- •Учебная история болезни
- •1. Паспортная часть
- •2. Жалобы
- •5. Анамнез жизни
- •2. Общеклиническое физическое обследование
- •3.Дополнительные методы иследования и их клиническая оценка
- •5.Данные дополнительных методов исследования и консультаций специалистов
- •4.Клинический диагноз
- •5. Лечение и его обосновнание
- •6. Эпикриз с рекомендациями при выписке из стационара
- •8. Прогноз
- •9. Список литературы:
2. Общеклиническое физическое обследование
общий осмотр
вес……………кг Индекс Кетле:………кг/м2
рост…………..см
Температура(c0)…………
Индекс Кетле:………..кг/м2
дефицит веса - 18
нормальный вес - 18-25
избыточная масса тела - 25-29
ожирение - 30-39
патологическое ожирение - более 40
тип телосложения:
нормостеник
астеник
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 |
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слева |
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Дыхательная подвижность нижнего края лёгких
Топографические линии |
Правое легкое |
Левое лёгкое |
Парастернальная линия |
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Среднеключичная линия |
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Передняя подмышечная линия |
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Средняя подмышечная |
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Задняя подмышечная линия |
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Лопаточная линяя |
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Паравертебральная линия |
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Дыхательная подвижность нижнего края легких
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правого |
левого |
Среднеключичная |
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Средняя подмышечная |
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Лопаточная линяя |
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Аускультация…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………......
Сердечно-сосудистая система
Осмотр и пальпация
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Перкуссия
Границы относительной сердечной тупости
правая |
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левая |
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верхняя |
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Границы абсолютной сердечной тупости
правая |
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левая |
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верхняя |
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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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