Methods of examination of the patient

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

And although more and more often, especially among young doctors, there is a desire to quickly master a narrow specialty (for example, electrocardiography, echocardiography), which, of course, is much easier than mastering the entire complex of methods of clinical examination of a patient, it is still necessary to warn the future doctor against neglecting traditional methods. Only a broad and deep medical education with a good knowledge of the clinical picture of the main patterns of development of internal diseases can be the foundation on which one or another narrow specialist is then formed.

The examination of the patient, and therefore the diagnostic process, begins from the moment of 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 provides a lot of important information: the doctor sees and hears the patient, studies his complaints, he can immediately note jaundice, cyanosis, edema, assess the degree of his activity, forced posture, facial asymmetry, slurred or other features of speech, which immediately directs the examination in a certain direction. Some manifestations of the disease (symptoms) can be immediately reported by the patient, but many of them are discovered by the doctor during the examination using physical or laboratory and instrumental tests, and as individual signs are revealed, the doctor repeatedly turns to questioning and examining a specific organ or system. Neatness or sloppiness in clothing, anxiety in behavior provide additional ideas about the patient's personality and often - about its change under the influence of the disease. The facial expression reflects unpleasant or distressing sensations (pain, anxiety), an indifferent face corresponds to deep depression or a comatose state. It is very important to note this right away, because no matter how vivid the clinical picture of the disease is, the patient as a whole cannot be lost behind its symptoms. An insightful doctor always considers various manifestations of the disease as signs related to the pathology of a particular patient at a given moment of the disease. The words of the leading Russian pathologist I. V. Davydovsky have become an aphorism: "It is not an abstract disease that lies in a hospital bed, but a specific patient, i.e., always some individual refraction of the disease." To paraphrase, we can say that the pattern (canvas) of the disease is outlined by the disease itself, its etiology, patterns of development (pathogenesis), but the patient with his individual somatic and mental characteristics creates the image of the disease according to this pattern.

"Treat the specific patient with more attention than the specific features of the disease," wrote W. Osler. And again from E. M. 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 from a 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 consonant with what the outstanding Russian clinicians M. Ya. Mudrov, G. A. Zakharyin, S. P. Botkin said.

When examining a patient, it is important to create and maintain maximum comfort for him/her throughout the examination: avoid excessive and prolonged nudity and unnatural positioning of his/her body, uncomfortable posture and associated haste, and therefore, lack of completeness of the examination. The doctor should also avoid an uncomfortable posture of his/her own: it is always advisable to sit down at the level of the patient's bed or couch and make sure that the conditions for talking and examining the patient are as favorable as possible.

Thus, the success of the diagnostic process depends on how fully the doctor will be able to identify the signs of a disease (or diseases) and understand why these signs are present in a particular patient. It would be a mistake to think that a diagnostic concept can be formed only on the basis of what has been read in a textbook and monograph, a manual or what has been heard at a lecture; a diagnostic concept is ultimately formed at the patient's bedside. "If a doctor does not have deep humanity and analytical thinking, it is better for him to work with devices rather than with people" (E. M. Tareyev).

When discussing the problems of examining a patient, one cannot help but touch upon some of its ethical aspects, immediately emphasizing the great importance of everything that a doctor undertakes in relation to a patient. The study of each patient is, of course, a clinical study, and both the doctor and the patient participate equally actively in it. At all stages of this work, laws operate that are very close to the laws of real, genuine art, since the object of study in both cases is a person.

Already in the process of studying the anamnesis and physical examination, ethical problems are quite clearly revealed. Of course, the hopeless situation in which a person is often put by his illness makes the patient largely agree with the actions of the doctor and even the student, but still the final result directly depends on the interaction between the doctor and the patient. Many ethical problems at the first stage are easier to solve if the level of culture of conversation, the appearance of the doctor, his manner of examining the patient are sufficiently adequate.

Additionally, ethical issues are particularly acute when it is necessary to use instrumental, laboratory, and in particular invasive research methods, 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 X-ray radiology (barium studies or X-ray contrast studies) can be accompanied by complications, the severity of which is aggravated by the use of more complex methods - bronchography, catheterization, but especially endoscopic, when ruptures and perforations of the organ walls, bleeding, embolism, fatal pneumothorax, cardiac arrest can occur, although the frequency of such complications does not exceed 0.2-0.3%.

The situation is especially difficult when the question of using diagnostic procedures that involve organ trauma is being decided - from thoracentesis to organ biopsy (kidneys, liver, lungs, heart). The risk of complications, for example, during liver biopsy (bleeding, including subcapsular hematomas; pneumothorax, bile peritonitis, purulent peritonitis, pleural shock, puncture of a large bile duct, pain syndrome) is quite definite. And medical institutions that use these research methods often find themselves in a less advantageous position compared to institutions that do not conduct them and, therefore, do not take risks. Of course, it should be emphasized that the tendency to "biopsy everything that can be biopsied" should not be fundamental. However, many years of experience in using these methods in medicine, correctly established diagnoses in thousands of patients with their help and, finally, the possibility of rational treatment of patients after such studies convince us of the expediency and necessity of their implementation.

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

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