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PLAN OF LIST

1. Passport data: name, age, home address, profession, date of entrance to clinic, entering diagnosis, preliminary diagnosis, final clinical diagnosis.

2. Complaints: main complaints (detalization) connected to main disease itself and connected to complications.

3. Anamnesis morby Indicate when disease started (age of the patient when it started or how many years ago), how it started (first symptoms), what kind of treatment was performed, efficiency of treatment. Indicate what kind of complications and when they appeared (age, years after first symptoms started), treatment of complications. Frequency of hospitalizations, Last one (indicate date). Aim or indications for present hospitalization.

4. Anamnesis vitae Growth and development at the childhood, infections during the childhood, obstetric`s anamnesis (for women), inheritance (especially for endocrine diseases, previous diseases, tuberculosis, hepatitis and so on, allergies, alcoholism, smoking, working anamnesis.

5. Status praesens (common state,BMI, skeen, serosus surfaces, lymphatic system, bone-muscle system, lungs and breath system, cardio-vascular system, gastro-intestinal system, hepar, renal, neurological, endocrine systems.

6. Preliminary diagnosis

7. Examination plan (what examinatioins and additional measurements would you prescribe to the patient?).

8. Results of examinations and measurements ( indicate results and make interpretation).

9. Final clinical diagnosis: main disease (and it`s prof), complications, additional diseases.

10. Differentiated diagnosis (to differentiate main disease. Ex: DM 1 and 2. DM and DI)

11. Dieries for 3 days of curation

12. Treatment Regimen, dietary, drug treatment with prescription of two main drugs (EX: insulin and oral antidiabetic drug). Treatment and profylaxy of complications.

 

ОГЛАВЛЕНИЕ

  1. Схема истории болезни (эндокринология) для студентов лечебного факультета………………………………………………………………3-13 с.
  2. Схема истории болезни (эндокринология) для иностранных студентов лечебного факультета…………………………………………………...13-18 с.
  3. Схема истории болезни (эндокринология) для студентов стоматологического факультета………………………………………………………18-28 с.
  4. Схема истории болезни (детская эндокринология) для студентов педиатрического факультета……………………………………………. ….29-33 с.
  5. Схема кураторского листа (диабетология) для отечественных и иностранных студентов лечебного факультета…………………………..34-35 с.

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