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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 / $art"#e%r
• SISTEM 6AN6LIONAR LIMFATIC
8/20/2019 Foaie de Observatie Clinica Medicala
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• SISTEM OSTEOARTICLAR
) art"$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
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) 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$urt / %un+
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1*. TRATAMENT :
• "+"en ) #"etet"$
• me#"$aments : %a "nternare / a$tua%
• "ntervent"na%
• $8"rur+"$a%1. 7ARTICLARITATILE CA5LI
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