The Medical prognosis
The

Medical prognosis

The medical prognosis is an anticipation of the probable development and outcome of the disease, based on knowledge of the regularities of pathological processes and the course of the disease.

Forms of prognosis: 1) whether the disease of life of the patient is not threatened (prognosis quoad vitam); 2) whether the patient will fully recover (prognosis quoad sanationem); 3) how long he will live (prognosis quoad longitudinem vitae); 4) how the disease will progress (prognosis quoad decursum morbi). Estimation of the general condition from the point of view of the forecast is expressed usually by such formulations: prognosis bona (good), dubia (doubtful), mala (bad), pessima (very bad).

Statistics allow to some extent justify the expected outcome, as well as the frequency and nature of complications (for example, small intestine perforation in typhoid fever , etc.).

The average duration of the disease is significant for the prognosis: the longer the acute disease, the more unfavorable the prognosis becomes.

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The prognosis of the disease depends first of all on the correctness of the diagnosis (see), correct evaluation of the patient's age characteristics, its exchange (exhaustion, obesity), emotional mood (calm, irritable, prone to anger), the nature of work activity, concomitant diseases, bad habits and and so forth.

The prognosis of a chronic disease causes more difficulties than an acute one. Some diseases, incurable at the modern level of medical science, inevitably lead to death within a few months or years, for example leukemia. Other diseases with timely diagnosis can be curable, for example, cancer in the initial stages of surgery or radiotherapy.

For chronic diseases, less severe and completely curable ( syphilis , tuberculosis , etc.), the prognosis may depend on the timing of the initiation of treatment, for example, complex therapy for pulmonary tuberculosis.

The possibility of compensation for damage or defect is often significant for forecasting.

Forecast and patient . Usually the patient is primarily interested in the prognosis, not the diagnosis of the disease. He also asks about the diagnosis from the point of view of the prognosis. A paramedic should always be prepared to answer. With patients suffering from malignant neoplasms, the conversation should be conducted more carefully and carefully, in order to avoid accidental awareness of the patient about the severity of the prognosis. If patients with operable malignant tumors persist in refusing the recommended operation, then in these cases the prognosis reported to the patient should only indicate that delay in the operation may threaten the transition, for example, of the alleged gastric ulcer into cancer.

Do not determine the exact timing and chances of recovery. The prognostic evaluation is usually expressed in a conditional mood ("if there are no complications" or "the situation is serious, but the recovery should come").

It is generally accepted to draw the attention of the patient to favorable symptoms of recovery and to divert attention from severe manifestations of the disease. In case of a serious condition of the patient, an unfavorable prognosis should be reported to the patient's relatives. The methods of medical foresight changed with the development of medicine.

At the dawn of medical science, the only forecasting method was empirical. The current forecast is based on a large number of actual data obtained as a result of monitoring the patient, researching the functional state of organs and systems, and treating the patient. Anamnestic data, development of the disease are also taken into account. Prognostics as a scientific discipline, studying methods, methods of medical foresight, is constantly being improved.

Prognosis (Greek prognosis - prediction, prognosis) is a medical prediction of the origin, development and outcome of the disease, based on knowledge of the patterns of pathological processes and the course of diseases; the forecast is also defined as the diagnosis of the future.

The general questions of the forecast represent the most necessary, but also the most difficult area of ​​clinical medicine. The value of the prognosis in the clinic is determined by the main goals of practical medicine - prevention of diseases and treatment of patients. In this respect, the doctor's work is analogous to the task of the scientist: to investigate laws in order to provide for phenomena, and to provide phenomena in order to master them. Knowledge of the etiology of diseases, harmful factors of work and life, worsening the state of health, makes it possible to foresee the conditions under which an individual or collective may fall ill. This precaution is based on measures to prevent public and private life. Extensive preventive measures against epidemic diseases are based on timely recognition of diseases and foreseeing the possibility of their occurrence, as well as knowledge of the ways of spreading a contagious disease. For example, the detection of the case of diphtheria or typhus causes a series of extensive sanitary and preventive measures, the prediction of a seasonal outbreak of flu makes it necessary to vaccinate against it at certain times. With the possibility of exacerbation or return of the disease, preventive treatment is carried out, for example, to prevent recurrence of rheumatism, peptic ulcer exacerbation, etc. The planning of the health authorities is based on the prognosis of the frequency of individual forms of diseases and the general morbidity of the population.

Forms of the forecast . The first and most important question that interests the doctor and the patient is not a fatal illness, whether the prognosis quoad vitam will remain alive, then the prognosis quoad sanationem will fully recover, how long he will live (prognosis quoad longitudinem vitae), how will to develop the disease in the first time and in the future (prognosis quoad decursum morbi). It is also important to know what effect the treatment will have, how dangerous the surgical intervention is, whether the health defects will remain after the disease, whether the patient is able to work, what his residual capacity is, and what form of work is harmless to him. Estimation of the general condition from the point of view of the forecast is usually expressed by such formulations: prognosis bona, dubia, mala, pessima. It is impossible to list all questions about the nature of the course of the disease and about the future of the patient that arise in medical practice. Each advice and action of a physician is preceded by a prediction or an assumption about the results of his activities.

The

Prognosis of the disease . In modern medicine the prognosis depends first of all on the exact diagnosis of the disease. The prognosis of the danger of the disease can be based on statistics, that is, the quantitative regularity in a mass study of cases of disease (frequency of complete recovery, residual events, mortality rate). Statistics can to some extent justify the expectation of a particular outcome, but it serves only as one of the guidelines for constructing an individual prognosis, that is, predicting the course of the disease of a particular patient. Equally important are statistical data on the frequency and nature of complications in a particular disease, for example, small intestine perforation in typhoid fever, gastrointestinal bleeding with cirrhosis of the liver, and so on.

The age of the patient determines the whole nature of the disease; at a young age, the prognosis is generally better; youth is the patient's best friend. However, in infants and especially in newborns, the prognosis should be placed with great caution. The constitution, hereditary characteristics and exogenous conditions (borne diseases, living conditions) influence the course of diseases, as well as the general state of the organism before the disease.

The severe prognostic significance of individual symptoms established long ago, such as the cooling of the extremities after surgery or infectious diseases or the pericardial friction noise with uremia, etc., is in most cases justified, but at the present time they are not considered as simple empirical signs, but as a manifestation of the degree or quality underlying their pathological process.

The prognosis is practically healthy . Life expectancy of a practically healthy person, if we exclude accidents, for example, a car accident, depends on the characteristics of the human body and the numerous environmental conditions. The definition (approximate) of the life expectancy of a healthy person is a task that always faces life insurance organizations.

These organizations, with the help of a number of indicators and the statistical processing of mass surveys, can give average life expectancy forecasts for people of different ages; these statistical patterns are justified on a mass scale.

The elucidation of the life expectancy of parents is sometimes essential for forecasting; as they say, "a wise choice of ancestors" often determines a long life. Directly to the question of heredity (see) adjoins the definition of the constitution (see) and its significance for the life of this person.

The role of labor in the preservation of health is revealed, for example, in some cases, lowering the nervous and somatic tone, resistance to a number of diseases in older people who have retired. It is well known that the conditions of everyday life (housing, food, etc.) and habits that do not meet hygiene standards predispose to the development of various diseases; excessive food, smoking, alcohol consumption should be considered as real diseases, and not just bad habits, often leading to serious consequences in the near or distant future.

The overall prognosis is closely related to the success of the treatment; the percentage of deaths from most diseases is decreasing every year as a result of new discoveries of scientific medicine and improvement of healthcare organization. It is necessary to note the importance of determining the stage of the disease, the regularity of its course, since each period of the disease conceals its dangers; deviations in the regularity of the flow cause anxiety. The value of the average duration of the disease is significant for the prognosis: the longer an acute disease lasts, the more gloomy the prognosis becomes. The reaction of the body to the etiologic factor may be so excessive that it leads to a lethal outcome.

The prognosis of a chronic disease causes more difficulties than an acute one. Some diseases, incurable at the modern level of medical science, inevitably lead to death within a few months or years, for example leukemia. Other diseases are, in principle, curable, as, for example, cancer in the initial stages with timely surgery or radiotherapy. In such cases, the prognosis is not unconditionally hopeless and is based on determining the possibility of cure. The state of vital organs and the degree of exhaustion allow us to assess in part the severity of the condition of the patients.

The third group consists of chronic diseases, less malignant and completely curable, such as tuberculosis, syphilis, with greater or lesser defects due to a transferred illness or applied treatment (for example, pulmonectomy, limb amputation). The duration and outcome of diseases of this group and, consequently, the predictions largely depend on the results of treatment.

The possibility of compensation for damage or defect is often significant for forecasting. In solving this problem, in particular, the time factor or the rate of damage progression must be taken into account.

Adaptability of the organism to changing environmental conditions is the basis for the prediction for chronic diseases. As you know, adaptability - the main quality of all living things - is far from the same for different people. To predict the course of the disease and the patient's ability to work, his temperament and characterological features are also essential.

Forecast and patient . Usually the patient is primarily interested in the prognosis, not the diagnosis of the disease (the patient lives mostly future); he also asks about the diagnosis from the point of view of the prognosis: whether it is a severe, curable disease. The doctor must immediately answer the patient's questions about the future, so he must always be prepared to answer. The relationship between the doctor and the patient is entirely subordinated to the purposes of medicine (prevention and treatment of diseases, alleviation of the patient's suffering), so the communication of the patient to the prognosis should not contradict the medical tasks. Fatal prognosis is always excluded from the conversation with the patient, as well as with others, if there is a possibility of transferring the latter to the patient. Exception is made with patients with operable malignant tumors, stubbornly refusing the recommended operation. But in these cases, the prognosis reported to the patient should contain an indication only that delay in the operation may threaten the transition of the disease (for example, the allegedly existing stomach ulcer) to cancer. The same caution may be required in the case of a truly precancerous disease, to which the patient treats lightly. The doctor should be careful not to randomly inform the patient about the severity of the prognosis (careless word, gesture, etc.). The doctor must communicate the prognosis with the help of the patient's understandable terms, without going into details. An uncertain prognosis, like the absence of a diagnosis, can only increase the patient's concerns and doubts, but the words "never" or "always" should not be used, and precise terms or chances for recovery should be determined. The prognostic evaluation is usually expressed in a conditional mood, for example, the prospects are quite favorable, if there are no complications, or the situation is serious, but recovery should occur if therapeutic appointments are performed, etc. In some cases, patients are afraid to find out the true state of the matter, for fear that the doctor will deprive them of the hope, confirming the incurable nature of suffering; in other cases, really severe, neither the patient nor the doctor is talking about the prognosis; It is not uncommon for patients, even sick doctors, to deceive themselves with the hope of recovery, despite the apparent severity of the disease, for example, cancer. This peculiar protective reaction of the psyche, a protective illusion, should be supported if it does not cause the patient to categorically refuse vital surgical measures, for example, amputation of the limb of IX, etc.

It is generally accepted to draw the attention of the patient to favorable symptoms, or signs, of recovery and to distract attention from severe manifestations of the disease. The doctor is forced to hide from the patient a difficult prediction, but a true assessment of the condition should be reported to one of the members of the family, if there is a certainty that this will remain a mystery, and also write it down in the medical history. A good prognosis is useful both for the patient's well-being and for the success of the treatment; if the prognosis calms and gives cheerfulness to the patient, then "the prediction coincides with the treatment" (GA Zakharin).

Methods of medical foresight changed with the development of medicine. At the dawn of medical science, the only forecasting method was empirical, which is of some importance at the present time.

A sharp deviation of individual body functions from the norm indicates a threatening situation, but does not allow to reliably determine the outcome of the disease, since changes in functions are not only from damage, but often represent the body's response to this damage (often a useful reaction), for example severe vomiting or diarrhea with some poisoning, etc., followed by recovery. The second method of the empirical prediction method is based on the assumption of recurrence of painful phenomena, if symptoms are found that usually precede nm, ie, foresight relies on signs of the disease. Such prognostic signs were of great value in the time of Hippocrates, but they do not have that binding or necessary force that appears only in the cause-effect relationship. Consequently, the evidence of such characteristics is relative. The third way of determining the forecast is based on the summation of a large number of single phenomena (that is, statistical regularities), but for the prediction of individual cases it has only a roughly approximate value. Statistical regularities in themselves do not yet reveal causal relationships, but can only contribute to their detection. The statistics for the prognosis of diseases are important only for a certain time, since with the success of treatment, the mortality from any disease can be several times reduced. One of the most important reasons for determining the prognosis is medical experience. Prognostic judgments usually rely on analogies, on memories of the flow and outcome of similar cases. Valuable for gaining experience in anticipating the course of the disease is the observation of the patient from the beginning to the end of the disease. Along with medical experience, scientific data on the features of the course and outcome of a disease that are important for predicting what can or should happen to a patient in the future is of paramount importance. Scientific research contains not only descriptions of the possible course of the disease depending on its form and stage, the constitution of the patient, etc., but also illuminates the causes of a particular course, the mechanisms of damage to the body, the nature of the healing processes and their signs. Knowledge of the etiological factors, the pathogenesis of the disease and the currently observed consequences of pathological processes in this patient make it possible to make the forecast more reliable and convincing. The disease occurs due to damage to the body (in whole or part of it) and the body's reaction to damage; An example is an inflammatory response due to a microbe or injury. In the simplest case, for a single-step action of the cause, for example, a burn, a chain biological reaction develops at the site of injury (inflammation, reparative processes) and the general reaction of the organism (temperature increase, change in blood composition, etc.) that occur for a certain time, t ie, self-development of the pathological process occurs, and local and general changes can be used to judge the severity of the protective reaction, the possibility of recovery, and the timing of the outcome of the disease. The prognosis of the course of a specific disease depends on the accuracy and completeness of the diagnosis, taking into account local changes and the general condition.

Thus, to determine the prognosis, more facts of the patient's condition are involved than for the diagnosis, and the results of the treatment are added. The process of reasoning is more complicated than when the present state of the organism is ascertained.

The logical basis of the forecast differs significantly from the diagnostic cognition. To recognize the present condition of the patient, the doctor examines it, looks for and fixes the manifestations (symptoms) of the disease and on the basis of their combination, the sequence of occurrence and other characteristics, comes to the conclusion about the nature of the pathological process (ie, from the phenomenon passes to the essence) and then refines the etiology and the conditions under which the disease occurred. Based on the present condition and history, the physician can restore the picture of the preceding development of the disease, that is, the past.

When forecasting the problem of reasoning lies in the fact that from the presence of the cause or conditions and the state of a particular patient, to deduce the consequences, which corresponds to the deductive method of inference. In view of the complexity of life processes, it is rarely possible to take into account all trends or patterns, and foresight should be based on the main of them.

It is known that any pathological process can not but change, that it always causes the opposite process and is combined with it, and thus, as a result of combining both processes, the disease passes to the next stage of its development or to a qualitatively new stage; the final is recovery or death. The reaction of an organism to damage is not one-stage, but represents a process that takes place in time and passes through certain phases, which can be considered as a self-development of the pathological process and on the basis of its basis for prediction. In fact, the situation is more complicated, because the doctor intervenes in the natural course of the illness; therefore, when determining the prognosis, treatment should be taken into account.

On the basis of factual data, by synthesizing them, that is, establishing the interconnection of all phenomena, an idea is created of the dynamics and direction of the development of the disease of the organism as a whole, and not merely the addition of attributes (Lao Tzu also said that the sum of the parts is not a whole) . Therefore, before the answer is formulated, it is necessary to discuss options for the future course of the disease, weigh all the pros and cons of one option or another, and determine the degree of probability of each. This part of the medical conclusions is the subject of differential prognostics, which has not yet been developed; it can be constructed according to the type of differential diagnosis. Prognostics as a scientific discipline, studying methods, methods of medical foresight, is still very imperfect, although it was initiated by Hippocrates. An important indicator of the most complete understanding and explanation of the patient's condition, other than the diagnosis (see), is the correct prognosis.