Salon____/ Pat_______

Numele Prenume __________________________________________________________________________________________

Data Nasterii ________________________________________________________________________________________________
Tipul internarii ______________________________________________________________________________________________
Motivul internarii in spital______________________________________________________________________________________
Istoricul Bolii CV______________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Istoricul patologiilor ne
CV______________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Antecedente Eredo-Colaterale
CV Digestive
Dismetabolice Alergice
Respiratorii

Antecedente Personale Patologice infectioase

-Heptatite/( )-Lues( ) -Amigdalite repetate( ) - Infectii dentare ( ) –TBC ( )
Interventii chirurgicale________________________________________________________________________________________
Antecedente Personale Patologice non-infectioase (Metabolice)
-Diabet ZD ( ), H/hTiroidie ( ), Suprarenale_________________________________________________________________________
Antecedente Personale Patologice non-infectioase ( Neu, Trau, )_______________________________________________________
__________________________________________________________________________________________________________
Condiții de viața
Alimentația Somn
Munca Alergii:

Factori de risc:
Fumat(__________________________________________)/ Alcool (___________________________________________________)
Medicația:
1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5.______________________________________________________________________________________
6.______________________________________________________________________________________
7.______________________________________________________________________________________
8.______________________________________________________________________________________
9.______________________________________________________________________________________
10._____________________________________________________________________________________
Examenul Fizic
Starea generala:_____________________________________________________________________________________________
Atitudine/Poziție____________________________________________________________________________________________
Tip constuțional______________________________________________________________________________________________
Tegumente/Mucoase/Gang____________________________________________________________________________________
Sis Osteo Articular/ Muscular ( Loc: Dureri, Deformații)____________________________________________________________
__________________________________________________________________________________________________________
Sistemul Resp:
-Durerea
-Dispnee

-FR
-Tusea
- Ascultația

- Saturația
Sistemul CV:
Dispnee ( Efort Mare/Mediu/ Mic/ Decubit/ Repaus/ Paroxistic)
Dureri precordiale:
-Caracter : Arsura/Intepatura/Constrictiva/ Compresiva
-Condiții apariției durerei:____________________________________________________________________________________
_________________________________________________________________________________________________________
-Condiții remisiei durerei: Repaus/ Nitrați/ Altele _________________________________________________________________
- Durata crizelor anginoase/ Frecvența _________________________________________________________________________
- Simptomatologia ce insoțește crize anginoase _________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Palpitații:
-Caracterul ritmului
______________________________________________________________________________________________________
- Condiții de apariție/ cedare/ Frecvența
_______________________________________________________________________________________________________
Claudicații:
Tensiunea Arteriala:
Puls:
Ascultația
Zg I
Zg II
Sufluri Cardiac/ Artere
Modificari Venoase

EKG

Sistemul Digestiv:

-Apetit
-Disfagie
-Pirozis
- Greața/ Voma
- Trasnzit intestinal
- Durerea abdominala
- Ficat

Sis Ren-Urinar
-Diureza
-Durerea