История болезни

ГБОУ ВПО ЮУГМУ Минздрава России

Кафедра пропедевтики детских болезней и педиатрии

Педиатрический факультет

История болезни

Ф. И.О. больного _______________________________________________________

Возраст ______________________________________________________________

Синдром поражения ___________________________________________________

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Дата курации: ___________

Куратор: студент ______ группы

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Проверил: ассистент (доцент)

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Челябинск 20…

I.  Паспортная часть

1.  Фамилия_________________________________________________________

2.  Имя_____________________________________________________________

3.  Дата рождения, возраст____________________________________________

4.  Национальность __________________________________________________

5.  Организован (д\с №, школа, класс) __________________________________

Неорганизован

6.  Место работы матери, № телефона __________________________________

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Место работы отца, № телефона ____________________________________ ___________________________________________________________________

7.  Специальность матери ___________________________________________

Специальность отца ______________________________________________

8.  Адрес __________________________________________________________

9.  Кем направлен к клинику _________________________________________

10.  Дата поступления в клинику _______________________________________

11.  Диагноз при поступлении _________________________________________

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II.  Анамнез болезни

( см. схему истории болезни)

1.  Жалобы при поступлении ________________________________________________________________________________________________________________________________

2.  С чего началось заболевание и его динамика. Проводимое лечение и его эффективность ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Жалобы в настоящее время ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

III.  Анамнез жизни

(см. схему истории болезни)

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Генеалогическое дерево

IV.  Данные объективного исследования

1.  Общее состояние ребёнка удовлетворительное, средней степени тяжести, тяжёлое (подчеркнуть нужное)

2.  Самочувствие _________________________________________

3.  Положение в постели свободное, вынужденное

4.  Поведение активное, пассивное.

5.  Сознание________________________________________________________

6.  Сон_____________________________________________________________

7.  Аппетит_________________________________________________________

8.  Температурная кривая

9.  Степень поражения органов (компенсация, субкомпенсация, декомпенсация) ________________________________________________________________________________________________________________________________________________________________________________________________

10.  Status praesens communis (по органам: кожа, подкожная клетчатка, периферические л/узлы, мышечная и костно-суставная системы, органы дыхания, кровообращения, желудочно-кишечный тракт, мочеполовая система, нервно-психическая сфера) см. схему истории болезни)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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V.  План обследования

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VI.  Результаты параклинических методов обследования с интерпретацией полученных данных

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VII.  Обоснование основного синдром поражения

VII а. Заключение по сопутствующим синдромам

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VIII.  Дифференциальный диагноз

(только по основному синдрому поражения)

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IX. Дневники кураций и назначений

(2 дня)

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X. Меню для здорового ребёнка данного возраста на 1 день

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XI. Список используемой литературы

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