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Psycho-motor development of the child
Gross motor development _________________________________________________
____________________________________________________________________________________________________________________________________________
Fine motor development __________________________________________________
______________________________________________________________________
Sensory development _____________________________________________________
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Vocalization development _________________________________________________
______________________________________________________________________
Socialization development _________________________________________________
______________________________________________________________________
Summery: ______________________________________________________________
Substantiation of the provisional diagnosis
On the establishment of the patient’s complaints _______________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Anamnesis morbi ________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anamnesis vitae ________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Genetic anamnesis ______________________________________________________
______________________________________________________________________
______________________________________________________________________
Data of objective examinations _____________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
It possible to make provisional diagnosis : ____________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ The plan of examination of the patient
1) ___________________________________________________________________
2) ___________________________________________________________________
3) ___________________________________________________________________
4) ___________________________________________________________________
5) ___________________________________________________________________
6) ___________________________________________________________________
7) ___________________________________________________________________
8) ___________________________________________________________________
9) ___________________________________________________________________
10) __________________________________________________________________
11) __________________________________________________________________
12) __________________________________________________________________
Results of additional methods of examination
Rooting blood analysis
| date | Íb | Eryth. õ1012 | CI | Leuc õ109 | eos | bas | juv. | band | seg. | lym | mon | ESR | Blood clotting time | Bleeding time |
The general examination of urine
| date | Amount | Specific gravity | pH | Proteinuria | Glucosuria | ketonuria | Epithelium | Leucocytes | Erythrocytes | Casts | Crystals: | Mucous |
Urinal examination according to Nechepurenco _______________________________
Biochemical analysis of blood
| date | protein | glucose | bilirubin | creatinine | urea | ALT | AST | Amylase | |
| total | total | conjugated | |||||||
Urinal examination according to Zymnitzky
| Portion | ||||||||
| Quantities of urine | ||||||||
| specific gravity |
Stool test ______________________________________________________________
______________________________________________________________________
______________________________________________________________________
Analysis of feces on worm ova _____________________________________________
______________________________________________________________________
Test on enterobiosis ______________________________________________________
______________________________________________________________________
Others methods of examination __________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ECG: _________________________________________________________________ ____________________________________________________________________________________________________________________________________________
USD __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Endoscopies examination of ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________
X-ray examination ______________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Differential the diagnosis
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Clinical diagnosis
On the establishment of the patient’s complaints _______________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Anamnesis morbi ________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anamnesis vitae ________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Genetic anamnesis ______________________________________________________
______________________________________________________________________
______________________________________________________________________
Data of objective examinations _____________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Data of additional methods of examination ___________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________
____________________________________________________________________________________________________________________________________________
It possible to make clinical diagnosis:
Basic diagnosis __________________________________________
__________________________________________
__________________________________________
Complication __________________________________________
__________________________________________
Concomitant disease __________________________________________
__________________________________________
__________________________________________
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 ¹ ___ _______________________________________________________ ____________________________________________________________________________________________________________________________________________
The menu for infant:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medicament treatment:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________
Physiotherapeutic measures:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Epicrisis
The patient ____________________________________________________________
_______ age, __________ date of birth, home address __________________________
______________________________________________________________________ ______________________________________________________________________ received treatment in _____________________________________________________ _______________________ from ________ 200_ on _______ 200_ with the diagnosis of: ___________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The general state and data of objective examination of the patient on admission (shortly) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Rooting blood analysis
| date | Íb | Eryth. õ1012 | CI | Leuc õ109 | eos | bas | juv. | band | seg. | lym | mon | ESR | Blood clotting time | Bleeding time |
The general examination of urine
| date | Amount | Spesific gravity | pH | Proteinuria | Glucosuria | ketonuria | Epithelium | Leucocytes | Erythrocytes | Casts | Cristals: | Mucous |
Urinal examination according to Nechepurenco _______________________________
Biochemical analysis of blood
| date | protein | glucose | bilirubin | creatinine | urea | ALT | AST | Amylase | |
| total | total | conjugated | |||||||
Urinal examination according to Zymnitzky
| Portion | ||||||||
| Quantities of urine | ||||||||
| specific gravity |
Stool test ______________________________________________________________
______________________________________________________________________
______________________________________________________________________
Analysis of feces on worm ova _____________________________________________
______________________________________________________________________
Test on enterobiosis ______________________________________________________
______________________________________________________________________
Others methods of examination __________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ECG: _________________________________________________________________ ____________________________________________________________________________________________________________________________________________
USD __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Endoscopies examination of ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________
X-ray examination ______________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prescribed treatment
______________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Dynamic of the main syndromes during treatment; the objective state of the patient at the moment of his discharge from the hospital
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Recommendations:
1. Diet ¹ ______________________________________________________________
2. Regimen _____________________________________________________________
3. Medical measures _____________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. Sanatorium treatment __________________________________________________
____________________________________________________________________________________________________________________________________________
Literature
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The curator (signature) __________________
Date: 2015-01-02; view: 1243
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