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Prezentare Caz Clinic Chirurgical

Prezentare Caz Clinic Chirurgical

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Published by Ruxandra Marin

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Published by: Ruxandra Marin on Apr 05, 2011
Copyright:Attribution Non-commercial

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01/09/2013

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PREZENTARE CAZ CLINIC CHIRURGICAL:
I. Am avut de examinat:
1. bolnavul A.B.: in varsta dede profesiedin mediul rural/urban2. care s-a internat in clinica: la data de/ in urma cu x zile/minute3. in ce conditii s-a internat: de urgenta/ in ambulator/ prin transfer din alta unit.4. motivele internarii: motive vitale + motive terapeutice
II. Antecedentele pacientului:
Heredocolaterale
Personale (fiziologice si patologice): VHB, ciroza, HIV, VE-B, HPV, alte infectii cr.alte boli cu semnificatie (TB, sifilis)antecedente parazitareboli profesionaleboli chirurgicale
Tratamente cronice (anticoagulante, cortizon, insulina etc)
Consumator de droguri/tutun/alcool
Alergii medicamentoase!!!se mentioneaza doar ce este semnificativ
III. Istoricul bolii active:
1. de cand dateaza2. cum a debutat (brusc/insidios) (la pacient sanatos/agravare afectiune cr.)3. daca exista factor declansato4. semnele de debut5. cum au evoluat semnele/ daca au aparut altele noi6. ce diagnostice documentate are pacientul, ce tratament a urmat si daca aavut efect
IV. Examen obiectiv :
- centrat pe localizarea afectiunii (general si local)- examen oncologic (gg etc)- tuseu rectal, tuseu vaginal- termometrizare, TA, puls perif/AV- diureza, curba ponderala- eliminarile neobisnuite
V. Diagnosticul clinic :
- de sindrom/ de simptom/ de boala/ rar de stadiu/ de complicatie/ deorgan (colica renala, tromboflebita etc)
VI.
Investigatii necesare :VII. Diagnosticul pozitiv :
- afectiunea principala + afectiuni asociate
VIII.
Diagnosticul diferential :
IX.
Diagnosticul definitiv :
- principal + asociate + tratament

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