CMI DR.

Loc

Data ________________
Nr. fi _____________

EXAMEN DE BILAN
Numele i prenumele ______________________________________ CNP __________________
AHC ___________________________________________________________________________
APP____________________________________________________________________________
Stare general: bun acuze ______________________________________________________
Teg. i mucoase: normal colorate , palide , icterice , hiperemice , altfel ______________
Sistem limfoganglionar periferic: nepalpabil , palpabil , unde _________________________
Gl. mamare: simetrice , asimetrice , consisten normal , crescut , form. tumoral
palpabil , mrime _____________ localizare ________________________
Sistem osteoarticular: integru , fr modificri , cu modificri , unde _________________
Col. vertebral: curburi fiziologice , dreapt , modificat , unde ______________________
la percuie: nedureroas , dureroas , localizare ______________________________________
Aparat respirator: tuse , expectoraie , mucoas , purulent , hemoptizie , catar
Torace: normal , nfundat , emfizematos , respiraii normale , ample , superficiale
Diafragme mobile , mobilitate redus , dr , stg
Sonoritate pulmonar: normal , hipersonoritate , submatitate , matitate , dr , stg
Murmur vezicular: fiziologie , accentuat , diminuat , dr , stg
Raluri: fr , bronice , sibilante , ronflante ,crepitante , subcrepitante , dr , stg
Aparat cardiovascular: TA _______ mm Hg AV _____/min. matitate card. ]n limite normale ,
crescut , deplas , oriz , vert , la dr , la stg , soc apex sp V m.cl st deplas dr st
Zg. card ritmce , aritmie , FA , ES , accentuate , diminuate
Sufluri: fr , sistolic , focar AO PU , Tric , Mitral grad _______________
Circ venoasa nemodif , venectazii , varice , mb inf dr , stg , ulcer varicos , edeme
Aparat digestiv: Cavit bucal i faringe normal color , hiperemic , depozite ____________
Apetit bun , sczut , tranzit normal , constipaie , diaree ________________________
Abdomen suplu , meteorism , ascit , circ colat , cicatrice postop , _________________
Palpare nedureros , sensibil , epigastric , periombilical , hipogastru , flanc dr , stg ,
Hernie ombilical , inghinal , scrotal , altele , _______________________________
Ficat nepalpabil , la rebord , sub rebord la _______ la palpare nedureros , dureros , consist
de organ , resc , supraf neted , modif ___________ Splin nepalp , palp _________
Aparat urogenital: mic spont fiziol , patol ___________ Loji ren libere , nedureroase ,
dureroase , Giordano neg , poz dr , stg , org genit ext normale , modif ___________
SNC: orientat TS , dezorientat , ataxie , vertij , alte _____________________________
ROT prezente bilat , unilat , dr , st , Funcii intelectuale normale , abolite ,
Memorie bun , alterat , funcii afective normale , modificate ________________________
Acuitate vizual: Bun AO , alterat OD _______________ OS ______________________
Acuitate auditiv: bun , hipoacuzie dr , stg .
Concluzii ________________________________________________________________________
________________________________________________________________________________
Recomandri _____________________________________________________________________
Dr. GABOR DOIN MARIUS