Documente Academic
Documente Profesional
Documente Cultură
I. DATELE DE PAAPORT
Numele de familie, prenumele_______________________________________________
Vrsta
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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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
Auscultaia
Caracterul respiraiei:__________________________________________________________________
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Zgomotele respiratorii supraadugate: _____________________________________________________
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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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