FOAIE DE OBSERVATIE CLINICA

I. DATELE DE PAŞAPORT
Numele de familie, prenumele_______________________________________________
Vîrsta sexul_____________________________________
Profesiunea şi specialitatea _____________________
Domiciliul _______________________________
Diagnosticul de internare ____________________________________
Diagnosticul clinic _____________________
Diagnosticul la externare __________________________
a)de baza______________________________________________________________
b)complicatii___________________________________________________________
c) afecţiunile asociate _________________

II. ACUZELE BOLNAVULUI

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III. ISTORICUL ACTUALEI BOLI

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 IV. ANAMNEZA (ISTORICUL) VIEŢII
1.Date succinte biografice-_________________________________________________________________
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2.Conditii de muncă.______________________________________________________________________
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3..Antecedentele personale fiziologice -_______________________________________________________

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4.Deprinderile nocive _____________________________________________________________________

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5.Antecendentele personale patologice –_______________________________________________________

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6.Anamneza alergologică – _________________________________________________________________

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7.Anamneza de asigurare socială –__________________________________________________________

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8.Antecendentele eredocolaterale –_________________________________________________________

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V. STAREA PREZENTĂ A BOLNAVULUI
1Inspecţia generală.
 Starea generală a bolnavului:_________________________________________________________

 Conştiinţa bolnavului: ______________________________________________________________

 Poziţia bolnavului__________________________________________________________________

 Facies___________________________________________________________________________

 Tipul constituţional: _________________________________________________________________

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 Tegumentele şi mucoasele vizibile_____________________________________________________

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 Fanere:.__________________________________________________________________________
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 Ţesutul adipos :_______________________________________________________________________

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 Edeme:__________________________________________________________________________
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 Ganglioni limfatici: _________________________________________________________________

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  Capul:___________________________________________________________________________
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 Gîtul:_____________________________________________________________________________
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 Muşchii: ____________________________________________________________________________
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 Oasele:_________________________________________________________________________________
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 Articulaţiil: _______________________________________________________________________
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2.APARATUL RESPIRATOR

Acuzele_______________________________________________________________________________________
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Inspecţia

 Nasul:__________________________________________________________________________________
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 Vocea: __________________________________________________________________________
  Cutia toracică___________________________________________________________________________

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 Tipul respiraţiei :__________________________________________________________________

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 Excursia respiratorie a cutiei toracice: _________________________________________________

Palpaţia

 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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Percuţia

 Percuţia comparativă: ___________________________________________________________________

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 Percuţia topografică:

înălţimea apexelor plămînilor din partea Dreapta stânga

Anterior

Posterior

Lăţimea benzilor Kroning

Limita inferioară a plămînilor

lin. parasternală

lin. medioclaviculară

lin. axilară anterioară

lin. axilară medie

 lin. axilară posterioară

lin. Scapulară

lin. paravertebrală

Mobilitatea maximală a limitei inferioare a plămînului

Pe linia axilară medie

Lăţimea hilului pulmonar

Auscultaţia

 Caracterul respiraţiei:__________________________________________________________________
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 Zgomotele respiratorii supraadăugate: _____________________________________________________

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3.APARATUL CARDIO- VASCULAR

Acuzele_______________________________________________________________________________________
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Inspecţia______________________________________________________________________________________
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Palpaţia_______________________________________________________________________________________
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Percuţia______________________________________________________________________________________
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Auscultaţia____________________________________________________________________________________
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Examinarea vaselor sanguine___________________________________________________________________

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 VI. DIAGNOSTICUL PREZUMTIV
În baza acuzelor pacientului la momentul intrernării: dispnee mixtă progresivă care se accentuează
la eform minim(2-3 pași)- MRC 3, tuse seacă chinuitoare și dintre semne nespecifice - febră 38.6
gr.C, fatigabilitate, slăbiciune generală, scădere în greutate cu 6 kg timp de un an.
În baza istoricului actualei boli - se consideră bolnavă din anul 2015 când a apărut dispneea, tusea
uscată, febră 37,6-38 gr C. A urmat tratament de sinestătător cu AINS, expectorante timp de 3-4 luni
A fost spitalizată de 7 ori în 2016-2017, fără ameliorare semnificativă după tratament. A fost
internată la IFP( 20-18.10.2016), cu acuze de dispnee la efort fizic mic MRC3, tuse seacă
chinuitoare diurnă/nocturnă, subfebrilitate <37,8gr. C, cefalee frontooccipitală, astenie,
fatigabilitate, junghi toracic interscapular, pierdere ponderală de 4 kg în 1,5 luni. A fost prescris
tratament cu prednisolon 5 mg. Consultația repetată in iunie 2017, la consultație repetată după 2
luni nu s-a prezentat, a întrerupt tratamentul cu prednisolon. Pe 08.10.2017 seara, dispeea se
accentuează, apare febra. Se internează din nou pentru tratament.

În baza examenului obiectiv – frecvenţa respirației- 20 r/min, tegumentele –palide cu steluțe

vasculare pe torace, umeri, abdomen, acrocianoză, degete hipocratice.
Percuția comparativă: sunet clar pulmonar , usor timpanic.
Percuția topografică: Limitele pulmonare ant. - 3.3 cm superior de claviculă, bilateral.
Banda Krőnig 4 cm dreapta, 4.2 cm stânga.
Auscultaţia plămânilor: bilateral - murmur vezicular cu nuanțe aspre.
Auscultaţia cordului- accentul zgII a. Pulmonară, FCC = 89 b/min.
La palpare marginea ficatului - rotunjita, proemină cu 2 cm sub rebordul costal.
Splina se plapează cu 3 cm sub rebordul costal.

S-a stabilit diagnosticul prezumtiv: Pneumopatie interstițială difuză.

Ciroză hepatică de etiologie virală B+C, evoluție progresivă.

ALAT,ASAT, bilirubina totală- mărite și proteina totală, albumina- micșorate

Absența micobacteriilor BAAR Negativ
Absența tuberculozei GeneXpert Negativ

Test de rezistență la efort Pacienta a parcurs 48,5% din prezis și a desaturat de la 97% la 89%
ceea ce denotă incapacitatea plămânilor de a asigura cantitatea necesară de oxigen la efort din
motivul dereglării permeabilității membranei alveolo-capilare.

FBS CU BIOPSIE (18.10.17)

Endobronșită atrofică bilaterală

Capacitatea de difuzie a monoxidului de carbon (DLCO=42,2%) este diminuată pronunțat, ceea de

denotă afectarea membranei de difuzie alveolo-capilară.
MĂSURAREA REZISTENȚEI CĂILOR AERIENE (16.10.17)
Rezistența bronhială totală (Rtot=1198% - 3,59kPA s/L) – mărită sever
GAZIMETRIA Pa O2- scăzută sever. Insuficiență respiratorie tip I (hipoxemică), grad 3.
Gradient alveolo-capilar conform regulii 130 = 73,2- crescut- este perturbată difuziunea gazelor
la nivelul membranei alveolo-capilare
ECOGRAFIA ORGANE ABDOMINALE + SIST. URINAR
ciroză hepatică. Hipersplenism. Hipertensiune portală. Colecistită acalculoasă. Modificări în
parenchimul pancreasului. Diateza urică.
CT : proces interstițial (pneumofibroză interstițială) în lobii superiori ai ambilor plămâni. Hilii
măriți din contul ramurilor AP ,Semne de suprasolicitare a cordului drept

Reducerea DLCO, hipoxemie în timpul efortului fizic (pr mers 6 min)

radiol infiltrat interstit bazal bilat
HRCT sticla mata