Detr 0 137-Hematemeza 7 Desrcotte 1 138-Dureri aba 1 236-Moctoi eee 1 249-Cotatoe Oi t78-Tuls. micsonale 0 260-Paralzio 179 0isurie Tegumente 1 180-Potakiurie QO 141-Caide OD 181-oliguie D1 142Reci 01 177-Hematurie 1 143-umede D1 182-ang. vaginal 0 151-Palide Ol 123-sarcina D1 152-cianotice D0 149-1cterice Ap. locomotor pee 1 146 chimoze EPartintamete Alergic la: D1 1s4-erupsi 01 205-Tumefactie sheer 0 144-Prurit 0 204-Durere Tralament a domi 1 155-arsurt 1 207-Imp. fant,EXAMEN OBIECTIV STAREGENERALA [1 10Nornalé CI tinfuenfaté C1 1@Alteraté__L] 19-Profund aterata Alte: CAP GAT NAS Sig Or 1 30-Normal (01 34-Normal NORMAL Caccpistaxis -410 Dist-Marc’ taumatics 1 35-Merc& traumatics ‘| 3@-Narine D42-corpi strain-as Hl o2-Leziunicav. bucala [1 26-Formafuni paipabile (C7 39-Mucoasa nazalé 1 44-Trauma [C1 33-Leziunidentare 1) 37-Marca traumatica ‘APARAT AUDITIV Sig Or NORMAL a or Cise-conjunctivte = 570 D1 45-Membrana timpanica (148-Otoragio | -49 Oi se-Midriaza 00 11 46.cai auaitve exteme 1) 50-Corpi strani 51 | s8-Pupile D00-Miows oO 0 4z-Pavilior 1152-Hemotimpan 530] | alte: Dieenistegrus 30 Me 1 6t-Devire gibi ocular 650 APARAT CARDIOVASCULAR [] 73-Pulsneregulat_ 1 78-Jugulare tugesc 1] 83-Sufl carctidian stg. NORMAL C1 74-Puls perif. filiform [J 79-Suflu sistolic 0 84-Sufu carotidian ar. 1 70-Ritm cardiac (1 75-Deficit de puis 1) 80-Suflu diastolic 1 85-Frecatura C1 21-Pus periteric 10 76-Zgomote artmice 1 81-Sutu aoric D86-catop O72 aiacordului = 1]. 77-Zgomote asurzite [] 82-Puls absent la art Observati TORACEIAPARAT RESPIRATOR Sig Dr Sig or NORMAL [1 94-Murmur veziculer diminust -05 C1 [1] 104-Tra intercost/supractavie 1050] 20-Aspectu toracelul [lo6-Murmur vezicular absent -67 1 ©) 106-Emfizom subcutanat = -1070] 91-Percutia toracelui (C1 98-Ralurisibilante 990 1 108-Trahee deviata 1090 Cl ezMurmurvezicularbiat —-—-) 100-Raluri crepitante 101 OO) 110-Wheezing D1 s3-0rofaringe C1 toz-Ralur subcrepitante 103 ate: Observati "ABDOMEN TEGUMENT NORMAL 124-Abd. destins ()128-Formayjune palpabia| C] 140-Normal [] 146-Escoriast [] 150-Piagi C1 120Palpare 1] 125-Tranzt absent 1129-Sensibil ia palpare |C]141-caid D] 146-Echimoze C1 151-Palid TD t2t-Porcue — 1126-Hepatomogaio]130-Tuseu rectal pozity |C] 142-Rece O147-Petesii 1) 152-Cianoza 1 122-Tranzit intost £1 127-Splenomegaie [1131-Intatie perteneais |E]143-Umee C1 1a8-Purpurd [] 153-Transpiat D0 123-Tuseu rectal Observatii: dolla 1D 144-Prurt 1) 149-Icter Alte: Locatzare: GENITO URINAR Sig Dr NORMAL TD 164-Scurgeri vaginale sanguinolente 0 169-Giordano pozitiv — -17010 Li 160.orvano gontale exteme 1] 165-Levcoree 171-Tumefier testou 17200 D1 161-Menstruatie requlata TI 166-Sensibittatea colului 1 173-Durere testi «= 1740 1175-Formatiune mamara -176 C1 1D 16: D0 167-Uter marit seu vaginal ID ee-oa ererte D1 168-Fornafiune latero-uterind i iri terchole D1 to¢-Brahiaa -195 1 204-Durere D1 196-Radiaa -197 D. 1 205-Tumefiere 0 198-Femuraia-199 0 1 206-Edem runchi [] 200-Popiitee -201 1 207-impotenta func. SS 1 193-Membre [] 202-Pedioasa-203 D1. 0 208-Cianoza Obsorvati 1 209-Fract. deschisa D1 2t0-Fract. inchisa a = NORMAL 1 225-Halucinati L] 231-Fotofobie 0 237-convusi Cl 220-orientat temp.-sp. O) 226-Delir Di 232-Redoareacefei Sto Or 1) 221-Nervicranieni 1] 227-Tulb. comp. [) 233-Parestezit C2sePlegie § -2390) C22e-Agitat 0) 234-Atanie OroParezs 2410 (0 228-0bnubilat 1] 235-Afazie 1 242-Anestezie -2430) 0 230-Confuz =O) 236-Miocionii 0 244-Babinski -2450)MANEVRE/PROCEDURI 1110-0, masca (Vin) ID111-Pipa Guede! |112-Aspirare cavitate bucala (m)). C1 12-Aspirare pe sonda 1OT (mi). [0114107 cu inductie [115.107 fara inductie Ci 16-1NT cu inductio [C17-combitub [C18-Masca laringiana 01 19-Decompresie toracica pe ac [120-Drenajtoracic (mi) 2 1-Minicricotrostomie [22-Traheostorie 1123-Ventilatie noninvaziva 124-Ventilatie mecanicd L2s-Acces venos periteric - nr. (126-Acces intraosos - nr... (D127-Acces venos central (vena) 129-Acces arterial (1130-Inj. intramuscular (1131-Inj. subcutanata Di32-Hr. intadermics 3s-Adm. intranazala D34-Nebutizare (1135-Compresiuni toracice externe (036-Masurere Ta invaziva (s7-Monitorizare EKG 3e-Monitorizare satO. (39-Capnometrie 140-aite monitorizai.... 041-Defibritare manual 142-Defibrilare automata Caltrans mall O144-Cardioversie O46. x x (046-PM transcutanat (mA/Frecv) J. (148-Punctie pericardica D4-Lavaj peritoneal diag s0-Reincatzire activa O51-Reincaizire pasiva Ds24Lava) gastric (ml) 1s3-sonda nazogastricd (mi) (54-Sonda vezica urinara (ml) (55-Guler cervical Dse-Targa cu lopeti s7-Targa coloana (58-Imobilizare membre Oss-atea Doo-aparet gipsat Cst-Toaleta plaga le2-Sutura Os3-Mesaj (64-Tamponament nazal Ate: C128-Masurare PVC (0147-PM transvenos (mA/Frecy) ...J. Observati: TRATAMENT Oe Medicament™ ‘Nr [Dozall Galea] Ore efect] Medic (OBSERVATILLE a ee] 1 2 3] _Radiologice cr EKG ORA 110-Coloana cervicata 1 60-Craniu 1 70-Ritm sinusal ()10-Het O 51-Coloana dorsal 1 61-Coloana cervicala 11 71-Freev__ (11-Hb 1 52-Colosna lombara =) 6 1-Torace 1 72-ST-Tnormal 2-H Di 53-Torace Dl e3-andomen Ora Dts. Ds4-stem Desate O rerviv Cat Di s5-Bazin RMN D75-1Psv (115-Na 56-Abdomen Cl 65-craniu 1 76-Asistolie Dex [157-Membru superior 1] 66-Coloana cervieala b17-ci C1 se.membru inforior —] 67-Torace (0118-Ca CO 50-alte 1 68-Abdomen [D19-Giicemie 1 62-Alte [1120-Uree Ea [121-Creatinina ([122-GOT/AST [23-GPT/ALT femeee L124-Amilaze 125-54 L126-HCOs (127-paoz [1128-pacoz [D29-8e [130-Bilirubina T| [31-Bilirubina D| 32-CK [133-CK-WB [134-ProBNP eee [[135-Troponina [136-Miogiobina [137-D-dimer 138- 139- 40- oat inte See SoS ES ria en [EVALUARE-RECOMANDARL Gabe ETL. Stare pacient O 50-Ametiorat D1 s2-Agravat 01 51-Stationar 1D 53-Decedat a |Refuz ora: [] 54-Examinare MGM", CO 55-Tratament eet mo L114 BD sointemare Set ea ne Predat la ora: (1 §7-Intemat sectia — tomer D1 5e-Transferat a LLL] 2 s0-Pieacs cu recomandariRP 4Data INT. Fig] on ] CONSULTATIL ORA ORA SEMNATURAMEDICULUI | SEMNATURAMEDICULUI SPECIALITATEA | souicrTArn | PREZENTARI ‘SOLICITAT ‘SOLICITANT CORA ORA ‘SEMNATURA MEDICULUI SEMNATURA MEDICULUI SPECIAUTATEA | soviciTarii_| pREZENTARIL SOLIGITAT SOLICITANT ORR, ORA SSENNATURAMEDICULUT | SEMNATURAMEDICULUI SPECIATIATEA | souiciTani_| prezeNTARW SOLICITAT 'SOLICITANT1G allaona allwoiaaw or 02, 0, OF. ig\e|gia|s| 05, 08, 02 0 08, 06 Or Ou fob ti ab Osh ti Det ost OF Sz oc ie DEL Br Ze Ser 6 Fr 002 ca er one oe Osh ze 96 SSI ez vi Dar ore 26. 91 sz 6e. DAL sz SLL ue Wy aL Ze. 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