O’ZBEKISTON RESPUBLIKASI
SOG’LIQNI SAQLASH VAZIRLIGI
TOSHKENT PEDIATRIYA TIBBIYOT
INSTITUTI
KASALLIK TARIXI
Bajardi:_____________________________________________
Qabul qildi:_____________________________________________
Toshkent- 2024.
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I.
Pasportga oid ma’lumotlar:
1. Bemorning familiyasi, ismi, otasining ismi __________________________________________
2. Yoshi __________
3. Ma’lumoti _______________________________________________________________________
4. Ish joyi _________________________________________________________________________
5. Millati _________________________________________________________________________
6. Turar joyi _______________________________________________________________________
7. Bemorning yo'llanmadagi diagnozi ____________________________________________________
_____________________________________________________________________________________
8. Dastlabki diagnoz _________________________________________________________________
_____________________________________________________________________________________
9. Kelgan vaqti –
________20_____, ketgan vaqti – ________20_____
II.
Bemorning kasalxonaga tushgandagi shikoyatlari:
Asosiy shikoyatlar: ___________________________________________________________________
_____________________________________________________________________________________
Ikkinchi darajali shikoyatlar: _________________________________________________________
_____________________________________________________________________________________
III.
Anamnesis morbi:
_____________________________________________________________________________________
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IV.
Anamnesis vitae:
1. Go’daklik, bolalik va o’smirlik davri:________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Jinsiy va oilaviy xayoti:___________________________________________________________
_____________________________________________________________________________________
3. Turmush sharoiti:
Uy sharoiti: ___________________________________________________________________
__________________________________________________________________________________
Moddiy sharoiti: _______________________________________________________________
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Ovqatlanishi:____________________________________________________________________
________________________________________________________________________________
4. Mexnat faoliyati: _________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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5. Zararli odatlari: _________________________________________________________________
6. Bemorning boshidan kechirgan kasalliklari: __________________________________________
_____________________________________________________________________________________
Nasliy ma’lumotlar: ____________________________________________________________
__________________________________________________________________________________
7. Allergologik anamnez:______________________________________________________________
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8. Epidemiologik anamnez: _____________________________________________________________
_____________________________________________________________________________________
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V.
Status praesens:
 Bemorning umumiy axvoli __________________________________________________________
 Bemorning xushi va psixikasi _______________________________________________________
 Bemorning xolati _________________________________________________________________
 Bemorning yuz ifodasi _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 Bemorning gavda tuzilishi ____________________ bo’yi_____sm, og’irligi _____kg
 Bemorning konstitutsiyasi __________________________________________________________
 Bemorning tana xarorati ____________ C0.(kelgandagi), kuratsiya davomida ____________Co
 Bemorning
terisi
va
ko’rinadigan
shilliq
qavatlar______________________
Terida_______________________________teri
namligi_________________________________
Teri osti yog’ kletchatkasi ___________________________________________________________
shilliq kavatlar __________________________________________________________________
_____________________________________________________________________________________
 Bemorning tirnoq va sochlarining rangi, xolati _______________________________________
_____________________________________________________________________________________
 Bemorda oyoqlarida_________________________________________________________________
 Bemorning mushaklari______________________________________________________________
_____________________________________________________________________________________
 Bemorning suyak va bo’g’imlari _______________________________________________________
__________________________________________________________________________________
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 Bemorning limfa tugunlarining xolati ______________________________________________
_____________________________________________________________________________________
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VI.
Nafas olish sistemasi:
Bemorning shikoyatlari: __________________________________________________________
_____________________________________________________________________________________
Bemorning ko’krak qafasini ko’zdan kechirilganda: _____________________________________
_____________________________________________________________________________________
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Bemorning ko’krak qafasining palpatsiyasida:
 Og’rik sezuvchi nuqtalar_____________________________________________________________
 Ko’krak qafasining qarshiligi_______________________________________________________
 Ovoz dirillashi___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 Epigastral burchak _____ga teng.
Bemorning ko’krak qafasining perkussiyasi:
1. Taqqoslama perkussiya:_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Topografik perkussiya:
A) O’pkalarning yuqorigi chegaralari:






Oldindan chap o’pkaning cho’qqisi _________________________________________
Oldindan o’ng o’pkaning cho’qqisi _________________________________________
Orqadan chap o’pkaning cho’qqisi _________________________________________
Orqadan o’ng o’pkaning cho’qqisi __________________________________________
CHap o’pkaning Krening maydoni ________sm.
O’ng o’pkaning Krening maydoni ________sm.
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B) O’pkalarning pastki chegaralari:
Perkussiya o’rni
O’ng o’pka
CHap o’pka
Linea parasternalis
Linea mediaclavicularis
Linea axillaris anterior
Linea axillaris media
Linea axillaris posterior
Linea scapularis
Linea paravertebralis
V) O’pkalarning pastki chegaralarining xarakatchanligi jadvali:
O’ng o’pka
Topografik chiziklar
N/o
N/ch
Jami
CHap o’pka
N/o
N/ch
Jami
Linea clavicularis media
Linea axillaris media
Linea scapularis
Bemorning ko’krak kafasining auskultatsiyasida: _____________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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VII.
Yurak va qon tomirlar sistemasi:
Bemorning shikoyatlari:___________________________________________________________
Bemorning yurak soxasini ko’zdan kechirilganda: _______________________________________
_____________________________________________________________________________________
Bemorning yurak soxasining palpatsiyasida: __________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Bemorning yurak soxasining perkussiyasi:
1. Yurakning nisbiy bo’g’iqlik chegaralari:
 Yurakning o’ng nisbiy bo’g’iqlik chegarasi _____________________________________
_____________________________________________________________________________
 Yurakning chap nisbiy bo’g’iqlik chegarasi ______________________________________
_____________________________________________________________________________
 Yurakning yuqorigi nisbiy bo’g’iqlik chegarasi _________________________________
_____________________________________________________________________________
2. Yurakning ko’ndalang uzunligi _________sm atrofida.
3. Yurakning mutloq bo’g’iqlik chegaralari:
 Yurakning o’ng mutloq bo’g’iqlik chegarasi ______________________________________
 Yurakning chap mutloq bo’g’iqlik chegarasi ______________________________________
_____________________________________________________________________________
 Yurakning yuqorigi mutloq bo’g’iqlik chegarasi __________________________________
_____________________________________________________________________________
4. Yurakning qon tomirlar tutami kengligi ________________________________________
5. Yurakning qiyalik burchagi (taliyasi) ____________________________________________
Bemorning yuragini auskultatsiyasi:
 1-nuqta (Yurak cho’qqisida, bu yerda mitral klapan eshitiladi) ________________________
 2-nuqta (II-qovurg’alararo soxada tush suyagining o’ng chekkasida, bu yerda aortal klapan
eshitiladi) _________________________________________________________________
 3-nuqta (II-qovurg’alararo soxada to’sh suyagining chap chekkasida, bu yerda o’pka
arteriyasining klapani eshitiladi) _____________________________________________
 4-nuqta (xanjarsimon o’simtaning asosida, bu yerda uch tabakali klapan eshitiladi)
_____________________________________________________________________________
 5-nuqta (Botkin-Erba nuqtasi xam deyiladi; u to’sh suyagining chap qirrasiga III-IVqovurg’alarning birikishi soxasida) ____________________________________________
Bemorning pulsini tekshirish:

Puls tulishi va tarangligi ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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

Puls soni_______ta. CHSS __________________Kuratsiyada - Puls soni_______________ta.
CHSS________________________________________________________
Tomir devori ________________________________________________________________
Bemorning arterial qon bosimi:


O’ng qo’lda _________mm.sim.ust.
CHap qo’lda _________mm.sim.ust.
VIII. Ovqat xazm qilish organlarini tekshirish:
Bemorning shikoyatlari____________________________________________________________
Bemorning og’iz bo’shlig’ini ko’zdan kechirilganda: Til___________________________________
_____________________________________________Milklar________________________________
Lablar _____________________________________________________________________________
Yumshoq va qattiq tanglay, zev va xiqildoq__________________________________________
Mindalinlar ___________________________________________________________________
Bemorning qornini ko’zdan kechirilganda: ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Bemorning qornini paypaslab ko’rish:
1. Yuzaki palpatsiya: _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. Obrazsov-Strajesko bo’yicha chuqur sirpanuvchi metodik palpatsiya:
 Sigmasimon ichak paypaslanganda ___________________________________________
_____________________________________________________________________________
 Ko’richak paypaslanganda ___________________________________________________
_____________________________________________________________________________
 CHuvalchangsimon o’simta___________________________________________________
 Yonbosh ichakning oxirgi bo’limlarini paypaslanganda __________________________
_____________________________________________________________________________
_____________________________________________________________________________
 Ko’tariluvchi chambar ichak paypaslanganda ____________________________________
_____________________________________________________________________________
 Ko’ndalang chambar va tushuvchi ichaklar
__________________________________________________________________________
 Oshqozon paypaslanganda __________________________________________________
_____________________________________________________________________________
Bemorning qornini perkussiyasida: _________________________________________________
________________________________________________________________________________
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Bemorning qornini auskultatsiyasida:_______________________________________________
________________________________________________________________________________
Bemorning jigarini tekshirish:
1. Palpatsiyada: _________________________________________________________________
Kurlov bo’yicha jigar perkussiyasi
A) O’ng tomonda Linea medioclavicularis (birinchi va ikkinchi nuqtalar oralig’i) bo’yicha ____sm.
B) Linea sternalis (Linea mediana anterior) bo’yicha (uchinchi va to’rtinchi nuqtalar oralig’i)____sm.
V) CHap qovurg’a yoyi bo’yicha (3- va 5-nuqtalar oralig’i) _____sm.
IX. Siydik ajratish organlarini tekshirish:
Bemorning shikoyatlari:___________________________________________________________
Bemorning buyraklar soxalari ko’zdan kechirilganda:__________________________________
________________________________________________________________________________
________________________________________________________________________________
Palpatsiyada: ___________________________________________________________________
________________________________________________________________________________
Perkussiyada:____________________________________________________________________
Bemorning qovug’ini tekshirish: ____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
X. Ichki sekretsiya bezlari sistemasi:
Bemorning shikoyatlari:___________________________________________________________
Bemor ko’zdan kechirilganda: Yuzda, qo’l-oyoqlarda va badanda endokrin sistemasiga taluqli
o’zgarishlar: teri osti yog’ klechatkasi_____ sm. Bo’yi -______sm, tana massasi ______kg. Birlamchi
va ikkilamchi jinsiy belgilarning rivojlanishi
_____________________________________________________________________________________
_____________________________________________________________________________________
Qalqonsimon bez palpatsiyasi:_______________________________________________________
_____________________________________________________________________________________
XI. Asab-ruxiy sfera va sezgi organlari:
Bemorning shikoyatlari:___________________________________________________________
Bemor ko’zdan kechirilganda: _______________________________________________________
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XII. Dastlabki taxminiy diagnoz:
Bemorning shikoyatlari: ____________________________________________________________
_____________________________________________________________________________________
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Anamnesis morbid______________________________________________________________________
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Anamnesis vitae
_____________________________________________________________________________________
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Allergologik anamnez: __________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Dastlabki tashxis ________________________________________________________________
____________________________________________________________________________________
Asorati: _______________________________________________________________________
XIII. Tekshiruvlar rejasi:
Tekshiruvlar ro’yxati
1.
2.
3.
4.
5.
6.
7.
Umumiy qon analizi.
Umumiy siydik analizi.
Balg‘am taxlili.
Bioximik qon analizi: bilirubin, ALT, AST, um. oqsil, qand, kreatinin, mochevina.
Koagulogramma
EKG.
Ko‘krak qafasi rentgenografiyasi.
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XIV. Laboratoriya va instrumental tekshirish natijalari:
 Umumiy qon taxlili:
№
1
Ertirotsit
2
Gemoglobin
3
4
5
6
Rang ko‘rsatkich
Trombotsit
Leykotsit
Neytrofil
7
8
9
10
Eozinofil
Monotsit
Limfotsit
ECHT
Testlar
ayol
erkak
ayol
erkak
t/ya
s/ya
ayol
erkak
normada
3,8-4,5*1012/l
4,5-5,0*1012/l
120-140g/l
120-160g/l
0,9-1,0
180,0-320,0*109/l
4,0-9,0*109/l
1-6 %
47-72 %
0,5-5 %
3-11 %
19-37
2-15 mm/soat
1-10 mm/soat
tekshiruvda
davolash davomida
 Siydik analizi:
Testlar
Rangi
Sol.og‘irligi
normada
somon rangli
1018-1025
Reaksiya
kislotali
Tiniqligi
Oqsil
tiniq
aniqlanmaydi
Qand
O‘t pigmenti
aniqlanmaydi
aniqlanmaydi
Epitelial xujayralar
2-4 ko‘ruv maydonida
Eritrotsit
0-1 ko‘ruv maydonida
Leykotsit
1-3 ko‘ruv maydonida
tekshiruvda
davolash davomida
tekshiruvda
davolash davomida
 Balg’am taxlili:
Testlar
Mikdori ml
Rangi
Xidi
Xarakteri
Mikroskopiya:
Epiteliy
normada
-
10
-
Leykotsitlar
Eozinofil
 Qonning bioximik taxlili:
№
1
2
3
4
Testlar
Bilirubin:
umumiy
erkin
bog‘langan
Kreatinin:
umumiy
ayol
erkak
Mochevina
Oqsil fraksiyalari:
Umumiy oqsil
Albumin
Globulin:
α1-globulin
α2-globulin
β-globulin
γ-globulin
Glyukoza
ALT
AST
normada
tekshiruvda
davolash davomida
8,5-20,3 mkmol/l
1,7-16,5 mkmol/l
0-5,1 mkmol/l
50-115 mkmol/l
53-97 mkmol/l
62-115 mkmol/l
4,2-8,3 mmol/l
100 %
56-66,5 %
2,5-5,0 %
5,1-9,2 %
8,1-12,2 %
12,8-19,0 %
3,0-6,1 mmol/l
0,1-0,68 mmol/l
0,1-0,45 mmol/l
 Koagulogramma:
Ko‘rsatkich
Gematokrit soni
Trombotest
Plazmaning geparinga
tolerantligi
Fibrinogen
Trombin indeks
Etalon testi
normada
tekshiruvda
davolash davomida
49-58% erkaklarda
38-42% ayollarda
V st
37
300-400 mg/%
70-100 %
manfiy
 EKG:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Xulosa:______________________________________________________________________________
_____________________________________________________________________________________
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Ko‘krak qafasi rentgenografiyasi :
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Xulosa:__________________________________________________________________________
XV. Klinik diagnoz va uni asoslash.
Dastlabki taxminiy diagnoz va klinik-laborator va instrumental tekshiruv. Gemoglobin – ____g/l.,
Eritrotsitlar –_______12/l., Leykotsitlar –_______9/l.,
Eozinofillar –___%. Limfotsitlar –
____%.Monotsitlar – __%.Eritrotsitlarning cho’kish tezligi –____mm/soat. Rangli ko’rsatkich – ____;
Balg’am taxlili: _____________________________mikroskopiya: Epiteliy ____%, Leykotsitlar –
______%, Eozinofil –____% ; Glyukoza –_____mmol/l. Qon bioximiyasi: Umumiy oqsil –
____g/l.ALT – ____mmol/l, AST –____ mmol/l, Kreatinin – ____ mmol/l, Mochevina – ____mmol/l,
Bilirubin: - umumiy –______mkmol/l.
UZI: Xulosa:________________________________________________________________________
EKG: Xulosa: ______________________________________________________________________
Ko’krak qafasi rentgenografiyasi Xulosa: __________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
natijalariga asoslangan xolda quyidagi klinik diagnoz qo’yildi:
Klinik tashxis:
 Asosiy diagnoz – _______________________________________________________________
____________________________________________________________________________________
 Asorati -_______________________________________________________________________
 Yondosh diagnoz – _______________________________________________________________
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Differensial diagnostika:
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Davolash
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