Казанская государственная академия ветеринарной медицины имени Н.Э. Баумана
Клиника____________________
ИСТОРИЯ БОЛЕЗНИ
Вид животного______________________пол_____________возраст__________________
Кличка_______________________________бирка__________________________________
Кому принадлежит____________________________________________________________
ДИАГНОЗ__________________________________________________________________
Дата поступления________________________Дата выписки________________________
ИСХОД:____________________________________________________________________
Старший ветврач_____________________________________________
Куратор (Ф.И.О., группа, курс)__________________________________________________
Клиника________________________________
ИСТОРИЯ ЗАБОЛЕВАНИЯ №___
I. Общие сведения
Хозяйство или Ф.И.О. владельца животного________________________________________
Адрес____________________________________________________Телефон_____________
Паспортные сведения о животном: вид_____________пол____________возраст__________
Кличка, тавро, бирка№__________________________масть,приметы___________________
____________Порода, сорт____________________Вес__________Беременность_________
Дата поступления_____________________Исход заболевания_________________________
Число дней лечения____________________________________________________________
Подпись врача (помощника куратора)_______________
II. Анамнез
А) Анамнез об условиях содержания, кормления, эксплуатации: ______________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Б) Анамнез о заболевании: (сведения о перенесенных ранее заболеваниях; санитарно-эпизоотическое состояние хозяйства; история настоящего заболевания – первоначальные симптомы, время и обстоятельства их появления, первые лечебные и профилактические меры, проведены кем и когда): ___________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Подпись врача (куратора) _____________________________________
III. Состояние животного при поступлении
“____”______________________ _______г.______________часов
Температура ______оС; Пульс_______уд/мин; Дыхание _______движ/мин.
Габитус______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Упитанность__________________________________________________________________
Шерстный покров и кожа________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Лимфоузлы_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Слизистые оболочки___________________________________________________________
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Органы кровообращения _______________________________________________________
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Органы дыхания_______________________________________________________________
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Органы пищеварения___________________________________________________________
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Молочная железа______________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Мочеполовые органы__________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Нервная система_______________________________________________________________
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Органы чувств________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Органы движения______________________________________________________________
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Status localis___________________________________________________________________
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ДОПОЛНИТЕЛЬНЫЕ ИССЛЕДОВАНИЯ
1. Рентгеновские, электрокардиографические и др._________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. Серологические, аллергические, бактериологические, паразитологические___________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Диагноз (первоначальный)______________________________________________________
__________________________________________________________________________________________________________________________________________________________
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ЗАКЛЮЧЕНИЕ
о состоянии животного и характере патологического процесса________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Подпись врача (куратора)____________________________________________
Дата |
Время дня |
Т |
П |
Д |
Течение болезни, режим содержания, лечение |
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Дата |
Время дня |
Т |
П |
Д |
Течение болезни, режим содержания, лечение |
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Дата |
Время дня |
Т |
П |
Д |
Течение болезни, режим содержания, лечение |
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Дата |
Время дня |
Т |
П |
Д |
Течение болезни, режим содержания, лечение |
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Диагноз (уточненный, заключительный)___________________________________________
__________________________________________________________________________________________________________________________________________________________
а) основной___________________________________________________________________
_____________________________________________________________________________
б) сопутствующие заболевания___________________________________________________
__________________________________________________________________________________________________________________________________________________________
в) осложнения_________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________