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Санкт-Петербургский фельдшерский медицинский колледж
УЧЕБНАЯ ИСТОРИЯ БОЛЕЗНИ
ПО ПРОПЕДЕВТИКЕ ВНУТРЕННИХ БОЛЕЗНЕЙ
DS:_________________________________________________________________________________________________________
Студента ____группы_____ курса
фельдшерского отделения
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Преподаватель: -_____________________________
20__/ 20__уч год.
История болезни
I. Общие сведения
Ф. И.О.______________________________________________________________________________________________________________________________ возраст____________________________________________полных лет________________________________________________________________________
место работы, адрес___________________________________________________________________________________________________________________
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должность___________________________________________________________________________________________________________________________
адрес проживания____________________________________________________________________________________________________________________
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дата потупления в клинику_________________________________________________________________________
II. Анамнез
1. жалобы_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________III. история настоящего заболевания (Anamnesis morbi)
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IV.
2. Перенесённые ранее заболевания
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V.
3. Аллергологический анамнез
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5. Семейный анамнез и наследственность________________________________________________________________________________________________
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VI.I6. Истории жизни больного______________________________________________________________________________________________________
6.1. Младенчество, детство, юность____________________________________________________________________________________________________
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6.2. Бытовой анамнез__________________________________________________________________________________________________________________
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6.3. Трудовой анамнез________________________________________________________________________________________________________________
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6.4. Половой анамнез_________________________________________________________________________________________________________________
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6.5. Вредные привычки________________________________________________________________________________________________________________
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VIII. Данные объективного исследования
1. Общий осмотр
1.1. Общее состояние_________________________________________________________________________________________________________________
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1.2. Положение больного в постели______________________________________1.3. Сознание____________________________________________________
1.4. Выражение лица_______________________________1.5. Рост, масса тела, телосложение, конституция_________________________________________
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1.6. Кожа и слизистые оболочки________________________________________________________________________________________________________
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1.7. Подкожная клетчатка_____________________________________________________________________________________________________________
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1.8. Лимфатические узлы______________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________1.9. Мышцы_________________________________________________________________________________________________________________________
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1.10. Кости__________________________________________________________________________________________________________________________
1.11. Суставы________________________________________________________________________________________________________________________
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IX. 2. Органы дыхания 2.1. Осмотр: форма носа, гортани, шеи; форма грудной клетки, её деформация, ассиметрия; тип, ритм. частота и глубина дыхания, характер одышки (экспираторная, инспираторная, смешанная и т. п.)
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2.2. Пальпация грудной клетки_________________________________________________________________________________________________________
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2.3. Перкуссия сравнительная и топографическая________________________________________________________________________________________
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2.4.Аускультация_____________________________________________________________________________________________________________________
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X. 3. С. С.С.
3.1. Осмотр сердечной области, верхушечный толчок __________________________________________________________________________
_ ___________________________________________________________________________________________________________________________________
3.2. Осмотр артерий и вен_____________________________________________________________________________________________________________
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3.3. Пальпация характеристика верхушечного толчка ______________________________________________________________________________________
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3.4. Перкуссия сердца_______________________________________________________________________________________________________________
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3.5. Исследование сосудов____________________________________________________________________________________________________________
3.5.1. Свойства пульса на лучевых артериях______________________________________________________________________________________________
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3.5.2. Аускультация сосудов____________________________________________________________________________________________________________
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3.5.3. А. Д.___________________________________________________________________________________________________________________________
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XI.
4. Органы пищеварения
4.1Осмотр___________________________________________________________________________________________________________________________
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4.2Перкуссия________________________________________________________________________________________________________________________
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4.3 Пальпация_______________________________________________________________________________________________________________________
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XII. Органы мочевыделения
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XIII. План лабораторных и инструментальных обследований
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IX. Выявленные синдромы и симптомы
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X. Патогенез выявленных синдромов и симптомов________________________________________
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