Clinical diagnosis

On the establishment of the patient’s complaints _______________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Anamnesis morbi ________________________________________________________

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Anamnesis vitae ________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Genetic anamnesis ______________________________________________________

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Data of objective examinations _____________________________________________

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Data of additional methods of examination ___________________________________

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It possible to make clinical diagnosis:

Basic diagnosis __________________________________________
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Complication __________________________________________

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Concomitant disease __________________________________________

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The temperature list

data

BP

P

T

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

Stool

Weight

diuresis

Treatment of the patient

Regimen ____________________________________________________________ ______________________________________________________________________

Diet № ___ _______________________________________________________ ____________________________________________________________________________________________________________________________________________

Medicamental treatment:

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Physiotherapeutic measures:

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Epicrisis

The patient ____________________________________________________________

_______ age, __________ date of birth, home address __________________________

______________________________________________________________________ ______________________________________________________________________ received treatment in _____________________________________________________ _______________________ from ________ 200_ on _______ 200_ with the diagnosis of: ___________________________________________________________________

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The general state and data of objective examination of the patient on admission (shortly) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Rooting blood analysis

date

Нb

Eryth. х10^12

CI

Leuc х10^9

eos

bas

juv.

band

seg.

lym

mon

E S R

calcium

potassium

Biochemical analysis of blood

date	protein total	glucose	bilirubin	creatinine	urea	LDL	HDL	Cholesterol
			total	conjugated

Glycemic profile

date	HbA1c	glucose	glucose	glucose	glucose	glucose	glucose
		7.00	10.00	14.00	16.00	22.00	4.00

The general examination of urine

date

Amount

Spesific gravity

pH

Proteinuria

Glucosuria

ketonuria

Epithelium

Leucocytes

Erythrocytes

Casts

Cristals:

Mucous

Urinal examination according to Nechiporenco L._____________Er.____________

24-hour urine protein ______________mg/day

Urinal examination according to Zymnitzky

Portion
Quantities of urine
specific gravity

GFR, glomerular filtration rate, (ml/min per 1.73 m² body surface area) _______

Stool test ______________________________________________________________

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Test on enterobiosis ______________________________________________________

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Others methods of examination __________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ECG: _________________________________________________________________ ____________________________________________________________________________________________________________________________________________

USD __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Endoscopies examination of ______________________________________________

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X-ray examination ______________________________________________________

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Prescribed treatment

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Dynamic of the main syndromes during treatment; the objective state of the patient at the moment of his discharge from the hospital

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Recommendations:

1. Diet № ______________________________________________________________

2. Regimen _____________________________________________________________

3. Medical measures _____________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Sanatorium treatment __________________________________________________

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Literature

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The curator (signature) __________________

Дата добавления: 2015-11-14