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

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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Examinarea vaselor sanguine___________________________________________________________________

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