Anexa nr.

la ord. nr. 46/ a din 29.05.2012

Extras
din fișa de observație medicală nr.______________
Pacientul(a)________________________________________________________anul nașterii_____________________
A fost examinat (ă) și a primit tratament în secția_______TERAPIE N1_________ Spitalul Clinic Bălți
de la __________________________________pînă la_____________________________________________________
DIAGNOSTICUL:____________________________________________________________________________________
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Analiza sîngelui:

Data Hb Eritr Leuc Trombo- Neu Limf Mon Eoz Baz Reticul. VSH
(g/l) (x1012) (x109) cite(x109) % % % % % (mm/h)

Glucoza sîngelui_____________________________________________________________________________mmol/l.
Proteine totale__________________g/l; albumine_______________%; globuline____________________________%;
Protrombina______________%; fibrinogen_________________g/l; INR______________ ; APTT______________sec;
D-dimer______________; Ureea_______________mmol/l; Creatinina________________mmol;
Bil. totală______________mcmol/l; Bil. directă________________mcmol/l; Bil. indirectă____________mcmol/l;
ALAT___________mmol/l; ASAT____________mmol/l; amilaza___________g/l; Ferum seric______________ mmol/l;
Folați ser__________________ng/ml; Vit.B12 ser_______________pg/ml; Helicobacter pylori_________________;
Colesterol tot._____________mmol/ l; Colesterol LDL_____________mmol/ l; Colesterol HDL_____________mmol/ l;
Trigliceride______________mmol/ l; Proteina C reactivă___________mg/l; Antistreptolizina-O_____________UI/ml;
Factorul reumatoid____________UI/ml ; Acid uric ser____________ mmol/l; Acid uric urina______________ mmol/l;
Ureaplasma urealiticum IgG__________; Chlamydia trahomatis IgG__________; Mycoplasma hominis IgG__________;
HBs Ag ______________; antiHBcore _____________; antiHCV ______________; Marcherii HIV________________;
Grupa de singe_______________; Rh______________; Kell__________; CEA ser_____________; CA19-9___________;
CA125_________; CA15-3___________; PSA total____________; PSA liber___________; Rap PSA tot/lib___________;
TSH_____________; T4 liber_____________; AntiTPO______________; Calcitonin___________;
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Analiza generală a urinei:

Data Densitatea Reacția Proteine Glucoza Corpi Epiteliu Leucocit Eritroc Mucus Bacterii
relativă cheton plat e ite
Proba Neciporenco L____________x10; E_______________x10/l Proba Zemnițki______________;
diureza diurnă______________ml; diureza nocturnă_________________ml;Densitatea relativă_________________.
ECG_____________________________________________________________________________________________
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Fibroesofagogastroduodenoscopia:___________________________________________________________________
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Videosigmoidoscopie_______________________________________________________________________________
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Examen radiologic_________________________________________________________________________________
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EUS: Ficatul: lobul drept__________________mm; lobul stîng____________________mm; contur: regulat, neregulat;
Coledocul_________________________mm; V.portae______________________mm;
Parenchimul (ne)-omogen, cu reflectivitate: normală,sporită,scăzută, Formațiune______________________________
Căile biliare intrahepatice____________________________________________________________________________
V.splenică_______________________________________________mm;
Colecistul: dimensiuni_______________________mm; forma___________________; pereții_____________________
Cudura la nivel: col,corp,fund; Calculi_________________________________________________
Pancreasul: dimensiuni____________; contur (ne)-regulat, șters; structura (ne) omogenă;
cu reflectivitate: normală,sporită,scăzută
Splina____________________________________________mm
RD_________________________mm; RS________________________cm; CCB RD_____________________________,
CCB RS______________________________; calculi_______________________________________________________
Vezica urinară: repleție,semirepleție, depleție ___________; Prostata_______________________________________;
Glanda tiroidă: lobul drept______________; lobul stîng_____________; istmul____________; structura (ne) omogenă;
cu reflectivitate: normală,sporită,scăzută; formațiuni______________________________________________________
Tratamentul administrat:___________________________________________________________________________
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Se recomandă:
1.Dieta_______________________ 2.Regimul_________________________
3.Evidența la medic de familie, _______________________________________________________________________
4.Tratamentul medicamentos:
 __________________________________________________________________________________________
 __________________________________________________________________________________________
 __________________________________________________________________________________________
 __________________________________________________________________________________________
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Medic curant: Serghei Apostoliuc

(Semnătura, cod personal, ștampila)