Methods of examination of the patient

With the development of new, primarily instrumental methods, one could expect a decrease in the importance of the principles of a classical examination of the patient, which necessarily includes the use of physical methods of research, and interrogation, but even today the classical examination of the patient is the basis for the diagnosis.

And although more and more often, especially for beginner doctors, there is a desire to quickly master a narrow specialty (for example, electrocardiography, echocardiography), which is certainly much easier than mastering the whole range of methods of clinical examination of a patient, nevertheless one should warn the future doctor against neglecting traditional methods . Only a broad and profound medical education with a good knowledge of the clinical picture of the main patterns of development of internal diseases can be the foundation upon which this or that narrow specialist is then formed.

The examination of the patient, and therefore the diagnostic process, begins with the first meeting of the doctor with the patient, when the doctor enters the ward where the patient is, or the patient enters the doctor's office. The moment of the first meeting gives the big and important information: the doctor sees and hears the patient, studies his complaints, he can immediately note jaundice, cyanosis, swelling, assess the degree of his activity, the compulsion of the posture, asymmetry of the face, indistinctness or other features of speech, which immediately directs the examination in a specific channel. Some of the manifestations of the disease (symptoms) can be immediately reported by the patient, but many of them the doctor discovers during the examination with the help of physical or laboratory-instrumental tests, and as the individual signs are revealed, the doctor repeatedly applies to the questioning and research of a particular organ or system. Accuracy or slovenliness in clothes, anxiety in behavior give additional ideas about the personality of the patient and often about its change under the influence of the disease. The facial expression reflects unpleasant or painful sensations (pain, anxiety), an indifferent person corresponds to a deep depression or a coma. It is very important to note at once, because, no matter how bright the clinical picture of the disease, its symptoms should not lose the patient as a whole. A discerning doctor always considers a variety of manifestations of the disease as signs relating to the pathology of that particular patient at a given time of the illness. The words of the great Russian pathologist IV Davydovsky became an aphorism: "On a hospital bed there is not an abstract illness, but a concrete patient, that is, there is always some individual refraction of the disease." Paraphrasing, we can say that the picture (canvas) of the disease is outlined by the disease itself, its etiology, the patterns of development (pathogenesis), but the patient with his individual somatic and psychic features creates the image of the disease entirely in this figure.

"Be very careful with a particular patient, rather than with specific features of the disease," W. Osler wrote. And again from EM Tareev: "Diagnosis should be the basis for the treatment and prevention of an individual patient." That is why it is a mistake to study the symptoms of diseases only according to the textbook, as students are often inclined to do. "Look, and then reason, compare, draw conclusions. But first, look. " These words of W. Osler are surprisingly in tune with what the outstanding domestic clinicians M. Ya. Mudrov, GA Zakharin, S. P. Botkin said.

When examining a patient, it is important to create and throughout the entire stay for him maximum comfort: avoid unnecessary and prolonged exposure and unnatural position of his body, uncomfortable posture and the associated haste, and therefore lack of completeness of the survey. The doctor should also avoid uncomfortable self-pose: it is always advisable to sit down at the level of the bed or a patient's couch and make sure that the conditions for conversation and examination of the patient are as favorable as possible.

Thus, the success of the diagnostic process depends on how fully the physician can identify the signs of the disease (or diseases) and understand why exactly these signs are present in a particular patient. It would be a mistake to believe that the diagnostic concept can be compiled only on the basis of what was read in the textbook and monograph, manual or heard at a lecture, the diagnostic concept is ultimately formed at the patient's bedside. "If the doctor does not have deep humanity and analytical thinking, he should work with apparatuses, and not with people" (EM Tareyev).

Discussing the problems of examining a patient, one can not fail to touch upon some of his ethical aspects, immediately stressing the great importance of everything that the doctor is doing towards the patient. The study of each patient is, of course, a clinical study, and the doctor and the patient participate equally in it. At all stages of this work there are laws that are very close to the laws of the present, genuine art, because the subject of research in both cases is a person.

Already in the process of studying anamnesis and physical examination, ethical problems manifest themselves very definitely. Of course, the hopeless situation, in which the patient often puts his illness, causes the patient to agree in many respects with the actions of the doctor and even the student, but the final result is directly dependent on the interaction of the doctor and the patient. Many ethical problems at the first stage are easier to solve, if the level of conversation culture, the appearance of the doctor, his manner of examining the patient is adequate.

In addition, ethical problems are especially acute when it is necessary to use instrumental, laboratory, in particular invasive methods of research, as well as when choosing one or another method of treatment.

This is due to the fact that the use of non-invasive research methods, such as radiological radiology (barium study or radiocontrast studies), can be accompanied by complications, the severity of which is aggravated by more complex methods - bronchography, catheterization, but especially endoscopy, when there may be tears and perforations of the walls organ, bleeding, embolism, fatal pneumothorax, cardiac arrest, although the incidence of such complications does not exceed in the main 0.2-0.3%.

Particularly difficult is the situation when the question of using diagnostic procedures accompanied by an organ trauma is solved - from thoracocentesis to organ biopsy (kidney, liver, lung, heart). The risk of complications, for example, with liver biopsy (bleeding, including subcapsular hematomas, pneumothorax, bile peritonitis, purulent peritonitis, pleural shock, large bile duct puncture, pain syndrome) is very definite. And the medical institutions in which these methods of research are used are more likely to be in a less favorable position in comparison with institutions that do not conduct them, and, therefore, are not at risk. Of course, it must be emphasized that the tendency to carry out a "biopsy of everything that can only be probiobsed" should not be fundamental. However, many years of experience in the use of these methods in medicine, correctly diagnosed with their help diagnoses in thousands of patients and, finally, the possibility of rational treatment of patients after carrying out such studies convince us of the expediency and necessity of their carrying out.

Another large circle of ethical problems in the activity of a modern internist is related to his therapeutic activity, primarily with the provision of drug therapy. Complications of drug therapy are well known, and sometimes medicines can even induce a severe clinical picture that completely repeats such vivid diseases as systemic lupus erythematosus (under the influence of novocainamide), fibrosing alveolitis (nitrofurans), nodular periarteritis (sulfonamides), etc.

[1], [2], [3], [4], [5], [6]