5 курс-20251107T185252Z-1-001 / Травма / Skhema_istorii_bolezni_lechebny_fakultet_8_semest
.pdfМочевыделительная 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 |
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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 |
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базофилы |
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эозинофилы |
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нейтрофилы: |
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палочкоядерные |
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сегментоядерные |
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лимфоциты |
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моноциты |
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тромбоциты |
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ESR(СОЭ) |
Mm/h |
Mm/h |
Mm/h |
Клиническая оценка: |
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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 |
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