Партнерка на США и Канаду по недвижимости, выплаты в крипто

  • 30% recurring commission
  • Выплаты в USDT
  • Вывод каждую неделю
  • Комиссия до 5 лет за каждого referral

Санкт-Петербургский фельдшерский медицинский колледж

УЧЕБНАЯ ИСТОРИЯ БОЛЕЗНИ

ПО ПРОПЕДЕВТИКЕ ВНУТРЕННИХ БОЛЕЗНЕЙ

DS:_________________________________________________________________________________________________________

Студента ____группы_____ курса

фельдшерского отделения

_____________________________________________

Преподаватель: -_____________________________

20__/ 20__уч год.

История болезни

I.  Общие сведения

Ф. И.О.______________________________________________________________________________________________________________________________ возраст____________________________________________полных лет________________________________________________________________________

место работы, адрес___________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

должность___________________________________________________________________________________________________________________________

адрес проживания____________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

дата потупления в клинику_________________________________________________________________________

НЕ нашли? Не то? Что вы ищете?

II.  Анамнез

1.  жалобы_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________III. история настоящего заболевания (Anamnesis morbi)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________

IV.

2.  Перенесённые ранее заболевания

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V.

3.  Аллергологический анамнез

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________VI.

5. Семейный анамнез и наследственность________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VI.I6. Истории жизни больного______________________________________________________________________________________________________

6.1. Младенчество, детство, юность____________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6.2. Бытовой анамнез__________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6.3. Трудовой анамнез________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6.4. Половой анамнез_________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6.5. Вредные привычки________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII. Данные объективного исследования

1. Общий осмотр

1.1. Общее состояние_________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.2. Положение больного в постели______________________________________1.3. Сознание____________________________________________________

1.4. Выражение лица_______________________________1.5. Рост, масса тела, телосложение, конституция_________________________________________

___________________________________________________________________________________________________________________________________

1.6. Кожа и слизистые оболочки________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.7. Подкожная клетчатка_____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.8. Лимфатические узлы______________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________1.9. Мышцы_________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

1.10. Кости__________________________________________________________________________________________________________________________

1.11. Суставы________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

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.)

____________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2.2.  Пальпация грудной клетки_________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2.3. Перкуссия сравнительная и топографическая________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2.4.Аускультация_____________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

X. 3. С. С.С.

3.1. Осмотр сердечной области, верхушечный толчок __________________________________________________________________________

_ ___________________________________________________________________________________________________________________________________

3.2.  Осмотр артерий и вен_____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.3.  Пальпация характеристика верхушечного толчка ______________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.4.  Перкуссия сердца_______________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.5.  Исследование сосудов____________________________________________________________________________________________________________

3.5.1. Свойства пульса на лучевых артериях______________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.5.2. Аускультация сосудов____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.5.3. А. Д.___________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

XI.

4.  Органы пищеварения

4.1Осмотр___________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4.2Перкуссия________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4.3 Пальпация_______________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

XII. Органы мочевыделения

______________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

XIII. План лабораторных и инструментальных обследований

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IX. Выявленные синдромы и симптомы

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

X. Патогенез выявленных синдромов и симптомов________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________