Anamneza
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I. Am examinat bolnavul de gen in varsta de nascut in cu domiciliul in de profesie/actual pensionar(b) fost Care s-a internat pentru: (durere,varsaturi,greata,febra,dispnee,disfagie,astenie,hemoptizii,cianoza,paloare,ortopnee,piroz is,fatigabilitate,vertij,palpitaii,adenopatii) II.A.H.C : Boli(Hta,Avc,diaget,guta,obezitate,litiaza renala,boli ale tiroidei,astm,alergii,neoplasme,epilepsie ,hemofilie, ulcer duodenal ,ciroza,pulmonar) Varsta si cauza mortii daca e patologica. III.A.P.F. : 1)menarha 5)Nr.sarcini /greutatea la nastere 2)Data ultimei menstruatii 6)La terment/premature(varsta) 3)Varsta mamei la nastere 7)Tipul nasterii 4)Avorturi(terapeutice/empirice/spontane)-Varsta 8)Tulburari legate de ap menopauzei IV.A.P.P: (Boala-Varsta: rubeola(L),rujeola,inf. Urliana,varicela, pneumonie,hepatite,apendicectomie, splenectomie,histerectomie,Traumatisme,operatii,alergii,transfuzii, + tratament) ………………….............. …………………………………………………………………………………………………………………………………………………………………......... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ................................................. …………………………………………………………………………………………………………………………………………………………………......... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ................................................ …………………………………………………………………………………………………………………………………………………………………......... 1
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Anamneza
Transcript of Anamneza
I. Am examinat bolnavul de gen in varsta de nascut in cu domiciliul in de profesie/actual pensionar(b) fost Care s-a internat pentru: (durere,varsaturi,greata,febra,dispnee,disfagie,astenie,hemoptizii,cianoza,paloare,ortopnee,pirozis,fatigabilitate,vertij,palpitaii,adenopatii)
II.A.H.C : Boli(Hta,Avc,diaget,guta,obezitate,litiaza renala,boli ale tiroidei,astm,alergii,neoplasme,epilepsie ,hemofilie, ulcer
duodenal ,ciroza,pulmonar) Varsta si cauza mortii daca e patologica.
III.A.P.F.: 1)menarha 5)Nr.sarcini /greutatea la nastere 2)Data ultimei menstruatii 6)La terment/premature(varsta) 3)Varsta mamei la nastere 7)Tipul nasterii 4)Avorturi(terapeutice/empirice/spontane)-Varsta 8)Tulburari legate de ap menopauzei
IV.A.P.P:(Boala-Varsta: rubeola(L),rujeola,inf. Urliana,varicela, pneumonie,hepatite,apendicectomie, splenectomie,histerectomie,Traumatisme,operatii,alergii,transfuzii, + tratament) ………………….............. …………………………………………………………………………………………………………………………………………………………………..................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................…………………………………………………………………………………………………………………………………………………………………
V.Conditii De viata si munca:
1)Loc de munca ……………………………………………………………………………………….................................................. 2)Factori de risc(Temp,spatiu, umiditate, zgomot,pulberi, zoonoze,vopsele, ORAR ) ……………………………… 5)Cate mese/zi-regulate .............................................................................................................................. 6)Diete(recomandate, voluntare, ce tip, de cand>hipersodate/hiperglucidica/hiperproteica<) . ....... .. ..... 7)Alcool (cat,regulat<->de cand) .................................................................................................................. 5)Cafea (cat,regulat<->de cand)................................................................................................................... 6)Tutun(varsta debut-nr. Tigari/zi , fumatorpasiv)………………………………… .................................................... ………………………………………………………………………………………………………………………………………………………………….
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VI.I.B.A. Boala actuala a debutat(cand)………………………………………,(cum)………………………………………………….. avand urmatoarele manifestari clince:durere(localizare/iradiere/intensitate/tipul/caracter/factori de
agravare-ameliorare/forme vegetative de insotire) Varsaturi (consistent/in rap cu alimentatia/cu
durerea) Dispnee (mixta /inspiratorie / expiratorie -obstructiva/restrictive) Tuse (uscata / umeda-Orar-
factori ameliorare)Disfagie (lichide / solide/mixta/ paradoxala)……………… O ALTA boalaactuala...……….. .........................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................…………………………………………………………………………………………………………………………………………………………………
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VII.Date de ordin general: 1)MasaPacient 2)Inaltime 3) IMC(kg/h2) 4)Apetit: 5)Somn (cateore,zi/noapte,regulat) 6)TA Gr.sanguin 7)Diureza(cate-zi/noapte,culoare,discomfort) 8)Scaun(cate-zi/noapte,consistenta,volum) 9)Curba ponderala (cat in cat timp)
Ex obiectiv general
1) Stare de constienta : Constient ,somnolent, obnubilare, stupoare,sincopa, lipotimie,coma.2) Atitudine: Activa/Pasiva3) Pozitie :activa/pasiva / fortata-antialgica,antidispneica,asociate cu contrac musculara4) Tip constitutional : normostenic/astenic(longilin)/hiperstenic(picnic)5) Tegumente:paloare/eritem/cianoza/icter/tulb de pigmentare…………………………………………
……………………………………………………………………………………………………………………………………………6) Facies:Vultuos, acromegalic, mixedem, luna plina( cushing), vultuos , Lupus, mitral,
peritoneal , cirotic, sclerodermie, Necaracteristic7) Lant gaglionar superficial nepalpabil/ Adenopatii: localizare,marime,nr. ,contur, forma, consistent,
sensibilitate, mobilitate. ..................................................................................................................................................... ........................................................................................................................................................................................
8) Tiroida9) Sistem osteoarticular: integru si mobil /daca a avut fracturi:...........................................................10) Sistem muscular :normoton , normokinetic / ..................................................................................11) Tesut celular subcutanat (bine reprezentat la nivel……………………………………………………………………)
Edeme:………………………………………………………………………………………………………………………………….12) Fanere:
Examen obiectiv al aparatului respirator
La inspectie :
Torace simetric, clavicule usor proeminente si orizontale, stern usor deprimat,< Luis vizibil, fose supraclaviculare usor adancite, < epigastric ~ 90, apofize spinoase usor vizibile, diametru A-P < diametru transversal ~ ½. + pag 104………………………………………………………………………………………………………………………….
Miscarire spiratorii: simetrice, ritmice, sincrone, cu amplitudine normala, raport inspir/expir -1/3, tip respirator:…………………………………………………………………………………………………………………………………………….
La palpare:
Freamat pectoral present , FR(14-20):……, Miscari respiratorii: simetrice, ritmice, sincrone, cu amplitudine normala, frecatura pleurala (abs/prezenta)
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La percutie: (sonoritate pulmonara) …………MAP:(4-6 cm) ………………………………………………………………………..
La auscultati e : (suflu tubar fiziologic si murmur vezicular – in normal rap 3/1) ……………………………… ………… ……………………………………………………………………………………………………………............................................
Examen obiectiv al aparatului cardiovascular
La inspectie : (normal /Bombari,Retractii, Sant Harrison,Soc apexian,Pulsatii epigastrice)……………………… ………………………………………………………………………………………………………………………………………………………………….
La palpare:Soc apexian present la nivelul spatiului intercostal……. Pelinia…………….Puls periferic(60-80):
La auscultatie:( urmarim- FC- Tahi/bradi , clare, zg 1/2 estompate-accentuate, suflu sistolic/diastolic, clicuri, frecatura pericardica)
Zgomote cardiace: ritmice/aritmice,clare, bine batute. FC:…………………………
………………………………………………………………………………………………………………………………………………………………….
Examen obiectiv al aparatului Digestiv
La inspectie:Abdomen normal conformat ceparticipa la miscarile respiratorii La palpare:Abdomen suplu elastic nedureros La percutie:Timpanism La auscultatie: Zgomote hidroaerice prezente
Examenul obiectiv al ficatului(daca e palpabil):
La palpare:
1 Marginea anterioara la …….. cm fata de arcul costal drept pe linia M.C.
2 Marginea anterioara: rotunjita/ascutita
3 Ficat insensibil la palpare
4 Suprafata :regulate /neregulata
5 Consistenta :
La percutie: Diametrul cranio-caudal pe linia M.C. de ………. Cm
Examen obiectiv al aparatului renal
La inspectie: normal La palpare :nepalpabil La percutie:insensibil/Giordano +-
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