Documente Academic
Documente Profesional
Documente Cultură
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 _________________
2.Conditii de muncă.______________________________________________________________________
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➢ Poziţia bolnavului__________________________________________________________________
➢ Facies___________________________________________________________________________
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➢ Fanere:.__________________________________________________________________________
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➢ Edeme:__________________________________________________________________________
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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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Palpaţia
✓ Palparea simetricitatii_______________________________________________________________
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✓ Determinarea elesticitatii________________________________________________________________
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Percuţia
✓ Percuţia topografică:
Posterior
lin. medioclaviculară
lin. Scapulară
lin. paravertebrală
Auscultaţia
✓ Caracterul respiraţiei:__________________________________________________________________
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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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