Landmark hali tarihi: wani misali da rubuce-rubuce

A Rasha, manufar "harka tarihi" sun san matsayin farko a matsayin 18th karni. Tarihi (. Daga cikin Greek shari'a, yanke shawara) - likita ra'ayi: a kan haƙuri ta kiwon lafiya, bayyanar cututtuka da cutar, ta haddasawa, ganewar asali, na farko magani da kuma ta da sakamakon. Case tarihi ne m daftarin aiki kasuwanci likita daftarin aiki game da shi, kuma za a tattauna a wannan labarin, wanda za a yi la'akari da iri, yanayi, Shirin zanen da template.

iri epicrisis

Ra'ayi a kan sakamakon magani ne a lokacin da haƙuri ya gano da kuma aka dakatar gida dolechivatsya wannan yanayin tarihin da aka kira - fitarwa. A shi ya sa shawarwari domin kara management na haƙuri. A gwaji kan gawar marasa lafiya sun mutu epicrisis, cikinsa da dalilin mutuwar kafa. A wani lokaci a lokacin da rashin lafiya, yawanci sau daya a kowace 10-14 kwanaki ne wani ƙarin hali tarihi, wanda aka mai suna - landmark hali tarihi.

A tarihin da cutar ne da za'ayi a kowace rana. A rana ta uku da cuta ko idan haƙuri shi ne a asibiti na fiye da kwanaki goma ko bukatar canja wurin zuwa wani likita, cike da alamar yanayin tarihi, abin da ya bayyana yanayin da haƙuri, da manufar bincike likita matakan. A bayanin su iya bambanta dangane da abin da bi-up da aka cika, a kan haƙuri ta tsananin rashin lafiya, shigar ko ba jinya.

yanayi

• Idan ganewar asali ne ba, a epicrisis tattauna da presumptive ganewar asali, bincike matakai don tabbatarwa.
• Idan ganewar asali An riga an shigar, shi ya bayyana mataki na cuta, ta hangen nesa. Bayyana gunaguni na haƙuri, dakin gwaje-gwaje da kuma instrumental bincike.
• Daga baya-mataki epicrisis bayyana tasiri na magani, da kashi na asali kwayoyi, canje-canje a far. M m dabara na haƙuri magani.
• A tsanani hanya da cutar, wannan daftarin aiki da aka yi sau da yawa idan ya cancanta.

babban

A gaskiya ma, cikin hali tarihi ya takaita da mataki na cuta, kuma ya nuna kara mataki. Case tarihi - shi ne ikon raba bayanai game da wani haƙuri tsakanin likita cibiyoyin. Musamman tsananin bi canja wurin bayanai daga marasa lafiya da suke sun gano tarin fuka, da ciwon daji, shafi tunanin mutum da rashin lafiya, jima'i cututtuka, cardio-jijiyoyin bugun gini cututtuka.

misali

Ga yadda za a kammala landmark hali tarihi - wani misali da rubuce-rubuce.

20.03.11. K.D.A. haƙuri, 6 years old, da wurin zama kamu da cirrhosis na hanta. Aka aika zuwa gastroenterological sashen na CSTO Moscow, inda cutar da aka ba a tabbatar, da canji na portal jijiya, splenomegaly da aka samu. Ya aka canjawa wuri zuwa ga Ma'aikatar Aikin Gona №2 CSTO domin kara jarrabawa da kuma magani. Ya shigar da shi cikin 05.03.11. A jihar matsakaici mai tsanani. Active hanta ne ba palpable, saifa 6 cm. An. fitsari al'ada, en. Jini - HB - 112 Lake. - 3.4, er. - 4.2, MP. - 70, da dabara a kullum. B \ x Blood - duk Manuniya ne na al'ada. UZGD: hanta ba tare da gagarumin tsarin canje-canje, ganuwar da portal tasa m 108h60 mm, yaduwa na connective nama, pancreas: 16h15h18 mm, da baƙin ciki ne kara girman, 124h46 mm. The canji na portal jannayẽnsa. EGD: a cikin c \ kuma n 3 \ 3 4 esophageal jijiyoyinmu m: 3,3,5,6 mm cyanotic, siga, da mahara nodes, tare da miƙa mulki ga wani sa na ciki. Kammalawa: EW 4 digiri. Gastro. CT angiography: m mesenteric Vienna 8 mm, fadada intrahepatic bile ducts 5 da 10 mm. A ganewar asali da aka tabbatar.

16.03.11g. Operation "Revision bar reshe na portal jijiya da aka yi. Formation splenitis-koda anastomosis gefe-da-gefe. Ligation na hagu gonadal jannayensa. " N / a lokacin da aka wuya da dama mai gefe lobar ciwon huhu. Gudanar da antibacterial, jiko far. N / o iko (3rd p / dare): An. Fitsari - al'ada jini: HB - 118 Lake. - 7.6, er. - 4.4, MP. - 160, da dabara ne OK. D \ x jini: gina jiki - 62 g / l (al'ada 60) 35 albumin (kudi na 35 g / l), bilirubin 18.9 (na kullum 14 micromole / lita), Alt - 63 (kudi na har zuwa 45 iu / l), da sauran Manuniya ne na al'ada.

Yana shirya 9-10 kwanaki bayan tiyata don cire seams, sa EGD. Lokacin da kyau kuzarin kawo cikas ga shirya sallama.

Epicrisis (misali sama) haƙuri da dispensary

A wani misali na aiwatar epicrisis haƙuri kwance a wani asibiti. Amma har yanzu akwai wata alama hali tarihi na haƙuri dispensary. Wannan harka tarihin ake bukata zuwa waƙa da tasiri na prophylactic likita jarrabawa. Clinical jarrabawa da ake bukata don inganta kiwon lafiya na yawan jama'ar, don bunkasa ta yadda ya dace. Clinical jarrabawa ya zama kamar lafiya persons: mata masu ciki, yara, dalibai, da ma'aikata da kamfanoni tare da m yanayin aiki, mutane a kusa lamba tare da yawan (masana'antun sarrafa kayayyakin abinci da ma'aikata, ma'aikatan kiwon lafiya, da dai sauransu), kazalika da wahala daga wani rashin lafiya.

matakai na asibiti jarrabawa

• Clinical jarrabawa hada 3, saukarwa.
• Shin wajibi na yau da kullum dubawa a Enterprises ko dispensary Nazarin (yara, dalibai) domin tantance jihar kiwon lafiya, wajen gano a farkon yiwu wani pathological tafiyar matakai.
• Kullum dauke da fitar kula da mutane, dauka a kan asusun da dispensary. A tsawon lokaci da kallo dogara a kan yanayin da cutar da kuma jeri daga wata daya zuwa karshen rayuwa na haƙuri.
• Analysis na dispensary. A karshen kowace shekara, da halartar likita cika da alama yanayin tarihi na haƙuri a cikin dispensary. Ya wallafa a biyu kofe: daya a cikin ambulatory haƙuri ta ginshiƙi, da sauran - a kan wani musamman tsari, wanda aka bai wa statistics ofishin ga Karkasa aiki na likitanci jarrabawa data, wanda assesses ingancinta.

template

Wannan abin da ya kamata ya zama alama hali tarihi: samfuri cewa dole ne su kasance ba da irin wannan abubuwa kamar:

• Sunan karshe, sunan farko, ranar haihuwa, da yadda da yawa cikakken shekaru, wurin zama.
• Unwrapped wani m ganewar asali.
• haƙuri gunaguni.
• Tarihi da cutar.
• A farko yanayin haƙuri.
• Laboratory da sauran gwaje-gwaje.
• Tare da shawara da kwararru.
• Abin da magani aka za'ayi. Ko cutar rigakafin da aka gudanar. Idan da za'ayi wani aiki, shi ya bayyana cikin shakka daga cikin aiki fiye da anesthetized, cikin shakka daga cikin cutar. Yadda yana da jihar na kiwon lafiya na haƙuri, rage ko kara yawan exacerbations kamar yadda canza yawan kwanaki daga tawaya.
• Hakkin da ake yi (kyautata, tabarbarewar, babu canji).

Epicrisis ba ga shiga shugaban polyclinic sashen.

ƙarshe

All yara bukatar da za a yi nazari da wani likita a kowace shekara, kuma a shekara 1, 3, 6, 7, 10, 14, 15, 16 da kuma 17 years old kwashe Kara zurfi dispensary. A 18 landmark hali tarihi da aka sanya a cikin fassarar da mutumin wanda ya girma a yara kananan dakunan shan magani a manya.

Saboda haka, alama hali tarihi da aka harhada domin kowane mutum, faro haihuwarsa, kuma shi ne mai dauri daftarin aiki na wani mutum, a magani, shi ne daidaita zuwa fasfo. A cewar shi, karatu tarihi da cutar, tare da abin da mãsu haƙuri kuma ya nẽmi taimakon likita.

Yana da daraja yana cewa al'amarin tarihi ne da ake kira "katin" na mutane, shi ne tare da wannan sunan duk fuskanta.