VIII. THE PLAN OF INSPECTION

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The plan of inspection of the patient is developed, proceeding from the preliminary diagnosis, with the purpose of an establishment of the final clinical diagnosis and carrying out of the differential diagnosis. The list of necessary laboratory and tool researches, and also consultations of experts is underlined. The plan of inspection should be planned and written down in the case record in day of primary inspection of the patient.

IX. THE DATA OF LABORATORY, TOOL METHODS OF RESEARCH AND CONSULTATION OF EXPERTS

Results of all additional and obligatory laboratory and tool methods of research, and also the conclusion of experts - advisers are specified.

X. THE CLINICAL DIAGNOSIS AND HIS{ITS} SUBSTANTIATION

The clinical diagnosis should be put and written down in the case record within first three days of stay of the patient in a hospital, after reception of results of laboratory and tool methods of researches and the conclusions of experts - advisers.

The clinical diagnosis should be formulated according to the standard classifications and to include:

1) The developed{unwrapped} diagnosis of the basic disease, switching:

а) The name of disease,

б) Clinical, клинико-morphological or pathogenetic, his{its} form,

в) Character of current,

г) Stages, phases, degrees of activity of process,

д) Degrees (stage) of functional frustration or weights of disease;

2) The diagnosis of complications of the basic disease;

3) The developed{unwrapped} diagnosis of accompanying diseases.

Further the substantiation of the clinical diagnosis which is expedient for describing under the following provisional plan is resulted:

а) To result the reference to a substantiation of the preliminary diagnosis (see section VII), not repeating it{him} it is detailed,

б) To note results of laboratory and tool inspection, the conclusion of experts - advisers, and also to analyse dynamics{changes} of a clinical picture of disease during 1-3 days of supervision over the patient in a hospital. To specify, whether confirm these new data earlier exposed preliminary diagnosis,

в) To specify, what changes, additions and specifications have been brought in the diagnosis according to the new clinical, laboratory and tool data,

г) If there is a necessity, to refuse earlier exposed preliminary diagnosis, it is necessary to give reason for these changes carefully,

д) It is necessary to prove specifications, additions or the changes brought at statement of the clinical diagnosis of complications and accompanying diseases.

XI. THE DIFFERENTIAL DIAGNOSIS

Problem{Task} of the differential diagnosis is exception синдромосходных diseases. The differential diagnosis is carried out{spent} under the following provisional plan:

1) The brightest both characteristic pathological symptoms and the syndromes available at the given patient which really give the basis to assume other disease (or diseases) are allocated;

2) A number{line} of similar diseases at which similar pathological symptoms and syndromes are observed is listed{transferred};

3) Prove, that the supervised patient has other essential symptoms and syndromes, not characteristic for these similar diseases;

4) Prove, that the supervised patient does not have number{line} of essential symptoms and syndromes, characteristic for differentiated similar diseases;

5) On the basis of such comparison of the clinical picture available at the given patient, to clinical attributes of the specified similar diseases, conclude true character of disease and correctness of statement of the clinical diagnosis.

XII. ЭТИОЛОГИЯ AND ПАТОГЕНЕЗ '

In this section the reasons caused occurrence and development of the given basic disease and his{its} complications are described. Modern sights on этиологию the basic disease are shortly described.

Besides on the basis of the data of inspection of the patient are resulted concrete этиологические the factors resulted in development of illness at the given patient. First of all, it is necessary to establish, whether disease at the given patient independent (primary) or secondary - consequence{investigation} of other diseases is. In the first case whenever possible it is necessary to define{determine} concrete этиологический the factor (an infection, a trauma, an intoxication, etc.) on the basis клинико-анамнестических the data and results of special methods of research.

In the second case it is necessary to define{determine} precisely the basic disease and to establish pathogenetic communication{connection} between it{him} and discussed disease.

In all cases it is expedient to establish other possible{probable} provoking factors promoting occurrence or an aggravation of the given disease, including so-called risk factors.

At the description патогенеза the standard theories патогенеза the given disease and his{its} complications are resulted, and also the most probable pathogenetic mechanisms having a place at the supervised patient are described. In the same section it is desirable to give an explanation of mechanisms of all clinical symptoms and the syndromes revealed at the given patient.

XIII. THE PLAN OF TREATMENT AND HIS{ITS} SUBSTANTIATION

In this section the purposes, problems{tasks}, main principles both modern methods and means of treatment of the given disease and preventive maintenance of his{its} complications (a mode, a diet, medicamentous and physical means, sanatorium treatment) with the instruction{indication} of efficiency of this or that therapy are stated.

After that on the basis of representations about specific features of clinical current of disease, a morphological and functional condition of bodies, and also in view of the social and psychological status of the patient concrete, optimal medical and preventive actions at the given patient are developed.

- First of all, it is necessary to define{determine} the real purposes of treatment of the given patient: full recovery, liquidation or reduction of an aggravation of disease, his{its} complications, stay of progressing or recourse of illness, improvement of the forecast, work capacity.

Further it is necessary to define{determine} ways of achievement of objects in view, i.e. the basic directions of treatment. To them concern:

а) этиологическое the treatment providing elimination or correction of causal, provoking factors, risk factors, antimicrobic means and

т. д.,

б) The pathogenetic treatment which is having for an object influence on the basic mechanisms of illness at the given patient (an inflammation, an allergy, functional infringements, deficiency of the certain factors, an intoxication, etc.),

в) The symptomatic treatment used at an inefficiency or impossibility first two.

In relation to each direction it is necessary to define{determine} and prove a choice of concrete medical actions (a mode, a diet, medicines, physiotherapy, ЛФК, physical and operative methods, sanatorium treatment) to specify a doze, ways and frequency of introduction in view of available indications and contra-indications concerning the given patient.

It is recommended to use only really necessary means, to avoid polypharmacy, to take into account interaction of medicines, to aspire to an individualization of treatment.

All medicamentous means are given in рецептурной прописи.

XIV. THE DIARY

The diary reflects results of daily survey of the patient with the attending physician. The special attention addresses on dynamics{changes} of all displays of illness, and also efficiency of treatment and attributes of possible{probable} undesirable (collateral) action of medicines.

In the beginning in a diary the estimation of a condition of the patient is given, complaints for the expired day, including quantity{amount} and character of episodes of illness (attacks of pains, an asthma, faults in work of heart are described, etc.), dream, appetite, a chair, мочеиспускание is estimated. Then cited the brief objective data on bodies under condition of their change in dynamics{changes}. The data of measurements (number of intimate reductions, pulse, number of respiratory movements, the HELL, диурез) are born{taken out} in a temperature sheet (a sheet of the basic parameters of a condition of the patient), and various medical purposes{assignments} - in a sheet of purposes{assignments}.

In a diary it is necessary to reflect medical interpretation of new clinical symptoms and results of additional methods of research, and also change in tactics of treatment.

Each 10 days of stay of the patient in a hospital, and also in case of sharp change in a condition of the patient or at revealing the new diagnostic attributes essentially changing representations of the doctor about the clinical diagnosis, it is made out этапный эпикриз. In it{him} the brief conclusion of the doctor about the clinical diagnosis concerning which the patient is in a hospital, about features of current of disease and presence of complications is resulted. The list of the medical means used at the given stage of treatment of the patient is resulted also. Dynamics{changes} of the basic attributes of disease, including dynamics{changes} of results of laboratory and tool research of the patient with the instruction{indication} conducting{leading} laboratory, электрокардиографических, the radiological and other parameters revealed at the patient for past period is especially in detail described. All by-effects of therapy used at the given stage having a place are described. On this basis it is judged adequacy of the appointed therapy and its{her} efficiency. The plan of the further treatment and inspection of the patient is proved.

In case of deterioration of a condition of the patient reasons of the doctor about the possible{probable} reasons of such deterioration (infringement of a diet, a mode, progressing of the basic disease, an inefficiency or inadequacy of the appointed therapy, etc.) are resulted. At not clear diagnosis, it is especial at occurrence of new symptoms of illness, it is necessary to plan the plan of the further inspection of the patient, and also the plan of the further treatment.

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