2015-05-27
336УЧЕБНАЯ ИСТОРИЯ БОЛЕЗНИ
ФИО пациента
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Клинический диагноз:
Основное заболевание………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Фоновое заболевание…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Сопутствующие заболевания……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Расспрос
Паспортная часть
Полное имя больного:
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Дата рождения:………………………….19….г
Возраст:………………………..
Домашний адрес:…………………………………………………………………………………………………….
Место работы:………………………………………………………………………………………………………….
Должность:……………………………………………………………………………………………….
Инвалидность:………………………………………………………………………………………….
Дата поступления…………..20….г Дата выписки…………..20….г
Дата начала курации……….....20….г Дата окончания курации……….…20….г
Жалобы
На момент поступления:
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На момент курации:
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сон…………………………………………… аппетит………………………………………….
стул………………………………………….. мочеиспускание…………………………..
3. Анамнез заболевания (основное заболевание подробно и кратко указать анамнез сопутствующих):
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Анамнез жизни
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Наследственность
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Перенесенные заболевания
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Диетический анамнез
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Гинекологический анамнез
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Аллергологический анамнез
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Санитарно-эпидемиологический анамнез
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Страховой анамнез
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ОБЩЕКЛИНИЧЕСКОЕ ФИЗИЧЕСКОЕ ОБСЛЕДОВАНИЕ
Общий осмотр
вес……………кг Индекс Кетле:………кг/м2
рост…………..см
Температура(c0)…………
Индекс Кетле:………..кг/м2
o дефицит веса - 18
o нормальный вес - 18-25
o избыточная масса тела - 25-29
o ожирение - 30-39
o патологическое ожирение - более 40
тип телосложения:
o нормостеник
o астеник
o гиперстеник
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Дыхательная система
Осмотр
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Пальпация
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Перкуссия
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Топографическая перкуссия
Верхушки лёгких
| сторона | спереди | сзади |
| справа | ||
| слева |
Дыхательная подвижность нижнего края лёгких
| Топографические линии | Правое легкое | Левое лёгкое |
| Парастернальная линия | ||
| Среднеключичная линия | ||
| Передняя подмышечная линия | ||
| Средняя подмышечная | ||
| Задняя подмышечная линия | ||
| Лопаточная линяя | ||
| Паравертебральная линия |
Дыхательная подвижность нижнего края легких
| правого | левого | |
| Среднеключичная | ||
| Средняя подмышечная | ||
| Лопаточная линяя |
Аускультация…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………......
Сердечно-сосудистая система
Осмотр и пальпация
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Перкуссия
Границы относительной сердечной тупости
| правая | |
| левая | |
| верхняя |
Границы абсолютной сердечной тупости
| правая | |
| левая | |
| верхняя |
Аускультация
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АД______/_____мм Hg
ЧСС_____/мин. Пульс______/мин.
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Пищеварительная система
осмотр
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Пальпация
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Границы абсолютной печеночной тупости по Курлову:
Правая среднеключичная линия……..см
Правая срединная линия……..см
Левая реберная дуга.........см
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Аускультация
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Мочевыделительная система
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Эндокринная система
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Нервная система
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Предварительный диагноз
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План обследования:
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ДОПОЛНИТЕЛЬНЫЕ МЕТОДЫ ИСЛЕДОВАНИЯ и их клиническая оценка
1. Общий анализ крови
| дата | |||
| RBC(эритроциты) | Х1012/l | X1012/l | X1012/l |
| WBC(лейкоциты) | X109/l | X1012/l | X109/l |
| Hb(гемоглобин) | g/l | g/l | g/l |
| цветной показатель | |||
| базофилы | |||
| эозинофилы | |||
| нейтрофилы: | |||
| палочкоядерные | |||
| сегментоядерные | |||
| лимфоциты | |||
| моноциты | |||
| тромбоциты | |||
| ESR(СОЭ) | Mm/h | Mm/h | Mm/h |
Клиническая оценка:
2. Биохимический анализ крови
| Показатель/дата | норма | ||
клиническая оценка:
3. общий анализ мочи
| Показатель/дата | ||
| цвет | ||
| прозрачность | ||
| плотность | ||
| белок | ||
| Эпителиальные клетки | ||
| WBC(лейкоциты) | ||
| RBC(Эритроциты) | ||
Клинический анализ:
ЭКГ
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