Результаты дополнительных методов исследования:
Лабораторные показатели:
Общий анализ крови
Дата |
Эритроциты |
Гемоглобин |
тромбоциты |
лейкоциты |
палочки |
Сегменты. |
лимфоциты |
моноциты |
СОЭ |
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Общий анализ мочи
Дата |
Цвет /прохрачность |
реакция |
плотность |
белок |
эпителий |
эритроциты |
лейкоциты |
бактрии |
соли |
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Бактериологическое исследование ________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________,
________________________________________________________________________________
Исследование кала, мокроты_____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Биохимические показатели крови:
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общий белок |
билирубин |
мочевина |
креатинин |
глюкоза |
натрий |
калий |
АСТ |
АЛТ |
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ЛДГ |
КФК |
ЩФ |
ГГТП |
СРБ |
ПСМ |
рН крови |
холестерин |
амилаза |
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Коагулограмма_________________________________________________________________
______________________________________________________________________________
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Группа крови _______________ резус – принадлежность ______________________________
Иммунограмма ___________________________________________________________
________________________________________________________________________________________________________________________________________________________________,
Нbs Ag _________________________антитела к Hbs Ag_______________________________,
Антитела к HCV____________, ВИЧ______________________________________________,
Антитела к бледной трепонеме ____________________, RW___________________________.
Инструментальные исследования: ____________________________________________________
____________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Л
учевые
исследования ___________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
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Функциональные исследования: ______________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Динамика функциональных показателей:
Дата |
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Сутки госпитализации |
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Температура *С |
утром |
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вечером |
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АД мм рт. ст. |
утром |
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вечером |
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Пульс уд. в минуту |
утром |
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вечером |
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Суточный диурез мл |
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Клинический диагноз
Обоснование диагноза____________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________ _______________________________________________________________________________
_________________________________________________________________________________
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Основной клинический диагноз ___________________________________________________
__________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________
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____________________________________________________________________________________
Осложнения ________________________________________________________________________
_________________________________________________________________________________
____________________________________________________________________________________
Сопутствующая патология ___________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Лечение:
Хирургическое лечение:
Обоснование операций ___________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Сроки, виды и объём оперативных вмешательств _____________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Местное лечение:
до оперативного вмешательства ____________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
после операции __________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Физиотерапия ___________________________________________________________________
________________________________________________________________________________
Реабилитация, ЛФК_______________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Лекарственная терапия:
Фарм. группа |
Препарат
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Доза
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Кратность введения |
Курс
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Обоснование назначения |
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Этиопатогенез
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Дневник
Дата ____________________ 20 г
Жалобы на момент осмотра: _____________________________________________________
_______________________________________________________________________________________________________________________________________________________________
Объективный статус: ____________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Локальный статус: _____________________________________________________________
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Лечение: _______________________________________________________________________
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Куратор _____________________________
Эпикриз ________________________________
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Заключение гистологии:
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