General approach to the examination of the patient
Last reviewed: 23.04.2024
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The situation is well known: the doctor can cure occasionally, relieve suffering more often and prolong life, but he must always console the patient, especially if the illness is incurable.
Understanding the nature of the pathological process (eg, infectious-inflammatory, autoimmune, tumor, etc.), the causes of the disease (if possible), the morphological changes in the organs, the degree of decrease in their function - all this is included in the concept of "disease recognition" and closely is associated with a carefully conducted examination of the patient.
Existing approaches to the examination of the patient have the goal to develop a skill for the doctor to a certain sequence and especially completeness in the study of patients. They are based on principles 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, it is common to examine the patient, which includes the definition of height, body weight, consciousness, facial expression, constitution, body temperature, the position of the patient; private - the study of individual systems and organs. The sequence involves examining the patient, beginning with the skin and mucous membranes, then subcutaneous fat, lymph nodes, musculoskeletal system (joints, bones, muscles), and only then study the system of respiration, circulation, digestion, hepatobiliary, urinary, endocrine, nervous, sense organs. In this case, each organ or system is studied in a certain sequence: for example, the lymph nodes are examined starting from the occipital, then the submandibular, cervical, supraclavicular, axillary, ulnar, and finally inguinal; a system of breathing - from the nasal passages, paranasal sinuses, larynx to the bronchi and lungs; the digestive system - from the oral cavity (including the tongue, teeth), tonsils to the esophagus, stomach, thin, thick, including the rectum.
When studying each system, the physician first uses simpler physical methods - interrogation, examination, then more complicated ones - palpation, percussion, listening (auscultation). Of course, the simplicity and complexity of research methods are very relative. However, remembering this list, the doctor will not forget, by examining breathing, ask, for example, nosebleeds, and when examining the digestive system, learn about the difficulties in swallowing or passing food through the esophagus (liquid and solid), etc.
The significance of these methods and the signs of disease that are detected with their help can be different. More often in patients with chronic diseases, it is possible to recognize the disease already when questioning and studying the extracts from previous case histories. However, it is often of decisive importance to get an examination of the patient with the help of physical, as well as laboratory and (or) instrumental methods used at the moment.
In the practical activity of a physician, the assumption of a specific clinical symptom, a syndrome or even a disease as a whole sometimes arises from the very beginning of the acquaintance with the patient in the study of the anamnesis from the moment of clarifying the complaints, and in some cases at the first glance at the patient: for example, with pulmonary edema or severe deformity of the spine as a result of an nkylosing spondylitis with a "petitioner" ( Bechterew's disease ) characteristic for such patients . But often, only with a special re-examination in connection with the emerging assumption of a disease, it is possible to detect certain symptoms and come close to a correct diagnosis. In this respect, the symptoms that become available for detection as they gradually increase only at a certain stage of the dynamic observation of the patient, for example, delayed jaundice (with acute hepatitis), an increase in the spleen and diastolic noise on the aorta (with infective endocarditis ) . It is clear that such a symptom as fingers in the form of tympanic sticks (Hippocrates fingers) can form when observing the patient for a long time, and at what stage the doctor will notice this symptom depends not so much on the physician's ability to visually assess the kind of fingers, how much on whether he is paying attention at all to the kind of fingers, ie, whether he is looking for this particular symptom.
As the outstanding therapeutist-cardiologist of modernity P. White wrote, "one can not be sure of the absence of symptoms and signs unless they are specifically identified and searched."
Objective research is modified in connection with the data obtained and the assumptions that have arisen. So, if a young person has persistent arterial hypertension, then it is necessary to measure blood pressure not only on both hands, but also on the legs (which usually can not be done at normal arterial pressure). If there is a hemoptysis and an infiltrate in the lung, an assumption arises about thromboembolism of pulmonary vessels, then it is necessary to measure the circumferences of both shins to exclude deep thrombophlebitis as a cause of thromboembolism.
Naturally, in order to conduct a rational diagnostic search, the physician must have a sufficiently extensive knowledge, obtained from literature and experience. Essentially, no matter what the symptom is, several possible assumptions about the cause and mechanism of its occurrence are possible. Systematic research of organs and systems, the receipt of new important facts (sometimes unexpectedly for the doctor) make it possible to concretise the diagnostic idea, but it is very important to keep objectivity, impartiality of judgments, readiness to perceive and evaluate new facts and symptoms in comparison with those already identified.
Additional methods of examining the patient
In the course of diagnosis, a patient is usually planned to be examined using laboratory and instrumental methods, taking into account the data of the previous survey, although it should not be used (especially in doubtful cases) to rely on the diagnoses established earlier.
At the same time, a respectful attitude towards the opinion of colleagues who supervised the patient in the past or who participates in his examination at the moment is an indispensable ethical rule. In all inconvenient or unclear cases, it should not be neglected to receive additional advice, advice, including in the form of a joint discussion at a consultation.
Currently, more and more often serious pathological changes are found in people who feel healthy or seek medical advice about other medical problems. This can be identified by using additional methods.
So, with a planned X-ray study, a peripheral infiltrate (tumor?) In the lung can be detected, in the laboratory study - proteinuria, microhematuria (latent glomerulonephritis?), In the general blood test - hyperleukocytosis with lymphocyticosis (lymphatic leukemia?). These changes can occur in people who consider themselves healthy, often in such cases, urgent treatment (including surgery) is required, which sometimes allows saving the life of the patient. Therefore, in a hospital or in clinical examination (that is, a preventive examination of a patient), in addition to the use of physical methods, a set of so-called routine, supplementary studies (general blood and urine tests, chest X-ray, electrocardiography ) is mandatory . Now this complex for certain categories of persons is supplemented by a number of other studies, including, for example, regular radiographic examination of the stomach or gastroscopy, etc., which is of particular importance for the early detection of certain diseases.
At additional inspection of the patient it is necessary to take into account the specificity, accuracy and informativeness of the methods used. There may be errors or objective difficulties in obtaining the material, for example sputum for bacteriological examination. Sometimes the significance of the data obtained can be refined only by observation (and long enough), including against the background of a trial treatment (diagnosis ex juvantibus).
Very rarely there are symptoms that are strictly pathognomonic for a particular disease. More specific for a specific pathology may be some combination of symptoms. So, long considered to be specific for mitral insufficiency, systolic murmur on the apex of the heart was possible with pure mitral stenosis, in which it was previously always regarded as a manifestation of concomitant valve failure.
Most often the doctor manages to identify almost all important manifestations of the disease, which allow you to approach the diagnosis, but sometimes you need the last sign ("stroke"), which gives the whole picture completeness, clarity. This may be a sign, such as sex or age, or the nationality of the patient. For example, periodic abdominal attacks accompanied by a fever in an Armenian or an Arab can confidently recognize the so-called periodic illness, or Mediterranean fever. In a young woman, the symptoms of pulmonary hypertension could only be explained after her report of long-term use of contraceptive drugs.
In some cases, the characteristic signs of the disease can be detected with the help of additional, including invasive, methods of investigation. The latter can be associated with some risk for the patient and therefore should be performed only with sufficient weight. This applies to angiography, liver biopsies, kidneys, myocardium, the information content of the morphological study of which has now become higher.
An analysis of the totality of all the data obtained makes it possible to formulate a diagnosis. This is primarily called the main nosological form of the disease, i.e. Pathology, which 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. Isolated in this nosological form are syndromes and complications. When there are medical complications, especially in the presence of so-called large syndromes ( ulcerative gastric bleeding, hypertension, etc.), they should be reflected in the diagnosis.
[Algortem and the rules of physical examination
The result of a multi-stage diagnostic search, and most importantly, attempts to understand the mechanisms of the appearance of the detected clinical signs and their relationship to the factors of the internal and surrounding diseased environment, to present the entire complex system of changes in response to the effect of these factors essentially corresponds to that concept of the disease that is given by leading clinicians. One of the most complete definitions of the disease belongs to EM Tareev: "Disease is the body's response to changed environmental conditions, the violation of specific forms of adaptability of the organism. It is the interaction of the environment and the organism with its changing reactivity and must always be taken into account in judging the cause, the origin of any disease. "
Students and novice doctors are recommended to consistently use the data of questioning, objective research, the results of additional research methods to justify the diagnosis. This sequence may be violated if, the data of the additional study are the most informative. It should be borne in mind the possibility of accidental combination of symptoms.
That is why it is necessary to conduct both a psychodynamic rationale and differential diagnosis, in each case it is necessary to cite facts, both confirming and contradicting the hypothesis, in the process of understanding clinical data to decide which symptoms are key and which are questionable.
The choice of key manifestations can be expressed in the graphic design of an anamnesis - a medical history. On the chart, you should present data that has already been understood by the doctor (and not only individual symptoms and syndromes) and which are essential for assessing the nature and course of the disease. At the same time, one should strive to reflect the dynamics of manifestations, that is, their evolution, including under the influence of treatment. It is also important to consider the time scale, keeping in mind the course of the disease not only by years, but if necessary, by months and even by days, taking into account the last hospitalization. The chart also shows the most important results of a single examination of the patient: for example, angiography, ultrasound, endoscopy, since the results are often of great importance for confirming the diagnosis. In essence, such an image of a clinical picture is somewhat analogous to a picture of a painter, in which there should be a theme, a plot, a basic idea and various artistic means, including various colors, their shades, combinations, etc.
When monitoring a patient, a diary is kept. It usually summarizes complaints and data from research of organs in the same sequence as in the medical history itself. First of all, the dynamics of complaints and changes in the organs should be reflected, using words such as "improved", "decreased", "amplified", "appeared", "disappeared," "grows", etc., expressions "previous state", "the same complaints", etc. In the diary, additions to the anamnesis, the doctor's impressions of the internal picture of the disease, the possible factors influencing the course of the disease and its changes, the tolerability of the treatment, the conclusion about the effectiveness and side effect of drugs.
Simultaneously with the diary it is desirable to maintain a temperature sheet. On it, in addition to the temperature curve, which usually fixes the morning and evening temperatures of the body, the frequency of the pulse is marked in red, if necessary, breathing, they write blood pressure, the daily diuresis in comparison with the amount of fluid taken during the day, the frequency of the stool, and the body weight. In addition, the most characteristic and dynamic symptoms of the disease and the main purposes are presented. It is important to show the effect of the main treatment on the manifestations of the disease.
As a result of the patient's stay in the hospital, a written epicrisis is written in which the diagnosis, brief history, examination and examination of the patient (mainly pathological manifestations or data important for differential diagnosis) should be presented, treatment, dynamics of the patient's condition, recommendations for therapeutic and prophylactic activities and work capacity. Particular importance is given to a brief explanation of the diagnosis and indications of the difficulties of diagnosis and the features of clinical observation.
"The diagnosis presented certain difficulties. The pain in the heart area was not quite typical for angina pectoris and was more like cardialgia. However, the presence of risk factors for atherosclerosis (arterial hypertension, hypercholesterolemia, smoking, overweight), a positive bicycle ergometric test, a good effect of nitrate treatment allow thinking about ischemic heart disease (CHD). There are no signs of circulatory insufficiency. The patient needs dynamic observation with ECG monitoring with repeated tests with physical exertion, as well as arterial pressure, lipid levels in the blood. It is recommended to have an outpatient long-term intake of antihypertensive agents prescribed in the hospital. The patient can work in his specialty as a designer. "