Documente Academic
Documente Profesional
Documente Cultură
Fisa de Observatie Exemplu 1
Fisa de Observatie Exemplu 1
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 _________________
2.Conditii de muncă.______________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________
Poziţia bolnavului__________________________________________________________________
Facies___________________________________________________________________________
________________________________________________________________________________
Fanere:.__________________________________________________________________________
_______________________________________________________________________________________
_________________________________________________________________________________
Edeme:__________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_________________________________________________________________________________
Gîtul:_____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Muşchii: ____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________________________________
Oasele:_________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Articulaţiil: _______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________________________________
2.APARATUL RESPIRATOR
Acuzele_______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Inspecţia
Nasul:__________________________________________________________________________________
_______________________________________________________________________________________
Vocea: __________________________________________________________________________
Cutia toracică___________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Palpaţia
Palparea simetricitatii_______________________________________________________________
_________________________________________________________________________________
Determinarea elesticitatii________________________________________________________________
________________________________________________________________________________
Percuţia
Posterior
lin. medioclaviculară
lin. Scapulară
lin. paravertebrală
Auscultaţia
Caracterul respiraţiei:__________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________________________________
Acuzele_______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________________________________________________________________________________
Inspecţia______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_______________________________________________________________________________________
Palpaţia_______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________________
Percuţia
Limita dreapta Limita stinga Limita superioara
Matitatea relativa
Matitatea absoluta
Latimea pediculului vascular
in spatiul 2 intercostal
Auscultaţia____________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____________________________________________________________________________________________
4.APARATUL DIGESTIV
Acuze________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Inspectia abdomenului__________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Palparea abdomenului__________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Percutia abdomenului___________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Auscultatia adbomenului________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Inspectia ficatului______________________________________________________________________________
_____________________________________________________________________________________________
Percutia
Limitele ficatului si dimensiunile dupa Kurlov
Limita superioara Limita inferioara Dimensiunile
Norma
Linia axil.anterioara 10-12 cm
Linia medioclav. dreapta 9-11 cm
Linia parasternala dreapta 8-11 cm
Linia mediana
Marginea reb. costal sting
Palparea ficatului______________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
5.SISTEMUL URINAR
Acuze________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Inspectia______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Palparea______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Percutia______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
UNIVERSITATEA DE STAT DE MEDICINĂ ȘI FARMACIE ”N.
TESTEMIȚANU” din REPUBLICA MOLDOVA
Fișa de observație
Data examinării
Data prezentarii foii de obdervație
Nota