Унифицированная история болезни

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ГБОУ ВПО ЮУГМУ Минздрава России
Кафедра пропедевтики детских болезней и педиатрии
Медико-профилактический факультет
История болезни
Ф.И.О. больного _______________________________________________________
Возраст ______________________________________________________________
Клинический диагноз __________________________________________________
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Дата курации: ___________
Куратор: студент ______ группы
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Проверил: ассистент (доцент)
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Челябинск 20…
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I.
Паспортная часть
Фамилия_________________________________________________________
Имя_____________________________________________________________
Отчество
Дата рождения____________________________________________________
Паспортный возраст_______________________________________________
Возрастная группа________________________________________________
Организован (д\с №, школа, класс) __________________________________
Не организован
8. ФИО, возраст, место работы, должность матери_______________________
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ФИО, возраст, место работы, должность отца__________________________
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9. Адрес дом. _____________________________________________________
10.Кем направлен к клинику _________________________________________
11.Дата поступления в клинику _______________________________________
12.Диагноз при поступлении _________________________________________
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II.
Анамнез болезни
( см. схему истории болезни)
1. Жалобы при поступлении
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Жалобы на момент курации________________________________________
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2. Как давно болен, с чего началось заболевание и его динамика.Первое
обращение к врачу. Проводимое лечение и его эффективность. Возможная
причина заболевания (обострения хронического заболевания).
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III. Анамнез жизни
(см. схему истории болезни)
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Генеалогическое дерево
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IV.
Данные объективного исследования
 Общее состояние ребёнка удовлетворительное, средней степени тяжести,
тяжёлое
 Самочувствие _________________________________________
 Положение в постели свободное (естественное), вынужденное
 Поведение активное, пассивное.
 Сознание________________________________________________________
 Сон_____________________________________________________________
 Аппетит_________________________________________________________
 Температурная кривая
 Степень поражения органов ( компенсация, субкомпенсация,
декомпенсация)
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Физическое развитие
 Паспортный возраст__________________________________________
 Возрастная группа___________________________________________
 Антропометрические показатели:
- рост (длина тела)____________________________________
- вес _______________________________________________
- окружность грудной клетки___________________________
- окружность головы__________________________________
- окружность плеча ___________________________________
- окружность бедра___________________________________
- окружность голени__________________________________
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 Заключение по оценке физического развития (с использованием
центильных таблиц):
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 Соотношение массы по росту(оценка):
 Индекс масс тела (расчёт и оценка)
 Индекс Чулицкой (расчёт и оценка)_________________________________
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 Индекс Эрисмана (расчёт и оценка)__________________________________
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 Расчёт должных показателей массы, роста (длины тела), окружностей
грудной клетки и головы (с учётом ПДК). У детей 1-го года жизни - с
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учётом данных при рождении.
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Половое развитие (у школьников) - оценка согласно алгоритму с
заключением
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Нервно-психическое развитие (у детей до 3-х лет по линиям развития с
определением группы развития):
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 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
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болезни)_________________________________________________________
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V.
Предварительный диагноз
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VI. План обследования
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VII. Результаты параклинических методов обследования с интерпретацией
полученных данных
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VIII. Заключительный клинический
диагноз и его обоснование
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Дифференциальный диагноз
(только основного заболевания)
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X.
Лечение
конкретно данного больного с обоснованием назначенного лечения. Режим.
Диета на 1 день с указанием потребности в белках, жирах, углеводах,
калориях на 1 кг массы тела (рациональное меню).
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XI. Дневники кураций и назначений
(2 дня)
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XII. Этиология (основного заболевания)
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XIII. Патогенез (дать анализ этиологическим и патогенетическим факторам,
имеющимся в данном конкретном случае, одновременно сопоставляя с их
литературными данными)
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XIV. Особенности данного случая
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XV. Эпикриз (кратко указываются данные объективного исследования,
оценивается эффективность лечения, конечный результат к концу курации
или к моменту выписки, рекомендации по дальнейшему наблюдению и
лечению)
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XVI. Прогноз относительно выздоровления и жизни
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XVII. Список используемой литературы
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XVIII. Рецептура лекарственных препаратов,
указанных в истории болезни для данного больного.
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