Assessment of the abdomen examination

During examination of the abdomen the pathological changes have not been revealed.
FORMULATING SUGGESTED (PRIMARY) DIAGNOSIS.

The patient’s symptoms: a moderate stabbing, chest pain in the right side without irradiation that increases due to cough and deep breathing, mixed dyspnea which increase due to physical exertion, a permanent cough with purulent sputum without smell; the moderate severe general condition, pale cyanotic wet and hot skin, flash on the right cheek, lagging right part of the chest from the left one, tachypnea (36 per min), participating accessory muscles (neck, back and nose muscles) in breathing by visual inspection, amplifying vocal fremitus over the right lung, painful point along the right axillary line from 4^th till 7^th intercostals spaces, the positive Potenzher’s sign of the right side by palpation; dull sound over the right lung, upward shift of the right lower border of the lung, limiting excursion of the right lungs edge by percussion; the pathological bronchial breathing is heard over the right lung by auscultation allow suggesting the syndrome of the consolidation of the lung tissue.

The patient’s symptoms: mixed dyspnea which increase due to physical exertion, the moderate severe general condition, pale cyanotic skin, tachypnea (36 per min), participating accessory muscles (neck, back and nose muscles) in breathing by visual inspection, tachycardia by examination of the cardiovascular system allow suggesting the syndrome of the severe respiratory failure.

The patient symptoms: light headache, malaise, fever with body temperature 38,0-38,8 °C during a day, and chill which developed during a couple of days; the moderate severe general condition, body temperature 38,2°C pale cyanotic wet and hot skin by visual inspection are the symptoms and signs of the acute inflammation. Taking into account the three described syndromes the community-acquired pneumonia of the lower lobe of the right lung may be diagnosed.

PLAN OF THE MANDATORY LABORATORY AND INSTRUMENTAL EXAMINATION

1. Blood investigations (Full blood test)

2. Blood glucose

3. Biochemical tests (C-peactive protein and immunologic tests, ALT,AST, total billirubin, urea, creatinine)

4. Coagulation tests

5. Urinalyses.

6. Glucose in daily urine.

7. Feces investigation

8. ECG

9. X-ray examination.

10. Bacteriologic blood investigations

11. Sputum examination: general, cultural, cytological.

12. Pulse oximetry or arterial blood gas measurement

13. Spirometry or lung function test

Дата добавления: 2015-11-14