МИНИСТЕРСТВО ЗДРАВООХРАНЕНИЯ

РОССИЙСКОЙ ФЕДЕРАЦИИ

ФГУ ОМСКАЯ ГОСУДАРСТВЕННАЯ МЕДИЦИНСКАЯ АКАДЕМИЯ

КАФЕДРА ОБЩЕЙ ХИРУРГИИ

С КУРСОМ ТОРАКАЛЬНОЙ ХИРУРГИИ

Заведующий кафедрой:

доктор медицинских наук,

профессор КК Козлов

Преподаватель:

,

,

.

История болезни.

____________________________________________________________________

(Фамилия, Имя, Отчество больного)

Диагноз:

Куратор:

студент группы

___________________________ факультет

______________________________________________

^{(Фамилия, Имя, Отчество)}

Время, курации:

с ___________ по__________ 2009 года,

Оценка преподавателя

Подпись

ОМСК 2009 г.

ПАСПОРТНЫЕ ДАННЫЕ.

Фамилия, имя, отчество __________________________________________

Возраст _______________________________________________________

Профессия _____________________________________________________

Место работы и должность _______________________________________

Место жительства _______________________________________________________________

Кем направлен и диагноз направившего лечебного учреждения.

____________________________________________________________________________________________________________________________

Диагноз при поступлении: __________________________________________________________________________________________________________________________

Клинический диагноз:

основной ________________________________________________________________________________________________________________

осложнение основного ________________________________________________________________________________________________________________

сопутствующие заболевания ________________________________________________________________________________________________________________

Операция (дата и название, вид обезболивания, осложнения после операции).

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Жалобы большого в момент развития заболевания.

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Жалобы по системам.

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История настоящего заболевания (Anаmnesis morbi).

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История жизни больного (Anemnesis vitae).

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Данные объективного обследования (Status praesens).

Осмотр.

Состояние ____________________________________________________

Сознание ____________________________________________________

Положение ____________________________________________________

Кожные покровы ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Телосложение ______________________________________________________ Походка ___________________________________________________________

Осанка ____________________________________________________________

Лицо ___________________________________________________________

Голос ________________________________________________________________

Речь ______________________________________________________________

Слизистая полости рта

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Слизистая конъюнктивы:

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Губы ________________________________________________________________________________________________________________________________________________

Глаза

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Шея

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Отёки ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Пальпация.

Лимфатические узлы __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Подкожно-жировой слой

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Мышцы

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Кости

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Суставы

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Позвоночник

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Щитовидная железа _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Исследование основных систем организма.

Органы дыхания.

Носовое дыхание

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Грудная клетка

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Перкуссия легких

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Аускультация легких

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Система кровообращения.

Осмотр

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Пальпация

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Перкуссия

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Аускультация

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Пульс ____________________________________________________

Артериальное давление __________________________________________

Система пищеварения.

Ротовая полость

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Осмотр живота

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Поверхностная пальпация живота

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Глубокая пальпация живота

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Печень

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Желчный пузырь

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Селезёнка

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Почки

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Перкуссия

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Аускультация живота

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Локальный статус.

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Данные рентгенологических и инструментальных

исследований.

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Данные лабораторных исследований.

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Обоснование диагноза.

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Лечение.

Дата назначения.	Назначения.	Описание.
Дата назначения.	Назначения.	Описание.

Дневник.

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Эпикриз.

Дата ______________________

Больной _______________________________

находился в__________________отд.

с __________ по ____________

Диагноз заключительный: _________

Диагноз установлен на основании

жалоб

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

анамнеза ________________________________________________________________________________________________________________________________

данных объективного обследования

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

данных инструментальных и лабораторных исследований __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Проведено лечение (операции, фармакотерапия, физиолечение) ___________________________________________________________________________________________________________________________________________________________________________________________________

В ходе проведенного лечения:

выздоровление, улучшение, ухудшение, без перемен.

При выписке состояние удовлетворительное, средней тяжести, тяжелое.

Прогноз для жизни и восстановления трудоспособности ____________________________________________________________________________________________________________________________________________________________________________________

Рекомендовано ____________________________________________________________________________________________________________________________

Особенности клинического случая и лечения заболевания __________________________________________________________________________________________________________________________________________________________________________________________

Подпись куратора:

Общая редакция

д.м.н., профессор Козлов К.К.