IV. Данные объективного обследования
Состояние:____________________Положение:___________________________
Температура:___________Пульс:______________Дыхание:________________
Телосложение:_____________________________________________________
Рост:____________________________Вес:______________________________
Кожа и слизистые:__________________________________________________
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Подкожная клетчатка:_______________________________________________
Лимфатическая система:_____________________________________________
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Мышечная система:_________________________________________________________
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Кости, суставы:______________________________________________________________
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Щитовидная железа:_________________________________________________________
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Дыхательная система:_______________________________________________
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Сердечно-сосудистая система:________________________________________
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Пищеварительная система:
Полость рта:________________________________________________________________
Зубы:_______________________________________________________________________
Язык:_______________________________________________________________________
Миндалины:_______________________________________________________
Исследования органов живота (перкуссия, пальпация):______________________
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Исследование нервной системы (сознание, интеллект, настроение, речь, движения, проба Ромберга, чувствительность, рефлексы, дермографизм, слух, зрение, обоняние):_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Данные осмтора заболевшего участка (Status localis: осмотр и пальпация почек, мочевого пузыря, половых орагнов у мужчин): ____________________________________
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V. Лабораторные и инструментальные методы исследования
1. Общий анализ крови (дата:________________)
Показатель
| Полученные данные
| Нормальные величины
| Гемоглобин, г/л
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| Эритроциты, 1012/л
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| Цветной показатель
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| Лейкоциты, 109/л
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| СОЭ, мм/час
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| Нейтрофилы п/я, %
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| Нейтрофилы с/я, %
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| Лимфоциты, %
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| Моноциты, %
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| 2. Общий анализ мочи (дата:___________________)
Показатель
| Полученные данные
| Цвет
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| Прозрачность
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| Удельный вес
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| Белок
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| Глюкоза
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| Уробилин
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| Микроскопия осадка
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3. Данные прочих лабораторных и инструментальных исследований:
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VI. Клинический диагноз и его обоснование
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VII. Дифференциальный диагноз
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VIII. Этиология и патогенез заболевания (своременные взгляды)
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Дата добавления: 2015-05-19 | Просмотры: 764 | Нарушение авторских прав
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