General approach to the examination of the patient

The situation is well known: a doctor can rarely cure, more often alleviate suffering and prolong life, but must always comfort the patient, especially if the disease is incurable.

Understanding the nature of the pathological process (for example, infectious-inflammatory, autoimmune, tumor, etc.), the cause of the disease (if possible), morphological changes in organs, the degree of decline in their function - all this is included in the concept of "disease recognition" and is closely related to a thorough examination of the patient.

The existing approaches to examining a patient are aimed at developing in the doctor the skill of a certain sequence and especially completeness in studying patients. They are based on the principles of from the general to the particular, from the more superficial to the deeper, from the simpler to the more complex.

General examination of the patient

So, the general examination of the patient is, which includes determining the height, body weight, consciousness, facial expression, constitution, body temperature, position of the patient; the specific one is the examination of individual systems and organs. The sequence provides for the examination of the patient, starting with the skin and mucous membranes, then the subcutaneous fat, lymph nodes, musculoskeletal system (joints, bones, muscles), and only then the respiratory, circulatory, digestive, hepatobiliary, urinary, endocrine, nervous systems, and sensory organs are examined. In this case, each organ or system is studied in a certain sequence: for example, the lymph nodes are examined starting with the occipital, then the submandibular, cervical, supraclavicular, axillary, elbow and, finally, inguinal; the respiratory system - from the nasal passages, paranasal sinuses, larynx to the bronchi and lungs; digestive system - from the oral cavity (including the tongue, teeth), tonsils to the esophagus, stomach, small intestine, large intestine, including the rectum.

When studying each system, the doctor first uses simpler physical methods - questioning, examination, then more complex ones - palpation, percussion, auscultation. Of course, the simplicity and complexity of research methods are very relative. However, keeping this list in mind, the doctor will not forget, when examining breathing, to ask, for example, about nosebleeds, and when examining the digestive system, to find out about difficulties in swallowing or the passage of food through the esophagus (liquid and solid), etc.

The significance of these methods and the signs of the disease revealed with their help may vary. Most often, in patients suffering from chronic diseases, it is possible to recognize the disease already during questioning and studying extracts from previous medical histories. However, often the examination of the patient with the help of physical, as well as laboratory and (or) instrumental methods used at the moment may acquire decisive significance.

In the practical activity of a doctor, an assumption about a specific clinical symptom, syndrome or even a disease in general sometimes arises already at the very beginning of acquaintance with a patient when studying the anamnesis from the moment of clarification of complaints, and in some cases at the first glance at the patient: for example, in case of pulmonary edema or severe deformation of the spine as a result of ankylosing spondylitis with the "petitioner" pose characteristic of such patients ( Bechterew's disease ). But often only during a special repeated examination in connection with the assumption that arose about a disease is it possible to detect certain symptoms and come significantly closer to the correct diagnosis. In this regard, symptoms that become available for detection as they gradually increase only at a certain stage of dynamic observation of the patient are of particular importance, for example, delayed onset of jaundice (in acute hepatitis), enlargement of the spleen and diastolic murmur on the aorta (in infective endocarditis ). It is clear that a symptom such as clubbed fingers (Hippocratic fingers) can develop when observing a patient over a long period of time, and the stage at which the doctor notices this sign depends not so much on the doctor's ability to visually assess the appearance of the fingers, but on whether he pays attention to the appearance of the fingers at all, i.e. whether he is looking for this specific symptom.

As the outstanding contemporary cardiologist P. White wrote, “one cannot be sure of the absence of symptoms and signs unless they are specifically identified and looked for.”

The objective examination is modified in connection with the data obtained and the assumptions that arise. Thus, if persistent arterial hypertension is detected in a young person, it is necessary to measure the arterial pressure not only on both arms, but also on the legs (which is usually not necessary with normal arterial pressure). If, in the presence of hemoptysis and infiltrate in the lung, there is an assumption of pulmonary embolism, then it is necessary to measure the circumference of both shins to exclude deep thrombophlebitis as a cause of thromboembolism.

Naturally, to conduct a rational diagnostic search, the doctor must have sufficiently extensive knowledge obtained from literature and experience. In essence, no matter what symptom is being discussed, several assumptions are possible about the cause and mechanism of its occurrence. Systematic examination of organs and systems, obtaining new important facts (sometimes unexpectedly for the doctor) allow us to concretize the diagnostic idea, but at the same time it is very important to constantly maintain objectivity, impartiality of judgments, readiness to perceive and evaluate new facts and symptoms in comparison with those already identified.

Additional methods of patient examination

During the diagnostic process, the patient's examination is usually purposefully planned using laboratory and instrumental methods, taking into account the data from the previously conducted examination, although one should not (especially in questionable cases) rely too much on previously established diagnoses.

At the same time, respect for the opinion of colleagues who supervised the patient in the past or are currently participating in his examination is an essential ethical rule. In all difficult or unclear cases, one should not neglect the opportunity to receive additional consultation, advice, including in the form of a joint discussion at a council.

Nowadays, serious pathological changes are increasingly being detected in people who feel healthy or who seek medical attention for other medical problems. This can be detected using additional methods.

Thus, during a routine X-ray examination a peripheral infiltrate (tumor?) in the lung may be detected, during a laboratory study - proteinuria, microhematuria (latent glomerulonephritis?), in a general blood test - hyperleukocytosis with lymphocytosis (lymphatic leukemia?). These changes may occur in people who consider themselves healthy, often in such cases emergency treatment is required (including surgery), which sometimes allows saving the patient's life. Therefore, in a hospital or during a medical examination (i.e., a preventive examination of the patient), in addition to using physical methods, a set of so-called routine, additional studies (general blood and urine tests, chest X-ray, electrocardiography ) is necessarily used. Now this set for certain categories of people is supplemented by a number of other studies, including, for example, regular X-ray examination of the stomach or gastroscopy, etc., which is of particular importance for the early detection of certain diseases.

During additional examination of the patient, it is necessary to take into account the specificity, accuracy and informativeness of the methods used. Errors or objective difficulties in obtaining material, such as sputum for bacteriological examination, are possible. Sometimes the significance of the data obtained can only be clarified during observation (and a fairly long one), including against the background of trial treatment (diagnosis ex juvantibus).

Symptoms that are strictly pathognomonic for a particular disease are very rare. Some combinations of symptoms may be more specific for a particular pathology. Thus, systolic murmur at the apex of the heart, long considered specific for mitral insufficiency, turned out to be possible also with pure mitral stenosis, in which it was previously always regarded as a manifestation of concomitant valve insufficiency.

Most often, the doctor manages to identify almost all the important manifestations of the disease, which allow one to approach the diagnosis, but sometimes the last sign ("stroke") is needed, which gives the whole picture completeness and clarity. This can be a sign such as the patient's gender or age, or nationality. For example, periodic abdominal attacks accompanied by fever in an Armenian or an Arab allow one to confidently recognize the so-called periodic disease, or Mediterranean fever. In a young woman, the symptoms of pulmonary hypertension could be explained only after she reported taking contraceptives for a long time.

In some cases, characteristic signs of the disease can be identified using additional, including invasive, research methods. The latter may be associated with some risk for the patient and therefore should be performed only with sufficiently compelling indications. This applies to angiography, liver biopsy, kidney biopsy, myocardium, the information content of the morphological study of which has now become higher.

An analysis of all the data obtained allows formulating a diagnosis. In this case, the main nosological form of the disease is named first, i.e. the pathology that has a characteristic clinical picture and morphological changes associated with certain etiological factors. Since most diseases occur with exacerbations and remissions, the corresponding phase of the disease is indicated. A functional diagnosis is formulated. Syndromes and complications included in this nosological form are identified. If drug complications occur, especially in the presence of so-called major syndromes ( ulcerative gastric bleeding, hypertension, etc.), they should be reflected in the diagnosis.

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Algorithm and rules of physical examination

The result of a multi-stage diagnostic search, and most importantly, an attempt to understand the mechanisms of occurrence of the detected clinical signs and their connection with the factors of the internal and surrounding environment of the patient, to present the entire complex system of changes in response to the action of these factors essentially corresponds to the idea of the disease given by leading clinicians. One of the most complete definitions of the disease belongs to E. M. Tareev: "Disease is the reaction of the organism to changed environmental conditions, a violation of specific forms of adaptability of the organism. It is the interaction of the environment and the organism with its changing reactivity that should always be taken into account when judging the cause, origin of any disease."

Students and novice doctors are recommended to consistently use data from questioning, objective research, and results of additional research methods to substantiate a diagnosis. This sequence may be violated if the data from additional research are the most informative. It is necessary to keep in mind the possibility of a random combination of symptoms.

That is why it is necessary to carry out both a syndromic justification and differential diagnostics; in each case, facts should be provided that both confirm and contradict the hypothesis that has arisen; in the process of understanding the clinical data, it is necessary to decide which symptoms are key and which are questionable.

The choice of key manifestations can be expressed in the graphic design of the anamnesis - the medical history. The graph should present data that has already been understood by the doctor (and not just individual symptoms and syndromes) and that are essential for assessing the nature and course of the disease. In this case, one should strive to reflect the dynamics of manifestations, i.e. their evolution, including under the influence of treatment. It is also important to take into account the time scale, meaning the course of the disease not only by years, but if necessary, by months and even days, taking into account the last hospitalization. The graph also shows the most important results of a single examination of the patient: for example, data from angiography, ultrasound, endoscopy, since their results are most often of great importance for confirming the diagnosis. In essence, such a depiction of the clinical picture is to some extent similar to a painter's painting, which must have a theme, plot, main idea and use various artistic means, including various colors, their shades, combinations, etc.

When observing a patient, a diary is kept. It usually briefly lists complaints and organ examination data in the same sequence as in the medical history itself. It is necessary to reflect, first of all, the dynamics of complaints and changes in organs, using such words as “improved”, “decreased”, “increased”, “appeared”, “disappeared”, “increased”, etc., if possible avoiding the expressions “previous condition”, “same complaints”, etc. The diary may include additions to the anamnesis, the doctor’s impressions of the internal picture of the disease, probable factors influencing the course of the disease and its changes, tolerance of treatment, a conclusion on the effectiveness and side effects of drugs.

Along with the diary, it is advisable to keep a temperature sheet. In addition to the temperature curve, which usually records the morning and evening body temperature, the pulse rate is marked in red, and if necessary, the respiration rate, blood pressure, the amount of daily diuresis compared to the amount of liquid taken per day, the frequency of stool, and body weight are written down. In addition, the most characteristic and dynamic symptoms of the disease and the main prescriptions are listed. It is important to show the effect of the main treatment on the manifestations of the disease.

Following the patient's stay in the hospital, a discharge summary is written, which should present the diagnosis, brief data on the anamnesis, examination and examination of the patient (mainly pathological manifestations or data important for differential diagnosis), treatment, dynamics of the patient's condition, recommendations for treatment and preventive measures and work capacity. Particular importance is given to a brief justification of the diagnosis and indications of the difficulties of diagnosis and the peculiarities of clinical observation.

"The diagnosis presented certain difficulties. The pain in the heart area was not quite typical for angina and was more like cardialgia. However, the presence of risk factors for atherosclerosis (arterial hypertension, hypercholesterolemia, smoking, overweight), a positive bicycle ergometric test, and a good effect of nitrate treatment suggest ischemic heart disease (IHD). There are no signs of circulatory failure. The patient requires dynamic observation with ECG monitoring with repeated tests with physical activity, as well as arterial pressure, and blood lipid levels. Long-term outpatient use of antihypertensive drugs prescribed in the hospital is recommended. The patient can work in his specialty as a designer."

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