6. Local Status

Describing affected areas or system in details:

• Visual examination

• Palpation

• Percussion

• Auscultation

• Checking the passive and active functions

7. Preliminary diagnosis

Should be concluded based on the previously collected data. May include several concurrent diagnoses, which should be proved or excluded with additional diagnostic methods (instrumental, laboratory, etc.)

8. Additional diagnostic methods

Blood group and Rhesus-factor

General blood analysis

Date	RBC, х1012/L	Hb, g/L	WBC, х109/L	Eos, %	Juvenile n, %	Stab n, %	Segm n, %	Limph, %	Mono, %	ESR, mm/h

Urinalysis

Date

amount, ml

color

pH

Specific gravity

Protein, g/L

CARB

RBC

WBC

Slime

Epithelial cells

Microbes

Salts

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. Bacteriologic tests

2. X-ray

3. MRI

4. Endoscopy

5. Ultrasound

6. CT scan

7. Biopsy

Etc.

Assessment of results of laboratory and instrumental investigation, comparison with age standards.

Conclusion, assessment of pathological deviation after every test.

9. 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.

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