The diagnosis is a brief conclusion about the nature of the disease and the condition of the patient.
Diagnosis is a section of medical science that studies methods of examining a patient to recognize a disease; consists of three sections: medical diagnostic techniques that study methods of patient research; semiotics (see) and methods of diagnosis, studying the features of thinking for correct recognition of the disease.
General plan of diagnostic study. After acquaintance with the patient's complaints and anamnesis, the patient's condition is studied by the main methods of clinical investigation (see below). Explore the morphological and functional state of various organs, paying special attention to the individual characteristics of the patient (physique, higher nervous activity , general reactivity , etc.).The
Further, based on the detected symptoms and the expected diagnosis, the doctor prescribes more detailed additional studies (laboratory, radiological, etc.) to clarify the cause of the disease, the place and nature of the lesion. Even in those cases when the diagnosis of the underlying disease is established already at the first glance (for example, thyrotoxic goiter , some forms of congenital heart disease), the methodical study of the patient is necessary for understanding the state of the organism as a whole and choosing the right treatment. The investigation should result in a diagnosis. The choice of therapeutic measures usually follows from the diagnosis. The diagnosis given to the patient may change in the course of the development of the disease (its progression, complications, improvement, etc.).
The diagnostic conclusion, covering the whole time of observation and treatment, is presented in the form of an epicrisis (see History of the disease ).
Clinical diagnostic methods of research are divided into basic and additional. Basic - questioning, examination, feeling, tapping, listening, measuring (see Auscultation, Patient Examination, Palpation , Percussion ) - must be applied by the doctor in every patient.
Additional methods (laboratory, instrumental, etc.) are often performed by a non-attending physician, but by other specialists. They are no less important for diagnosis than the basic methods.
Methods of diagnostic research . Necessary conditions for the success of the diagnosis: 1) the doctor (or paramedic) must master the technique of clinical research;
2) clearly know the symptoms (see);
3) be able to compare the relevant indicators of the norm and pathology (for example, heart sounds in a patient and in a healthy one). Further, the doctor (or paramedic) must first think about the most common diseases, take into account the presence of an epidemic (eg, influenza, etc.), the nature of the terrain, the time of the year, and the age of the patient. Observation should be accurate, complete and planned. Very important is the rule of double or triple ensuring the accuracy of determining the observed symptoms: each symptom, sign or measurement is checked repeatedly, using different methods. Only the coincidence of the results ensures the reliability of the symptom, and its concretization provides benign material for diagnosis.
There are several periods of diagnostic research: 1) the study of the life of the patient (see Anamnesis); 2) the study of each patient of all organs and systems in a certain order; 3) a detailed study of the bodies from which violations were detected; 4) study of the individual reactions of the patient accompanying the disease; 5) the study of the history of the disease in its connection with the life of the patient, i.e., the establishment of a socio-biological diagnosis of the patient.
In severe diseases (for example, shock, " acute abdomen ", etc.) and limited possibilities, the rule is to study primarily vital organs in order to determine the degree of threat to life. Then the recognition stops on a preliminary diagnosis and the doctor (or the paramedic performing it) immediately goes to therapeutic actions if there is urgent evidence.
Organization of diagnostic studies. The doctor (or the paramedic performing his functions), fully responsible for the diagnosis, must personally interview and examine the patient and arrange for additional clinical studies. In addition, often consultations are conducted by physicians of various specialties, and sometimes the solution of complex diagnostic issues is brought to the consultation (see).
At registration of the diagnosis it is required: 1) allocation of the basic disease; it is necessary to specify the nosological unit, the degree of compensation or the stage of the disease, the nature of the pathological process and its course, the nature and extent of functional disorders, the pathogenesis and etiology of the disease; 2) complications; 3) concomitant diseases. The diagnosis is repeated in the epicrisis, indicating the course of the disease, the treatment and its results applied, prescriptions for the future.
Preliminary diagnosis is made in those cases, if the reliability of the main pathological process is still questionable for the doctor (often due to lack of data). Especially important is the early diagnosis, allowing timely treatment (for example, cancer, tuberculosis, etc.). One of the ways to solve the problem of an early diagnosis is a dispensary examination of practically healthy people.