Formulating suggested (primary) diagnosis.

Using obtained data of the subjective and objective examinations highlight the symptoms and signs of the main syndromes that patient has. Analyzing syndromes form the primary diagnosis and make up plan of the laboratory and instrumental investigations that may confirm your diagnosis.

Plan of the mandatory laboratory and instrumental examination

1. Blood investigations (Full blood test)

2. Blood glucose and other biochemical tests

3. Coagulation tests

4. Urinalyses.

5. Glucose in daily urine.

6. Feces investigation

7. ECG

8. X-ray examination.

Using lists of special investigations for different diseases showed below chose the most appropriate for confirming your diagnosis.

Laboratory and instrumental investigations for confirming respiratory diseases:

1. C-peactive protein and immunologic tests

2. Bacteriologic blood investigations

3. Sputum examination: general, cultural, cytological.

4. Pulse oximetry or arterial blood gas measurement.

5. Peak expiratory flow

6. Spirometry or lung function test

7. Fibreoptic bronchoscopy with bronchoalveolar lavage and biopsy.

8. Examination of the pleural fluid

9. Computer tomography

10. Pulmonary angiography

Laboratory and instrumental investigations for confirming cardiovascular diseases:

1. Exercise ECG testing

2. Ambulatory ECG and blood pressure monitoring (Holter)

3. Echocardiography

4. Coronary angiography and ventriculography.

5. Cardiac X-ray examination.

6. Blood tests of cholesterol and lipids

7. C-peactive protein

8. Creatine phosphokinase-MB, myoglobin, LDH, AST.

9. Cardiac troponin.

Laboratory and instrumental investigations for confirming gastrointestinal diseases:

1. Fibrogastroscopy with biopsy

2. Contrasting X-ray examination of the esophagus, stomach and duodenum.

3. pH-metry

4. H.pylori revealing tests

5. Study of the gastric secretion

6. 6-staging chromatic duodenal intubation

7. Ultrasound examination of the abdominal cavity

8. Contrasting cholecystography

9. Biochemical liver function tests

10. Virology tests for hepatitis

11. Doppler flow studies of the portal vein

12. Liver biopsy

13. Colonoscopy with biopsy

14. Rectoromanoscopy

15. Irrigoscopy

16. Coprologic tests

17. Stool microscopy, culture and sensitivity

PRESENTATION OF RESULTS OF THE LABORATORY AND INSTRUMENTAL EXAMINATIONS

All available results of the laboratory and instrumental investigations should be written. Highlight results that confirm primary diagnosis.

FOUND AND FORM CLINICAL DIAGNOSIS ACCORDING TO CLASSIFICATION.

Using obtained data of the subjective and objective examinations, confirming results of the instrumental and laboratory investigations prove the clinic diagnosis.

Add patient’s temperature chart.

EXAMPLE OF THE CASE HISTORY REPORT.

Passport part

Patient’s name: Ivanov Petr Sergeevich

Patient’s age: 45 years

Patient’s address: Vinnytsia, Pyrogova str. 129

Patient’s work: private entrepreneur

Date of admission: 25MAR2009

Main complaints

The patient complains of a moderate chest pain in the right side without irradiation. It has stabbing character, increases due to cough and deep breathing. His chest pain diminished if the patient lies on the right side.

Patient fills a breathlessness, difficult inhalation and exhalation which increase due to physical exertion. Patient does not have an asthma attack.

He has a permanent cough with purulent sputum without smell. Amount of sputum is near 60 ml per day. It expectorates easy. Patient has not had rusty, bloody, foamy sputum. He could not say which posture is the best for discharge of sputum.

Patient’s voice is not change. He does not have a sore throat, cold in the head. He breathes through the nose.

Patient has light headache, malaise, fever with body temperature 38,0-38,8 °C during a day, and chill.