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Registration of clinical and pathological epicrisis and conclusions on the cause of death



The opinion of the pathologist about thanatogenesis, the mechanisms of the onset of death, taking into account clinical and morphological data, is presented in the clinical and pathological epicrisis containing the doctor's judgment on the cause of death. The conclusion about the cause of death is more accessible for understanding by relatives and representatives of non-medical departments, who are obliged to get acquainted with the pathological documentation on duty.

More A.I. Abrikosov (1939) recommended, in the anatomical diagnosis, to put in the first place (and emphasize) the underlying disease, and after it the changes depending on the underlying disease; at the end of the anatomical diagnosis to make side finds. With this order of presentation, the anatomical diagnosis gives an idea of ​​the successive development of the detected changes and the cause of death. However, in difficult cases this may not be enough and the proctor must add a special conclusion to the protocol, in which he expresses an opinion on the course of the process, the dependence of various changes on each other and the cause of death. Consequently, A.I.Abrikosov considered it necessary to decipher the pathogenetic and thanatogenetic chain in conclusion. Currently, discussions are continuing on the design of the pathological diagnosis and the content of the clinical and pathological epicrisis.

The wording of the death certificate and the content of the clinical and pathological epicrisis with a conclusion on the cause of death (in the same terminology) should flow from the pathoanatomical diagnosis.

Currently, certain requirements have been practically established for the clinical and pathoanatomical epicrisis, reflecting the views of the pathologist on the nature of the diseases, their etiological, pathogenetic and clinical features and the cause of death of the patient. It conducts clinical and anatomical comparisons, as well as evaluates diagnostic and therapeutic measures, their timeliness and expediency, compares the clinical and pathological diagnoses, and in cases of discrepancy, they establish the causes and category of discrepancy.

Based on this, the following questions are usually reflected in the clinical and pathoanatomical epicrisis: 1) substantiation of the diagnosis of the underlying disease; 2) the nature of thanatogenesis; 3) analysis of manifestations of pathomorphism in connection with the treatment; 4) a comparison of clinical and pathological diagnoses of the underlying disease and fatal complications; 5) indications of delayed diagnosis and treatment; 6) a conclusion on the cause of death.

In a shorter version of the epicrisis, they indicate that the patient (last name, first name, middle name, age in the ward, term) had (indicate the main disease that was acute, subacute, with exacerbations, chronically), complicated (nosology, syndrome, pathological process ) There were concomitant diseases.
The patient died from (the underlying disease), in the presence of complications indicate their nature.

It is advisable to streamline the conclusion on the cause of death of the patient, as is customary in forensic practice, in connection with the increase in legal and legal requirements for medical care. Therefore, we propose to complete the clinical and pathoanatomical epicrisis with a brief conclusion on the patient’s death, exactly corresponding to the contents of the death certificate.

Samples of conclusions about the cause of death, inscribed at the end of the clinical and pathological epicrisis

1. Monocausal option (one nosological unit is taken into account - the main disease):

a. The death of the patient - Name, ..., ... years, came from - the main disease - the initial cause of death, complicated - the intermediate and immediate causes of death, with phenomena - the mechanism of death;

b. The patient’s death - full name, ..., ... years, came from - the main disease - the initial and at the same time immediate cause of death, with phenomena - the mechanism of death.

2. Bicausal option (two nosological units are taken into account). When making a combined underlying disease:

a. Patient's death - full name, ..., ..., years, came from - the first underlying disease, in the presence of - the second competing disease;

b. Or, in combination with - a second associated disease;

in. Or, in the background - a background disease;

complicated - the intermediate and immediate causes of death, with phenomena - the mechanism of death.

3. When diagnosing polypathy (multiple pathology - only one nosological unit is to be accounted for so far - the initial cause of death):

a. A “family” of diseases pathogenetically related to each other. The death of the patient - Name, ..., ..., ... years, came from - the initial cause of death, if available - a listing of the family of nosological units and pathological conditions complicated by the direct cause of death, with the phenomena - death mechanism;

b. An “association” of diseases that randomly fit together. The patient’s death - full name, ..., ..., ... years, came from - the initial cause of death, combined with - the listing of accidentally coincident nosological units, complicated - the immediate cause of death, with phenomena - the mechanism of death.

4. Death of the fetus (child) - Name, surname, ... days, came from - the main disease or pathological condition, if any (list other major diseases, pathological conditions). Adverse effect on the fetus (child) was exerted by the mother - the main disease, combined with - other major diseases. The death of the fetus (child) occurred in the conditions - enter.

Date Signed Pathologist

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Registration of clinical and pathological epicrisis and conclusions on the cause of death

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