Numele pacientului ____________________

Vrsta ____

Data ntocmirii:

Nr FO____________

...............................
________________

Antecedente personale
AVC/AIT IM/AP/Revascularizare IC
Arteriopatie ATS mb. inf Retinopatie HTA (std 3 sau 4)
DZ 1/2
Neuropatie DZ
Retinopatie ne/proliferativa DZ
Nefropatie/BRC std 1-5 DZ/nonDZ

Risc CV global
F inalt

Modificare glicemie bazal

Risc CV global

FiA/ Ft A Htir/ hTir

Scdere toleran la glucoza Sdr metabolic

AB/BPOC

HBP

Glaucom

Investigaii minimale la pacientul HTA /DZ

Parametrul

Valori
patologice

HLG
Glicemie a jeune

> 126mg%

Sumar urin
(Macroalbuminurie)

>300 mg%

Colesterol total
LDL colesterol
HDL colesterol
Trigliceride
Creatinin seric
Acid uric

Dislipidemie

Migren

Anticoncepionale

Valori nregistrate

> 190 mg%

> 115 mg%
< 40 mg% M
< 50 mg% F
> 150 mg%
> 1 mg %
> 5 mg%

HVS

Parametrul
Potasemie
Proteina C reactiv
Microalbuminurie*
(obligatorie la DZ)
TTGO la 2 h*
(la nevoie pt Dg la DZ)
Hb A1C*

Echo cord

FO

Doppler vascular
carotidian

RX pulmonar

Doppler periferic
Examen clinic
nlime
Greutate/IMC
Circumferina abdominal
Valoare TA sezand/in picioare
(media a 2-3 masuratori la 1 min )

Semne de insuficien cardiac

Tulburri de ritm
Semne clinice ale ATS sistemice
(pulsaii la arterele periferice,
sufluri carotidiene/a.renale))
Semne clinice ale disfunciei
tiroidiene
Ex. picior complet

Actual ..
Proiectat .

Investigaii suplimentare HTA /DZ*

(Se vor efectua dupa caz si adaptate situatiei)

(obligatorie la DZ)

EKG

H uricemie

Rezultat

MATA

Diagnostic:

Valori
patologice
> 4,5 mEq/l
> 1mg/dl
30-300 mg%
> 200 mg/dl
>7%

Valori nregistrate

Inspectia, sensibilitate termica,

tactila, dureroasa, vibratorie,
monofilament

CNSMF

Plan terapeutic
Prescripia dietetic

Exerciii fizice

Total calorii:

Tip exerciii:

Raie Hidrocarbonate:
Lipide:
Frecven

Proteine:
Alte recomandri:

Schema de tratament
Tratament medicamentos

Medicament

Doza

Frecvena adm.

Diur: DT/DTlike/DEK/DA
BB
BCC DHP/NDHP
IECA/BRA
STATINE/FIBRATI
ASPIRINA
ALTE: ex Vacc Antigripal

Biguanide/Sulfonilureice
Tiazolidindione
Inhib de alphaglucozidaza
Metiglinide
Insulina
Alte

Ritm de dispensarizare la:

O 3 luni

O 6 luni

O 1an

Plan de management
La fiecare vizit
Sfat ntrerupere fumat, scdere n greutate, exerciii fizice, automonitorizare TA/glicemie* i discu ie rezultate, glicemia a
jeune*, msurarea TA, inspecia picior diabetic*

La 3 luni + plan fiecare vizit

Observaii
inte agreate

Consum de alcool, dieta, HbA1c**, HDL* col, LDL* col, TG*

La 6 luni + plan 3luni+plan fiecare

vizit
Creatinin, HDL col, LDL col, TG, ionograma* s (Na, K), HbA1c*

La 12 luni- +plan 6 luni+ plan

3luni+plan fiecare vizit

- TA <150/90 ; <140/90
- G scadere ...............kg in urmatoarele 3 luni
- diet
- micare

Col total, HDL col, LDL col, TG, Ionograma* s (Na, K), acid uric, probe hepatice, amilazemie*, Examen complet sensib.
tactil,termic, dureroasa, monofilament, Comsult oftalmologic, Consult diabetolog
* analizele marcate se efectueaza in conditii speciale (mentionate in fisa de monitorizare)
** daca conditiile financiare permit

CNSMF
Semntura i parafa