REPUBLICA MOLDOVA

UNIVERSITATEA DE STAT DE MEDICINĂ ȘI FARMACIE

“NICOLAE TESTEMIȚANU”

FIȘA DE OBSERVAȚIE CLINICĂ

ELABORATOR: AXENTI CĂTĂLINA-FRANCESCA

CONDUCĂTOR:DIANA SASU
FACULTATEA: STOMATOLOGIE, GR. S1703

CHIȘINĂU 2019
 I. DATELE DE PAŞAPORT
Numele şi prenumele:Vieru Ecaterina Gavriil
Anul şi data naşterii : 19.07.1955
Adresa completă:r-nul Căușeni, satul Baccealia
Profesia, instituţia unde lucrează: pensioneră
Data şi ora internării: 06.12.2019 la ora 13:09
Diagnostic de îndreptare:Alte forme specificate de angină pectorală
Diagnostic la internare: Angina instabilă
Diagnosticul clinic: a) de bază Angina instabilă
b) boli concomitente – Hipertensiune Arterială
II. ACUZELE BOLNAVULUI
____ Dureri acute in regiunea inimii, hipertensiunea arterială, amețeli.

III. ISTORICUL ACTUALEI BOLI

_____ Se socoate bolnav din 2011, cînd a observat creșterea tensiunii arteriale, și a simțit dureri în regiunea inimii.

IV. ANAMNEZA (ISTORICUL) VIEŢII

1.Date succinte biografice__S-a născut in satul Baccealia, într-o familie de 3 copii, al doilea la număr.Căsătorită, 2
copii

2.Conditii de muncă.____Satisfăcătoare la fabrica de conserve mai mult de 20 de ani

3..Antecedentele personale fiziologice -_2 gravidități, 2 nașteri. Prima metroragie-13ani.

4.Deprinderile nocive _consum moderat de alcool. Fumat-nu.

5.Antecendentele personale patologice –__Hipertensiune arterială. Microinfarct miocardic.

6.Anamneza alergologică – __. Reacţii alergice la preparate medicamentoase şi alţi alergeni-neagă.

Acasă, după spusele bolnavului, are parte de o alimentaţie

7.Anamneza de asigurare socială –__
diversificată, biologic echilibrată, suficientă în plan cantitativ şi calitativ.

8.Antecendentele eredocolaterale –_ tatăl a suferit de hipertensiune arterială și a decedat din

motivul insultului cerebral.

V. STAREA PREZENTĂ A BOLNAVULUI

1Inspecţia generală.
 Starea generală a bolnavului:__Satisfăcătoare_________________________________________
  Conştiinţa bolnavului: _______Clară________________________________________

 Poziţia bolnavului_____Activă_____________________________________________________________

 Facies______Obișnuită__________________________________________________________________

 Tipul constituţional: _____Normostenic____

 Tegumentele şi mucoasele vizibile_______ Tegumentele de culoare roz-pală, curate.Umeditatea și turgorul
pielii în normă.

 Fanere:._ Părul – cu luciul păstrat, unghiile normale, cu luciul păstrat, puls capilar nu se determină .
 Ţesutul adipos :__ Ţesutul celulo-adipos subcutanat dezvoltat suficient, stare de nutriţie satisfăcătoare
 Edeme:____La picioare-nosptea.
 Ganglioni limfatici: __. Ganglionii limfatici ( sternocleidomastoidieni, supraclaviculari, submandibulari,
infraclaviculari, axilari ) palpator nu se determină, sînt nedureroşi
 Capul:__ Capul este proporţional, puncte dureroase nu se determină.
 Gîtul:_proporțional.
 Muşchii: _____Nivel de dezvoltare mediu. Nu prezintă puncte dureroase
Oasele:_ Ţesutul osos – oasele sînt proporţionale, fără deformaţii, percutor puncte dureroase nu se determină.
 Articulaţiil: ____Proporționale, nu sunt inflamate, nu sunt deformate, nu prezintă puncte dureroase.

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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