Universitatea de Stat de Medicin i Farmacie

Nicolae Testemianu

Catedra__________________________________________________

ef.catedrei_________________________________
Conductor gr.______________________________
Curator____________________________________
Grupa_______________ anul__________________
Facultatea__________________________________

FI DE OBSERVAIE

Data currii__________________

- Chiinu 2014 -

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I. DATE PAAPORTALE
Nume,prenume________________________________________________________________
Vrsta________________________________________________________________________
Sexul________________________________________________________________________
Adresa_______________________________________________________________________
Ocupatia_____________________________________________________________________
Data internrii______________________________
Ora______________________________________
Institutia care a trimis bolnavul___________________________________________________
Diagnosticul la internare________________________________________________________

DIAGNOSTICUL CLINIC.

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II. ACUZELE

1. La ziua curatiei:
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2. La internare:
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III. ANAMNEZA BOLII

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IV. ANAMNEZA VIEII

1. Date biografice
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2.Anamneza sexual
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3.Antecedente patologice
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4.Deprinderi duntoare

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 5.Antecedente familiale.
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6. Anamneza alergologic
1. Intolerana la medicamente_________________________________________________
2. Vaccinuri_______________________________________________________________
3. Alimente________________________________________________________________

V. STAREA GENERAL.

1. Stare general___________________________________________________________
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2. Contiina______________________________________________________________
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3. Poziia_________________________________________________________________
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4. Faciesul________________________________________________________________
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5. Constituia___________________ talia________________ masa corpului___________
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6. Tegumentele, mucoasele i anexele pielii_____________________________________
o umeditatea i turgorul_________________________________________________
7. esutul celuloadipos______________________________________________________
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8. Edeme_________________________________________________________________
9. Ganglionii limfatici_______________________________________________________
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10.Capul__________________________________________________________________
11.Gtul___________________________________________________________________
o Pulsarea patologic a carotidelor________________________________________
12.Muchii: nivelul de dezvoltare, tonusul_______________________________________

o Dureri la palpare_____________________________________________________

13.Oasele:
o Prezena deformaiilor, dureri_
o Modificarea oaselor

14.Articulaiile:

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 o schimbarea conturului, edeme, hiperemie, durere___________________________
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o limitarea micrilor__________________________________________________
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15.Sistemul respirator
o Acuze__________________________________________________________________
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o Inspectie_______________________________________________________________
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o Palpare________________________________________________________________
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o Percutie
Comparativ:._________________________________________________
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Topografic:__________________________________________________
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o Ausucultatie_____________________________________________________________
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16.Sistemul cardiovascular.

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 o Acuze__________________________________________________________________
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o Palpare
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Caracteristica ocului apexian
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o Percutie
Limita relativ a cordului________________________________________
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Limita absolut a
cordului______________________________________________________
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o Ausucultatie
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FCC n minut________________
Pulsul______________________
TA :________________________

17. Tractul gastrointestinal

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 o Acuze__________________________________________________________________
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o Palpare_________________________________________________________________
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o Inspectie________________________________________________________________
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o Palpare
Palpare superficial_____________________________________________
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Palparea dup Obrasov-Strjescu__________________________________
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o Percutie________________________________________________________________
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o Ficatul i vezica biliara___________________________________________________

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o Splina__________________________________________________________________
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18. Sistemul urinar

o Acuze__________________________________________________________________
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o Palparea:
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o Percutia:_______________________________________________________________
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19. Sistemul hematopoetic:

o Acuze__________________________________________________________________
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o Palparea oaselor (regiuni dureroase)________________________________________

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20. Sistemul endocrin:________________________________________________________

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21. Starea neuropsihic:

o Contiina: clar, difuz, com, sopor, stupor, delir, halucinaii

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o Dispoziia: indiferent, indispoziie, apatie, obinuit,iritabilitate
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22. Organele de sim

o Sensibilitatea____________________________________________________________
o Vzul__________________________________________________________________
o Auzul__________________________________________________________________

23. CLINICA DERMATOLOGIC (status localis)

Descrierea leziunilor pielii i mucoaselor se face dup principii topografice(ncepnd de la
pielea piloric a capului pn la tlpi), cu evidenierea amnunit a focarului principal.
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o Caracteristica general a leziunilor : erupiile snt localizate ori rspndite,,cu
caracter diseminat ori difuz,cu caracter simetric ori asimetric
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o Caracterul leziunilor monomorf,polimorf (real,fals) cu tendin spre o cretere
periferic, confluare sau grupare, cu localizare figurat i altele
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o Localizarea de elecie ale erupiilor: (locul, regiunea unde iniial au aprut,
localizarea maximal)
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o Caracteristica detaliat a elementelor morfologice:

Primare mrimea, conturul (rotund, ovalar, poligonal),limita (conturat,
neconturat), forma (plat, conic, semisferic, depresiune central),
culoarea (roz, albstrie), suprafaa (neted, rugoas, eroziv, zemuind-
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Secundare descrierea se face n corespundere cu caracterul erupiilor
(pigmentaia, cruste, scuoame, eroziuni, cicatrici, etc).
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o Datele cercetrilor specifice: palpaia (consistena, limitarea elementelor, stratificarea,
caracterul descuamrii, fenomenele psoriazisului), vitropresiunea, simptomul Nicolsky,
Unna-Darier, Kbner, Mescerski, Pospelov i altele).___________________________
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o Cercetarea dermografismului i reflezului pilomotor, determinarea secreiei glandelor
sebacee i sudoripare. Starea sistemului limfatic._______________________________
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24. Diagnostic prezumtiv

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25. Planul de investigaii (Examen de laborator i alte investigaii de ultima or)

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26. Rezultatele analizelor de laborator i alte investigaii (Efectuate)

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27. Diagnostic difereniat

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28. Diagnosticul clinic final (argumentat)

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29.Tratament individual (argumentat i prescris conform datelor de ultima or)

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30. Evolutia zilnic
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31. Recomandri i pronostic

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32. Epicriza
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