ИСТОРИЯ БОЛЕЗНИ ЛОР

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Если у больного жалоб на состояние слуха нет, исследуют восприятие ш¸потной речи, фиксируя результат для каждого уха в форме: ШРAD иAS= 6 м. В том случае если слух снижен и при наличии выявленной патологии уха в обязательном порядке должен быть составлен слуховой паспорт, исследуют барофункцию ушей. При жалобах на головокружение и расстройство равновесия исследуют вестибулярную функцию.

Результаты исследования слуха ш¸потной и разговорной речью, а так же камертонами вносят в слуховой паспорт.

СЛУХОВОЙ ПАСПОРТ

(Формула слуха)

	AD		Тесты		AS
Ê		Â		Â		Ê
			C128
			C2048
			ØÐ
			ÐÐ

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ПРЕДВАРИТЕЛЬНЫЙДИАГНОЗИЕГООБОСНОВАНИЕ

Подвести итог субъективным и объективным данным, полученным при первичном обследовании больного (учитываются жалобы, данные анамнеза заболевания и жизни, результаты внешнего и эндоскопического исследований).

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ДОПОЛНИТЕЛЬНЫЕМЕТОДЫИССЛЕДОВАНИЯ

Результаты лабораторного, рентгенологического, инструментального исследований.

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ДИФФЕРЕНЦИАЛЬНЫЙДИАГНОЗ

Прежде чем сделать вывод об окончательном диагнозе необходимо сопоставить фактический материал, полученный у больного с клиническими проявлениями сходных заболеваний.

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ОКОНЧАТЕЛЬНЫЙДИАГНОЗ

Ставится на основании данных клинического обследования, результатов дополнительных исследований с учетом проведенной дифференциальной диагностики. Заключение о состоянии больного выносится в виде окончательного диагноза, который состоит из трех частей:

1.Основное заболевание.

2.Осложнения.

3.Сопутствующего заболевания.

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ЭТИОЛОГИЯ,ПАТОГЕНЕЗ,ПАТОЛОГИЧЕСКАЯАНАТОМИЯ,КЛИНИКА, ТЕЧЕНИЕЗАБОЛЕВАНИЯ

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ЛЕЧЕНИЕ

Консервативное (медикаментозное), хирургическое лечение данного заболевания. Цель операции. Показания к хирургическому методу лечения. Вид обезболивания (местное,

общее). Описание хода операции.

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