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Psycho-motor development of the childGross motor development _________________________________________________ ____________________________________________________________________________________________________________________________________________ Fine motor development __________________________________________________ ______________________________________________________________________ Sensory development _____________________________________________________ ______________________________________________________________________ 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
The general examination of urine
Urinal examination according to Nechepurenco _______________________________
Biochemical analysis of blood
Urinal examination according to Zymnitzky
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
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
The general examination of urine
Urinal examination according to Nechepurenco _______________________________ Biochemical analysis of blood
Urinal examination according to Zymnitzky
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: 1104
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