Лечащий врач Зав. отделением
(фамилия, подпись) (фамилия, подпись)
Основные синдромы:
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Предварительный диагноз:
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Круг заболеваний для дифференциального диагноза:
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План лабораторных и инструментальных методов исследований больного:
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__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ РЕЗУЛЬТАТЫ ЛАБОРАТОРНЫХ И ИНСТРУМЕНТАЛЬНЫХ МЕТОДОВ ИССЛЕДОВАНИЙ И ИХ КЛИНИЧЕСКАЯ ОЦЕНКА
КЛИНИЧЕСКИЕ
Общий анализ крови
Дата
| Эритр.
| Hb
| Тромб
| Лейкоц
| Баз
| Эозин
| Н.пал.
| Н.сегм.
| Лимф.
| Мон.
| СОЭ
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Общий анализ мочи
Дата
| Реакция
| Цвет
| Уд. вес
| Белок
| Сахар
| Ацетон
| Эпит.
| Лейкоц.
| Эритроц.
| Слизь
| Соли
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БИОХИМИЧЕСКИЕ
Показатель
| Значение
| Единицы
| Показатель
| Значение
| Единицы
| ЩФ
|
| Ед/л
| Хлор
|
| ммоль/л
| АЛТ
|
| Ед/л
| Калий
|
| ммоль/л
| АСТ
|
| Ед/л
| Натрий
|
| ммоль/л
| Альфа-амилаза
|
| Ед/л
| Общий белок
|
| ммоль/л
| Общий билирубин
|
| мкмоль/л
| Мочевина
|
| ммоль/л
| Прямой билирубин
|
| мкмоль/л
| Креатинин
|
| мкмоль/л
| Тимоловая проба
|
| ед
| Общий холестерин
|
| ммоль/л
| Сывороточное железо
|
| мкмоль/л
| Витамин В12
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| пмоль/л
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| Фоллаты
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| Нмоль/л
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ИНСТРУМЕНТАЛЬНЫЕ
ЭКГ:
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Rtg:
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Дифференциальный диагноз (с использованием полученных данных):
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Обоснование и формулировка окончательного диагноза:
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План лечения
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Особенности клинического случая
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Прогноз.
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Список использованной литературы:
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Дата
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Дата добавления: 2015-09-27 | Просмотры: 468 | Нарушение авторских прав
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