yids nbn Phy luc 1 MAU GIAY KHAM SUC KHOE DUNG CHO NGUOI TU DU 18 TUOLTRO (Kem theo Thing ne sé 14.2013 TT-BYT ngay 06 thing 5 nam 2013 cua Bo tring Bo ¥ té) SG Y TE DONG NAL col + BENH VIEN DA KHOA DONG NAI Si /Syaiai K-BVDN GIAY KHAM SUC KHOE Ho va tén (chit in hoa) pBlEN PM. DAM. DIEU... igi : Nam Nir a Tudi iho CMND hoe Hé chi .cap ngay wtb ltohlbo8 L¥do kham stte khée : TIEN SU BENH CUA DOI TUQNG icra stic KHOE 1. Tién sw gia dinh: Cé ai trong gia dinh dng (ba) mac mot tréng cae bénh: truyén nhiém, tim mach, dai thao dong, lao, hen phé quan, ung thu, déng kinh, roi loan tam than, bénh kha a)Khéng 7]; b) Co L]: N ~ 48 nahi ghi cu thé t8n én... 2. Tién siz ban than: Ong (ba) di/dang mac bénh, tinh trang bénh nao sau dy khong: Bénh truyén nhiém, b . dai thao duong, lao, hen phé quan, ung thu, dng kinh, r6i loan tam than, y Khong (J: b) C Néu dé nghi ghi cy thé tén bénh: wo 3. Cau hoi khac (néu 6) a) Ong (ba) c6 dang didu tri bénh gi khéng? Néu cd, xin hay list ké cae thude dang ding va li¢u lugng: b) Tién str thai san (D6i voi phy nit): Toi xin cam doan nhimg- digu _bida.te.. ngdiy 04. thangod..namoditl Khai trén day hoan to’n ding voi sy Nguoi d8 nghj kham sire khoe that theo sy hiéu biet cuia t6i. VKy Vil ghl #0 ho, ten) AL Bary Thy by VosI. KHAM THE LUC Chidu cao! ABU. em; Can nang: M2.-kas Chisé BME: 8 Aly Mach: .... Roo... dan/phit; Huyét ap... do. /. 62... mmHg Phan loai thé lye!“ Db. Brin he Si Se I. KHAM LAM SANG Ho tén, chit ky Noi dung khim ren cnn ctia Bac sy 1. NOi khoa a) Tuan hoan: Phan loai ..... b) H6 hap: ........ Phan loai .. ¢) Tiéu hoa: Phan loai d) Than-Tiét nigu: Phan loai .. d) Co-xuong-khép: Phan loai e) Than kinh: Phan loai 3. San phu khoa : Phan loai ... 4. Mat: = Két qua kham thi lye: Khéng kinh: Mat phai: di AO, Mat trai: Co kinh: ped Mat phai: 4c./.0(02... Mat trdi:.. “dO ed Ts = Cée bérh vé mat (néu 06): .MACET.)..lae...thie. = Phan logiNoi dung kham Ho tén, chir ky cia Bae sy 5. Tai-Mai-Hong - Ket qua khdm thinh lye: Tai trai: Noi thuron; oj tham:..... Tai phai: Noi thuon; - Cac bénh - Phan loai: fai mai hong (neu ¢6) +... s 6, Rang-Ham-Mat <ét qua khm: + Ham trén + Ham dudi: - Cée bénh vé Ring-Ham-Mat (néu co) - Phan logi: 7. Da liéu: . Phan loai: HO m; Noi tham: eu. m | eae Hing a “pao Il. KHAM CAN LAM SANG NOi dung kham Ho tén, chit ky ciia Bac sf 1. Xét nghigm mau: b) Sinh héa mau: Duong mau: = Creatinin 2.022. hong? - ASAT (GOT): G93... ALAT (GPT) : Bet. c) Khac (néu 6) : 2. Xét ngl nurse tieue a) Duong ¢ «dan. MD. b) Prétéin : c) Khe (néu 66) + eee wfflessT. . Hg tén, chi ky Noi dung kham ein Bie sf 3. Chan doan hinh anh: ... si BS He THM G0 ‘TIMPHOL BINH THUONG. LOATH KHOE. IV. KET LUAN 1. Phin loai stre khoe : 2. Cae bénh, tat (néu c6) LUAN a déng diiu) |G PHONG KHTH Egg“ CKIT Neuyén Trong Chav