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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 (с указанием ожидаемых результатов)

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3.ДОПОЛНИТЕЛЬНЫЕ МЕТОДЫ ИСЛЕДОВАНИЯ

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:

4. ЭКГ

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5. Данные дополнительных методов исследования и консультаций специалистов

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4.КЛИНИЧЕСКИЙ ДИАГНОЗ

Основное заболевание

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Осложнение основного заболевания

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Фоновое заболевание

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Сопутствующие заболевания

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ОБОСНОВАНИЕ ДИАГНОЗА

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5. ЛЕЧЕНИЕ

Режим……………………………………………………………………………………………………………………….…..

Диета…………………………………………………………………………………………………………………………..…

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Цели и задачи

терапии..............................................................................................................

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Лекарственые препараты (рецепты)

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6. ДНЕВНИК КУРАЦИИ

Дата; ад; чсс, пульс

Клинические данные

Лечение