Ministerul Sntii Republicii Moldova

IP Universitatea de Stat de Medicin i Farmacie Nicolae

Testemianu

Catedra Medicin Intern Semiologie

eful catedrei
Conductorul grupei
Studentul examinator
Grupa
. Anul
Facultatea

Fia de Observaie
Data examinrii __________________
Data prezentrii foii de observaie _____________________

Nota

FOAIE DE OBSERVATIE CLINICA

I. DATELE DE PAAPORT
Numele de familie, prenumele_______________________________________________
Vrsta
sexul_____________________________________
Profesiunea i specialitatea
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Domiciliul
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Diagnosticul de internare
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Diagnosticul clinic
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Diagnosticul la externare
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a)de baza______________________________________________________________
b)complicatii___________________________________________________________
c) afeciunile asociate
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II. ACUZELE BOLNAVULUI

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III. ISTORICUL ACTUALEI BOLI
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IV. ANAMNEZA (ISTORICUL) VIEII

1.Date succinte biografice-_________________________________________________________________

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2.Conditii de munc.______________________________________________________________________
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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 alergologic _________________________________________________________________
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7.Anamneza de asigurare social __________________________________________________________
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8.Antecendentele eredocolaterale _________________________________________________________
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V. STAREA PREZENT A BOLNAVULUI

1Inspecia general.
Starea general a bolnavului:_________________________________________________________
Contiina bolnavului: ______________________________________________________________
Poziia bolnavului__________________________________________________________________
Facies___________________________________________________________________________
Tipul constituional: _________________________________________________________________
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Tegumentele i mucoasele vizibile_____________________________________________________
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Fanere:.__________________________________________________________________________
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esutul adipos :_______________________________________________________________________
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Edeme:__________________________________________________________________________
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Ganglioni limfatici: _________________________________________________________________
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 Capul:___________________________________________________________________________
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Gtul:_____________________________________________________________________________
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Muchii: ____________________________________________________________________________
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Oasele:_________________________________________________________________________________
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Articulaiil: _______________________________________________________________________
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2.APARATUL RESPIRATOR
Acuzele_______________________________________________________________________________________
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Inspecia
Nasul:__________________________________________________________________________________
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Vocea: __________________________________________________________________________

 Cutia toracic___________________________________________________________________________
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Tipul respiraiei :__________________________________________________________________
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Excursia respiratorie a cutiei toracice: _________________________________________________
Palpaia
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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Percuia
Percuia comparativ: ___________________________________________________________________
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Percuia topografic:
nlimea apexelor plmnilor din partea
Anterior
Posterior
Limea benzilor Kroning
Limita inferioar a plmnilor
lin. parasternal
lin. medioclavicular
lin. axilar anterioar
lin. axilar medie

Dreapta

stnga

lin. axilar posterioar

lin. Scapular
lin. paravertebral
Mobilitatea maximal a limitei inferioare a plmnului
Pe linia axilar medie
Limea hilului pulmonar

Auscultaia
Caracterul respiraiei:__________________________________________________________________
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Zgomotele respiratorii supraadugate: _____________________________________________________
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3.APARATUL CARDIO- VASCULAR

Acuzele_______________________________________________________________________________________
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Inspecia______________________________________________________________________________________
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Palpaia_______________________________________________________________________________________
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Percuia______________________________________________________________________________________
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Auscultaia____________________________________________________________________________________
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Examinarea vaselor sanguine___________________________________________________________________
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APARATUL DIGESTIV

Acuzele________________________________________________________________________________
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Inspecie
Cavitatea bucal:

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Limba:

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Dinii:

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FORMULA DENTAR
87654321
87654321

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12345678

Inspecia valului palatin:

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Abdomenul:

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Circumferina abdomenului:_______________________________________________________________________________

Palpare:______________________________________________________________________________________
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Palpare superficial:
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Palpare metodic, profund, glisant dup Obrazov-Starjesko:
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Auscultaia:
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Peristaltismul intestinului:

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FICATUL
Inspecia:

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Palpare:
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VEZICA BILIARA:
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Palpare:
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Percuia:
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PANCREASUL
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Palpare:
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SISTEMUL URINAR
Acuzele:______________________________________________________________________________________
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Inspecia:
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Palpaia______________________________________________________________________________________
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Percuia______________________________________________________________________________________
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6. SISTEMUL HEMATOPOETIC
Acuzele_______________________________________________________________________________________
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Inspecia______________________________________________________________________________________
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Palpaia______________________________________________________________________________________
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Percuia______________________________________________________________________________________
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Auscultaia____________________________________________________________________________________
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7.SISTEMUL ENDOCRIN
Acuzele_______________________________________________________________________________________
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Inspecia______________________________________________________________________________________
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Palpaie_______________________________________________________________________________________
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Auscultaia____________________________________________________________________________________
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8.STAREA NEURO-PSIHIC I ORGANELE DE SENSIBILITATE
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VI.
DIAGNOSTICUL PREZUMTIV
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VII. PLANUL EXAMENULUI DE LABORATOR, INSTRUMENTAL I
SUPLIMENTAR_______________________________________________________________________________
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