Ministerul Sănătății Republicii Moldova

IP Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”

Catedra Medicină Internă – Semiologie

Şeful catedrei –
Conducătorul grupei –
Studentul examinator –
Grupa – . Anul
Facultatea –

Fişa de Observaţie

Data examinării – __________________

Data prezentării foii de observaţie – _____________________

Nota
 FOAIE DE OBSERVATIE CLINICA

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 _________________

II. ACUZELE BOLNAVULUI

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III. ISTORICUL ACTUALEI BOLI

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IV. ANAMNEZA (ISTORICUL) VIEŢII

1.Date succinte biografice-_________________________________________________________________
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2.Conditii de muncă.______________________________________________________________________
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3..Antecedentele personale fiziologice -_______________________________________________________

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4.Deprinderile nocive _____________________________________________________________________

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5.Antecendentele personale patologice –_______________________________________________________

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6.Anamneza alergologică – _________________________________________________________________

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7.Anamneza de asigurare socială –__________________________________________________________

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8.Antecendentele eredocolaterale –_________________________________________________________

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V. STAREA PREZENTĂ A BOLNAVULUI
1Inspecţia generală.
 Starea generală a bolnavului:_________________________________________________________

 Conştiinţa bolnavului: ______________________________________________________________

 Poziţia bolnavului__________________________________________________________________

 Facies___________________________________________________________________________

 Tipul constituţional: _________________________________________________________________

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 Tegumentele şi mucoasele vizibile_____________________________________________________

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 Fanere:.__________________________________________________________________________
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 Ţesutul adipos :_______________________________________________________________________

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 Edeme:__________________________________________________________________________
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 Ganglioni limfatici: _________________________________________________________________

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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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 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

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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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APARATUL DIGESTIV
Acuzele________________________________________________________________________________
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Inspecţie
Cavitatea bucală:
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Limba:
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Dinţii:
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FORMULA DENTARĂ

87654321 12345678
87654321 12345678
Inspecţia valului palatin:
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Abdomenul:
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Circumferinţa abdomenului:_______________________________________________________________________________
Palpare:______________________________________________________________________________________
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Palpare superficială:
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Palpare metodică, profundă, glisantă după Obrazţov-Starjesko:
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Auscultaţia:
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Peristaltismul intestinului:
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FICATUL
Inspecţia:
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Palpare:
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VEZICA BILIARA:
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Palpare:
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Percuţia:
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PANCREASUL
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Palpare:
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SISTEMUL URINAR
Acuzele:______________________________________________________________________________________
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Inspecţia:
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Palpaţia______________________________________________________________________________________
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Percuţia______________________________________________________________________________________
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6. SISTEMUL HEMATOPOETIC
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Inspecţia______________________________________________________________________________________
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Palpaţia______________________________________________________________________________________
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Percuţia______________________________________________________________________________________
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Auscultaţia____________________________________________________________________________________
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7.SISTEMUL ENDOCRIN
Acuzele_______________________________________________________________________________________
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Inspecţia______________________________________________________________________________________
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Palpaţie_______________________________________________________________________________________
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Auscultaţia____________________________________________________________________________________
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8.STAREA NEURO-PSIHICĂ ŞI ORGANELE DE SENSIBILITATE

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VI. DIAGNOSTICUL PREZUMTIV

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VII. PLANUL EXAMENULUI DE LABORATOR, INSTRUMENTAL ŞI
SUPLIMENTAR_______________________________________________________________________________
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