foaie de observatie

I. Datele de paaport

Numele de familie, prenumele_______________________________________________ Vrsta

sexul_____________________________________ Profesiunea i specialitatea

_____________________Domiciliul

_______________________________Diagnosticul de internare

____________________________________Diagnosticul clinic

_____________________Diagnosticul la externare

__________________________a)de baza______________________________________________________________b)complicatii___________________________________________________________c) afeciunile asociate

_________________ II. Acuzele bolnavului_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ III. Istoricul actualei boli_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IV. Anamneza (istoricul) vieii

1.Date succinte biografice-__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2.Conditii de munc.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3..Antecedentele personale fiziologice -________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.Deprinderile nocive _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5.Antecendentele personale patologice __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6.Anamneza alergologic __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7.Anamneza de asigurare social ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8.Antecendentele eredocolaterale ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________ V. Starea prezent a bolnavului

1Inspecia general. Starea general a bolnavului:_________________________________________________________ Contiina bolnavului: ______________________________________________________________ Poziia bolnavului__________________________________________________________________ Facies___________________________________________________________________________ Tipul constituional: _________________________________________________________________________________________________________________________________________________ Tegumentele i mucoasele vizibile____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Fanere:.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ esutul adipos :______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________ Edeme:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Ganglioni limfatici: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Capul:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Gtul:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Muchii: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Oasele:_________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Articulaiil: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2.APARATUL RESPIRATOR

Acuzele___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Inspecia Nasul:_________________________________________________________________________________________________________________________________________________________________________ Vocea: __________________________________________________________________________ Cutia toracic_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Tipul respiraiei :_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Excursia respiratorie a cutiei toracice: _________________________________________________Palpaia Palparea simetricitatii________________________________________________________________________________________________________________________________________________

Determinarea elesticitatii________________________________________________________________________________________________________________________________________________

Evidentierea punctelor dureroase______________________________________________________________________________________________________________________________________________

Trasmiterea vibratiei vocale_________________________________________________________________________________________________________________________________________________

Percuia Percuia comparativ: ___________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________

Percuia topografic:nlimea apexelor plmnilor din partea Dreaptastnga

Anterior

Posterior

Limea benzilor Kroning

Limita inferioar a plmnilor

lin. parasternal

lin. medioclavicular

lin. axilar anterioar

lin. axilar medie

lin. axilar posterioar

lin. Scapular

lin. paravertebral

Mobilitatea maximal a limitei inferioare a plmnului

Pe linia axilar medie

Limea hilului pulmonar

Auscultaia Caracterul respiraiei:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Zgomotele respiratorii supraadugate: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3.APARATUL CARDIO- VASCULARAcuzele_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Inspecia_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Palpaia___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Percuia__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Auscultaia________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examinarea vaselor sanguine___________________________________________________________________

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