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СЕВЕРО-ЗАПАДНЫЙ ГОСУДАРСТВЕННЫЙ
МЕДИЦИНСКИЙ УНИВЕРСИТЕТ
Им. И.И.МЕЧНИКОВА
КАФЕДРА ХИРУРГИЧЕСКИХ БОЛЕЗНЕЙ №1
С КУРСОМ ДЕСКОЙ ХИРУРГИИ ИМ. ПРОФ. В.А. ОППЕЛЯ
АКАДЕМИЧЕСКАЯ ИСТОРИЯ БОЛЕЗНИ
САНКТ – ПЕТЕРБУРГ
-2012-
СХЕМА ИСТОИИ БОЛЕЗНИ
Титульный лист (отдельная страница)
1. Паспортная часть
2. Жалобы больного; опрос по системам органов (записываются только патологические
отклонения)
3. Anamnesis morbi
4. Anamnesis vitae 4.1. Перенесённые заболевания и травмы
4.2. Гинекологический анамнез
4.3. Эпиданамнез
4.4. Аллергологический анамнез
4.5. Страховой анамнез
5. Status praesens objectivus
6. Осмотр по системам 6.1. Сердечно-сосудистая система
6.2. Дыхательная система
6.3. Желудочно-кишечный тракт
6.4. Мочевыделительная система
6.5. Нервная система
6.6. Опорно-двигательная система
6.7. Эндокринная система
6.8. Status localis
7. Предварительный диагноз и его обоснование
8. План обследования больного
9. Данные лабораторных и инструментальных исследований, заключения консультантов
10. Дифференциальный диагноз
11. Клинический диагноз и его обоснование
12. Изложение данных о сущности заболевания
13. Способы лечения данного заболевания
14. Лечение больного
15. Прогноз
16. Профилактика (первичная и вторичная)
17. Дневник курации
18. Эпикриз
19. Библиография
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СЕВЕРО-ЗАПАДНЫЙ ГОСУДАРСТВЕННЫЙ
МЕДИЦИНСКИЙ УНИВЕРСИТЕТ им. И.И.МЕЧНИКОВА
КАФЕДРА ХИРУРГИЧЕСКИХ БОЛЕЗНЕЙ №1
С КУРСОМ ДЕСКОЙ ХИРУРГИИ ИМ. ПРОФ. В.А. ОППЕЛЯ
КЛИНИЧЕСКАЯ ИСТОРИЯ БОЛЕЗНИ
Фамилия, имя, отчество: _______________________________________________________________
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Возраст: _____________________________________________________________________________
Постоянное место жительства: __________________________________________________________
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Место работы, профессия: _____________________________________________________________
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Кем направлен больной: _______________________________________________________________
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Диагноз клинический: _________________________________________________________________
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Операция: (название, дата) _____________________________________________________________
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Начало курации: ________________________ Завершение курации: _________________________
Куратор: студент ________________ группы ___________________________ факультета
Ф.И.О.: ______________________________________________________________________________
Преподаватель: ___________________________________________________________________
ЗАВЕДУЮЩИЙ КАФЕДРОЙ – д.м.н., профессор Э.Э. Топузов
2. ЖАЛОБЫ больного: ________________________________________________________________
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3. ANAMNESIS MORBI: (изложить в хронологическом порядке основные моменты развития заболевания, виды полученного консервативного и оперативного лечения и его эффект (при оперативном лечении – название операции, дата, где поведена) ______________________________
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18. ЭПИКРИЗ: (краткое содержание анамнеза, данные исследований, оперативное вмешательство, течение послеоперационного периода, прогноз для жизни и трудоспособности, рекомендации) ___
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_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. ANAMNESIS VITAE с учётом социального положения в настоящее время (условия быта, члены семьи, с которыми живёт больной; характер работы в настоящее время). Вредные привычки: _____________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.1. ПЕРЕНЕСЁННЫЕ ЗАБОЛЕВАНИЯ И ТРАВМЫ (в хронологии): _______________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.2. ГИНЕКОЛОГИЧЕСКИЙ АНАМНЕЗ: начало месячных, число беременностей, родов, абортов, период менопаузы _____________________________________________________________
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4.4. АЛЛЕРГОЛОГИЧЕСКИЙ АНАМНЕЗ: непереносимость лекарственных средств и пищевых продуктов (указать характер реакции организма) __________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.5. СТРАХОВОЙ АНАМНЕЗ: количество дней, месяцев болезни по листу нетрудоспособности за последние 12 календарных месяцев; наличие инвалидности и дата её получения: _____________
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5. STATUS PRAESENS OBJECTIVUS.
Общая характеристика больного: оценка общего состояния (удовлетворительное, средней тяжести, тяжёлое, терминальное) ________________________________________________________________
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Положение в постели (активное, пассивное, вынужденное)__________________________________
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Кожные покровы (цвет, влажность, подкожные кровоизлияния, отёки, раны, рубцы, свищи), периферические лимфоузлы, упитанность, тип телосложения ________________________________
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6. ОБСЛЕДОВАНИЕ ПО СИСТЕМАМ И ОРГАНАМ.
6.1. СЕРДЕЧНО-СОСУДИСТАЯ СИСТЕМА: общая характеристика пульса, сердечных сокращений, АД. Границы сердечной тупости при наличии патологии сердечно-сосудистой системы _____________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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17. ДНЕВНИК КУРАЦИИ: (Состояние больного, пульс, тоны сердца, АД. Тип дыхания, наличие хрипов, ЧД. Пальпация живота, физиологические отправления (обязательное отражение динамики состояния, подробное описание изменений; назначения) ____________________________________
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6.2. ДЫХАТЕЛЬНАЯ СИСТЕМА: частота дыхания, наличие хрипов, характеристика типов дыхания _____________________________________________________________________________
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6.3. ЖЕЛУДОЧНО-КИШЕЧНЫЙ ТРАКТ: Осмотр полости рта, формула зубов. Описать слизистую языка. Данные пальпации и перкуссии печени и органов брюшной полости. Характер и частота стула _________________________________________________________________________
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6.4. МОЧЕВЫДЕЛИТЕЛЬНАЯ СИСТЕМА: _______________________________________________
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6.5. НЕРВНАЯ СИСТЕМА: Сознание и адекватность поведения. Периферическая иннервация. Чувствительные и двигательные расстройства. ____________________________________________
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15. ПРОГНОЗ: ________________________________________________________________________
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16. ПРОФИЛАКТИКА: (первичная и вторичная) ___________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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6.6. ОПОРНО-ДВИГАТЕЛЬНАЯ СИСТЕМА: Осмотр больного стоя и лёжа в обнажённом виде. Состояние кожных покровов (чистые, наличие пигментных пятен, гипертрихоза, ихтиоза)________
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6.7. ЭНДОКРИННАЯ СИСТЕМА: _______________________________________________________
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6.8. STATUS LOCALIS: ________________________________________________________________
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14. ЛЕЧЕНИЕ БОЛЬНОГО: _____________________________________________________________
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13. СПОСОБЫ ЛЕЧЕНИЯ данного заболевания: ___________________________________________
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7. ПРЕДВАРИТЕЛЬНЫЙ ДИАГНОЗ и его обоснование: ____________________________________
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8. ПЛАН ОБСЛЕДОВАНИЯ БОЛЬНОГО: ________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. ДАННЫЕ ЛАБОРАТОРНЫХ И ИНСТРУМЕНТАЛЬНЫХ ИССЛЕДОВАНИЙ, ЗАКЛЮЧЕНИЯ КОНСУЛЬТАНТОВ
Клинический анализ крови: ____________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Общий анализ мочи: ___________________________________________________________________
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Биохимические исследования:
Билирубин крови: __________________
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