Universitatea de Stat de Medicină şi Farmacie

„Nicolae Testemiţanu”

Catedra__________________________________________________

Şef.catedrei_________________________________
Conducător gr.______________________________
Curator____________________________________
Grupa_______________ anul__________________
Facultatea__________________________________

FIŞĂ DE OBSERVAŢIE A BOLNAVULUI

Data curării__________________

CHIȘINĂU 2019
I. DATE PAŞAPORTALE
Nume,prenume______________________________________________________
Vîrsta_____________________________________________________________
Sexul______________________________________________________________
Adresa_____________________________________________________________
Ocupatia___________________________________________________________
Data internării________________________
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 VIEŢII

1. Date biografice
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2.Anamneza sexuală
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3.Antecedente patologice
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4.Deprinderi dăunătoare
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5.Antecedente familiale.
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6. Anamneza alergologică
1. Intoleranţa la medicamente___________________________________________
2. Vaccinuri_________________________________________________________
3. Alimente_________________________________________________________

V. STAREA GENERALĂ.
1. Stare generală____________________________________________________
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2. Conştiinţa________________________________________________________
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3. Poziţia___________________________________________________________
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4. Faciesul_________________________________________________________
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5. Constituţia__________________ talia______________ masa corpului_______
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6. Tegumentele, mucoasele şi anexele pielii_______________________________

O umeditatea şi turgorul_______________________________________________

7. Ţesutul celuloadipos_______________________________________________
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8. Edeme__________________________________________________________

9. Ganglionii limfatici_______________________________________________
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10. Capul__________________________________________________________

11. Gîtul___________________________________________________________
O Pulsarea patologică a carotidelor______________________________________

12. Muşchii: nivelul de dezvoltare, tonusul________________________________

O Dureri la palpare___________________________________________________

13. Oasele:
O Prezenţa deformaţiilor, dureri
O Modificarea oaselor

14. Articulaţiile:
O schimbarea conturului, edeme, hiperemie, durere__________________________
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O limitarea mişcărilor________________________________________________
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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
Comparativă:.__________________________________________________
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Topografică:__________________________________________________
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Ausucultatie_____________________________________________________
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16. Sistemul cardiovascular.

O Acuze_________________________________________________________
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O Palpare________________________________________________________
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Caracteristica şocului apexian
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O Percutie
Limita relativă a cordului_________________________________________
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Limita absolută a cordului_________________________________________
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O Ausucultatie
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FCC în minut________________
Pulsul______________________
TA :________________________

17. Tractul gastrointestinal

O Acuze__________________________________________________________
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O Palpare_________________________________________________________
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O Inspectie_________________________________________________________
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o Palpare
Palpare superficială__________________________________________________
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Palparea după Obrasţov-Străjescu_______________________________________
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O Percutie_________________________________________________________
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O Ficatul şi 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 neuropsihică:

O Conştiinţa: clară, difuză, comă, sopor, stupor, delir, halucinaşii
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O Dispoziţia: indiferentă, indispoziţie, apatie, obişnuită,iritabilitate
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22. Organele de simţ

O Sensibilitatea_____________________________________________________
O Văzul___________________________________________________________
O Auzul___________________________________________________________

23. CLINICA DERMATOLOGICĂ (status localis)

Descrierea leziunilor pielii şi mucoaselor se face după principii topografice(începînd
de la
pielea pilorică a capului pînă la tălpi), cu evidenţierea amănunţită a focarului
principal.
O Caracteristica generală a leziunilor : erupţiile sînt localizate ori
răspîndite,,cu caracter diseminat ori difuz,cu caracter simetric ori asimetric
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O Caracterul leziunilor – monomorf,polimorf (real,fals) cu tendinţă spre o
creştere periferică, confluare sau grupare, cu localizare figurată şi altele
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O Localizarea de elecţie ale erupţiilor: (locul, regiunea unde iniţial au apărut,
localizarea maximală)
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O Caracteristica detaliată a elementelor morfologice:
Primare – mărimea, conturul (rotund, ovalar, poligonal),limita (conturată,
neconturată), forma (plată, conică, semisferică, depresiune centrală),
culoarea (roză, albăstrie), suprafaţa (netedă, rugoasă, erozivă,
zemuindăumedă).____________________________________________________
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Secundare – descrierea se face în corespundere cu caracterul erupţiilor
(pigmentaţia, cruste, scuoame, eroziuni, cicatrici, etc).
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O Datele cercetărilor specifice: palpaţia (consistenţa, limitarea elementelor,

stratificarea, caracterul descuamării, fenomenele psoriazisului), vitropresiunea,
simptomul Nicolsky, Unna-Darier, KÖbner, Mescerski, Pospelov şi
altele)._____________________________________________________________
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o Cercetarea dermografismului şi reflezului pilomotor, determinarea secreţiei
glandelorsebacee şi sudoripare. Starea sistemului
limfatic.____________________________________________________________
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24. Diagnostic prezumtiv

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25. Planul de investigaţii (Examen de laborator şi alte investigaţii de ultima oră)

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26. Rezultatele analizelor de laborator şi alte investigaţii (Efectuate)

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27. Diagnostic diferenţiat

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28. Diagnosticul clinic final (argumentat)
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29. Tratament individual (argumentat şi prescris conform datelor de ultima oră)

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30. Evolutia zilnică

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31. Recomandări şi pronostic

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32. Epicriza
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