Documente Academic
Documente Profesional
Documente Cultură
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 _________________
Poziţia bolnavului__________________________________________________________________
Facies___________________________________________________________________________
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Fanere:.__________________________________________________________________________
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Edeme:__________________________________________________________________________
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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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Palpaţia
Palparea simetricitatii_______________________________________________________________
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Determinarea elesticitatii________________________________________________________________
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Percuţia
Posterior
lin. medioclaviculară
lin. Scapulară
lin. paravertebrală
Auscultaţia
Caracterul respiraţiei:__________________________________________________________________
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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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