Primary diagnosis

In this chapter curator, according  to anamnesis, must group all found symptoms into syndromes and mark main syndrome. According to probable mechanisms of origin, give conclusion about probable nosologic diagnosis- create primary diagnosis.

Plan of examination.

(Mark all necessary examinations to prove  diagnosis)

Show data of laboratory and instrumental examinations patient  passed. You should remember, that there are obligatory examinations in  clinics: general blood analysis, general urine analysis, analysis of feces on gelmints presence, content of sugar in blood, x-ray  examination of chest organs, ECG, Wasserman’s reaction. Their examinations are done if they are necessary to prove clinic diagnosis.

Differential diagnosis.

According to clinic examination data you have to mark the main syndrome, explain its pathogenesis, determine list of diseases, that can have main syndrome mentioned above.

Than compare symptoms of every disease in list with symptoms of patient and choose the most suitable, true  signs - so find the disease. During thinking is necessary to use data of accessory methods of examinations to verify your conclusions.

So, by comparing and removing off the diseases with resembling to cured patient symptoms, we are able to determine true final diagnosis of disease (it is still nosologic diagnosis).

Clinical diagnosis.

In this chapter is necessary to verify the diagnosis of ill person (clinical diagnosis) by usage of clinic, laboratory and instrumental signs of disease (that were found in cured patient), by carried differential diagnosis. This (clinical) diagnosis should be made according to clinical diagnosis structure, that is mentioned below,  every its structural part mast be confirmed .

Structure of clinical diagnosis.

I.                           Main disease:

a)  name of disease;

b)  degree of severity or phase (if present in classification);

c)  stage of compensation;

d) clinical form of manifestation;

e)  clinical form of duration;

f)   functional diagnosis.

II. Complications of main disease.

III. Accompanying diseases.

Principles of treatment and prophylactic.

 In this chapter you should light main principles of  treatment of disease, according to last achievements of  science in this field, ways of prophylactics, than give a scheme of complex therapy, confirm every prescription. Write a prescription of each preparation. After that principles of prophylactics and scheme of prophylactic measures have to be mentioned. Then you have to give recommendations on ambulatory treatment.

Diary of disease

The main meaning of  diary-  registration of disease lasting is written according the scheme:

Date

Condition of the patient

Prescriptions in Latin transcription

(Signature)

At the beginning of diary’s marks patients feeling in concrete time and comparatively to previous days is written . Then  complains , that appeared, complains, that the patient had are described . Describe, how did the patient sleep ,had he defecation or not , how many times, peculiarities of feces ,quantity of urination , day and night amount of urine.Than data about the dynamics of objective   status of patient are given.  Frequency of pulse,   breathing and blood pressure to tell for all patients every day. If it is negative dynamic presenting, you should tell or explain the reasons of this fact.

If in that day fix some new drug or physiotherapeutic, procedures, you need detail substantiate the necessity of that.

In diary must be all examinations and consultations of the specialists.

In column prescription must be: regime, number of diet, all names of drugs (main at first, and than additional) it doses, time and methods of using.

If prescription during some days wasn’t change in column note: “Prescription the same”. During page changing all prescriptions must be copy.