ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî ³ñòî𳿠õâîðîáè õâîðîãî ç åíäîêðèííîþ ïàòîëî㳺þ
Äàòà ________ Ñêàðãè: Ãîëîâíèé á³ëü: òàê/í³,ïîñò³éíèé/ïåð³îäè÷íèé, ëîêàë³çàö³ÿ _______________, Çàïàìîðî÷åííÿ: òàê, í³.
Áîë³ â ñåðö³ òàê/í³, ïðè÷èíè _____________________ Ñåðöåáèòòÿ: òàê/í³, â ñïîêî¿, ïðè íàâàíòàæåíí³/õâèëþâàíí³.ÀÒ: íîðìà/ï³äâèùåííÿ/çíèæåííÿ äî ________ ìì. ðò. ñò. Íàáðÿêè: º,í³, ëîêàë³çàö³ÿ: îáëè÷÷ÿ, ãîì³ëêè, _______________________________ Áîë³ â ñïèí³: òàê/í³. Ñïðàãà: òàê/í³, ______ ë/äîáó,óäåíü ____ ë, óíî÷³ ____ ë, ïîë³óð³ÿ: òàê/í³, óäåíü ____ ë, óíî÷³ ____ ë.
Âàãà: ñòàá³ëüíà/çá³ëüøèëàñü/çìåíøèëàñü íà ___ êã çà _________.
Àïåòèò: íîðìàëüíèé/çíèæåíèé/ï³äâèùåíèé, õàð÷îâ³ çâè÷êè ______Ñëàáê³ñòü, øâèäêà âòîìëþâàí³ñòü, Ïîã³ðøåííÿ çîðó: òàê/í³Ïàì'ÿò³ òàê/í³ ________________ϳãìåíòàö³ÿ øê³ðè (ëîêàë³çàö³ÿ) _____________________________Ñìóãè ðîçòÿãàííÿ íà øê³ð³: êîë³ð ________________, ëîêàë³çàö³ÿ ______________________________________________________
__________________________________________________________________ Àíàìíåç õâîðîáè: Óïåðøå ñêàðãè ç'ÿâèëèñÿ ____________________ Ìîæëèâà ïðè÷èíà: ____________________________________________ Ïåðøå çâåðòàííÿ äî åíäîêðèíîëîãà â _______ ð. Ïîïåðåäíº îáñòåæåííÿ: (äå, ð³ê) __________________________________
Âñòàíîâëåíî ä³àãíîç: _____________________________________________ Ðåçóëüòàòè îáñòåæåííÿ: ________________________________________________________________________________________________________ Ïîïåðåäíº ë³êóâàííÿ, éîãî òðèâàë³ñòü: ___________________________________________________________________________________________________________________________________________________________ Åôåêòèâí³ñòü____________________________________________________________________________________________________________________________________ ²íøå: ___________________________________________________________________________________________________________________________________________________________________________________________ Àíàìíåç æèòòÿ: Âàãà ïðè íàðîäæåíí³ ___ êã. Äèòÿ÷³ ³íôåêö³¿ _________________ Íàäì³ðíà ìàñà ò³ëà ç ___ ðîê³â ______________________________ Õðîí³÷í³ õâîðîáè: ___________________________________________ "Ðîáî÷èé" ÀÒ _________ ìì ðò. ñò. Ïðèéìຠã³ïîòåíçèâí³ ïðåïàðàòè: _________________________________
(íå) ðåãóëÿðíî ______________________________________________ Ìåíñòðóàëüíèé öèêë (íå) ðåãóëÿðíèé/__________________________ ѳìåéíèé àíàìíåç ____________________________________________ Îïåðàö³¿ _____________________ Òðàâìè _______________________ Àëåðã³ÿ ______________________ ²íøå: ________________________ Äàí³ îá'ºêòèâíîãî îáñòåæåííÿ: Çàãàëüíèé ñòàí õâîðîãî çàäîâ³ëüíèé. Çð³ñò _____ ñì, ìàñà ò³ëà _____ êã. ²ÌÒ _____.
Îêðóæí³ñòü òà볿 (ÎÒ) _____ ñì, ñòåãîí (ÎÑ) _____ ñì.ÎÒ/ÎÑ = ________ Áóäîâà ò³ëà: (íå)ïðîïîðö³éíà ________________________________Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/íàäì³ðíî âîëîãà: ëîêàëüíî/äèôôóçíî
____________ ÷èñòà/º âèñèïè ______________, êîë³ð çâè÷àéíèé/áë³äà/ã³ïåðåì³ÿ/ _______________, ö³àíîç _______________ (äå/ã³ïåð)ï³ãìåíòàö³ÿ ____________________________________________Ñò𳿠â³äñóòí³/÷åðâîí³/òåìíî-÷åðâîí³ ________________________
Õàðàêòåð â³äêëàäåííÿ æèðó ð³âíîì³ðíèé/ïåðåâàæíî â ä³ëÿíêàõ:__________________________________________________________________Îðãàíè äèõàííÿ: ×Ä _____ íà õâ., çàäèøêà: í³/â ñïîêî¿/ïðè õîä³.
Ïåðêóòîðíî: ÿñíèé ëåãåíåâèé çâóê _________________________________
Õðèïè â³äñóòí³/ñóõ³/âîëîã³ ____________________________________________________________________________________________________ Ñåðöåâî-ñóäèííà ñèñòåìà: ïóëüñ ____ íà õâ., (à)ðèòì³÷íèé._________________________________ ÀÒ ëåæà÷è ________ ìì ðò. ñò.,ñòîÿ÷è _________ ìì ðò. ñò. Ìåæ³ ñåðöÿ íå çì³íåí³ ______________ ____________ Òîíè ñåðöÿ ãó÷í³/àêöåíòîâàí³/îñëàáëåí³ ______________ Àêöåíò __________________, Øóì:______________________________
Îðãàíè òðàâëåííÿ: ÿçèê âîëîãèé/ñóõèé, êîë³ð ______________, îáêëàäåíèé ____________ íàëüîòîì
Æèâ³ò ì'ÿêèé/çàïàëèé/ðîçäóòèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿ __________________________________________________________________
Ïå÷³íêà (íå)çá³ëüøåíà íà ____ ñì, êðàé ì'ÿêèé/ù³ëüíèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿
Ñå÷î-ñòàòåâà ñèñòåìà: ijóðåç _____ ë/äîáó. Ñå÷îâèä³ëåííÿ íîðìàëüíå/óòðóäíåíå/áîë³ñíå.
Ñèìïòîì Ïàñòåðíàöüêîãî íåãàòèâíèé/ïîçèòèâíèé: ñïðàâà/çë³âà. Òèï ðîñòó âîëîññÿ æ³íî÷èé/÷îëîâ³÷èé _________________________Ùèòîïîä³áíà çàëîçà (íå)çá³ëüøåíà ______ ñò., ì'ÿêà/åëàñòè÷íà/ù³ëüíà/ãîðáêóâàòà, ïðè ïàëüïàö³¿ (íå)áîëþ÷à _____, âóçëîâ³ óòâîðåííÿ (íå)ïàëüïóþòüñÿ ________________________________
__________________________________________________________________ Ïåðèôåðè÷í³ ë³ìôîâóçëè (íå)çá³ëüøåí³ ________________________ ʳñòêîâî-ì'ÿçîâà ñèñòåìà äåôîðìàö³¿: __________________________________________________________________________________________ Ñèìïòîì Õâîñòåêà I, II, III. Ñèìïòîì Òðóññî _________________ Íàáðÿêè(ïàñòîçí³ñòü) â³äñóòí³/íà îáëè÷÷³/ãîì³ëêàõ/ñòóïíÿõ/____________________________________________________________________________________________________________________________________ Ïîïåðåäí³é ä³àãíîç: ___________________________________________________________________________________________________________
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ÏËÀÍ ÎÁÑÒÅÆÅÍÍß |
ÏËÀÍ Ë²ÊÓÂÀÍÍß |
Çàãàëüíèé àíàë³ç êðîâ³/ç ôîðìóëîþ |
Ðåæèì |
Öóêðîâà êðèâà (ç íàâàíòàæåííÿì ãëþêîçîþ) |
Ñò³ë N |
Õîëåñòåðèí, òðèãë³öåðèäè, áåòà-ë³ïîïðîòå¿äè |
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Á³ë³ðóá³í, òðàíñàì³íàçè |
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Êàë³é, íàòð³é, êàëüö³é (³îí³çîâàíèé), ôîñôîð êðîâ³ |
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Ëóæíà ôîñôàòàçà |
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ÒÒÃ, âÒ4 |
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ÔÑÃ, ËÃ, ÏÐË, Òåñòîñòåðîí, åñò ðàä³îë, ÄÃÅÀ, 17-ÎÏà |
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17-ÊÑ â äîáîâ³é ñå÷³ |
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Êîðòèçîë â äîáîâ³é ñå÷³ |
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Ïðîáà ç äåêñàìåòàçîíîì |
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Ñ-ïåïòèä êðîâ³ |
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Çàãàëüíèé àíàë³ç ñå÷³ |
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Àíàë³ç êàëà íà ÿ/ãëèñò, åíòåðîá³îç |
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ÅÊÃ |
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Ðåíòãåíîãðàô³ÿ ÎÃÊ/÷åðåïà (òóðåöüêîãî ñ³äëà) |
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ÌÐÒ |
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ÓÇÄ ùèòîïîä³áîä³áíî¿ çàëîçè, ÎÌÒ, Î×Ï |
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Îêóë³ñò (ïîëÿ çîðó), íåâðîëîã, õ³ðóðã, |
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óíåêîëîã, óðîëîã |
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"___" __________ 200_ ð. ˳êàð _____________ ï³äïèñ ___________
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî ³ñòî𳿠õâîðîáè õâîðîãî íà öóêðîâèé ä³àáåò
Äàòà ___________ Ñêàðãè:Ñïðàãà ________ ë, ïîë³óð³ÿ ________, âòðàòà (ïðèáàâêà) âàãè íà ___ êã/ ____ ïðè ____________ àïåòèò³
Ïîã³ðøåííÿ çîðó ___________,á³ëü â íîãàõ ïðè õîä³ íà â³äñòàíü ________, ïî ñõîäàõ, â ñïîêî¿, âíî÷³, ñóäîìè í³ã ïðè õîä³ (âíî÷³), çàí³ì³ííÿ í³ã/ðóê, çíèæåííÿ ÷óòëèâîñò³ í³ã/ðóê, ñò³ëåöü __________
ϳäâèùåííÿ ÀÒ äî _______ ìì ðò. ñò., ãîëîâí³ áîë³ ___________íàáðÿêè ____________________________________________________________________________________________________________________________Àíàìíåç õâîðîáè: Õâî𳺠öóêðîâèì ä³àáåòîì ç _______ ð., ïîâ'ÿçóº ç __________________________________________________________________
Ïåðåá³ã õâîðîáè ñòàá³ëüíèé/ëàá³ëüíèé (ïðè÷èíà) ______________Îòðèìóâàâ íà ïî÷àòêó õâîðîáè òàáëåòîâàí³ öóêðîïîíèæóþ÷³ ïðåïàðàòè ___ ðîêè(³â)/³íñóë³í
Îòðèìóº: ðàíêîì __________________, âäåíü ___________________ ââå÷åð³ __________________________________________________________
Ïðîòÿãîì îñòàííüîãî ðîêó öóêîð â êðîâ³ _____________________,ÀÒ _________ ìì ðò. ñò., âàãà _____ êã ÍâÀ1ñ ______________, õîëåñòåðèí ___________ ×àñòîòà êîíòðîëþ ãë³êå쳿 _____ ð/___ ì³ñ.Çàñîáè ñàìîêîíòðîëþ: â³çóàëüí³ òåñò-ñìóæêè ______________, ãëþêîìåòð _______________________
Ïîïåðåäíº ñòàö³îíàðíå ë³êóâàííÿ â ____ ð. ïëàíîâå/ç ïðèâîäó äåêîìïåíñàö³¿ ÖÄ/äëÿ ÌÑÅÊ
Ïðè÷èíà ïîã³ðøåííÿ ñòàíó ____________________________________Ñòàö³îíàðíå/õ³ðóðã³÷íå ë³êóâàííÿ ç ïðèâîäó ñèíäðîìó ä³àáåòè÷íî¿ ñòóïí³ â ______ ð. ________
__________________________________________________________________Àíàìíåç æèòòÿ: Âàãà ïðè íàðîäæåíí³ ____ êã. Ñïàäêîâ³ñòü ïî ÖÄ _________________________
Ïåðåíåñåí³ õâîðîáè: ãåïàòèò ______ ð., òóáåðêóëüîç ______ ð., âåíåðè÷í³ õâîðîáè _____________ ð. ³íôàðêò _______ ð., ³íñóëüò _______ ð.,______________________ Õðîí³÷í³ õâîðîáè: ___________________________________________
Îïåðàö³¿ ____________________________________________________ Òðàâìè ______________________________________________________ Àëåðã³ÿ _____________________________________________________Øê³äëèâ³ çâè÷êè: òþòþíîçàëåæí³ñòü, çëîâæèâàííÿ àëêîãîëåì, íàðêîìàí³ÿ
óíåêîëîã³÷íèé àíàìíåç: ìåíñòðóàö³¿ ç ______ ðîê³â, (íå)ðåãóëÿðí³ _______ ð./ ìåíîïàóçà ç _____ ð.
Âàãà ä³òåé ïðè íàðîäæåíí³ _____ êã, _____ êã ________________ Äàí³ îá'ºêòèâíîãî îáñòåæåííÿ: Çàãàëüíèé ñòàí õâîðîãî çàäîâ³ëüíèé/ñåðåäíüî¿ âàæêîñò³/âàæêèé Ïðè ñâ³äîìîñò³/ñòóïîð/ñîïîð/êîìà. Ïîëîæåííÿ â ë³æêóàêòèâíå/ïàñèâíå/âèìóøåíå/îðòîïíîåØê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/äåã³äðàòàö³ÿ/ íàäì³ðíî âîëîãà ______________________, ÷èñòà/º âèñèïè ______________________, êîë³ð çâè÷àéíèé/áë³äà/ã³ïåðåì³ÿ/ö³àíîç_______________________ (äå)ï³ãìåíòàö³ÿ _________________________________, ë³ïîäèñòðîô³¿
__________________________________________________________________Çð³ñò ______ ñì, âàãà _____ êã, ²ÌÒ _____. Õàðàêòåð â³äêëàäåííÿ æèðó ð³âíîì³ðíèé/àáäîì³íàëüíèé
ʳñòêîâî-ì'ÿçîâà ñèñòåìà ____________________________________Îðãàíè äèõàííÿ: ÷àñòîòà _____ íà õâ., õàðàêòåð _________, çàäèøêà ³í(åê)ñï³ðàòîðíà â ñïîêî¿/ïðè õîä³.
Çàïàõ àöåòîíó ³ç ðîòà _______.
Ïåðêóòîðíî: ÿñíèé ëåãåíåâèé çâóê/âêîðî÷åííÿ ñïðàâà__________________________, çë³âà ________________________________ Õðèïè â³äñóòí³/ñóõ³/âîëîã³ __________________________________ Ñåðöåâî-ñóäèííà ñèñòåìà: ïóëüñ ___ íà õâ., (à)ðèòì³÷íèé ____ ÀÒ ëåæà÷è ________ ìì ðò. ñò., ñòîÿ÷è _________ ìì ðò. ñò.Ñóäèííèé ïó÷îê ___________________ Ìåæ³ ñåðöÿ __________________________________________________ Òîíè ñåðöÿ ãó÷í³/àêöåíòîâàí³/îñëàáëåí³ ______________________ Àêöåíò ______________________. Øóìè: ________________________Îðãàíè òðàâëåííÿ: ÿçèê âîëîãèé/ñóõèé, ÷èñòèé/îáêëàäåíèé _____ íàëüîòîì _____________
Æèâ³ò ì'ÿêèé/çàïàëèé/ðîçäóòèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿________________________________Ïå÷³íêà (íå)çá³ëüøåíà íà ____ ñì, êðàé ì'ÿêèé/ù³ëüíèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿
Ñå÷î-ñòàòåâà ñèñòåìà: Ñå÷îâèä³ëåííÿ íîðìàëüíå/óòðóäíåíå/áîë³ñíå. Ñèìïòîì Ïàñòåðíàöüêîãî íåãàòèâíèé/ïîçèòèâíèé ñïðàâà / çë³âà.
Òèï ðîçïîä³ëó âîëîññÿ æ³íî÷èé/÷îëîâ³÷èé. Ãðóäí³ çàëîçè ______Ùèòîïîä³áíà çàëîçà (íå)çá³ëüøåíà ______ ñò., ì'ÿêà/åëàñòè÷íà/ù³ëüíà/ãîðáêóâàòà, ïðè ïàëüïàö³¿ (íå)áîëþ÷à _____, âóçëîâ³ óòâîðåííÿ (íå)ïàëüïóþòüñÿ ______________
Ïåðèôåðè÷í³ ë³ìôîâóçëè (íå)çá³ëüøåí³ ________________________×óòëèâ³ñòü: òåìïåðàòóðíà - íîðìàëüíà (D S)/çíèæåíà (D S) _________/â³äñóòíÿ (D S)___________ áîëüîâà - íîðìàëüíà (D S)/çíèæåíà (D S)/â³äñóòíÿ (D S) ________/ï³äâèùåíà (D S) ___________ òàêòèëüíà - íîðìàëüíà (D S)/çíèæåíà (D S) ____________/â³äñóòíÿ (D S) __________/ï³äâèùåíà (D S) _______________ â³áðàö³éíà - D ____, S ____.
Ðåôëåêñè: êîë³ííèé íîðìàëüíèé (D S)/çíèæåíèé (D S)/â³äñóòí³é (D S),
àõ³ëîâèé íîðìàëüíèé (D S)/çíèæåíèé (D S)/â³äñóòí³é (D S) .
Ïóëüñàö³ÿ íà a.femoralis: íîðìàëüíà (D S)/çíèæåíà (D S)/ â³äñóòíÿ (D S),
íà a.poplitea: íîðìàëüíà (D S)/çíèæåíà (D S)/ â³äñóòíÿ (D S),
íà a.dorsalis pedis: íîðìàëüíà (D S)/çíèæåíà (D S)/ â³äñóòíÿ(D S),
íà a.tibialis posterior: íîðìàëüíà (D S)/ çíèæåíà (D S)/â³äñóòíÿ (D S)
Òóðãîð øê³ðè íà íîãàõ íîðìàëüíèé/çíèæåíèé/ï³äâèùåíèé.
Âîëîññÿ íà íîãàõ çâè÷àéíå/â³äñóòíº.
ͳãò³ íå çì³íåí³/ïîòîâùåí³/êðèõê³/ âðîñë³ êðà¿/óðàæåí³ ãðèáêîì __________Äåôîðìàö³ÿ ïàëüö³â (D S)_____________ óïåðêåðàòîç ï³äîøîâ, ëîêàëüí³ îìîçîë³ííÿ______________
Âèðàçêîâ³/íåêðîòè÷í³ óøêîäæåííÿ _____________________________
Íàáðÿêè(ïàñòîçí³ñòü) â³äñóòí³/íà îáëè÷÷³/ãîì³ëêàõ/ñòóïíÿõ/ ïîïåðåêó/ïåðåäí³é ÷åðåâí³é ñò³íö³ ____ ì'ÿê³/ù³ëüí³, âèçíà÷àºòüñÿ â³ëüíà ð³äèíà â ÷åðåâí³é ïîðîæíèí³.
____________________________________________________________________________________________________________________________________ Ïîïåðåäí³é ä³àãíîç: Öóêðîâèé ä³àáåò __ òèï ____________________________________________________________________________________
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Ïëàí îáñòåæåííÿ |
Ïëàí ë³êóâàííÿ |
Çàãàëüíèé àíàë³ç êðîâ³/ç ôîðìóëîþ |
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Ãë³êåì³÷íèé ïðîô³ëü |
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Ãë³êîçèëüîâàíèé ãåìîãëîá³í |
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Õîëåñòåðèí, òðèãë³öåðèäè, áåòà-ë³ïîïðîòå¿äè |
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Á³ë³ðóá³í, òðàíñàì³íàçè |
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Êðåàòèí³í, ñå÷îâèíà/ïðîáà Ðåáåðãà |
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Êîàãóëîãðàìà, ÷àñ çãîðòàííÿ êðîâ³, ïðîòðîìá³í. ³íäåêñ |
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Ñ-ïåïòèä |
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Êàë³é, íàòð³é, êàëüö³é (³îí³çîâàíèé), ôîñôîð êðîâ³ |
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Çàãàëüíèé àíàë³ç ñå÷³/ëåéêîöèòàðíà ôîðìóëà ñå÷³ |
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Ãëþêîçóðè÷íèé ïðîô³ëü |
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Àöåòîí ñå÷³ |
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Äîáîâà ïðîòå¿íóð³ÿ/ì³êðîàëüáóì³íóð³ÿ |
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ÅÊÃ, ÅõîÊà |
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Äîïïëåðîãðàô³ÿ ñóäèí í³ã/ñóäèí øè¿, àíã³îãðàô³ÿ |
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Ðåíòãåíîãðàô³ÿ ÎÃÊ |
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ÓÇÄ îðãàí³â ÷åðåâíî¿ ïîðîæíèíè/ ùèòîïîä³áíî¿ çàëîçè |
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Îãëÿä îêóë³ñòà, íåâðîïàòîëîãà, õ³ðóðãà, ã³íåêîëîãà |
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"___" __________ 200_ ð.˳êàð _____________ ï³äïèñ ___________
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî ³ñòî𳿠õâîðîáè äèòèíè
ç ïîðóøåííÿì ðîñòó ³ ñòàòåâîãî ðîçâèòêó
Ñêàðãè: ³äñòàâàííÿ/âèïåðåäæåííÿ ðîñòó/ñòàòåâîãî ðîçâèòêó __________________________________________________________________ Äèíàì³êà ðîñòó çà îñòàíí³ 6 ì³ñ. ____ ñì, çà îñòàíí³ 3 ðîêè:200_ ð. ___ ñì, 200_ ð. ___ ñì, 200_ ð. __ ñì Ñëàáê³ñòü, øâèäêà âòîìëþâàí³ñòü, Ïîã³ðøåííÿ çîðó: òàê/í³,Ïàì'ÿò³ òàê/í³ ___________________________________________________ Âàãà: ñòàá³ëüíà/çá³ëüøèëàñü/çìåíøèëàñü íà ___ êã çà ______,Àïåòèò: íîðìàëüíèé/çíèæåíèé/ï³äâèùåíèé, __________________________ Àíàìíåç õâîðîáè: ³äñòàº/âèïåðåäæຠîäíîë³òê³â ó ðîñò³ ç ___ ðîê³â. Ïîðóøåííÿñòàòåâîãî ðîçâèòêó ç ___ ðîê³â Ìîæëèâà ïðè÷èíà: ñïàäêîâ³ñòü/çàõâîðþâàííÿ/òðàâìà ____________ Ïåðøå çâåðòàííÿ äî åíäîêðèíîëîãà â _____ ð. _________________ Ïîïåðåäíº îáñòåæåííÿ: (äå) __________________________________ Ðåçóëüòàòè îáñòåæåííÿ: ʳñòêîâèé â³ê _____ (_____ ð.), ________________________________________________________________________ Ïîïåðåäíº ë³êóâàííÿ, éîãî òðèâàë³ñòü: _________________________________________________________________________________________ Åôåêòèâí³ñòü ________________________________________________ Çð³ñò áàòüêà ____ ñì, ìàòåð³ ____ñì. Î÷³êóâàëüíèé îñòàòî÷íèé çð³ñò äèòèíè ____ ñì. ѳìåéíèé àíàìíåç ïîðóøåííÿ ðîñòó/ñòàòåâîãî ðîçâèòêó ___________________________________________________________________________ Ïî÷àòîê ïóáåðòàòó ó ìàòåð³/áàòüêà ___________________________ Ðîçâèòîê áðàòà/ñåñòðè _______________________________________ ²íøå: _________________________________________________________________________________________________________________________ Àíàìíåç æèòòÿ: Âàãà ïðè íàðîäæåíí³ ____ êã. Çð³ñò ïðè íàðîäæåíí³ ____ ñì.Íàðîäèâñÿ â³ä _____ âàã³òíîñò³, (íå)äîíîøåíèé. Âàã³òí³ñòü, ïîëîãèíîðìàëüí³/óñêëàäíåí³ _____________________________________________ Ïðèéîì ìàò³ð'þ ï³ä ÷àñ âàã³òíîñò³ ïðåïàðàò³â ________________ Ïåðåíåñåí³ õâîðîáè: ãåïàòèò ______ ð., ______________________ Õðîí³÷í³ õâîðîáè: ___________________________________________ Îïåðàö³¿ ____________________________________________________ Òðàâìè ______________ Ïðîô³ëàêòèêà ðàõ³òó: òàê/í³ ___________ Âèãîäîâóâàííÿ: ïðèðîäíå/øòó÷íå, äî ____ ì³ñ./ðîê³â. Àëåðã³ÿ _____________________________________________________ ²íøå: _______________________________________________________ Äàí³ îá'ºêòèâíîãî îáñòåæåííÿ: Çàãàëüíèé ñòàí õâîðîãî çàäîâ³ëüíèé. Çð³ñò___ ñì (___ äåëüòà),âàãà ___ êã (___%), ðîçìàõ ðóê ____ ñì Áóäîâà ò³ëà: ïóåð³ëüíà/ºâíóõî¿äíà, àñòåí³÷íà/íîðìîñòåí³÷íà/ã³ïåðñòåí³÷íà, (íå)ïðîïîðö³éíà ___________________________________ Ñòèãìè äèçåìáð³îãåíåçó: â³äñóòí³/ ___________________________ Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/íàäì³ðíî âîëîãà:ëîêàëüíî/äèôóçíî _______________ ÷èñòà/º âèñèïè _________________,êîë³ð çâè÷àéíèé/áë³äà/ã³ïåðåì³ÿ/ _____________, ö³àíîç ___________(äå/ã³ïåð)ï³ãìåíòàö³ÿ ______________________________________________________________________________________________________________ Ñò𳿠â³äñóòí³/÷åðâîí³/òåìíî-÷åðâîí³ ________________________ Õàðàêòåð â³äêëàäåííÿ æèðó ð³âíîì³ðíèé/ïåðåâàæíî â ä³ëÿíêàõ:__________________________________________________________________ Îðãàíè äèõàííÿ: ÷àñòîòà __ íà õâ. Ïåðêóòîðíî: ÿñíèé ëåãåíåâèéçâóê _____________________ Õðèïè â³äñóòí³/ñóõ³/âîëîã³ __________________________________ Ñåðöåâî-ñóäèííà ñèñòåìà: ïóëüñ ___ íà õâ., (à)ðèòì³÷íèé _____ ÀÒ _____ ìì ðò. ñò. Ìåæ³ ñåðöÿ íå çì³íåí³ ___________________ Òîíè ñåðöÿ ãó÷í³/àêöåíòîâàí³/îñëàáëåí³. Àêöåíò _____________,Øóì:______________________________________________________________ Îðãàíè òðàâëåííÿ: ÿçèê âîëîãèé/ñóõèé, êîë³ð _____________,îáêëàäåíèé ___________ íàëüîòîì Æèâ³ò ì'ÿêèé/çàïàëèé/ðîçäóòèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿ ______________________________________________________________________ Ïå÷³íêà (íå)çá³ëüøåíà íà ___ ñì, êðàé ì'ÿêèé/ù³ëüíèé,(íå)áîëþ÷èé ïðè ïàëüïàö³¿ Ñå÷î-ñòàòåâà ñèñòåìà: ijóðåç _____ ë/äîáó. Ñå÷îâèä³ëåííÿ íîðìàëüíå/óòðóäíåíå/áîë³ñíå. Ñèìïòîì Ïàñòåðíàöüêîãî íåãàòèâíèé/ïîçèòèâíèé: ñïðàâà/çë³âà. Òèï îâîëîñ³ííÿ æ³íî÷èé/÷îëîâ³÷èé ____________________________ Ñòàòåâèé ðîçâèòîê: ijâ÷àòêà: Ax __, P __, Ma __, Me __ (íà ____ ðîê³â). Õëîï÷èêè: F __, Ax __, P __, Îß __, ÄÏ ___. ²Ì = ___ (íà ___ ðîê³â). Ïàñïîðòíèé â³ê ____ ðîê³â, "ʳñòêîâèé" â³ê _____ ðîê³â, Ô³çè÷íèé ðîçâèòîê ____ ðîê³â. Ùèòîïîä³áíà çàëîçà (íå)çá³ëüøåíà ______ ñò., ì'ÿêà/åëàñòè÷íà/ù³ëüíà/ãîðáêóâàòà, ïðè ïàëüïàö³¿ (íå)áîëþ÷à ____________________,âóçëîâ³ óòâîðåííÿ (íå)ïàëüïóþòüñÿ ________________________________ Ïåðèôåðè÷í³ ë³ìôîâóçëè (íå)çá³ëüøåí³ ________________________ ʳñòêîâî-ì'ÿçîâà ñèñòåìà: äåôîðìàö³¿: _________________________________________________________________________________________ Íàáðÿêè (ïàñòîçí³ñòü) â³äñóòí³/íà îáëè÷÷³/ãîì³ëêàõ/ñòóïíÿõ/ _______________________________________________________________________________________________________________________________________________________________________________________________________ Ïîïåðåäí³é ä³àãíîç: _________________________________________
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ÏËÀÍ ÎÁÑÒÅÆÅÍÍß |
ÏËÀÍ Ë²ÊÓÂÀÍÍß |
Çàãàëüíèé àíàë³ç êðîâ³/ç ôîðìóëîþ |
Ðåæèì |
Öóêðîâà êðèâà (ç íàâàíòàæåííÿì ãëþêîçîþ) |
Ñò³ë N |
Õîëåñòåðèí, òðèãë³öåðèäè, áåòà-ë³ïîïðîòå¿äè |
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Á³ë³ðóá³í, òðàíñàì³íàçè |
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Êàë³é, íàòð³é, êàëüö³é (³îí³çîâàíèé), ôîñôîð êðîâ³ |
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ÒÒÃ, |
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ÑÒà (ôîí, ï³ê, ïðîáà ç êëîôåë³íîì/ô³ç. íàâàíòàæåííÿì) |
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ÔÑÃ, ËÃ, ÏÐË, Òåñòîñòåðîí, åñò ðàä³îë, ÄÃÅÀ, 17-ÎÏà |
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17-ÊÑ â äîáîâ³é ñå÷³ |
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Çàãàëüíèé àíàë³ç ñå÷³ |
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Àíàë³ç êàëà íà ÿ/ãëèñò, åíòåðîá³îç |
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ÅÊÃ |
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Ðåíòãåíîãðàô³ÿ ÎÃÊ/÷åðåïà (òóðåöüêîãî ñ³äëà)/êèñò³ |
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ÌÐÒ |
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ÓÇÄ ùèòîïîä³áîä³áíî¿ çàëîçè, ÎÌÒ, Î×Ï |
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Ãåíåòèê, ÏÕ, êàð³îòèï |
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Îêóë³ñò (ïîëÿ çîðó), íåâðîëîã, õ³ðóðã, ã³íåêîëîã, óðîëîã |
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Ïåä³àòð |
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"__" ________ 200_ ð. ˳êàð __________________ ϳäïèñ _________
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî ³ñòî𳿠õâîðîáè äèòèíè ç ïàòîëî㳺þ ùèòîïîä³áíî¿ çàëîçè
Äàòà _____________
Ñêàðãè: Áîë³ â îáëàñò³ øè¿ (D S) ________, ³ððàä³àö³ÿ _______ Âàæê³ñòü êîâòàííÿ òâåðäî¿/ð³äêî¿ ¿æ³, (íå)ïîñò³éíå â³ä÷óòòÿäàâëåííÿ â îáëàñò³ øè¿: í³/òàê Ïî÷óòòÿ "êîìà" ó ãîðë³ ïðè õâèëþâàíí³, ïåðåâòîì³. Çíèæåííÿòåìáðó/ñèïë³ñòü ãîëîñó: í³/òàê Ñëàáê³ñòü, øâèäêà âòîìëþâàí³ñòü, ñîíëèâ³ñòü, áàéäóæ³ñòü,ïîäðàçëèâ³ñòü, ïëàêñèâ³ñòü: í³/òàê Ïîã³ðøåííÿ ïàì'ÿò³, ñëóõó, çîðó: òàê/í³. Çìåðçàííÿ.ϳòëèâ³ñòü ëîêàëüíà/äèôóçíà, (íå)ïîñò³éíà Ïîã³ðøåííÿ çîðó, äâî¿ííÿ, â³ä÷óòòÿ ï³ñêó â î÷àõ, ñëüîçîòå÷à,çá³ëüøåííÿ î÷åé: í³/òàê __________________________________________ Òðåìò³ííÿ ðóê ïðè ¿õ íàïðóæåíí³/ïîñò³éíî, çì³íà ïî÷åðêó:òàê/í³. Òðåìò³ííÿ âñüîãî ò³ëà: òàê/í³ Âèïàä³ííÿ âîëîññÿ ç ãîëîâè/ï³ä ïàõâàìè/íà ëîáêó: òàê/í³.__________________________________________________________________ Âòðàòà (ïðèáàâêà) âàãè íà _____ êã/____ ïðè _____________àïåòèò³ òà _______________ õàð÷óâàíí³ Á³ëü â ä³ëÿíö³ ñåðöÿ, ïîñò³éíèé/ïåð³îäè÷íèé, ³ððàä³àö³ÿ _______________________________________________________________________ Ñåðöåáèòòÿ ïîñò³éíå/ïåð³îäè÷íå: òàê/í³. Ïåðåáî¿ â ðîáîò³ñåðöÿ: í³/òàê Çàäèøêà â ñïîêî¿/ïðè õîä³ Ï³äâèùåííÿ ÀÒ: í³/òàê: äî ___ ìì ðò. ñò., ïîñò³éíå/ïåð³îäè÷íå__________________________________________________________________ Ãîëîâí³ áîë³: í³/òàê _____________________________,çàïàìîðî÷åííÿ í³/òàê ______________________ Á³ëü â ì'ÿçàõ/ñóãëîáàõ í³ã/ðóê: í³/òàê: â ñïîêî¿, ïðè õîä³.Ñóäîìè í³ã/ðóê: í³/òàê: â ñïîêî¿/ïðè ¿õ íàïðóæåíí³, çàí³ì³ííÿí³ã/ðóê: í³/òàê. Ñò³ëåöü íîðìàëüíèé/çàïîðè/ïðîíîñè _____ ðàçíà _______________________________________________________________ Íàáðÿêè/ïàñòîçí³ñòü: í³/òàê: îáëè÷÷ÿ/______ ïîâ³ê/ðóê/í³ã/ïîïåðåêó - ïîñò³éí³/ðàíêîì/ââå÷åð³ _________________________________________________________________________________________________ Àíàìíåç õâîðîáè: ùèòîïîä³áíà çàëîçà çá³ëüøåíà ç _____ ð.Ïåðøå çâåðòàííÿ äî ë³êàðÿ â _____ ð. ijàãíîç ________________ âñòàíîâëåíî â _____ ð. _____________ Ïîïåðåäíº ë³êóâàííÿ ³ éîãî òðèâàë³ñòü ___________________________________________________________________________________________________________________________________________________________ Åôåêò ë³êóâàííÿ: ïîêðàùåííÿ/ïîã³ðøåííÿ/áåç çì³í (ïðè÷èíà:íåäîòðèìàííÿ ïðèçíà÷åíîãî ë³êóâàííÿ/éîãî íåàäåêâàòí³ñòü/íåðåãóëÿðí³ñòü ïðèéîìó ë³ê³â/³íøà: ______________________________) Ïåðåá³ã õâîðîáè ñòàá³ëüíèé/ðåöèäèâè/÷àñòà äåêîìïåíñàö³ÿ(ïðè÷èíè: _____________________________) Îïåðàòèâíå ë³êóâàííÿ (ð³ê, îá'ºì) ___________________________ Îòðèìóº: ____________________________________________________ Îñòàíí³ ïîêàçíèêè: ÒÒà ______, âÒ3 __________,(íà äîç³ ______________________________) Ïîïåðåäíº ñòàö³îíàðíå ë³êóâàííÿ â ______ ð. ïëàíîâå/äëÿ ÌÑÅÊ/ç ïðèâîäó äåêîìïåíñàö³¿ __________________________________________ Ïðè÷èíà ãîñï³òàë³çàö³¿: ïëàíîâà /ïîã³ðøåííÿ ñòàíó (ïðè÷èíà)__________________________________________________________________ Àíàìíåç æèòòÿ: íàðîäè _____ â³ä ___ âàã³òíîñò³, _____________ Ïðîæèâàííÿ â åíäåì³÷í³é ïî çîáó ì³ñöåâîñò³. Ñïàäêîâ³ñòü _________________________________________________ Ïåðåíåñåí³ õâîðîáè: ãåïàòèò ______ ð., òóáåðêóëüîç ______ ð.,òèôè, ïàðàòèôè __________ ð. Õðîí³÷í³ õâîðîáè: ___________________________________________ Îïåðàö³¿ ____________________________________________________ Òðàâìè/ïåðåëîìè _____________________________________________ Àëåðã³ÿ _____________________________________________________ Ïåðåëèâàííÿ êðîâ³ ó ______ ð. _______________________________ Ìåíñòðóàö³¿ ç ___ ðîê³â, (íå)ðåãóëÿðí³ ______ ð., ¿õ õàðàêòåð(íå)çì³íèâñÿ ___________ Äèíàì³êà ìàñè ò³ëà çà ð³ê: _____ êã _______________________________________________________________________ Äàí³ îá'ºêòèâíîãî îáñòåæåííÿ: Çàãàëüíèé ñòàí çàäîâ³ëüíèé/ñåðåäíüî¿ âàæêîñò³/âàæêèé. Ñâ³äîì³ñòü ______________________________. Ïîëîæåííÿ â ë³æêóàêòèâíå/ïàñèâíå/âèìóøåíå. Ïñèõî-åìîö³éíèé ñòàí: ìåòóøëèâ³ñòü/åìîö³éíà ëàá³ëüí³ñòü/áðàäèïñèõ³çì/óïîâ³ëüíåí³ñòü ðóõ³â Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà, çàøêàðóáëà ________________/ íàäì³ðíî âîëîãà: äèôóçíî, ëîêàëüíî __________________ ÷èñòà/º âèñèïè _____________________ Òóðãîð íîðìàëüíèé/ï³äâèùåíèé/çíèæåíèé, êîë³ð çâè÷àéíèé/áë³äà/ç æîâòèíîþ/ã³ïåðåì³ÿ/ö³àíîç _________________________ äåðìîãðàô³çì÷åðâîíèé ñò³éêèé/íå âèðàæåíèé, (äå)ï³ãìåíòàö³ÿ: í³/òàê:__________________________________________________________________ Ïåäèêóëüîç: í³/òàê, êîðîñòà: í³/òàê. Çð³ñò ____ ñì, âàãà ___ êã. Õàðàêòåð â³äêëàäåííÿ æèðó(íå)ð³âíîì³ðíèé __________________ Åêçîôòàëüì: D S: I, II, III ñò. Ñèìïòîìè: Ìàð³ ___, Ðîçåíáàõà ___, Ãðåôå ___, Äàëüðèìïëÿ ___,Êðàóñà ___, Ðîçåíáàõà ___, Ìåá³óñà ___ Õîðåî¿äí³ ïîñìèêóâàííÿ ì'ÿç³â ðóê: º/íåìàº. Ñèìïòîì ÕâîñòåêàI, II, III. Ñèìïòîì Òðóññî _____ Ùèòîïîä³áíà çàëîçà (íå)çá³ëüøåíà ____ ñò., ì'ÿêà/åëàñòè÷íà/ù³ëüíà/ãîðáêóâàòà, ïðè ïàëüïàö³¿ (íå)áîëþ÷à _____________________,âóçëîâ³ óòâîðåííÿ (íå)ïàëüïóþòüñÿ â D/S äîë³: ___ ðóõîì³. Øê³ðàíàä çàëîçîþ __________________________ Ñóäèííèé øóì íàä çàëîçîþ(íå) âèñëóõîâóºòüñÿ. Ïåðèôåðè÷í³ ë³ìôîâóçëè (íå)çá³ëüøåí³ ________________________ ʳñòêîâî-ì'ÿçîâà ñèñòåìà ____________________________________ Îðãàíè äèõàííÿ: ÷àñòîòà ____ íà õâ., õàðàêòåð _______,çàäèøêà ³í(åê)ñï³ðàòîðíà â ñïîêî¿/ïðè õîä³. Ïåðêóòîðíî: ÿñíèéëåãåíåâèé çâóê/âêîðî÷åííÿ/êîðîáî÷íèé: ñïðàâà ____________________çë³âà _______________ Õðèïè â³äñóòí³/ñóõ³/âîëîã³ _________________ Ñåðöåâî-ñóäèííà ñèñòåìà: ïóëüñ ____ íà õâ., (à)ðèòì³÷íèé ____ ÀÒ ëåæà÷è ________ ìì ðò. ñò., ñòîÿ÷è _________ ìì ðò. ñò.Ìåæ³ ñåðöÿ ________________________ Òîíè ñåðöÿ ãó÷í³/àêöåíòîâàí³/îñëàáëåí³ ______________________ Àêöåíò __________________. Øóìè:_____________________________ Îðãàíè òðàâëåííÿ: ÿçèê _____________ âîëîãèé/ñóõèé,÷èñòèé/îáêëàäåíèé ____________ íàëüîòîì Æèâ³ò ì'ÿêèé/çàïàëèé/ðîçäóòèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿ ______________________________________________________________________ Ïå÷³íêà (íå)çá³ëüøåíà íà ____ ñì, êðàé ì'ÿêèé/ù³ëüíèé,(íå)áîëþ÷èé ïðè ïàëüïàö³¿ Ñå÷î-ñòàòåâà ñèñòåìà: ijóðåç ____ ë/äîáó. Ñå÷îâèä³ëåííÿíîðìàëüíå/óòðóäíåíå/áîë³ñíå. Ñèìïòîì Ïàñòåðíàöüêîãî íåãàòèâíèé/ïîçèòèâíèé: ñïðàâà/çë³âà. Òèï îâîëîñ³ííÿ æ³íî÷èé/÷îëîâ³÷èé ____________________________ Ñòàòåâèé ðîçâèòîê: ä³â÷àòêà: Ax __, P __, Ma __, Me __.(íà ____ ðîê³â) __________________________________________________ õëîï÷èêè: F __, Ax __, P __, Îß __, ÄÏ __.²Ì = ___ (íà ____ ðîê³â) _____________ Íàáðÿêè(ïàñòîçí³ñòü): â³äñóòí³/íà îáëè÷÷³/ãîì³ëêàõ/ñòóïíÿõ/ïîïåðåêó/ïåðåäí³é ÷åðåâí³é ñò³íö³, ì'ÿê³/ù³ëüí³, âèçíà÷àºòüñÿâ³ëüíà ð³äèíà â ÷åðåâí³é ïîðîæíèí³.____________________________________________________________________________________________________________________________________ Ïîïåðåäí³é ä³àãíîç: ___________________________________________________________________________________________________________
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Ïëàí îáñòåæåííÿ |
Ïëàí ë³êóâàííÿ |
Çàãàëüíèé àíàë³ç êðîâ³/ç ôîðìóëîþ |
Ðåæèì |
Öóêðîâà êðèâà (ç íàâàíòàæåííÿì ãëþêîçîþ) |
Ñò³ë N |
Õîëåñòåðèí, òðèãë³öåðèäè, áåòà-ë³ïîïðîòå¿äè |
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Á³ë³ðóá³í, òðàíñàì³íàçè |
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Êàë³é, íàòð³é, êàëüö³é (³îí³çîâàíèé), ôîñôîð êðîâ³ |
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ÒÒÃ, âÒ , âÒ , òèòð ÀÌÔ |
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Çàãàëüíèé àíàë³ç ñå÷³ |
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Àíàë³ç êàëà íà ÿ/ãëèñò, åíòåðîá³îç |
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ÅÊÃ, ÅõîÊÃ, ÐÂà |
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Ðåíòãåíîãðàô³ÿ ÎÃÊ/÷åðåïà (òóðåöüêîãî ñ³äëà)/ êèñò³ |
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ÓÇÄ ùèòîïîä³áîä³áíî¿ çàëîçè, îðá³ò |
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Òîíêîãîëêîâà àñï³ðàö³éíà ïóíê³éíà á³îïñ³ÿ |
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Îêóë³ñò (ïîëÿ çîðó), íåâðîëîã, õ³ðóðã, ã³íåêîëîã, óðîëîã |
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"___" __________ 200_ ð. ˳êàð _____________ ï³äïèñ ___________
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî ³ñòî𳿠õâîðîáè äèòèíè, õâîðî¿ íà öóêðîâèé ä³àáåò
Ñêàðãè: Ñïðàãà _____ ë, ïîë³óð³ÿ _____, âòðàòà (ïðèáàâêà)âàãè íà _______ êã/ ________ ïðè ____________ àïåòèò³. Ïîã³ðøåííÿçîðó ______, á³ëü â íîãàõ ïðè õîä³ íà â³äñòàíü _______, ïî ñõîäàõ,â ñïîêî¿, âíî÷³, ñóäîìè í³ã ïðè õîä³ (âíî÷³), çàí³ì³ííÿ í³ã/ðóê,çíèæåííÿ ÷óòëèâîñò³ í³ã/ðóê, ñò³ëåöü ____________ ϳäâèùåííÿ ÀÒäî ________ ìì ðò. ñò., ãîëîâí³ áîë³ _____________________________íàáðÿêè ______________________________________________________________________________________________________________________________________________________________________________________________ Àíàìíåç õâîðîáè: Õâî𳺠öóêðîâèì ä³àáåòîì ç _______ ð.,ïîâ'ÿçóº ç _______________________________________________________ Ïåðåá³ã õâîðîáè ñòàá³ëüíèé/ëàá³ëüíèé (÷îìó) _________________ Îòðèìóº: ðàíêîì ______________________________________________________ âäåíü _______________________________________________________ ââå÷åð³ _____________________________________________________ Ïðîòÿãîì îñòàííüîãî ðîêó öóêîð â êðîâ³ ___, ÀÒ ___ ìì ðò.ñò.,âàãà _____ êã ÍâÀ1ñ ____________, õîëåñòåðèí _____________ ×àñòîòà êîíòðîëþãë³êå쳿 _________________________________________________________ Ïîïåðåäíº ñòàö³îíàðíå ë³êóâàííÿ â ____ ð. ïëàíîâå/ç ïðèâîäóäåêîìïåíñàö³¿ ÖÄ/äëÿ ÌÑÅÊ Ïðè÷èíà ïîã³ðøåííÿ ñòàíó ________________________________________________________________________________________________________________________________________________________________________ Àíàìíåç æèòòÿ: Âàãà ïðè íàðîäæåíí³ ____ êã. Ñïàäêîâ³ñòü ïî ÖÄ ______________ Ïåðåíåñåí³ õâîðîáè: ãåïàòèò ______ ð, _________________________________________________________________________________________ Õðîí³÷í³ õâîðîáè, ___________________________________________ Îïåðàö³¿ ____________________________________________________ Òðàâìè ______________________________________________________ Àëåðã³ÿ _____________________________________________________ Ìåíñòðóàö³¿ ç ___ ðîê³â, (íå)ðåãóëÿðí³ ___ ð. Äèíàì³êàçà ð³ê: ðîñòó _____ ñì, ìàñè ò³ëà ____ êã ²íø³ äàí³: ____________________________________________________________________________________________________________________ Äàí³ îá'ºêòèâíîãî îáñòåæåííÿ: Çàãàëüíèé ñòàí õâîðîãî çàäîâ³ëüíèé/ñåðåäíüî¿ âàæêîñò³/âàæêèé Ñâ³äîì³ñòü: çáåðåæåíà/ñòóïîð/ñîïî /êîìà. Ïîëîæåííÿ â ë³æêóàêòèâíå/ïàñèâíå/âèìóøåíå Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/äåã³äðàòàö³ÿ/íàäì³ðíî âîëîãà________________________, ÷èñòà/º âèñèïè ________________________,êîë³ð çâè÷àéíèé/áë³äà/ã³ïåðåì³ÿ/ ____________ ö³àíîç _____________(äå)ï³ãìåíòàö³ÿ ________________ ë³ïîäèñòðîô³¿ ___________________˳ïî¿äíèé íåêðîá³îç ______________________________________________ Çð³ñò ____ ñì (____ äåëüòà), âàãà _____ êã (__%). Õàðàêòåðâ³äêëàäåííÿ æèðó ______________________ Îðãàíè äèõàííÿ: ÷àñòîòà _____ íà õâ., õàðàêòåð ______________çàäèøêà ³í/åê/ñï³ðàòîðíà ______ â ñïîêî¿/ïðè õîä³. Çàïàõ àöåòîíó_________________________ Ïåðêóòîðíî: ÿñíèé ëåãåíåâèé çâóê/âêîðî÷åííÿ ñïðàâà __________çë³âà _____________ Õðèïè â³äñóòí³/ñóõ³/âîëîã³ __________________________________ Ñåðöåâî-ñóäèííà ñèñòåìà: ïóëüñ ____ íà õâ., (à)ðèòì³÷íèé ____ ÀÒ ëåæà÷è _________ ìì ðò. ñò., ñòîÿ÷è ___________ ìì ðò. ñò. Ìåæ³ ñåðöÿ _______________________ Òîíè ñåðöÿ ãó÷í³/àêöåíòîâàí³/îñëàáëåí³. Àêöåíò _____________,Øóì: __________________ Îðãàíè òðàâëåííÿ: ÿçèê âîëîãèé/ñóõèé, êîë³ð ______________,îáêëàäåíèé ____________ íàëüîòîì Æèâ³ò ì'ÿêèé/çàïàëèé/ðîçäóòèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿ ______________________________________________________________________ Ïå÷³íêà (íå)çá³ëüøåíà íà ____ ñì, êðàé ì'ÿêèé/ù³ëüíèé,(íå)áîëþ÷èé ïðè ïàëüïàö³¿ Ñå÷î-ñòàòåâà ñèñòåìà: ijóðåç _____ ë/äîáó. Ñå÷îâèä³ëåííÿ íîðìàëüíå/óòðóäíåíå/áîë³ñíå. Ñèìïòîì Ïàñòåðíàöüêîãî íåãàòèâíèé/ïîçèòèâíèé: ñïðàâà/çë³âà. Òèï îâîëîñ³ííÿ æ³íî÷èé/÷îëîâ³÷èé ____________________________ Ñòàòåâèé ðîçâèòîê â³äïîâ³äíî ñòàò³ ³ â³êó. ijâ÷àòêà: Ax __,P __, Ma __, Me __ (íà ____ ðîê³â) Õëîï÷èêè: F __, Ax __, P __, Îß __, ÄÏ ___. ²Ì = ___(íà ____ ðîê³â). "ʳñòêîâèé" â³ê íà _____ ðîê³â Ùèòîïîä³áíà çàëîçà (íå)çá³ëüøåíà ______ ñò.,ì'ÿêà/åëàñòè÷íà/ù³ëüíà/ãîðáêóâàòà, ïðè ïàëüïàö³¿ (íå)áîëþ÷à _____,âóçëîâ³ óòâîðåííÿ (íå)ïàëüïóþòüñÿ ______________ Ïåðèôåðè÷í³ ë³ìôîâóçëè (íå)çá³ëüøåí³ ________________________ ʳñòêîâî-ì'ÿçîâà ñèñòåìà ____________________________________ ×óòëèâ³ñòü: òåìïåðàòóðíà - íîðìàëüíà (D S)/çíèæåíà (D S)_________/â³äñóòíÿ (D S) ___________ áîëüîâà - íîðìàëüíà (D S)/çíèæåíà (D S) /â³äñóòíÿ (D S)________/ï³äâèùåíà (D S) ___________ òàêòèëüíà - íîðìàëüíà (D S)/çíèæåíà (D S) ____________/ â³äñóòíÿ (D S) __________/ï³äâèùåíà (D S) _______________ â³áðàö³éíà - D _____, S_____. Ïóëüñàö³ÿ íà a.femoralis çë³âà ____________ ñïðàâà __________ a.poplitea çë³âà ____________ ñïðàâà __________ a.dorsalis pedis çë³âà ____________ ñïðàâà __________a.tibialis posterior çë³âà ____________ ñïðàâà __________
Òóðãîð øê³ðè íà íîãàõ íîðìàëüíèé/çíèæåíèé/ï³äâèùåíèé. Âîëîññÿ
íà íîãàõ çâè÷àéíå/â³äñóòíº. ͳãò³ íå çì³íåí³/ïîòîâùåí³/êðèõê³/âðîñë³ êðà¿/óðàæåí³ ãðèáêîì ________________________________ Äåôîðìàö³ÿ ïàëüö³â (D S) _____________ óïåðêåðàòîç ï³äîøîâ,ëîêàëüí³ îìîçîë³ííÿ ______________ Âèðàçêîâ³/íåêðîòè÷í³ óøêîäæåííÿ _____________________________ Íàáðÿêè(ïàñòîçí³ñòü) â³äñóòí³/íà îáëè÷÷³/ãîì³ëêàõ/ñòóïíÿõ/ ïîïåðåêó/ïåðåäí³é ÷åðåâí³é ñò³íö³ _______________ ì'ÿê³/ù³ëüí³, âèçíà÷àºòüñÿ â³ëüíà ð³äèíà â ÷åðåâí³é ïîðîæíèí³.____________________________________________________________________________________________________________________________________ Ïîïåðåäí³é ä³àãíîç: Öóêðîâèé ä³àáåò __ òèï ____________________________________________________________________________________
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Ïëàí îáñòåæåííÿ |
Ïëàí ë³êóâàííÿ |
Çàãàëüíèé àíàë³ç êðîâ³/ç ôîðìóëîþ |
Ðåæèì |
Ãë³êåì³÷íèé ïðîô³ëü |
Ñò³ë N 9 |
Ãë³êîçèëüîâàíèé ãåìîãëîá³í |
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Õîëåñòåðèí, òðèãë³öåðèäè, áåòà-ë³ïîïðîòå¿äè |
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Á³ë³ðóá³í, òðàíñàì³íàçè |
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Êðåàòèí³í, ñå÷îâèíà/ïðîáà Ðåáåðãà |
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Êàë³é, íàòð³é, êàëüö³é (³îí³çîâàíèé), ôîñôîð êðîâ³ |
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Çàãàëüíèé àíàë³ç ñå÷³/ëåéêîöèòàðíà ôîðìóëà ñå÷³ |
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Ãëþêîçóðè÷íèé ïðîô³ëü |
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Àöåòîí ñå÷³ |
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Äîáîâà ïðîòå¿íóð³ÿ/ì³êðîàëüáóì³íóð³ÿ |
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Àíàë³ç êàëà íà ÿ/ãëèñò, åíòåðîá³îç |
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ÅÊÃ, ÅõîÊÃ, ÐÂà |
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Äîïïëåðîãðàô³ÿ ñóäèí í³ã/ñóäèí øè¿, àíã³îãðàô³ÿ |
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Ðåíòãåíîãðàô³ÿ ÎÃÊ, êèñò³, ÷åðåïà |
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ÓÇÄ îðãàí³â ÷åðåâíî¿ ïîðîæíèíè/ùèòîïîä³á.çàëîçè |
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Îêóë³ñò, íåâðîïàòîëîã, õ³ðóðã, ã³íåêîëîã, óðîëîã |
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"___" __________ 200_ ð. ˳êàð _____________ ï³äïèñ ___________
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî ³ñòî𳿠õâîðîáè äèòèíè ç åíäîêðèííîþ ïàòîëî㳺þ
Ñêàðãè: Ãîëîâíèé á³ëü: òàê/í³, ïîñò³éíèé/ïåð³îäè÷íèé,ëîêàë³çàö³ÿ ______________________, Çàïàìîðî÷åííÿ: òàê, í³. Áîë³ â ñåðö³ òàê/í³, ïðè÷èíè ________Ñåðöåáèòòÿ: òàê/í³, â ñïîêî¿, ïðè íàâàíòàæåíí³/õâèëþâàíí³.ÀÒ: íîðìà/ï³äâèùåííÿ/çíèæåííÿ äî ________ ìì ðò. ñò. Áîë³ â ñïèí³: òàê/í³. Íàáðÿêè: º, í³, ëîêàë³çàö³ÿ: îáëè÷÷ÿ,ãîì³ëêè, __________________________ Ñïðàãà: òàê/í³, ______ ë/äîáó, óäåíü ___ ë, óíî÷³ ____ ë,ïîë³óð³ÿ: òàê/í³, óäåíü ___ ë, óíî÷³ ____ ë Âàãà: ñòàá³ëüíà/çá³ëüøèëàñü/çìåíøèëàñü íà ___ êã çà ________. Àïåòèò: íîðìàëüíèé/çíèæåíèé/ï³äâèùåíèé, õàð÷îâ³ çâè÷êè ________________________________________________________________________ Ñëàáê³ñòü, øâèäêà âòîìëþâàí³ñòü, Ïîã³ðøåííÿ çîðó: òàê/í³,Ïàì'ÿò³ òàê/í³____________________ ³äñòàâàííÿ/âèïåðåäæåííÿ ðîñòó/ñòàòåâîãî ðîçâèòêó _______________________________________________ Äèíàì³êà ðîñòó çà îñòàíí³ 6 ì³ñ. ____ ñì, çà îñòàíí³ 3 ðîêè:200_ ð. ___ ñì, 200_ ð. ___ ñì, 200_ ð. ___ ñì ϳãìåíòàö³ÿ øê³ðè (ëîêàë³çàö³ÿ) _____________________________ Ñìóãè ðîçòÿãàííÿ íà øê³ð³: êîë³ð _______, ëîêàë³çàö³ÿ _________________________________________________________________________ Àíàìíåç õâîðîáè: Óïåðøå ñêàðãè ç'ÿâèëèñÿ ____________________ Ìîæëèâà ïðè÷èíà: ____________________________________________ Ïåðøå çâåðòàííÿ äî åíäîêðèíîëîãà â ______ ð. Ïîïåðåäíº îáñòåæåííÿ: (äå, ð³ê) _____________________________ Ðåçóëüòàòè îáñòåæåííÿ: ________________________________________________________________________________________________________ Ïîïåðåäíº ë³êóâàííÿ, éîãî òðèâàë³ñòü: _________________________________________________________________________________________ Åôåêòèâí³ñòü ________________________________________________ ѳìåéíèé àíàìíåç ____________________________________________ Ðîçâèòîê ìàòåð³/áàòüêà ___________ áðàòà/ñåñòðè _____________ ²íøå: _________________________________________________________________________________________________________________________ Àíàìíåç æèòòÿ: Âàãà ïðè íàðîäæåíí³ ____ êã. Çð³ñò ïðè íàðîäæåíí³ ____ ñì.Íàðîäèâñÿ â³ä _____ âàã³òíîñò³, (íå)äîíîøåíèé. Âàã³òí³ñòü, ïîëîãèíîðìàëüí³/óñêëàäíåí³ _____________________________________________ Ïðèéîì ìàò³ð'þ ï³ä ÷àñ âàã³òíîñò³ ïðåïàðàò³â ________________ Âèãîäîâóâàííÿ: ïðèðîäíå/øòó÷íå, äî ____ ì³ñ./ðîê³â. Ùåïëåíèé çà â³êîì/ç ïîðóøåííÿì ãðàô³êà. _____________________ Ðîçâèòîê ô³çè÷íèé/ïñèõ³÷íèé _________________________________ Äèòÿ÷³ ³íôåêö³¿ _____________________________________________ Õðîí³÷í³ õâîðîáè: ___________________________________________ Îïåðàö³¿ ____________________________________________________ Òðàâìè ______________________________________________________ Àëåðã³ÿ __________________________ ²íøå: ____________________ Äàí³ îá'ºêòèâíîãî îáñòåæåííÿ: Çàãàëüíèé ñòàí õâîðîãî çàäîâ³ëüíèé. Çð³ñò __ ñì (__ äåëüòà),âàãà ___ êã (___%), ðîçìàõ ðóê ____ ñì. Áóäîâà ò³ëà: ïóåð³ëüíà/ºâíóõî¿äíà, àñòåí³÷íà/íîðìîñòåí³÷íà/ã³ïåðñòåí³÷íà, (íå)ïðîïîðö³éíà__________________________________________________________________ Ñòèãìè äèçåìáð³îãåíåçó: â³äñóòí³/____________________________ Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/íàäì³ðíî âîëîãà: ëîêàëüíî/äèôóçíî ___________________ ÷èñòà/º âèñèïè ______________________,êîë³ð çâè÷àéíèé/áë³äà/ã³ïåðåì³ÿ _____________, ö³àíîç ____________(äå/ã³ïåð)ï³ãìåíòàö³ÿ ____________________________________________ Ñò𳿠â³äñóòí³/÷åðâîí³/òåìíî-÷åðâîí³ ________________________ Õàðàêòåð â³äêëàäåííÿ æèðó ð³âíîì³ðíèé/ïåðåâàæíî â ä³ëÿíêàõ:__________________________________________________________________ Îðãàíè äèõàííÿ: ×Ä ____ íà õâ., çàäèøêà: í³/â ñïîêî¿/ïðèõîä³. Ïåðêóòîðíî: ÿñíèé ëåãåíåâèé çâóê ___________________________ Õðèïè â³äñóòí³/ñóõ³/âîëîã³ __________________________________ Ñåðöåâî-ñóäèííà ñèñòåìà: ïóëüñ ____ íà õâ., (à)ðèòì³÷íèé.ÀÒ ________ ìì ðò. ñò. Ìåæ³ ñåðöÿ íå çì³íåí³ _____________________Òîíè ñåðöÿ ãó÷í³/àêöåíòîâàí³/îñëàáëåí³. Àêöåíò __________________, Øóì: _____________________________ Îðãàíè òðàâëåííÿ: ÿçèê âîëîãèé/ñóõèé, êîë³ð _____________,îáêëàäåíèé ____________ íàëüîòîì Æèâ³ò ì'ÿêèé/çàïàëèé/ðîçäóòèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿________________________________ Ïå÷³íêà (íå)çá³ëüøåíà íà ____ ñì, êðàé ì'ÿêèé/ù³ëüíèé,(íå)áîëþ÷èé ïðè ïàëüïàö³¿ Ñå÷î-ñòàòåâà ñèñòåìà: ijóðåç _____ ë/äîáó. Ñå÷îâèä³ëåííÿíîðìàëüíå/óòðóäíåíå/áîë³ñíå. Ñèìïòîì Ïàñòåðíàöüêîãî íåãàòèâíèé/ïîçèòèâíèé: ñïðàâà/çë³âà. Òèï îâîëîñ³ííÿ æ³íî÷èé/÷îëîâ³÷èé ____________________________ Ñòàòåâèé ðîçâèòîê: ijâ÷àòêà: Ax __, P __, Ma __, Me __ (íà ____ ðîê³â) _________ Õëîï÷èêè: F __, Ax __, P __, Îß d __, s __, êîíñèñòåíö³ÿ __, ÄÏ ___. ²Ì = ___ (íà ___ ðîê³â)____________________ Ïàñïîðòíèé â³ê _____ ðîê³â, "ʳñòêîâèé" â³ê _____ ðîê³â,Ô³çè÷íèé ðîçâèòîê ______ ðîê³â. Ùèòîïîä³áíà çàëîçà (íå)çá³ëüøåíà ____ ñò., ì'ÿêà/åëàñòè÷íà/ù³ëüíà/ãîðáêóâàòà, ïðè ïàëüïàö³¿ (íå)áîëþ÷à _____________________,âóçëîâ³ óòâîðåííÿ (íå)ïàëüïóþòüñÿ ______________ Ïåðèôåðè÷í³ ë³ìôîâóçëè (íå)çá³ëüøåí³ ________________________ ʳñòêîâî-ì'ÿçîâà ñèñòåìà: äåôîðìàö³¿: _________________________________________________________________________________________ Ñèìïòîì Õâîñòåêà I, II, III. Ñèìïòîì Òðóññî _________________ Íàáðÿêè(ïàñòîçí³ñòü) â³äñóòí³/íà îáëè÷÷³/ãîì³ëêàõ/ñòóïíÿõ/ ______________________________________________________________________________________________________________________________________ Ïîïåðåäí³é ä³àãíîç:______________________________________________________________________________________________________________________________________________________________________________________________________
Ïëàí îáñòåæåííÿ |
Ïëàí ë³êóâàííÿ |
Çàãàëüíèé àíàë³ç êðîâ³/ç ôîðìóëîþ |
Ðåæèì |
Öóêðîâà êðèâà (ç íàâàíòàæåííÿì ãëþêîçîþ) |
Ñò³ë N |
Õîëåñòåðèí, òðèãë³öåðèäè, áåòà-ë³ïîïðîòå¿äè |
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Á³ë³ðóá³í, òðàíñàì³íàçè |
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Êàë³é, íàòð³é, êàëüö³é (³îí³çîâàíèé), ôîñôîð êðîâ³ |
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ÒÒÃ, âÒ4 |
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ÑÒà (ôîí, ï³ê, ïðîáà ç êëîôåë³íîì/ ô³ç. íàâàíòàæåííÿì) |
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ÔÑÃ, ËÃ, ÏÐË, Òåñòîñòåðîí, åñò ðàä³îë, ÄÃÅÀ, 17-ÎÏà |
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17-ÊÑ â äîáîâ³é ñå÷³ |
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Êîðòèçîë â äîáîâ³é ñå÷³ |
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Ïðîáà ç äåêñàìåòàçîíîì |
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Ñ-ïåïòèä êðîâ³ |
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Çàãàëüíèé àíàë³ç ñå÷³ |
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Àíàë³ç êàëà íà ÿ/ãëèñò, åíòåðîá³îç |
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ÅÊÃ |
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Ðåíòãåíîãðàô³ÿ ÎÃÊ/÷åðåïà (òóðåöüêîãî ñ³äëà)/êèñò³ |
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ÌÐÒ |
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ÓÇÄ ùèòîïîä³áîä³áíî¿ çàëîçè, ÎÌÒ, Î×Ï |
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Ãåíåòèê, ÏÕ, êàð³îòèï |
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Îêóë³ñò (ïîëÿ çîðó), íåâðîëîã, õ³ðóðã, ã³íåêîëîã, óðîëîã |
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Ïåä³àòð |
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"__" ________ 200_ ð. ˳êàð __________________ ϳäïèñ _________
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
ùîäåííèêà äî ³ñòî𳿠õâîðîáè ñòàö³îíàðíîãî õâîðîãî ç ïàòîëî㳺þ ùèòîïîä³áíî¿ çàëîçè
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Äàòà |
Ùîäåííèê |
Îáñòåæåííÿ |
Êîðåêö³ÿ ë³êóâàííÿ |
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Ñêàðãè: ________________________________________________________________˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ _______________________Ñò³ëåöü __________________________ Îá'ºêòèâíî: Øê³ðà: ñóõà/çâè÷àéíî¿ âîëîãîñò³/íàäì³ðíî âîëîãà ______________________________________________ ×èñòà/º âèñèïè _________________________________________________________________Î÷í³ ñèìïòîìè ___________________________________________________Òðåìîð _____________________________Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ____ÀÒ ________ ìì ðò. ñò.Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³Äèõàííÿ âåçèêóëÿðíå ________________ Õðèïè â³äñóòí³/º __________________Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé Íàáðÿêè â³äñóòí³/º _________________ Ùèòîïîä³áíà çàëîçà _________________ |
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Ñêàðãè: ________________________________________________________________˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ _______________________Ñò³ëåöü __________________________ Îá'ºêòèâíî: Øê³ðà: ñóõà/çâè÷àéíî¿ âîëîãîñò³/íàäì³ðíî âîëîãà ______________________________________________ ×èñòà/º âèñèïè _________________________________________________________________Î÷í³ ñèìïòîìè ___________________________________________________Òðåìîð _____________________________Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ____ÀÒ ________ ìì ðò. ñò.Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³Äèõàííÿ âåçèêóëÿðíå ________________ Õðèïè â³äñóòí³/º __________________Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé Íàáðÿêè â³äñóòí³/º _________________ Ùèòîïîä³áíà çàëîçà _________________ |
˳êàð |
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ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
ùîäåííèêà äî ³ñòî𳿠õâîðîáè ñòàö³îíàðíîãî õâîðîãî
ç åíäîêðèííîþ ïàòîëî㳺þ
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Äàòà |
Ùîäåííèê |
Îáñòåæåííÿ |
Êîðåêö³ÿ ë³êóâàííÿ |
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Ñêàðãè: _____________________________________________________________ijóðåç _____ ë, ___________________˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ ________________Ñò³ëåöü ____________________________Îá'ºêòèâíî: øê³ðà ÷èñòà/º âèñèïè _____________________________________ ñò𳿠______________________Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ___________________________________ÀÒ ________ ìì ðò. ñò.Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³________________________________________Äèõàííÿ âåçèêóëÿðíå ________________ Õðèïè â³äñóòí³/º____________ Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé ________________________________ Íàáðÿêè â³äñóòí³/º __________________________________________________________________________________________________________________ |
˳êàð |
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Ñêàðãè: _____________________________________________________________ijóðåç _____ ë, ___________________˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ ________________Ñò³ëåöü ____________________________Îá'ºêòèâíî: øê³ðà ÷èñòà/º âèñèïè _____________________________________ ñò𳿠______________________Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ___________________________________ÀÒ ________ ìì ðò. ñò.Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³________________________________________Äèõàííÿ âåçèêóëÿðíå ________________ Õðèïè â³äñóòí³/º____________ Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé ________________________________ Íàáðÿêè â³äñóòí³/º __________________________________________________________________________________________________________________ |
˳êàð |
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Ñêàðãè: _____________________________________________________________ijóðåç _____ ë, ___________________˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ ________________Ñò³ëåöü ____________________________Îá'ºêòèâíî: øê³ðà ÷èñòà/º âèñèïè _____________________________________ ñò𳿠______________________Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ___________________________________ÀÒ ________ ìì ðò. ñò.Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³________________________________________Äèõàííÿ âåçèêóëÿðíå ________________ Õðèïè â³äñóòí³/º____________ Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé ________________________________ Íàáðÿêè â³äñóòí³/º __________________________________________________________________________________________________________________ |
˳êàð |
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ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
ùîäåííèêà äî ³ñòî𳿠õâîðîáè ñòàö³îíàðíîãî õâîðîãî íà öóêðîâèé ä³àáåò
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Äàòà |
Ùîäåííèê |
Îáñòåæåííÿ |
Êîðåêö³ÿ ë³êóâàííÿ |
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Ñêàðãè: ______________________________________________________ ______________________________________________________________ ijóðåç ____/äîáó. Ñò³ëåöü ___________________________________. ijºòó (íå)äîòðèìóº. __________________________________________ ______________________________________________________________ ˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ _____________________ Îá'ºêòèâíî: Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/âîëîãà ÷èñòà/º âèñèïè ______________________________________________________________ Çàïàõ àöåòîíó ó âèäèõàºìîìó ïîâ³òð³: º/íåìຠ____________________ Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ______________________________ ÀÒ ________ ìì ðò. ñò. Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³ ___________ Ïåðêóòîðíî ëåãåíåâèé çâóê __________ Äèõàííÿ âåçèêóëÿðíå _______ Õðèïè â³äñóòí³/º ___________________ Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé ____________________________ Ïå÷³íêà _____ Íàáðÿêè â³äñóòí³/º _______________________________ |
˳êàð |
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Ñêàðãè: ______________________________________________________ ______________________________________________________________ ijóðåç ____/äîáó. Ñò³ëåöü ___________________________________. ijºòó (íå)äîòðèìóº. __________________________________________ ______________________________________________________________ ˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ _____________________ Îá'ºêòèâíî: Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/âîëîãà ÷èñòà/º âèñèïè ______________________________________________________________ Çàïàõ àöåòîíó ó âèäèõàºìîìó ïîâ³òð³: º/íåìຠ____________________ Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ______________________________ ÀÒ ________ ìì ðò. ñò. Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³ ___________ Ïåðêóòîðíî ëåãåíåâèé çâóê __________ Äèõàííÿ âåçèêóëÿðíå _______ Õðèïè â³äñóòí³/º ___________________ Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé ____________________________ Ïå÷³íêà _____ Íàáðÿêè â³äñóòí³/º _______________________________ |
˳êàð |
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Ñêàðãè: ______________________________________________________ ______________________________________________________________ ijóðåç ____/äîáó. Ñò³ëåöü ___________________________________. ijºòó (íå)äîòðèìóº. __________________________________________ ______________________________________________________________ ˳êóâàííÿ ïåðåíîñèòü äîáðå/º óñêëàäíåííÿ _____________________ Îá'ºêòèâíî: Øê³ðà íîðìàëüíî¿ âîëîãîñò³/ñóõà/âîëîãà ÷èñòà/º âèñèïè ______________________________________________________________ Çàïàõ àöåòîíó ó âèäèõàºìîìó ïîâ³òð³: º/íåìຠ____________________ Ïóëüñ ____ óä./õâ. (à)ðèòì³÷íèé ______________________________ ÀÒ ________ ìì ðò. ñò. Òîíè ñåðöÿ ãó÷í³/îñëàáëåí³ ___________ Ïåðêóòîðíî ëåãåíåâèé çâóê __________ Äèõàííÿ âåçèêóëÿðíå _______ Õðèïè â³äñóòí³/º ___________________ Æèâ³ò ì'ÿêèé/ðîçäóòèé, (íå)áîëþ÷èé ____________________________ Ïå÷³íêà _____ Íàáðÿêè â³äñóòí³/º _______________________________ |
˳êàð |
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ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî àìáóëàòîðíî¿ êàðòêè îãëÿä ó õâîðîãî äèòÿ÷èì åíäîêðèíîëîãîì
Äàòà _______________ Ñêàðãè: __________________________________________________________________________________________________ Àíàìíåç:_______________________________________________________________________________________________________________________ Ñïàäêîâ³ñòü (íå) îáòÿæåíà ___________________________________ Õâîðîáà Áîòê³íà __________________ Åï³äàíàìíåç ______________õ³ðóðã³÷í³ (ñòîìàòîëîã³÷í³) âòðó÷àííÿ çà îñòàíí³ 6 ì³ñ. __________ Îá'ºêòèâíî: Çð³ñò ___ ñì (___ äåëüòà), âàãà ____ êã ____ (___%) ²ÌÒ _____ Áóäîâà ò³ëà (äèñ) ïðîïîðö³éíà _______________________________ Øê³ðà _______________________________________________________skabies _______________________ ïåäèêóëüîç _______________________ Ñëèçîâ³ îáîëîíêè ______________ (íå) çàïàëåí³ _______________ Ïóëüñ ___ óä. íà õâ., (à)ðèòì³÷íèé. Ñåðöå: òîíè çâó÷í³/ïðèãëóøåí³, (à) ðèòì³÷í³. ÀÒ __ ìì ðò. ñò. Ëåãåí³: äèõàííÿ âåçèêóëÿðíå (æîðñòêå), õðèïè â³äñóòí³(âîëîã³, ñóõ³). ßçèê âîëîãèé/ñóõèé, îáêëàäåíèé __________ íàëüîòîì Æèâ³ò ì'ÿêèé/çàïàëèé/ðîçäóòèé, (íå)áîëþ÷èé ïðè ïàëüïàö³¿ ______________________________________________________________________ Ïå÷³íêà (íå)çá³ëüøåíà íà ____ ñì ijóðåç _____ ë/äîáó. Íàáðÿêè ________________________________ Ñòàòåâèé ðîçâèòîê: ijâ÷àòêà: Ax __, P __, Ma __, Me __ (íà ____ ðîê³â). Õëîï÷èêè: F __, Ax __, P __, Îß __, ÄÏ ___. ²Ì = ___ (íà ___ ðîê³â). _____________________________________________________________________________________________________ Ùèòîïîä³áíà çàëîçà (íå)çá³ëüøåíà ______ ñò., ì'ÿêà/åëàñòè÷íà/ù³ëüíà/ãîðáêóâàòà, ïðè ïàëüïàö³¿ (íå)áîëþ÷à _____________, âóçëîâ³óòâîðåííÿ (íå)ïàëüïóþòüñÿ ________________________________________ Ïåðèôåðè÷í³ ë³ìôîâóçëè (íå)çá³ëüøåí³ ________________________ Íåðâîâî-ïñèõ³÷íèé ñòàòóñ ____________________________________ Ñõóäíåííÿ _______________ òðåìò³ííÿ ðóê _____________________ ñèìïòîìè: Ãðåôå, ______________________________________________________ ijàãíîç:_________________________________________________________________________________________________________________________________________________________________________________________
Ïðèçíà÷åííÿ |
Îáñòåæåííÿ |
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˳êàð __________________________ ϳäïèñ ______________ (Ï.².ï-Á)
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî àìáóëàòîðíî¿ êàðòêè îãëÿäó õâîðîãî ë³êàðåì åíäîêðèíîëîãîì
Äàòà _______________ Ñêàðãè______________________________________________________________________________________________________________________________________________________________________ Àíàìíåç: ________________________________________________________________________________________________________________________________________________________________________________________ Îá'ºêòèâíèé îãëÿä: Áóäîâà ò³ëà ______________________________çð³ñò _____ ñì, âàãà _____ êã, ²ÌÒ ______ Îæèð³ííÿ ____ ñò. ______ Òîíóñ ì'ÿç³â ________________________________________________ Òóðãîð ______________________________________________________ Øê³ðà òà ñëèçîâ³ îáîëîíêè: êîë³ð ____________________________ âîëîã³ñòü ____________________ ñóõ³ñòü ______________________ ï³ãìåíòàö³ÿ ___________________ íàáðÿêè _____________________ Âòîðèíí³ ñòàòåâ³ îçíàêè: â³äïîâ³äàþòü ñòàò³ òà â³êó,íåäîðîçâèíåí³, ïåðåä÷àñíî ðîçâèíåí³, ë³á³äî, ñòàòåâå îâîëîñ³ííÿ,ìåíñòðóàëüíèé öèêë __________________________________________________________________________________________________________________________________________________________________________________ Ùèòîïîä³áíà çàëîçà: áåç çì³í, çá³ëüøåííÿ I, II, III ñò.,êîíñèñòåíö³ÿ _____________________________________________________ ðóõîì³ñòü _________________ áîë³ñí³ñòü ______________________ âóçëè ________________________ òàõ³êàðä³ÿ ___________________ Ñõóäíåííÿ _________________ òðåìò³ííÿ ðóê ___________________ çÿáê³ñòü __________ îôòàëüì. ñèìïòîì Ãðåôå òà ³í. ___________ Íàáðÿêè îáëè÷÷ÿ òà ê³íö³âîê _________________________________ Ñîíëèâ³ñòü __________________________________________________ Ëåãåí³: äèõàííÿ âåçèêóëÿðíå ___________________________________________________________________________________________________ Õðèïè (ñóõ³, âîëîã³, äçâ³íê³)________________________________ Ñåðöåâî-ñóäèííà ñèñòåìà: òîíè ñåðöÿ __________, øóì _________ ÀÒ _____ ìì ðò. ñò. Ïóëüñ ______ çà õâ., (íå) ðèòì³÷íèé _____ Æèâ³ò: ì'ÿêèé __________________ áîë³ñíèé ___________________ Ïå÷³íêà ________________________ Êîñà _______________________ Çàïîðè ______________________________________________________ Íåðâîâî-ïñèõ³÷íèé ñòàòóñ ______________________________________________________________________________________________________ Äîäàòêîâ³ äàí³ __________________________________________________________________________________________________________________________________________________________________________________ ijàãíîç____________________________________________________________________________________________________________________________________
Ïðèçíà÷åííÿ |
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Ëèñò òèì÷àñîâî¿ íåïðàöåçäàòíîñò³ N ____ ç "__" ________ ïî "______________________" 200_ ð.
˳êàð __________________________ ϳäïèñ ______________ (Ï.².ï-Á)
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî àìáóëàòîðíî¿ êàðòè òà/àáî ³ñòî𳿠õâîðîáè îãëÿäó õâîðîãî íà öóêðîâèé ä³àáåò ë³êàðåì õ³ðóðãîì-ïîäîëîãîì
Äàòà ________________ Ñêàðãè ________________________________________________________________________________________________________________________ Àíàìíåç: ______________________________________________________________________________________________________________________ Îá'ºêòèâíî: _________________________________________________ øê³ðà í³ã _____________________________________________________________________________________________________________________ âîëîñÿíèé ïîêðèâ íà ãîì³ëêàõ òà ñòîïàõ ______________________ í³ãò³ ñòîï __________________________________________________ íàÿâí³ñòü ã³ïåðêåðàòîçó _______________________________________________________________________________________________________
Ïóëüñàö³ÿ |
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aa. dorsalis pedis |
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a. tibialis posterier |
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a. poplitea |
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a. femoralis |
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²íø³ çì³íè ______________________________________________________________________________________________________________________________________________________________________________________ ijàãíîç: ________________________________________________________________________________________________________________________________________________________________________________________ Ðåêîìåíäîâàíî: 1. Äîãëÿä çà íîãàìè _________________________________________ 2. Ïîäîêîðåêòîðè ____________________________________________ 3. ______________________________________________________________________________________________________________________________________________________________________________________________ Ïîâòîðíèé îãëÿä ÷/ç _________________________________________ ˳êàð __________________________ ϳäïèñ ______________ (Ï.².ï-Á)
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
ÂÊËÀÄÈØ
äî àìáóëàòîðíî¿ êàðòè òà/àáî ³ñòî𳿠õâîðîáè îãëÿäó õâîðîãî íà öóêðîâèé ä³àáåò ë³êàðåì íåâðîëîãîì
Äàòà __________________ Ñêàðãè: _______________________________________________________________________________________________ Àíàìíåç: ____________________________________________________ Îá'ºêòèâíî: ×óòëèâ³ñòü: òåìïåðàòóðíà - íîðìàëüíà (D, S)/çíèæåíà (D, S)/â³äñóòíÿ (D, S) áîëüîâà - íîðìàëüíà (D, S)/çíèæåíà(D, S)/â³äñóòíÿ (D, S)/ï³äâèùåíà (D, S)
òàêòèëüíà - íîðìàëüíà (D, S)/çíèæåíà (D, S)/â³äñóòíÿ (D, S)/
ï³äâèùåíà (D, S) â³áðàö³éíà - D = ___, S = ____. Ðåôëåêñè: êîë³ííèé íîðìàëüíèé (D, S)/çíèæåíèé (D, S)/ â³äñóòí³é (D, S), àõ³ëîâèé íîðìàëüíèé (D, S)/çíèæåíèé (D, S)/â³äñóòí³é (D, S). Ðåôëåêñè ñóõîæèëüí³ ç âåðõí³õ ê³íö³âîê ______________________ Áðþ÷í³ ðåôëåêñè: ____________________________________________ Ñ-ìè Âàññåðìàíà, Ëàññåãà ____________________________________ Ïàòîëîã³÷í³ ðåôëåêñè ________________________________________ Êîîðäèíàö³éí³ ïðîáè: N, â ïîç³ Ðîìáåðãà _________________ Ïàëüöå-íîñîâà ïðîáà _____________________________________ Ì'ÿçåâà ñèëà ____________________ òîíóñ _______________________________________________________________________________________ IJÀÃÍÎÇ: ________________________________________________________________________________________________________________________________________________________________________________________
Îáñòåæåííÿ: |
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˳êàð __________________________ ϳäïèñ ______________ (Ï.².ï-Á)
ÇÀÒÂÅÐÄÆÅÍÎ
Íàêàç ÌÎÇ Óêðà¿íè
01.10.2007 N 609
ÂÊËÀÄÈØ
äî àìáóëàòîðíî¿ êàðòè òà/àáî ³ñòî𳿠õâîðîáè îãëÿäó õâîðîãî íà öóêðîâèé ä³àáåò ë³êàðåì îôòàëüìîëîãîì
Äàòà _____________ Ñêàðãè: _______________________________________________________________________________________________________________________ Îá'ºêòèâíî: VOD = VOS = ̳êðîàíåâðèçìè ïîîäèíîê³/÷èñëåíí³ __________________________,íàáðÿê ñ³òê³âêè, êðîâîâèëèâè ðåòèíàëüí³/â ñêëîâèäíå ò³ëî/________, åêñóäàòèâí³ âîãíèùà: òâåðä³/ì'ÿê³, ïîîäèíîê³/÷èñëåíí³. Àðòå𳿠_____________________________________________________ àíîìà볿 âåíîçíèõ ñóäèí (âåðâè÷åïîä³áí³ñòü, çâèâèñò³ñòü,ïåòë³, ïîäâîºííÿ, çíà÷í³ êîëèâàííÿ êàë³áðó ñóäèí), ì³êðîñóäèíí³àíîìà볿: ³íòðàðåòèíàëüí³ _____________________________, ñêîòîìè, Íåîâàñêóëÿðèçàö³ÿ äèñêó çîðîâîãî íåðâó _____________________, Ô³áðîçíà òêàíèíà â ä³ëÿíö³ ïðåðåòèíàëüíèõ êðîâîâèëèâ³â, _______________________________________________________________________ ³äøàðóâàííÿ ñ³òê³âêè ______________________________________. Ðóáåîç ðàéäóæêè ______________. Âòîðèííà ãëàóêîìà ___________ ijàãíîç: ________________________________________________________________________________________________________________________________________________________________________________________
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˳êàð __________________________ ϳäïèñ ______________ (Ï.².ï-Á)