Universitatea de Stat de Medicină şi Farmacie

„Nicolae Testemiţanu”

Catedra__________________________________________________

Şef.catedrei_________________________________
Conducător gr.______________________________
Curator____________________________________
Grupa_______________ anul__________________
Facultatea__________________________________

FIŞĂ DE OBSERVAŢIE

Data curării__________________

- Chişinău 2014 -

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I. DATE PAŞAPORTALE
Nume,prenume________________________________________________________________
Vîrsta________________________________________________________________________
Sexul________________________________________________________________________
Adresa_______________________________________________________________________
Ocupatia_____________________________________________________________________
Data internării______________________________
Ora______________________________________
Institutia care a trimis bolnavul___________________________________________________
Diagnosticul la internare________________________________________________________

DIAGNOSTICUL CLINIC.

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II. ACUZELE

1. La ziua curatiei:
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2. La internare:
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III. ANAMNEZA BOLII

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IV. ANAMNEZA VIEŢII

1. Date biografice
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2.Anamneza sexuală
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3.Antecedente patologice
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4.Deprinderi dăunătoare

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 5.Antecedente familiale.
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6. Anamneza alergologică
1. Intoleranţa la medicamente_________________________________________________
2. Vaccinuri_______________________________________________________________
3. Alimente________________________________________________________________

V. STAREA GENERALĂ.

1. Stare generală___________________________________________________________
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2. Conştiinţa______________________________________________________________
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3. Poziţia_________________________________________________________________
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4. Faciesul________________________________________________________________
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5. Constituţia___________________ talia________________ masa corpului___________
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6. Tegumentele, mucoasele şi anexele pielii_____________________________________
o umeditatea şi turgorul_________________________________________________
7. Ţesutul celuloadipos______________________________________________________
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8. Edeme_________________________________________________________________
9. Ganglionii limfatici_______________________________________________________
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10.Capul__________________________________________________________________
11.Gîtul___________________________________________________________________
o Pulsarea patologică a carotidelor________________________________________
12.Muşchii: nivelul de dezvoltare, tonusul_______________________________________

o Dureri la palpare_____________________________________________________

13.Oasele:
o Prezenţa deformaţiilor, dureri_
o Modificarea oaselor

14.Articulaţiile:
o schimbarea conturului, edeme, hiperemie, durere___________________________
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 o limitarea mişcărilor__________________________________________________
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15.Sistemul respirator
o Acuze__________________________________________________________________
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o Inspectie_______________________________________________________________
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o Palpare________________________________________________________________
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o Percutie
Comparativă:._________________________________________________
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Topografică:__________________________________________________
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o Ausucultatie_____________________________________________________________
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16.Sistemul cardiovascular.

o Acuze__________________________________________________________________
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o Palpare
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Caracteristica şocului apexian
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o Percutie
Limita relativă a cordului________________________________________
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Limita absolută a
cordului______________________________________________________
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o Ausucultatie
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FCC în minut________________
Pulsul______________________
TA :________________________

17. Tractul gastrointestinal

o Acuze__________________________________________________________________
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 o Palpare_________________________________________________________________
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o Inspectie________________________________________________________________
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o Palpare
Palpare superficială_____________________________________________
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Palparea după Obrasţov-Străjescu__________________________________
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o Percutie________________________________________________________________
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o Ficatul şi vezica biliara___________________________________________________

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o Splina__________________________________________________________________
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18. Sistemul urinar

o Acuze__________________________________________________________________
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o Palparea:
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 o Percutia:________________________________________________________________
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19. Sistemul hematopoetic:

o Acuze__________________________________________________________________
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o Palparea oaselor (regiuni dureroase)________________________________________

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20. Sistemul endocrin:________________________________________________________

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21. Starea neuropsihică:

o Conştiinţa: clară, difuză, comă, sopor, stupor, delir, halucinaşii

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o Dispoziţia: indiferentă, indispoziţie, apatie, obişnuită,iritabilitate
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22. Organele de simţ

o Sensibilitatea____________________________________________________________
o Văzul__________________________________________________________________
o Auzul__________________________________________________________________

23. CLINICA DERMATOLOGICĂ (status localis)

Descrierea leziunilor pielii şi mucoaselor se face după principii topografice(începînd de la
pielea pilorică a capului pînă la tălpi), cu evidenţierea amănunţită a focarului principal.

o Caracteristica generală a leziunilor : erupţiile sînt localizate ori răspîndite,,cu

caracter diseminat ori difuz,cu caracter simetric ori asimetric
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o Caracterul leziunilor – monomorf,polimorf (real,fals) cu tendinţă spre o creştere
periferică, confluare sau grupare, cu localizare figurată şi altele
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o Localizarea de elecţie ale erupţiilor: (locul, regiunea unde iniţial au apărut,
localizarea maximală)
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o Caracteristica detaliată a elementelor morfologice:

Primare – mărimea, conturul (rotund, ovalar, poligonal),limita (conturată,
neconturată), forma (plată, conică, semisferică, depresiune centrală),
culoarea (roză, albăstrie), suprafaţa (netedă, rugoasă, erozivă, zemuindă-
umedă)._____________________________________________________
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 ____________________________________________________________
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Secundare – descrierea se face în corespundere cu caracterul erupţiilor
(pigmentaţia, cruste, scuoame, eroziuni, cicatrici, etc).
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o Datele cercetărilor specifice: palpaţia (consistenţa, limitarea elementelor, stratificarea,
caracterul descuamării, fenomenele psoriazisului), vitropresiunea, simptomul Nicolsky,
Unna-Darier, KÖbner, Mescerski, Pospelov şi altele).___________________________
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o Cercetarea dermografismului şi reflezului pilomotor, determinarea secreţiei glandelor
sebacee şi sudoripare. Starea sistemului limfatic._______________________________
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24. Diagnostic prezumtiv
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25. Planul de investigaţii (Examen de laborator şi alte investigaţii de ultima oră)

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26. Rezultatele analizelor de laborator şi alte investigaţii (Efectuate)

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27. Diagnostic diferenţiat

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28. Diagnosticul clinic final (argumentat)
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29.Tratament individual (argumentat şi prescris conform datelor de ultima oră)

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30. Evolutia zilnică
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31. Recomandări şi pronostic

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32. Epicriza
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