Fișa Dermato, Model.docx

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”

Catedra__________________________________________________

Şef.catedrei_________________________________ Conducător gr.______________________________ Curator____________________________________ Grupa_______________ anul__________________ Facultatea__________________________________

FIŞĂ DE OBSERVAŢIE A BOLNAVULUI Data curării__________________

CHIȘINĂU 2019

I. DATE PAŞAPORTALE Nume,prenume______________________________________________________ Vîrsta_____________________________________________________________ Sexul______________________________________________________________ Adresa_____________________________________________________________ Ocupatia___________________________________________________________ Data internării________________________ Ora_________________________________ Institutia care a trimis bolnavul_________________________________________ Diagnosticul la internare______________________________________________

DIAGNOSTICUL CLINIC. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

II. ACUZELE 1. La ziua curatiei: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. La internare: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

III. ANAMNEZA BOLII __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ IV. ANAMNEZA VIEŢII 1. Date biografice __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2.Anamneza sexuală __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

3.Antecedente patologice __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4.Deprinderi dăunătoare __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 5.Antecedente familiale. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 6. Anamneza alergologică 1. Intoleranţa la medicamente___________________________________________ 2. Vaccinuri_________________________________________________________ 3. Alimente_________________________________________________________ V. STAREA GENERALĂ. 1. Stare generală____________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. Conştiinţa________________________________________________________ __________________________________________________________________ 3. Poziţia___________________________________________________________ __________________________________________________________________ 4. Faciesul_________________________________________________________ __________________________________________________________________

5. Constituţia__________________ talia______________ masa corpului_______ __________________________________________________________________ 6. Tegumentele, mucoasele şi anexele pielii_______________________________ O umeditatea şi turgorul_______________________________________________ 7. Ţesutul celuloadipos_______________________________________________ __________________________________________________________________ 8. Edeme__________________________________________________________ 9. Ganglionii limfatici_______________________________________________ __________________________________________________________________ 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__________________________ __________________________________________________________________ __________________________________________________________________ O limitarea mişcărilor________________________________________________ __________________________________________________________________ __________________________________________________________________ 15. Sistemul respirator O Acuze__________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

O Inspectie________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Palpare________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Percutie Comparativă:.__________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Topografică:__________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Ausucultatie_____________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________ 16. Sistemul cardiovascular. O Acuze_________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Palpare________________________________________________________ __________________________________________________________________ __________________________________________________________________ Caracteristica şocului apexian __________________________________________________________________

__________________________________________________________________ O Percutie Limita relativă a cordului_________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Limita absolută a cordului_________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Ausucultatie __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________ FCC în minut________________ Pulsul______________________ TA :________________________ 17. Tractul gastrointestinal O Acuze__________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Palpare_________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Inspectie_________________________________________________________ __________________________________________________________________

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ o Palpare Palpare superficială__________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Palparea după Obrasţov-Străjescu_______________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Percutie_________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Ficatul şi vezica biliara_____________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Splina___________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 18. Sistemul urinar O Acuze___________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Palparea: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Percutia:________________________________________________________ __________________________________________________________________ __________________________________________________________________

19. Sistemul hematopoetic: O Acuze___________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Palparea oaselor (regiuni dureroase)_________________________________ __________________________________________________________________ __________________________________________________________________ 20. Sistemul endocrin:________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 21. Starea neuropsihică: O Conştiinţa: clară, difuză, comă, sopor, stupor, delir, halucinaşii __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Dispoziţia: indiferentă, indispoziţie, apatie, obişnuită,iritabilitate __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 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 __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

__________________________________________________________________ __________________________________________________________________ ________________________________________________________________ O Caracterul leziunilor – monomorf,polimorf (real,fals) cu tendinţă spre o creştere periferică, confluare sau grupare, cu localizare figurată şi altele __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Localizarea de elecţie ale erupţiilor: (locul, regiunea unde iniţial au apărut, localizarea maximală) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _____________________________________________________________ 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, zemuindăumedă).____________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Secundare – descrierea se face în corespundere cu caracterul erupţiilor (pigmentaţia, cruste, scuoame, eroziuni, cicatrici, etc). __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ O Datele cercetărilor specifice: palpaţia (consistenţa, limitarea elementelor, stratificarea, caracterul descuamării, fenomenele psoriazisului), vitropresiunea, simptomul Nicolsky, Unna-Darier, KÖbner, Mescerski, Pospelov şi altele)._____________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ o Cercetarea dermografismului şi reflezului pilomotor, determinarea secreţiei glandelorsebacee şi sudoripare. Starea sistemului limfatic.____________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 24. Diagnostic prezumtiv __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 25. Planul de investigaţii (Examen de laborator şi alte investigaţii de ultima oră) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 27. Diagnostic diferenţiat __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 30. Evolutia zilnică __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 31. Recomandări şi pronostic __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

32. Epicriza __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________