CMI DR GABOR DORIN MARIUS

CMI DR.

Data ________________Loc

Nr. fi _____________EXAMEN DE BILAN

Numele i prenumele ______________________________________ CNP __________________AHC ___________________________________________________________________________

APP____________________________________________________________________________

Stare general: bun acuze ______________________________________________________

Teg. i mucoase: normal colorate , palide , icterice , hiperemice , altfel ______________

Sistem limfoganglionar periferic: nepalpabil , palpabil , unde _________________________Gl. mamare: simetrice , asimetrice , consisten normal , crescut , form. tumoral

palpabil , mrime _____________ localizare ________________________

Sistem osteoarticular: integru , fr modificri , cu modificri , unde _________________

Col. vertebral: curburi fiziologice , dreapt , modificat , unde ______________________

la percuie: nedureroas , dureroas , localizare ______________________________________

Aparat respirator: tuse , expectoraie , mucoas , purulent , hemoptizie , catar

Torace: normal , nfundat , emfizematos , respiraii normale , ample , superficiale

Diafragme mobile , mobilitate redus , dr , stg

Sonoritate pulmonar: normal , hipersonoritate , submatitate , matitate , dr , stg

Murmur vezicular: fiziologie , accentuat , diminuat , dr , stg

Raluri: fr , bronice , sibilante , ronflante ,crepitante , subcrepitante , dr , stg

Aparat cardiovascular: TA _______ mm Hg AV _____/min. matitate card. ]n limite normale ,

crescut , deplas , oriz , vert , la dr , la stg , soc apex sp V m.cl st deplas dr st

Zg. card ritmce , aritmie , FA , ES , accentuate , diminuate

Sufluri: fr , sistolic , focar AO PU , Tric , Mitral grad _______________

Circ venoasa nemodif , venectazii , varice , mb inf dr , stg , ulcer varicos , edeme Aparat digestiv: Cavit bucal i faringe normal color , hiperemic , depozite ____________Apetit bun , sczut , tranzit normal , constipaie , diaree ________________________

Abdomen suplu , meteorism , ascit , circ colat , cicatrice postop , _________________

Palpare nedureros , sensibil , epigastric , periombilical , hipogastru , flanc dr , stg ,

Hernie ombilical , inghinal , scrotal , altele , _______________________________Ficat nepalpabil , la rebord , sub rebord la _______ la palpare nedureros , dureros , consist de organ , resc , supraf neted , modif ___________ Splin nepalp , palp _________

Aparat urogenital: mic spont fiziol , patol ___________ Loji ren libere , nedureroase ,

dureroase , Giordano neg , poz dr , stg , org genit ext normale , modif ___________

SNC: orientat TS , dezorientat , ataxie , vertij , alte _____________________________

ROT prezente bilat , unilat , dr , st , Funcii intelectuale normale , abolite ,

Memorie bun , alterat , funcii afective normale , modificate ________________________

Acuitate vizual: Bun AO , alterat OD _______________ OS ______________________

Acuitate auditiv: bun , hipoacuzie dr , stg .

Concluzii ________________________________________________________________________

________________________________________________________________________________ Recomandri _____________________________________________________________________

Dr. GABOR DOIN MARIUS_1276007171.unknown