Local Status

Describing affected areas or system with details :

1. Visual examination

2. Palpation

3. Percussion

4. Auscultation

5. Checking the functions ( passive and active)

7. Placing preliminary diagnose should be concluded based on the previously collected data. Students should copy and paste data collected from previous analysis

8. Results of clinical methods of investigation (if needed)

General blood analysis

Urinalysis

Also analysis of other vital tissues, vessels, organs and systems should also be done to give a wide angel of understanding of the patient’s condition. This test may include:

1. Faeces examination for microbes

2. X-ray

3. MRI

4. Endoscopy

5. Ultrasound

6. CT scan , to mention but a few

Assessment of results of laboratory and instrumental investigation, comparison with age standards. Conclusion, assessment of pathological deviation.

9. Brief diagnostic conclusion (clinical diagnosis)

according results of patient complains, anamnesis morbi, status praesens, results of para clinical investigation, to state the main pathological symptoms and syndromes.

The concluding may be done in such form: Taking into consideration (point complains, anamnesis, results of clinical and paraclinical investigation) it is possible to diagnose (point pathological syndromes and the disease). All possible differential diagnoses should be eliminated or proved.

10. Recommendations for management

Surgical operative treatment or/with therapeutic treatment.

Preoperative preparing if needed. Operation size type and volume. Recommendations in postoperative period.

Date: 2014-12-22; view: 1150