FISA UPU ‘ANAMNEZA ANTECEDENTE PATOLOGICE ‘Observatit COCARDIACE (DNEUROLOGICE (CORENALE ( PULMONARE Otec CUHePanice Dcastrice CO DIABET ZAHARAT CBOLI INF-CONTAGIOASE CB0LI CU TRANSM. SEXUALA COIALTELE |ANAMNEZA, poe Gastrointestinal: (01 132-Greata, ()246-Depresie 133.voma 1247-Tub. comportament [= 1S to FisesPiened (1135-Rectoragie ae 136-Melona (01137-Hematemeza Dh2sy-convulsi 1138-Dureri abd. (1 236-Miocionit Genito urinar 1240 Coton: (1) 178-Tulb. Micfionate (250-Paralizie D170 Disurie Bares, orem 181-Otigurie = pane D1 177-Hemature 0181-Patide Rigor aoe (01182-Cianotice OB) ud-ctorco ‘Ap. locomotor wu (21146-Echimoze (211-Inftamagie ar ae aaa VLG aR 1) 154-Erupsi 121205-Tumetactio fae a aa Se em EI AL Chapt Dare Tratament ta domicliu:, 1155 1207-1mp. funct. EXAMEN OBIECTIV. ORA: ‘STARE GENERALA, (10-Normats C0 tinfiuengatas 1112-Alterata (0113-Profund alterata Ale: CAP GAT WAS Sta. Dr. (130-Normal ()34-Normal NORMAL 40-Epistaxis 440 (031-MareS traumatic «(1 35-Marcd traumatics | [1 38-Narina: (142-Compi straini 43 (132-Leziunicav. busts —([136-Formatiuni palpabile |]38-Mucoada nazala ()44-Trauma 0133-Leziuni dentare (37-Marea traumatic’ Alta: ‘APARAT AUDITIV om Sta, Dr NORMA EA De | (58-Conjunctvte = 87] Menta osc L148-otoragie 90/8 [se-Midriaza oO )s0-Comp strain’ 20 a Cleese “0 stant }§2-Hemotimpan -53| |62-Nistagmus 63 a i ae oes Tlee-Deviere globi ocular 65°] aRRaT CONDI EOC (73-Puls neregulat — [] 7-Jugutare turgesc [1)83-Sufu carotidian stg. NORMAL (174-Puis peri. fiform []79-Suftu sistlic (]84-Sutu carotidian dr (()70-Bitm carding 75-Deficttde pus] 80-Sufu diastolic (1) 85-Frecatura 5) 76-Zgomote artmice [=] 81-Sut aortic 86-Galop (Z1-Puls perieric o [Liz2-Auscultatia cordului ___((} 77-Zgomote asurzite [J82-Pulsabsentiaart. 00Observatil TORAGE /APARAT RESPIRATOR Sig. De Ste, Dr ‘NORMAL (194-Murmur vezicular diminuat -95 [] [] 104-Tira intercostsupraciavic -105( (C) 90-Aspectul toracelul lee-Murmurvezicular absent -87(] [1 106-Emifizem subcutanat §— -107(. 1D) 91-Percutia toracslul 1 96-Raluri sibilante -981) 1) 108-Trahee deviats 10901 Ci 92-Murmur vezicularbilat 100 Raturicrepitante 1015] D)110-wheezing 0 98-0rofaringe TD to2-Raluri subcrepiante — -1030] Alte: narnn Observati z| | ABDOMEN: [TEGUMENT NORMAL [1 124-abd destins 1] 128-Formatiune palpabila|L1140-Normal (]145-Escoriagii []150-Plagi (1z0-Palpare 1) 125-Tranait absent []129-Sensibilla palpare |LI141-Cald [1146-Echimoze [1}151-Palid [12t-Percutie [] 126-Hepatomegalie [] 130-Tugeu rectal pozitv |C1142Rece [}147-Petesii_ [1152-Cianozd (© 122-Tranzit intest."] 127-Splenomegalie [] 131-Iritatie peritoneal 11143-Umed []148-Purpura [] 13-Transpirat (11 423-Tuseu rectal Observati r4aprunt Ft4sicter Alte Localizare GENITO URINAR Sig. Dr. pasual ives eaters vaginale sanguinolente g 469-Giordano pozitiv -170 q 160-Organe genitale externe en 471-Tumefiee testicul -172 161-Menstruaie requlaté ritaine coluh pea Le Senet ae Orrsdureretestou’ 17410 Cesc pts 01168-Formajune latero-uterina elite regnete meresk TSC] (1 ie2-Data utmansinati, —_ CO 177-Hematurie ‘AP LOCOMOTOR 1204-Durere ee NORMAI une prorat an ()205-Tumefiere -Brahiala ~195 LI aaa aTTaEEE ()190-can 96 Radiata 197 — Ease eae SS Casas aoe ene — 10.207-Impotent funct. 5 ; emuraia-t99 CI} ‘A = Cs9z-Tnunchi 5) 200-Popitee -201 0] Hieeceea : Cltes Membre 5} 559 pesioesa 203 E] L200 Frat. deschis = Observafi B20 Fraet. inchs =e NEURO-PSIHIATRIC Obs; ——_—— | NORMAL. (225Halucinati []231-Fotofobie 1 237-Convulsi Socio chara (1220-Orientat temp-sp (1) 226-Delir (1)232-Redoarea cefei Dlzzt-Nenicranien’ 1227-Tulb. comp. []23¢-Parestezi S10. Dr Giza Llzzetgtat (1234-Atmdo 236-Piesie -239 1] 1 223-Senaitiv 1229-0bnubilat 1)236-Afazio (240-Parezs -241[] (224-ROT (C1230-confuz 1) 236-Mioctoni (.242-Anestezie -243 ‘Ae O244-Babineki 2450) MANEVRE / PROCEDURI ‘ORA: we 10-0, masca (1/min. 120-Acces arterial (1)48-Punctie pericardica 11-Pipa Guedet ]30-in. intramuscular 1 49-Lava peritoneal diag ()12-Aspirare cavitate bucala (rl)... £131-Inj subcutanata (s0-Remodtzire activ (113-Aspirare pe sondi OT (mi) 32-in.intradermica (st-Remncatzire pasiva (114407 ou inducfie 32-Adm. intranazala 1) 52-Lavaj gastric (mi) (15-107 fara inductie (134-Nebulizare (1153-Sonda nazogastrica (mi). [16NT cu inductie 1135-Compresiunitoracice exteme _£]§4-Sonda vezica urinara (mi) 17-combitub (D.36-Masurare TA invaziva 1155-Guler cervical a (118-Masca laringiana (0137-Monitorizare EKG (156-Targa cu lopeti 119-Decompresie toracicd pe ac 3e-Monitorizare sat, (57-Targi coloand 20-Drenaj toracie (Mn )39.Capnometrie Cise-mobilizare membre (124-Minicricotrestomie T40-Alte moritor28e ncneninse EISQ-AteL (122-Traheostomie (41-Defibrilare manual (160-Aparat gipsat (23-Ventiate noninvaziva (l42-Detbrtare automata C1-Toaleta piag (24Ventiatie mecanio& LEAS ee lh Ce2-sutura (.25-Acces venos periferic- ar. D44-Cardioversio (e3-Mesaj (2.26-Acoes intraos0s =n... AB abt: adh 64-Tamponament nazal )27-Acces venos central (vend) (146-PMm transcutanatimAFrecy)(26-Masurare PVC Observatti: TRATAMENT Ora Medicamert™ Nr [Dozal|Calea] Ora ofect [Medic | OBSERVATI 5 Cir TERR COMANCHE 1 Observati | 1_[_2 [3] Radiologice or EKG OPA. (150-Coloana cervical (]60-Craniu [170-Ritm sinusal [E1t0-Het [151-Coloana dorsal. []61-Coloana cervical. ]71-Frecv. CH [52-Coloana lombars © [162-Torace (172-ST-7 normal C24 (53-Torace Gles-abdomen O73Fia ast (54-Stem Cles-atte O7a-rvav Chaar (ss-Bazin RMN (Oi75-1esv ENA (156-abdomen (965-Craniu O76-Asistolie thax (1157-Membru superior [166-Coloana cervicala | ches [se-Membru inferior J67-Torace | ince [1s50-Alte [ss-abdomen | (119-Glicemie | yenee Lee eee | 1)20-Uree a = 121-Creatining | ()22-GOTIAST [123-GPT/ALT [Di24-amilaze (125-pH E)26-HC03 { ([127-pa02. { [)28-paco2 C29-BE (Q30-Bilirubina T = {(2131-Bitirubina D Examen sumer de uring [Cisz-ck (O33-ck-mB i i (C)34-ProBNP ‘| ez [135-Troponina, ‘ORA. [[136-Mioglobina [40- [37-D-dimer (Dat C38. (a2. (Cigs- (as20 ‘i 78-40. 38 ‘ORA ORA_ | SEMNATURAMEDICULUI | _ SEMNATURA MEDICULUT SPECIALITATEA | SoLICITARI| PREZENTARII SOLICITA SOLICITANT ORK, ORA__|_SEMNATURAMEDICULUI | SEMNATURAMEDICULUI SPECIALITATEA | SOLICITARI| PREZENTARI STAT