foaie de observatie clinica medicala

8/20/2019 Foaie de Observatie Clinica Medicala

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FOAIE DE OBSERVATIE CLINICA MEDICALA

1. DATE DE IDENTITATE: nume / varsta /sex / pr!es"e / #m"$"%"u&. MOTIVELE INTERNARII '()* +rupate , - DATA INTERNARII(. ISTORICL BOLII

A. a% ep"s#u%u" a$tua% :

• s"mptme

• #eut: %ent0 rus$0 "ns"#"s

• ev%ut"e "n t"mp '"na"nte s" #upa "nternare,• !a$tr" pre$"p"tant"

• tratament a$tua%B. a% %"" $rn"$e:

• etape: #"a+nst"$e0 !un$t"na%e '"nsu$"enta #e r+an,0 terapeut"$e

• $nrmate "n sp"ta%2 $ate sp"ta%"3ar"2 !re$venta2C. a% %"%r ass$"ate

• %" $e repre3"nta FR0 F pre$"p"tant"

• %" $e repre3"nta CI pentru tratamentu% ep"s#u%u" a$tua% 'se ment"nea3a #a$a ex"sta sau

nu,4. ANTECEDENTE

A. FI5IOLO6ICE 'F,

• menstruat"e / u%t"ma menstruat"e

• menpau3a

• naster"

• avrtur" spntane

• avrtur" prv$ateB. 7ATOLO6ICE

• !n# pat%+"$

• "ntervent"" $8"rur+"$a%e

• %" "n!e$t)$nta+"ase s" para3"tare

• a%er+""C. 9EREDO)COLATERALE

• par"nt"

• !rat"/surr"

• $p""

*. CONDITII DE VIATA SI DE MNCA• !umatr

• $nsum #e a%$%

• a%"mentat"e

• smn

• expunere %a nxe pr!es"na%e. E;AMENL OBIECTIV

• ta%"e

• +reutate

• IMC '<+/m&, ) supn#era%: =1>0*) nrma%: 1>0* ) &40?) pree3: &* ) &?0?) e3 $%. I: (@ ) (40?

) e3 $%. II: (* ) (?0?) e3 $%. III: 4@

• $"r$um!er"nta a#m"na%a

• stare +enera%a %a "nternare

• at"tu#"ne/p3"t"e: a$t"va0 pas"va0 !rtata

• !a$"es: m"tra%0 $"ant"$0 p%etr"$0 ase#"an0 pa%"#0 rsu0 su"$ter"$

• examenu% $8"%r

• t"p $nst"tut"na%: sten"$0 asten"$0 8"persten"$

• te+umente s" mu$ase: $"ant"$e0 e#emat"ate0 pa%"#e0 rs"at"$e0 pa%"#)terase0 "$ter"$e0 $a!ea $u %apte0

petes"" su$nun$t"va%e0 suun+8"a%e0 er"tem "ne%ar 'R.A.A.,0 8"p$rat"sm #"+"ta%

• !anere

• re+"unea $erv"$a%a anter"ara: tur+es$enta u+u%are%r0 pu%sat"%e u+u%are%r / $art"#e%r

• SISTEM 6AN6LIONAR LIMFATIC



• SISTEM OSTEOARTICLAR

) art"$u%at"": m"%e0 #urerase0 #e!rmate0 tumeate) s"stem ss

• SISTEM MSCLAR

• A7ARAT RES7IRATOR) #urere tra$"$a: %$a%"3ata/#"!u3a0 "ntens"tate0 $ara$tere) #"spnee: "nsp"ratr"e/exp"ratr"e0 ra#"pnee/p%"pnee) numar #e resp"rat"" pe m"nut) tuse: pr#u$t"va0 aspe$t sputa) 8empt"3"e

) $a" resp"ratr"" super"are: %"ere/struate0 #ev"at"e #e sept) pun$te s"nusa%e #urerase: !rnta%e/max"%are/etm"#a%e) tra$e m#"$at: as"metr"$0 $"!t"$0 s$%"t"$0 em3emats) amp%"at"") v"rat"" v$a%e) snr"tate pu%mnara: $res$uta0 t"mpan"sm0 #"m"nuata) murmur ve3"$u%ar: #"m"nuat0 a$$entuat0 a%"t - raprt I/E) suur") 3+mte supraa#au+ate: rnante0 s""%ante0 $rep"tante0 su$rep"tante0 !re$atur"

• A7ARAT CARDIOVASCLARA. DIS7NEE 'I / E - 7OLI7NEE,

) %a e!rt: mare0 me#"u0 m"$) "n #e$u"t) parx"st"$a) $nt"nua

B. DRERE 7RECORDIALA) $ara$ter: pres"va0 $nstr"$t"ve0 arsura0 "ntepatura0 a%t $ara$ter) $n#"t"" #e apar"t"e a #urer""

mment neurps"8"$

$n#"t"" spe$"a% #e a$t"v"tate

mment tx"$: ex$es tutun0 $a!ea

$n#"t"" meter%+"$e: !r"+0 $a%#

mment pat%+"$ a#m"na%: "n#"+est"e0 $nst"pat"e0 $%"$"0 ep"s# u%$ers

mment "n!e$t"s: am"+#a%"an0 s"nusa%0 +r"pa%0 R.A.A.

mment vas$u%ar: $restere rus$a a TA0 p"er#ere san+v"na0 p"er#ere 8"#rsa%"na0

ep"s# e"t"$ mment a%"mentar: $"na $p"asa0 a%"mentat"e n$"va0 man"!estar" a%er+"$e

) $n#"t"" #e retr$e#are: repaus0 n"tr"t"0 eru$tat"") #urata $r"3e%r an+"nase) !re$venta $r"3e%r an+"nase) s"mptme "nst"tare:

en$e!a%"$e: $e!a%ee0 tu%urar" #e smn0 tu%urar" v"3ua%e0 tu%urar" au#"t"ve0 e$%"pse

$erera%e semne #e IVS

semne #e "nsu$"enta $"r$u%atr"e $erera%a

#"+est"ve: eru$tat""0 p"r3"s0 #urer" ep"+astr"$e0 #urer" "n 8"p$n#ru% #rept

per"!er"$e: pareste3""0 $rampe mus$u%are0 $%au#"$at""

C. 7AL7ITATII) parx"st"$e) r"tm: rap"#0 re+u%at) $n#"t"" #e apar"t"e: e!rt0 emt""0 !r"+0 pstpran#"a%) $n#"t"" #e $e#are: spntan0 repaus0 pstterapeut"$) #urata) !re$venta) s"mptme "nst"tare: amete%"0 star" s"n$pa%e0 #urer" pre$r#"a%e0 +retur"0 p%"ur"e reexa0

#"spneeD. CLADICATII INTERMITENTE

) %$a%"3are: memru% "n!er"r #rept sau stan+) $n#"t"" #e apar"t"e: %a e!rt mare0 me#"u0 m"$

E. ACCESE RANAD) %$a%"3are: memru% super"r/"n!er"r #rept/stan+) !re$venta: rare0 #ese) tu%urar" tr$e

F. TENSINEA ARTERIALA S/D) $%"nstat"sm: rat #rept/stan+) rtstat"sm



) memre "n!er"are6. INS7ECTIE RE6INE 7RECORDIALA9. SOCL A7E;IAN

) se#"u%: $rat0 as$ens"nat0 #ep%asat %atera%) "ntens"tate: nrma%0 amp%u0 #"m"nuat) retra$t"a s"st%"$a a var!u%u") s$ #u%u) s$ m"%

I. MATITATE CARDIACA) nrma%a0 mar"ta0 m"$srata

#"ametru% transvers stan+ 'N: ?)11 $m,#"ametru% %n+"tu#"na% 'N: 11)1( $m,#"ametru% transvers #rept 'N: =& $m,#"ametru% $ar#"8epat"$ 'N: 0* $m,

G. 56OMOTE CARDIACE NORMALEH. SFLRI

) s"st%"$/#"ast%"$: m"tra%a0 arta0 pu%mnara0 tr"$usp"#aL. 6ALO7 / ALTE 56OMOTE

) %$a%"3are) t"p

M. CIANO5A) t"p: $entra%0 per"!er"$0 m"xt) "ntens"tate: #"s$reta0 me#"e0 severa

N. FRECATRA 7ERICARDICAO. EDEME

) %$a%"3are) $ara$ter

7. MODIFICARI ARTERIALE. MODIFICARI VENOASE

) var"$e memre "n!er"are) "nsu$"enta venasa $rn"$a) trme"ta super$"a%a/pr!un#a

R. FEBRA0 FRISON0 TRANS7IRATII0 ASTENIE / 7IERDERE IN 6RETATE

• A7ARAT DI6ESTIV - 6LANDE ANE;E

• A7ARAT RENO)RINAR

• A7ARAT 6ENITAL

• SISTEM NERVOS

• E;AMEN 7SI9IC

• SISTEM ENDOCRIN

J. CRBE : AV0 TA0 numar resp"rat""0 #"ure3a0 temperatura0 +reutate>. DIA6NOSTIC CLINIC?. E;7LORARI 7ARACLINICE SI DE LABORATOR

• %"+atr"") 9L6) VS9: B K v/& F K 'v - 1@,/&) REE: 1* ) *@ m+) CREATININA: @0@ ) 10(@ m+) 6LICEMIE: J@ ) 11* m+) TRANSAMINA5E: 6OT/AST K 1@ ) 4 I/% 67T/ALT K 1@ ) I/%) VDRL 's"%"s,) TIMOL '$apa$"tatea $atu%u" #e a s"ntet"3a prte"ne,) SMAR RINA

• Rx pu%mnar

•

EH6 %"+atr"u • examene #e spe$"a%"tate: TR %a B4* an"0 examenu% +%an#e" mamare s" examenu% +"ne$%+"$ %a F %a

menpau3a1@. DIA6NOSTICL COM7LET

• L K %es"n

• E K et"%+"e

• F K !un$t"na%

• C K $mp%"$at""

• O K t8ers11. DIA6NOSTICL DIFERENTIAL1&. EVOLTIE : natura%a / su tratament1(. COM7LICATII : a$ute0 sua$ute0 tar#"ve14. 7RO6NOSTIC : pe termen s$urt / %un+



1*. TRATAMENT :

• "+"en ) #"etet"$

• me#"$aments : %a "nternare / a$tua%

• "ntervent"na%

• $8"rur+"$a%1. 7ARTICLARITATILE CA5LI

foaie de observatie clinica medicala

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