Documente Academic
Documente Profesional
Documente Cultură
„Nicolae Testemiţanu”
Dermatovenerologie
Catedra__________________________________________________
Bețiu Mircea
Şef.catedrei_________________________________
Caproș Valeriu
Conducător gr.______________________________
Curator____________________________________
Malanciuc Anastasia
Grupa_______________
M1423 anul__________________
VI
Facultatea__________________________________
Medicina 1
FIŞĂ DE OBSERVAŢIE
Data curării__________________
15.4.2020
- Chişinău 2014 -
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I. DATE PAŞAPORTALE
Nume,prenume________________________________________________________________
Ciubuc Vitalie
Vîrsta________________________________________________________________________
46 ani
Sexul________________________________________________________________________
M
Adresa_______________________________________________________________________
Chisinau
Ocupatia_____________________________________________________________________
Sofer
Data internării______________________________
13.4.2020
Ora______________________________________
13:45
Institutia care a trimis bolnavul___________________________________________________
CMF
Diagnosticul la internare________________________________________________________
Pemfigus vulgar
DIAGNOSTICUL CLINIC.
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II. ACUZELE
1. La ziua curatiei:
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2. La internare:
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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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o 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 :________________________
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 Acuze__________________________________________________________________
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o Palparea:
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o Percutia:________________________________________________________________
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32. Epicriza
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