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INTRODUCTION TO NOSOLOGY. TEACHING ABOUT DIAGNOSIS. PRINCIPLES OF CONSTRUCTION OF CLINICAL AND PATHOLOGICAL DIAGNOSIS. REASONS AND CATEGORIES OF DIAGNOSIS DIVERSION. The concept of iatrogenism
The main task of studying a particular pathological anatomy is the knowledge of the structural and functional foundations of diseases. Millennial experience in the struggle of mankind with diseases and the generalization of this experience resulted in the creation of a very capacious science - nosology - the doctrine of diseases (from the Greek. Nosos - disease and logos - teaching). Nosology includes the biological and medical foundations of diseases, as well as questions about the cause of their occurrence, i.e. their etiology, on the mechanisms of development, or pathogenesis, which are accompanied by certain morphological changes, the so-called morphogenesis. In addition, the study of diseases and their morphology necessarily involves the study of complications of the disease, since patients very often die precisely because of them. Any disease has outcomes that can be different, and nosology also provides for their study. The most important section of nosology is the doctrine of the nomenclature and classification of diseases known to medicine. The treatment of diseases is impossible without knowledge of the theory of diagnosis, i.e. identification of diseases, as well as their variability under the influence of various factors and circumstances - pathomorphosis. Finally, in medical practice, medical errors are inevitable, the interpretation of which is very complicated and associated with the concepts of medical deontology and medical ethics, i.e. with a philosophical category of morality. All these problems are the content of nosology, and the answers to all these questions require both the theory and practice of medicine. And the first to try to answer them was J. Morgagni, who wrote a 6-volume work in 1761, “On the Location and Causes of Diseases Discovered by Dissection,” thereby laying the foundation for nosology, as he created the first scientific classification and nomenclature of diseases. At present, in accordance with nosology, nosological units or specific diseases are distinguished, with a clinical picture typical of each of them, consisting of a combination of characteristic symptoms and syndromes, as well as with a specific etiology and pathogenesis, the knowledge of which allows these diseases to be treated. What is a "disease"? This is a very complex concept, for which there is still no comprehensive definition, and each of the existing ones emphasizes only this or that side of this state of man. However, they all agree that illness is a form of life. So, R.Virkhov defined the disease as "life under abnormal conditions," L. Aschoff believed that "the disease is a violation of functions, resulting in a threat to life." The Big Medical Encyclopedia gives the following definition: “A disease is life, disrupted in its course by damage to the structure and function of the body under the influence of external and internal factors during reactive mobilization in qualitatively peculiar forms of its compensatory-adaptive mechanisms; the disease is characterized by a general and partial decrease in adaptability to environment and restriction of freedom of life of the patient. " In this cumbersome, but most complete definition, however, there is a lot of relative, non-specific, and in general it still does not completely exhaust the concept of “disease”. What is, for example, "reactive mobilization in qualitatively peculiar forms"? or what is a patient’s freedom of life? Interpretations of these concepts can be very different. However, in understanding the disease there are fundamental provisions of an absolute nature: 1) illness, like health, is one of the forms of life; 2) the disease is the general suffering of the body; 3) for the occurrence of the disease, a certain combination of factors of the external and internal environment is necessary; 4) in the occurrence and course of the disease, the most important role belongs to the compensatory and adaptive reactions of the body, which may be sufficient or not sufficient to cure, but their participation in the dynamics of the disease is necessary; 5) any disease is accompanied by morphological changes in organs and tissues, which is determined by the unity of structure and function. Thus, the concept of "disease" necessarily implies a violation of the interaction of the body with the external environment and the "floor" of homeostasis. Why do diseases arise, what is their cause? This is a cardinal question of medicine, which mankind has been trying to answer throughout its history, creating, in the end, the doctrine of the causes of diseases, called etiology (from the Greek. Aitia - reason, logos - doctrine). The question of the etiology of diseases is a question that interests not only doctors. The causality problem is an important philosophical category of cause-effect relations, which has always occupied philosophers of various directions. Therefore, the doctrine of etiology dates back to Democritus, the founder of causal thinking, who at the basis of the causes of diseases, as well as other phenomena, saw violations of atomic movements (IV century BC), and Plato (IV – III centuries BC) .e.) - the founder of objective idealism, explaining the causes of phenomena by the relationship between soul and body, which is the philosophical basis of modern psychosomatics. The doctrine of the causes of diseases went through several stages - through beliefs in various demonic forces that inhabit the person, through the solidarity teachings of Hippocrates (IV-III centuries BC) on the causes of diseases as a result of violations of the fundamental principle of nature - water in the form of blood, mucus , yellow and black bile, and a number of other teachings, many of which have now lost their meaning. However, two areas in philosophical doctrines about etiology still retain a certain interest - causality and conditionalism. The causalists, a prominent representative of which was, in particular, the famous pathologist and physiologist K. Bernard (XIX century), believed that each disease has its own cause, but it manifests itself only in certain, and objective, conditions, which, therefore, and allow the reason to prove itself. Thus, C. Bernard wrote that the doctor should know three things: 1) the conditions of health in order to support them, 2) the conditions for the development of diseases to prevent them, and 3) the conditions of recovery in order to use them. Since the 70s. XIX century., Microbiology is rapidly developing, the successes of which were associated primarily with the name of L. Pasteur. This led to the idea that any disease has only one cause - the bacterium and that the conditions for the development of the disease are secondary and mediated by the bacterium. Against this background, a variety of causalism appeared - monocausalism. However, it soon became clear that not every disease is caused by microbes, that the presence of a microbe in the body is still not enough for the disease to appear (there were ideas about a bacillus carriage, a dormant infection), that under equal conditions, two people react differently to the same microbe. Researchers' attention has focused on the study of the reactivity of the body and its effect on the onset or non-occurrence of the disease. During the development of the doctrine of reactivity, an idea of allergy appeared. Causalism, as a doctrine of the causes of disease, began to be sharply criticized and lose its supporters. Against this background, there is growing interest in conditionalism, which generally denies the causes of diseases and recognizes only the conditions for their occurrence, and only subjective ones. The founder of conditionalism, the German physiologist and philosopher M. Ferworn (XIX century), believed that the concept of causality should generally be excluded from scientific thinking and instead introduce the same abstract concepts as in mathematics. Representatives of the materialistic direction in medicine believe that a disease occurs when, under the influence of a cause, homeostasis is violated under appropriate conditions, i.e. the balance of the body with the external environment or, in other words, when the adaptability of the body to changing environmental factors, to living conditions becomes insufficient. Moreover, living conditions make up the external environment - social, geographical, biological, physical and other factors, and the internal environment, i.e. conditions that are formed in the body itself under the influence of hereditary, constitutional and other factors. At the same time, a more narrow interpretation of the concept of etiology is used in the doctor’s practice - as the cause and condition for the occurrence of a specific disease, a specific pathological process, which greatly facilitates the diagnosis and allows for etiological therapy, i.e. treatment aimed at eliminating the causes of this disease. Thus, etiology is the doctrine of the complex processes of interaction of the human body with the cause of the disease and the complex of additional conditions in which this interaction is realized. Hence the fundamental postulate of modern medicine - there can be no disease without a cause, and the cause determines its specificity, i.e. qualitative features of a particular disease. The causes of so many diseases are known, for example, most infectious diseases, endocrine or traumatic diseases. But there are a large number of diseases, the etiology of which has not yet been established, among them - mental diseases, malignant tumors, atherosclerosis, sepsis, sarcoidosis, a number of nephrological diseases and many others. Often, even the wealth of facts does not allow to reveal the cause of the disease, which nevertheless allows you to successfully treat it, influencing the mechanisms of the disease. So, the clinic, course, complications and outcomes of appendicitis are well known, hundreds of thousands of vermiform appendages are removed annually in the world, but the etiology of appendicitis has not yet been established. In addition, the causes of diseases affect a person in certain specific conditions of the internal and external environment, and depending on these conditions, they can cause disease in some people, but not in others. Such is the complex dialectic of the concept of etiology. Therefore, summarizing all the above, it should be emphasized once again that any disease, any pathological process has its own cause, which, however, manifests itself only in the interaction of the external environment, in a broad sense, and the internal environment of the body and only in the presence of certain conditions, including both external biological, physical, chemical, social factors, and adaptability, reactivity, psyche, and a number of other factors of the internal environment of the body. The problem of etiology is closely connected with the problem of pathogenesis (from the Greek pathos - suffering, disease and genesis - development, origin) - the doctrine of the general laws and mechanisms of development, course and outcome of pathological processes and diseases. As in the case of the concept of “etiology”, there is a broad interpretation of the concept of “pathogenesis” as a study of the general laws of the development of diseases in general, and a narrow concept of pathogenesis as a mechanism for the development of a specific disease or pathological process. With any disease, the doctor raises the question - how did this disease arise and how did it develop? If etiology answers the question - why did this disease arise, then pathogenesis answers the question - how did it arise. For example, if we are talking about croupous pneumonia, the etiology of which is known, then questions arise - how pneumococci got into the lungs, how the inflammatory process in the lung parenchyma spreads, how to relate a cold factor or chest injury to pneumonia, what are the relationships between the local process in the lung and general body reaction? In contrast to etiology, pathogenesis primarily takes into account the role of factors of the internal environment of the body, i.e. physiological processes on the basis of which pathological reactions develop. In contrast to etiological factors, i.e. mainly environmental factors, characterized by variability depending on many conditions, pathogenetic factors are distinguished by a known constancy, like all hereditary physiological mechanisms. This creates not only stability, but also the stereotypic reactions of the body sometimes to completely different effects. So, for example, cancer can be caused by a wide variety of chemical and physical carcinogens, which indicates many etiological factors and a single pathogenetic factor. However, one and the same carcinogen causes cancer in one person, but not in another. This suggests that the etiological significance of certain environmental factors is determined by pathogenetic factors, speaks of the decisive role of precisely internal, pathogenetic factors. However, in turn, internal factors, i.e. physiological systems, especially the internal environment of the body, are ultimately products of nature, products of the external environment. Therefore, the etiology and pathogenesis should be studied in their dialectical unity. Pathogenesis is inseparable from morphogenesis (from the Greek. Morphe - form and genesis - development) - a set of mechanisms for the development of morphological changes in the dynamics of a disease or pathological process. The essence of any disease is that it causes morphological changes in the structure of organs and tissues. These changes cause certain violations of the functions of damaged organs and systems, which is manifested by symptoms, i.e. signs of the disease, and syndromes, which are a set of symptoms associated with a single pathogenesis that are characteristic of a particular disease or group of diseases. Pathogenesis and morphogenesis are inextricably linked dialectic, they develop parallel to each other and, in principle, correspond to each other - the deeper and heavier the morphological changes in organs and tissues, the harder the course of the disease. Recovery from the disease implies not only the destruction of the pathogenic etiological factor, but also the disappearance of the mechanisms of the disease development, which corresponds to the repair, healing of those morphological lesions that were caused by the pathogenic factor and underlie the organs and systems, which manifested itself in the form of a clinical picture of the disease. Therefore, when analyzing the problem of pathogenesis, it should be borne in mind that the pathogenetic laws of the development of diseases are based on similar morphogenetic laws. The pathogenesis problem has two components: genesis itself, i.e. the origin, occurrence (but not the reason!) of the pathological process, and pathokinesis, i.e. dynamics, staged development. And if it is not possible to prevent the occurrence of the disease, then you can intervene in its dynamics at one stage or another of its development. For practical medicine, both of these points play an extremely important role, although the clinic sometimes does not share these concepts, combining them with the term "pathogenetic therapy." Of course, the possibility of intervention in the pathogenesis of the disease is associated with knowledge of the specific mechanisms of its development. This is all the more important because a sick person often goes to the doctor, since the early symptoms of the disease were elusive neither subjectively nor objectively sometimes for a long time. So, patients who already have a tumor of the stomach, which has reached a certain size and only then began to manifest itself, usually turn to the doctor. At the same time, no one knows, including the patient himself, when this tumor arose. And in this case, of course, we cannot talk about etiological treatment, and therapy is only pathogenetic, i.e. based on intervention in the pathogenesis of the disease. However, this does not mean that pathogenetic treatment is ineffective. The experience of medicine suggests that diseases can be successfully treated without knowing their etiology, but intervening in the pathogenesis of the disease. So, oncology does not know the etiology of malignant tumors, however, acting with a large arsenal of surgical and therapeutic agents on various pathogenesis links of these tumors, it can often not only get the effect of treatment, but also achieve a complete recovery of patients. It should be emphasized another important feature of the pathogenetic process - its homeostatic orientation. The biological meaning of all pathogenesis reactions is to use the available set of physiological and pathological reactions, including adaptation and compensation for injuries, to eliminate the cause of the disease and return the physiological constants that make up homeostasis, i.e. return health status. In this case, pathogenetic mechanisms consist in combinations of general pathological reactions that the human body has. The features of these combinations depend on the etiology of the disease. However, due to the fact that the number of general pathological reactions is limited, the pathogenetic mechanisms, the essence of which are these reactions, are stereotyped and not so diverse. They have more or less the same dynamics and a specific morphological expression, which is indicated either by a general formulation, for example, "inflammation", "infection", "cancer", or by a more specific formulation - "pneumonia", "typhoid fever", "stomach cancer" . And in cases where the etiology of the disease is unknown, the pathogenetic mechanisms still remain stereotypical, and this allows us to predict the course of the disease and successfully influence the links of its pathogenesis. So, for example, the etiology of diabetes mellitus is not completely known, but the mechanisms, morphology and dynamics of metabolic disorders in this disease are well studied, which allows for successful pathogenetic treatment. Therefore, the treatment of diseases can be not only etiological, but also pathogenetic, provided that the pathogenesis of the disease is known and understood. At the same time, the stereotypic response of the organism to various influences is often manifested by the same pathogenetic trait, which characterizes, however, various diseases. For example, hypertension, i.e. increased blood pressure may be a manifestation of hypertension as an independent nosological unit, but it can also be a symptom of kidney disease or atherosclerosis, or, for example, an adrenal tumor - pheochromocytoma, or, finally, diabetes mellitus. Often, the doctor is faced with a situation where not only the cause, but essentially the pathogenesis of the disease is unknown, but there are only some syndromes or symptoms of the disease, which, of course, are also links in the pathogenesis, but it is not clear which disease. For example, a syndrome such as coma can be a stage in the development of diabetes mellitus, malaria, uremia with renal failure, etc. And then the treatment is aimed not at eliminating the cause of the disease, but at eliminating the life-threatening syndrome, condition. However, such a syndromological treatment is also pathogenetic, affecting only some link in the pathogenesis of the disease, but this effect is intended to save a person’s life. Thus, to summarize, it should be said that pathogenesis is the doctrine of the mechanisms of the development of diseases in which the factors of the internal environment of the body play a leading role, which determines the stereotypical and homeostatic orientation of pathogenetic factors that are in dialectic unity with the cause of the disease. An indispensable part of nosology is the nomenclature and classification of diseases. What is it? Medical nomenclature is a list of agreed names for diseases and causes of death. A medical classification is a grouping of nosological units and causes of death to achieve specific goals. Both the classification and the nomenclature are not unchanged; they are constantly supplemented and modernized in parallel with changes in knowledge about the diseases included in the nomenclature or in connection with the emergence of new diseases. This modernization is the prerogative of the World Health Organization (WHO), which collects information about diseases from all UN member countries. The WHO Expert Committee analyzes this information and compiles the International Classification of Diseases (ICD), which is a system of rubrics reflecting the incidence and causes of death. From time to time, the WHO expert committee meets in its assemblies and takes into account all the changes that have occurred in understanding the etiology and pathogenesis of diseases over 6-8 years, revising the existing classification and nomenclature of diseases, and compiles a new one, taking into account new knowledge and ideas. The compilation of a new nomenclature and classification of diseases is called revision. Currently, the whole world uses the ICD of the 10th revision (1993). After compiling this document, it is translated into the languages of countries belonging to the UN, and then by order of the Minister of Health of the country it is introduced as a mandatory guide to action for all medical institutions and medical workers. Medical diagnoses must comply with the nomenclature and classification of WHO diseases, even if sometimes the name of the disease or its form does not correspond to national ideas about it. Such unification is necessary so that world health can have a clear idea of the medical situation in the world and, if necessary, provide special or humanitarian assistance to one or another country, develop and carry out preventive measures on a regional or continental scale, and also train qualified medical personnel for different countries . Thus, each nomenclature and classification of diseases reflects a certain level of medical knowledge of society and allows you to determine the direction of searches to decipher the essence of many diseases. ICD-10 consists of three volumes: 1st volume - a special list for statistical development; 2nd volume - a collection of instructions for using the ICD-10; 3rd volume - an alphabetical index of diseases and injuries by their nature. The index includes three sections: 1 - an index of diseases, syndromes, pathological conditions and injuries that served as the reason for seeking medical help; 2 - a pointer to the external causes of injuries, a description of the circumstances in which the event occurred (fire, explosion, fall, etc.); 3 - a list of drugs and biological agents and chemicals that caused poisoning or other adverse reactions. The alphabetical index contains leading terms or keywords indicating the name of the disease, injury, syndrome, iatrogenic pathology, which are subject to special unified coding. To do this, there are alphanumeric code numbers for which 25 letters of the Latin alphabet and four-digit codes are provided in which the last digit is placed after the period. Each letter corresponds to 100 three-digit numbers. Various medical associations have created additional International classifications for individual medical disciplines (oncology, dermatology, dentistry, psychiatry, etc.), which are included in the ICD, but as additional classifications, encoded by additional numbers (fifth and sixth). ICD-10 contains several thousand diseases, divided into 21 classes of diseases and health problems, united in each class into families according to related characteristics. Moreover, the main principle of the classification is classification by nosological basis, i.e. taking into account the etiology, pathogenesis and outcomes of diseases. So, class I - "Infectious and parasitic diseases", fully meets these conditions, is encrypted using code A00-B99. To a certain extent, this principle also corresponds to class II - Neoplasms, which is encrypted using the C00 – D48 code and, although the exact causes of a particular disease are not always known in this class, the etiological factors, tumor pathogenesis, and their outcomes are known. The nosological principle is also preserved during the classification of disease families according to the anatomical-localistic criterion, for example, class III - "Diseases of the blood and blood-forming organs", which is encrypted using the code D50 — D89. The nosological principle is retained even if diseases are classified according to an organ-group basis, for example, class X - “Respiratory diseases”, code J00 — J99, class XI - “Digestive diseases”, code K00 — K93, class XIV - "Diseases of the genitourinary system", code N00 — N99, etc. Finally, the rubrication may reflect syndromology, when the etiology is unknown, pathogenesis is not clearly defined, and classification is impossible not only by the nosological principle, but also by pathogenesis, for example, class XVIII - “Symptoms, signs and abnormalities detected in clinical and laboratory studies” , is encrypted by the code R00 — R99; class XXI "Factors affecting the state of health and treatment in a healthcare institution" is encrypted using the code Z00 — Z99, etc. A feature of coding is also accounting for the duration of the disease (acute, chronic). Thus, the ICD allows not to drown in the immense number of diseases, syndromes, symptoms, unclear pathological conditions, injuries, etc., creates a harmonious hierarchical system of disease priorities when writing diagnoses, based on principles common to the entire world community and, finally, allows assess the state of morbidity and mortality in the world, identify trends in the health situation of the population of certain regions, which makes it possible to carry out appropriate preventive measures. The classification and nomenclature of diseases are directly related to the doctrine of diagnosis. Diagnosis (from the Greek. Diagnosis - recognition) is a medical opinion on the state of health of the subject, on the existing disease or on the cause of death, expressed in terms provided for by the accepted classifications and nomenclature of diseases. There are many types of diagnosis - it can be preliminary or final, histological or anatomical, retrospective or forensic, etc. However, in clinical medicine there are two main types of diagnosis - a clinical diagnosis and a pathoanatomical diagnosis. Diagnosis, i.e. recognition of the disease is one of the first and main tasks of the doctor. Depending on the clinical diagnosis, treatment is prescribed that can be adequate and effective if the diagnosis is correct. But it can be ineffective and even cause fatal consequences for the patient if an erroneous diagnosis is made. By formulating the diagnosis, one can trace the doctor’s thinking in the process of recognizing and treating a disease, find an error in the diagnosis, and try to understand the cause of this error. Therefore, a good doctor is first and foremost a good diagnostician. No less important is the pathoanatomical diagnosis, which is formulated by the pathologist after opening the corpse of a deceased patient on the basis of detected morphological changes. Comparing the clinical and pathological diagnoses, the pathologist determines their coincidence or discrepancy, and this reflects the level of diagnostic and medical work of the medical institution and individual doctors working in the hospital or clinic. Errors found in the diagnosis and treatment are discussed at clinical and anatomical conferences of the hospital, which serve as a school for both clinicians and pathologists. Based on the pathological diagnosis, the cause of the patient’s death is determined, which makes it possible for medical statistics to develop questions of mortality and its causes. And this, in turn, to a certain extent contributes to the conduct of state measures aimed at improving the country's health care and the development of social protection measures for the population. Naturally, in order to compare the clinical and pathological anatomical diagnoses, they must be drawn up on the same principles. Moreover, the uniformity in the nature and structure of the diagnosis requires ICD, since the diagnosis serves as the basic document for all subsequent medical documentation. The fundamental principle of making a diagnosis is the presence of three main sections in it - the underlying disease, its complications and concomitant diseases. In this case, the underlying disease is usually a nosological unit, and the concomitant is the pathological background against which the underlying disease has developed. In the clinical diagnosis, the underlying disease is the condition for which treatment or examination was performed while seeking medical help. In the pathoanatomical diagnosis, the main disease is that disease, which in itself or through its complications caused the death of the patient. The underlying disease is coding for the cause of death. A complication is a disease pathogenetically associated with the main one, which aggravates its course and outcome. In this definition, the key concept is "pathogenetically related", and this connection is not always easy to catch, and without this disease can not be a complication. Let us examine these provisions by examples. A patient of 80 years developed croupous pneumonia, from which he died. Consequently, croupous pneumonia will be the main disease, and the pathological diagnosis begins with it. But this croupous pneumonia occurred in an old person with reduced reactivity, who even before pneumonia suffered from atherosclerosis with a primary lesion of the heart vessels. Atherosclerosis of the coronary arteries was accompanied by chronic progressive hypoxia, which led to a significant violation of the metabolism of the heart muscle, the development of diffuse small focal cardiosclerosis and decreased myocardial functionality. This, in turn, caused a number of compensatory processes in the heart, including the hyperfunction of preserved muscle fibers. Myocardial hyperfunction in combination with hypoxia caused the development of protein and fatty degeneration in cardiomyocytes, which, however, allowed the heart to function in the patient's relative health. At the same time, the involutive processes in the old man led to the development of emphysema, a decrease in the level of gas exchange in them and, as a result of a combination of these factors, to diffuse pneumosclerosis. While the person was relatively healthy, these changes in the heart and lungs allowed them to function at a level that provides life. But extreme conditions arose, the disease appeared, the respiratory surface of the lungs decreased, hypoxia intensified, the factor of general intoxication of the body joined, which aggravated myocardial fatty degeneration. At the same time, the functional loads on the heart and lungs sharply increased, however, the compensatory abilities of the old organism are largely exhausted, metabolism and reactivity are reduced. Under these conditions, the heart does not cope with the load and stops. How will the pathological diagnosis be formulated? The main disease is croupous pneumonia, because it led the patient to death. In this case, it is necessary to indicate the localization, prevalence of the inflammatory process and the stage of the disease. Therefore, the diagnosis will begin with the heading: the main disease is left-sided, lower-lobe croupous pneumonia in the stage of gray ward. In the rubric of concomitant diseases, it is necessary to indicate atherosclerosis with damage to the blood vessels of the heart (atherocalcinosis with stenosis of the lumen of the artery by 60%), diffuse small focal cardiosclerosis, fatty degeneration of the myocardium, senile pulmonary emphysema, diffuse pneumosclerosis. Thus, the abstract, in general, the concept of "lobar pneumonia" gets a certain content against the background of concomitant diseases, and such a diagnosis allows you to specify the disease specifically in relation to this patient and understand the cause of his death. Let's expand our example a little. The same patient, suffering from lower lobe croupous pneumonia, developed an abscess in the area of fibrinous inflammation - a focal point of purulent inflammation, which sharply worsened the patient's condition. As a result of severe intoxication, the patient's reactivity and resistance sharply decreased, and abscesses appeared in other lobes of the lung. Then putrefactive bacteria got into the affected lung through the bronchi, lung gangrene began, and the patient died. In this case, the diagnosis after the underlying disease - left-sided lower lobar croupous pneumonia - should be a section of "complications", which will indicate multiple abscesses and gangrene of the left lung. Concomitant diseases will remain the same. In this example, lung abscesses are pathogenetically associated with the underlying disease and therefore a complication thereof. This pathogenetic relationship is not always easy to recognize. For example, a fairly common situation: an elderly woman fell and broke her thigh neck. On this occasion, she was hospitalized in the trauma unit of the hospital where osteosynthesis was performed, and the patient was sent to the ward. In a forced position, lying on her back, she is for 3 weeks, after which she develops congestive bilateral lower lobar pneumonia, and the patient dies. Often, the clinical diagnosis is as follows: the main disease is a fracture of the neck of the left thigh, a condition after osteosynthesis; complication of the underlying disease - bilateral congestive lower lobar pneumonia; the cause of death is a complication of the underlying disease. In this case, the complication is associated with the forced position of the patient - in bed on the back, due to a fracture of the femoral neck and surgical intervention. But is it? Where is the pathogenetic relationship between a femoral neck fracture and a patient's forced position? She is not there. Fracture of the femoral neck is in no way associated with congestive pneumonia. And the position of the patient in bed, lying on his back, is not at all compelled. Wasn’t it possible to put the patient in bed, to carry out appropriate breathing exercises, massage the chest, walk on a gurney, in the end? And there would be no stagnation in the lungs. Consequently, congestive pneumonia is not a complication of a femoral neck fracture, but essentially iatrogenic, i.e. a disease caused by medical workers, and it could well be prevented in the conscientious performance of their duties by medical personnel. And at first glance, without taking into account the key provisions on the pathogenetic relationship of the two diseases, pneumonia really seems to be a complication. It should be noted that resuscitation complications are recorded in the diagnosis on their own and describe the changes that have arisen in connection with resuscitation measures, and not in connection with the underlying disease and therefore, naturally, have no pathogenetic relationship with it. However, it is far from always possible to put all the pathology that the patient has and was discovered at autopsy into one underlying disease. Very often there are several diseases that should be considered as the main disease, and in order to describe such a situation in the diagnosis, a rubric of the combined main disease is introduced, which allows to name the main several diseases that led the patient to death. However, these diseases are in a relationship with each other that is defined as competing and combined. Two or more diseases are competing, each of which, by itself or through its complications, could lead the patient to death. To clarify this situation, imagine a situation that often arises in the clinic. An elderly patient was hospitalized for stage IV gastric cancer with multiple metastases and tumor decay. The patient dies, this is beyond doubt, and it is no longer possible to help him. Of course, the oncological process causes a restructuring in the body, including an increase in blood coagulation. At the same time, atherosclerosis of the coronary arteries of the heart is expressed in this patient, and against this background, thrombosis of the descending branch of the left coronary artery, extensive left ventricular myocardial infarction, acute heart failure develops. 12 hours after a heart attack, the patient dies. What is the main disease, i.e. the disease that led the patient to death? He was dying and had to die of cancer, but in this state he still lived and, perhaps, would have lived a few more days.
Of course, he could die from myocardial infarction, but it is far from always a heart attack that leads patients to death, you can survive two, and four myocardial infarction. Thus, a situation arises when it is impossible to say with certainty which of the two diseases led the patient to death, because each of them could play a fatal role. That is, there is a competition of two fatal diseases, and in this case, the underlying disease is a combination, consisting of two competing diseases. In the diagnosis, this combination should be described as follows: "the main combined disease: cancer of the antrum with the collapse of the tumor and multiple metastases in the perigastric lymph nodes, liver, omentum, bodies of the 5th and 7th thoracic vertebrae. Cancer cachexia. Competing disease: infarction of the anterolateral wall of the left ventricle of the heart, atherocalcinosis and thrombosis of the descending branch of the left coronary artery. " Then you should write about complications and concomitant diseases. In the clinic, one often has to face a situation where the patient simultaneously develops several serious diseases. For example, again, a very elderly patient suffering from widespread atherosclerosis with a primary lesion of the vessels of the lower extremities, coronary arteries of the heart and brain arteries develops atherosclerotic gangrene of the right foot, about which he was hospitalized. In the clinic, against the background of increasing intoxication, accompanied by hemolysis of red blood cells, suprahepatic jaundice, impaired hematopoietic function of the liver, the patient develops myocardial infarction. Two days later, against the background of increasing cardiovascular failure, an ischemic stroke develops in the stem part of the brain, and the patient dies. What was the main disease that led the patient to death? The fact is that according to ICD-10, atherosclerosis cannot be considered as a nosological form, but can only be a background of myocardial infarction or cerebrovascular diseases. However, in this patient, each of the three diseases could lead to death. Therefore, the underlying disease will be combined, including three competing nosological forms - gangrene of the right foot, myocardial infarction of the left ventricle of the heart and ischemic stroke in the brain stem. Background to all three competing diseases will be atherosclerosis in the stage of atherocalcinosis with a primary lesion of the vessels of the lower extremities, coronary arteries of the heart and the basilar artery of the base of the brain. As a complication, intoxication and its morphological manifestations, as well as edema and swelling of the brain with the insertion of its stem into the large occipital foramen, should be considered. Then it is necessary to write down the concomitant diseases - senile emphysema, gallstones. However, let us return to the situation with the patient who had a hip fracture and congestive lower lobar pneumonia. We came to the conclusion that pneumonia is not a complication of a serious injury, but it is also impossible to assume that these two diseases are not related to each other, if only because they occurred in one patient and at the same time, and the body at the same time somehow reacted to injury and pneumonia. And if a femoral neck fracture, as the main disease, is not in doubt, because the patient has asked for medical help and received appropriate treatment about it, then what about pneumonia, which arose later than the fracture, but it was of the most significant importance in thanatogenesis? For such situations, there is the concept of a combined underlying disease. Combined diseases are diseases with different etiology and pathogenesis, each of which individually is not the cause of death, but coinciding in time of development and mutually burdening each other, they lead the patient to death. In this example, the diagnosis should be written as follows: the main combined disease: a fracture of the neck of the left thigh, a condition after osteosynthesis. Concomitant disease: bilateral lower lobar pneumonia. Then complications should be described, i.e. pathogenetically associated with concomitant diseases, for example, suppuration of a postoperative wound in the region of the left hip joint or asthmatic syndrome in a patient suffering from bilateral pneumonia. After complications, concomitant diseases are written, for example, atherosclerosis with a primary lesion of the heart vessels. There is another group of diseases that can be included in the heading “underlying disease”. These are the so-called background diseases - diseases that can be etiologically related or not related to the underlying disease, but included in its pathogenesis, creating an unfavorable background for the course and outcome of the underlying disease. The introduction of the concept of "background disease" has its own history. Until the middle of the last century, myocardial infarction, being a complication of atherosclerosis or hypertension, did not fall into the WHO statistics, which takes into account only the main diseases. Meanwhile, myocardial infarction, or coronary heart disease, became the main cause of death in the world, and statistics on morbidity and mortality from myocardial infarction were needed to develop measures for its prevention and treatment. Therefore, in 1965, the WHO Assembly adopted a special resolution: in order to develop preventive measures and organize a system for combating acute coronary heart disease, consider myocardial infarction as the main disease and start writing a diagnosis with it. However, realizing that myocardial infarction is pathogenetically a complication of atherosclerosis and hypertension, introduce the concept of background disease and consider atherosclerosis and hypertension as such. This principle of writing a diagnosis did not immediately, but gradually found worldwide application and after a while began to be used in writing a diagnosis of cerebrovascular disorders, because, in essence, they are also a complication of atherosclerosis or hypertension and are associated with arterial stenosis with atherosclerotic plaques. But atherosclerosis of the arteries develops not only with these diseases. Diabetes mellitus, for example, is also accompanied by severe atherosclerosis, including coronary arteries. And diabetes was also written in the diagnosis as a background disease. However, all these background diseases were written for a long time only in the diagnosis, where the main disease was myocardial infarction or cerebrovascular diseases (cerebral strokes). But over time, obviously, it was forgotten why and for what the concept of background diseases was introduced, and now often consider any diseases that precede the development of the underlying disease and aggravate its course. For example, the diagnosis may be as follows: underlying disease: massive cancer of the right lung, cancer metastases to regional lymph nodes. Background disease: chronic suppurative bronchitis. Complication: respiratory distress - adult syndrome. Here, obviously, it is understood that chronic bronchitis is a precancerous disease, and therefore can be considered as the background against which carcinoma developed. This can hardly be considered correct, if only because chronic bronchitis does not always precede lung cancer. However, there are no clear rules for distinguishing a background disease, and therefore this or that style of gradation of the diagnosis headings largely depends on the practice in the medical institution. Often, hospital doctors agree on how they will formulate clinical and pathological diagnoses. However, in any case, the diagnoses should correspond to ICD-10 for the underlying disease, since it encodes nosologies. ICD-10 allows the participation in the combined underlying disease of the so-called polypathy - two or more competing, combined and background to one of the main diseases. Prof. G.G. Avtandilov, who has been constructing the diagnosis for many years, believes that polypathy is a group of basic diseases that consists of either aetiologically and pathogenetically related several diseases (a "family of diseases"), or a random combination of several diseases (an "association of diseases"). In such cases, determine the immediate cause of death and the initial cause preceding it, which is taken for the underlying disease. Thus, in the clinical and pathological diagnosis, the heading “underlying disease” can be represented by a single nosological form, a combination of competing diseases, a combination of concomitant diseases and a combination of the underlying disease with the background. In addition, the equivalent of the underlying disease, according to the ICD, may be complications of therapy or errors in medical manipulations, the so-called iatrogenics, which are recorded in the diagnosis under the heading “underlying disease”. These include: complications during infusion and transfusion (anaphylactic shock, hemolysis, hepatitis B and C, etc.), the consequences of radiation therapy, hypoxia during anesthesia and an overdose of anesthetics, complications and long-term effects of therapy ("second diseases"), diagnostic complications treatment procedures and preventative measures (e.g. vaccinations). The diagnosis ends with the writing of a "conclusion about the cause of death." According to the ICD-10 definition, the cause of death is a disease or trauma that caused a sequential series of painful processes that directly led to death, i.e. we are talking about the main disease, which in itself or through its complications led the patient to death. So, in one of the above examples, the conclusion about the cause of death should read as follows: "The death of a patient Iv, 80 years old, suffering from left-sided lower lobar croupous pneumonia, complicated by multiple abscesses and gangrene of the left lung, came from pulmonary heart failure with symptoms of severe intoxication. " Thus, it is understood that every disease has outcomes. The outcome may be favorable, i.e. recovery, and adverse, i.e. death. But a favorable outcome can be complete and incomplete. A complete favorable outcome implies a complete recovery, repair of damaged tissues, restoration of homeostasis and the possibility of returning to normal life and work. A favorable but incomplete outcome of the disease implies the occurrence of irreversible changes in the organs, the development of disability and the appearance of compensatory and adaptive changes in the body. For example, for cavernous tuberculosis of the apex of the right lung, the patient underwent a lobectomy, and he was cured of cavernous tuberculosis, i.e. the outcome of the disease is generally favorable. However, a coarse postoperative scar was formed in the middle lobe of the right lung, compensatory emphysema developed in the middle and lower lobes, and connective tissue grew in place of the former upper lobe. This led to chest deformity, curvature of the spine and displacement of the heart. All this will undoubtedly negatively affect the ability to carry out the previous work and lead the same way of life. After writing the pathological diagnosis, a comparison is necessarily made with the clinical diagnosis. This must be done for many reasons. First of all, to finally, usually with the attending physician, to understand the etiology, pathogenesis and morphogenesis of the disease in a particular patient. Therefore, a joint discussion of the autopsy results is a large, everyday and necessary school for both the clinician and pathologist, as basically it is at the autopsy that you can see, evaluate and clarify what changes and in which organs arose as a result of the disease, what compensatory processes developed in this case and what was the mechanism of death. As a result of a joint analysis of the revealed pathological changes, the professional level of doctors increases, because in the prosektura, according to K. Rokitansky, "the dead teach the living." Such a joint analysis, accounting for errors and understanding of their causes contributes to an increase in the level of diagnostic and medical work of a hospital or clinic. In addition, comparison of diagnoses is one of the important indicators of the quality of work of a medical institution - a large number of coincidences of clinical and pathological diagnoses indicates the good work of the hospital and the high professionalism of its staff and vice versa. However, no matter how good the clinic, no matter how it is equipped with modern diagnostic equipment, there is always one or another percentage of discrepancies in the clinical and pathological diagnoses. Obviously, the human brain and the clinical thinking of a doctor cannot take into account all the nuances of the course of diseases in a particular patient and absolutely adequately evaluate the readings of diagnostic devices. In addition, clinical thinking is a creative process, and creativity is unique, inexplicable and purely individual. Therefore, with the same basic training, all doctors differ as professionals. And the combination of the individual characteristics of the course of the disease in a specific, also unique, patient with the individual characteristics of the clinical thinking of a particular doctor, probably creates such a lot of nuances that it is impossible to take into account the human mind, therefore, diagnostic errors arise. In addition, a severe, sometimes unconscious state of the patient or an inadequate assessment of the patient's feelings may interfere with the diagnosis, in which case the probability of error increases even more. Finally, there may be some relevant factors affecting the assessment of the clinical picture and diagnosis — errors in laboratory studies, incorrect interpretation of x-ray data, insufficient experience of a doctor, etc. That is why medical consultations are practiced in medicine for complex diseases of specific patients, and at these consultations, specialists usually evaluate the clinical picture differently and, if they come to a common opinion, then, as a rule, by compromise. Thus, the discrepancy between clinical and pathological diagnoses is inevitable, the question is only in the number of such discrepancies. Usually there is some more or less the same percentage of diagnosis discrepancies in most medical institutions of a city or region, and it is a criterion for the level of medical and diagnostic work of health authorities. At the same time, the reasons for the discrepancy between the clinical and pathologo-ontomic diagnoses can be not only objective, but also subjective. Objective reasons may be: the shortness of the patient’s stay in the hospital (up to 3 days), the serious, including unconscious, condition of the patient, which does not allow to perform the necessary diagnostic tests, the difficulty of diagnosis, for example, due to the rarity of the disease. The subjective causes of diagnostic errors are insufficient examination of the patient, despite the fact that there were all the possibilities for this, incorrect interpretation of laboratory and X-ray data due to insufficient professional knowledge, an erroneous conclusion by a consultant, and incorrect construction and preparation of a diagnosis. The consequences of a diagnostic error and the responsibility of the doctor may be different. Therefore, according to the nature, causes of errors and their consequences, the discrepancies in the diagnoses are divided into three categories, and discrepancies in nosology are additionally taken into account, i.e. on the underlying disease, on the localization of the pathological process, as well as on the complication of the underlying disease. If the discrepancy between the clinical and pathological diagnoses is established, then the reason for the discrepancy must be indicated. The first category of divergence of diagnoses is when the reason for the divergence of diagnoses was objective reasons - the short stay of the patient in the clinic (for 3 days), as well as the serious, sometimes unconscious, state of the patient, which made it difficult to conduct diagnostic studies or made them impossible. For example, a patient of 65 years old in an unconscious state was admitted to the ambulance clinic. Relatives reported that he suffered from hypertension. Clinical examination, including spinal canal puncture and consultation of a neurologist, made it possible to suspect cerebral hemorrhage. The necessary measures were carried out in accordance with the diagnosis, but they were ineffective, and 18 hours after admission to the intensive care unit, the patient died. In the section, lung cancer with metastases to the brain and hemorrhage to the metastasis region was detected. There is a discrepancy in diagnoses. But can doctors be blamed? Of course not. They did everything possible to establish the underlying disease, but in difficult conditions, due to the severe unconscious state of the patient, they could only establish the localization of the pathological process that caused the clinical symptoms, and tried to save the patient. This is a discrepancy of diagnoses of the 1st category in nosology, the reasons for the discrepancy are objective - the severity of the patient's condition and the shortness of his stay in the clinic. The 2nd category of divergence of diagnoses characterizes the divergence of clinical and pathoanatomical diagnoses for objective or subjective reasons, when a diagnostic error did not lead to a fatal outcome for the patient. For example, in a clinic, a patient was diagnosed with cancer of the head of the pancreas, and cancer of the Vater's nipple was found in the section. There is a divergence of diagnoses in the localization of the pathological process. The reason for the divergence of diagnoses should be recognized as objective, since the clinic for both localizations of the tumor in the terminal stage of the disease is the same, and the diagnostic error did not affect the outcome of the disease - in both cases it is the same. However, there may be another situation: a 82-year-old patient is admitted to the clinic with a diagnosis of "suspected gastric cancer." Upon admission to the clinic, her blood, urine was examined, an ECG was taken and a chronic coronary artery disease was detected, a fluoroscopy was performed, but she did not receive clear data for the presence of a tumor and decided to repeat the study after a few days, but did not. Nevertheless, for some reason, cancer of the stomach did not raise doubts and the patient was practically no longer examined. On the 60th day of her stay in the clinic, the patient died, and she was given a clinical diagnosis of gastric cancer, liver cancer metastases. A small cancer, but of the fundus of the stomach, without metastases, and, in addition, an extensive myocardial infarction of the left ventricular wall, 3 days ago, was indeed found in the section. Therefore, there are competing diseases - stomach cancer and acute myocardial infarction. The unrecognition of one of the competing diseases is a divergence of diagnoses, since each of the competing diseases could cause death. Given the patient’s age and condition, she could hardly have undergone radical surgical treatment of gastric cancer - gastrectomy, an overlay of an esophageal-intestinal anastomosis. And myocardial infarction should have been treated, and treatment could be effective, although this cannot be argued. At the same time, an analysis of the medical history showed that the rounds of the attending physician and the head of the department were formal, no one paid attention to the fact that the latest tests and ECG were done 40 days ago and have not been repeated since then, finally, no one noticed that the patient had a clinic for myocardial infarction, and therefore the necessary studies were not carried out, which was the cause of the diagnostic error. Thus, there is a 2nd category of discrepancy between clinical and pathoanatomical diagnoses of a competing disease, but the reason for the discrepancy is subjective - insufficient examination of the patient, although there were all conditions for this. The reason is the negligent discharge of their duties by the department’s doctors, which, unfortunately, is often found in our hospitals, especially when it comes to old patients. The 3rd category of diagnosis discrepancy has to be used when a diagnostic error has led to incorrect medical tactics, which had fatal consequences for the patient. For example, a patient with a diagnosis of interstitial pneumonia is in the clinic, but the symptomatology of the disease is somewhat different from that typical for this disease, and the treatment is not successful. A TB consultant is suspected of having suspected pulmonary tuberculosis and has prescribed a number of diagnostic tests, including skin tuberculin tests, repeated sputum tests, and a tomographic examination of the right lung. However, the attending physician complied with only one recommendation - he sent sputum for analysis, received a negative result and did not examine the sputum anymore. But he did not comply with the rest of the recommendations, as he was busy with other matters, but continued to carry out ineffective treatment. Meanwhile, the patient 3 weeks after consulting a TB specialist was quickly "heavy" and soon died. In the clinical diagnosis, the main disease was "interstitial pneumonia of the lower and middle lobes of the right lung." The section revealed tuberculous caseous pneumonia of the right lung, which was the cause of severe intoxication and death of the patient. In this case, incorrect diagnosis, and without objective reasons, led to incorrect ineffective treatment and to the death of the patient. At the same time, if the recommendations of the TB consultant were implemented, the diagnosis could be made correctly, transferring the patient to a TB clinic, where special treatment would be purposefully carried out. Thus, this is a divergence of diagnoses of the 3rd category, where incorrect clinical diagnosis led to improper treatment and a fatal outcome of the disease. The cause of the diagnostic error is subjective in nature and became possible as a result of insufficient examination of the patient and failure to comply with the recommendations of the consultant. The 3rd category of divergence of diagnoses often stands on the verge of a medical crime, for which the doctor is criminally liable. Therefore, very often with errors of this nature, relatives of the deceased file complaints, and either an administrative or criminal investigation is carried out on them. The need to put the 3rd category of divergences of diagnoses requires a great responsibility and adherence from the pathologist, since at the same time his colleagues with whom he works in the same hospital will almost certainly have big troubles. Diagnostic errors require a comprehensive analysis to prevent their repetition. Such an analysis is carried out at clinical and anatomical conferences, which are regularly held in each hospital under the chairmanship of the chief physician and the head of the pathology department. All hospital doctors participate in these conferences and, therefore, everyone learns from mistakes. The discussion of the conference includes cases of discrepancy between clinical and pathological diagnoses, presenters from clinicians are appointed, usually this is the attending physician, and pathologists are the prozector who performed the autopsy. In addition, an opponent is necessarily appointed - one of the most experienced doctors in the hospital who had no relation to the parsed observation. As a result of the general discussion, the causes of the diagnostic error are revealed, and, if necessary, the hospital administration takes appropriate measures. These measures may not necessarily be repressive for doctors who have made a mistake. They can be aimed at strengthening the material base necessary to improve the diagnosis in the hospital. In addition to discussing diagnostic and medical errors, rare observations are made at clinical anatomical conferences, especially if they were correctly diagnosed. All this makes clinical and anatomical conferences a necessary professional school for the entire medical staff of the hospital. A very important and complex medical problem are diseases or various complications of diseases associated with the actions of medical personnel, the so-called iatrogenic (from the Greek. Iatros - doctor and genes - arising, damaged). Iatrogenicity is any adverse effect of preventive, diagnostic or therapeutic interventions or procedures that lead to impaired body functions, disability or death of the patient. Iatrogenism should be divided into medical errors and medical misconduct or crime. It should be noted, however, that a medical crime can only be established by a court. A medical error is a bona fide delusion of a doctor in the performance of his professional duties and therefore is not an offense or a crime. A medical error, unlike a medical misconduct or crime, cannot be foreseen and prevented by this doctor, it is not the result of his neglect of his duties, ignorance or malicious action. The medical error in the vast majority of cases is the result of insufficient professional experience or lack of the necessary laboratory or hardware capabilities for proper diagnosis and appropriate treatment. However, regardless of whether the patient is harmed as a result of a medical error or as a result of the negligence of a doctor or nurse, the disease or pathological condition that occurs is iatrogenic. Most often, iatrogenicity occurs during various medical procedures, for example, on vessels. So, during catheterization, for example, of the subclavian artery, its thrombosis may occur, followed by thromboembolism. Against the background of thrombosis, septicopyemia may develop, the catheter is sometimes destroyed, and its pieces become foreign emboli. Fundamentally the same complications are fraught with angiography. In endoscopic studies, damage to the wall of the organ is possible, accompanied by bleeding, for example, perforation of the esophagus during gastroscopy. Such common manipulation as hemodialysis gives many iatrogenic complications - serum hepatitis C, which can result in liver cirrhosis, heparin bleeding, impaired calcium-phosphorus metabolism, septicopyemia (so-called shunt sepsis), etc. Surgical interventions are possible, for example, intersection of the iliac artery when removing ureter stones, erroneous removal of a single horseshoe kidney. Sometimes, as a result of negligence, surgeons leave napkins and surgical instruments in the abdominal cavity, which leads to the development of purulent diffuse peritonitis and often to the death of the patient. If the rules of asepsis and antiseptics are not observed during medical procedures or operations, infectious complications are possible. Iatrogenism can occur as a result of tactical errors by a doctor, such as the wrong choice of research methods as a result of underestimating the degree of risk of manipulation due to underestimation of the patient’s age, his medical history or individual reaction to the manipulation, incorrect choice of indications for surgery or the introduction of some medications to preventive vaccinations for children, etc. But more often technical errors occur that are made by doctors, nurses, and other medical personnel. Such errors may be, for example, incorrect execution of diagnostic or medical procedures, or incorrectly prepared medical documentation, on the basis of which some medical measures that are contraindicated to the patient were erroneously performed. Finally, iatrogenic effects may be associated with the technical imperfection of medical equipment. And if iatrogeny associated with certain mistakes of doctors can somehow be investigated and applied to doctors some measures of influence - from discussion at the clinical anatomical conference and referral to continuing education courses to criminal liability, then in case of death of the patient in the operating room table as a result of the failure of the heart-lung machine, any measures to doctors to take is useless. However, the patient died, the investigating authorities will understand this and someone should bear responsibility for this. But who? Thus, the iatrogenic problem is a very complex problem that always goes hand in hand with the daily activities of a doctor and exists in any clinic. And no matter how difficult it is in each particular case of iatrogeny to find and, most importantly, evaluate its cause, the problem of iatrogeny is an integral problem of medical activity. And therefore, the task of training young specialists and the task of organizing the medical and diagnostic process in any clinical institution is to create conditions, if not excluding the possibility of iatrogenic, then at least minimizing them. Finally, an essential part of nosology, as the doctrine of diseases, is pathomorphism (from the Greek pathos - disease and morphosis - formation) - a persistent change in the clinical and morphological manifestations of the disease under the influence of any environmental factors. Knowledge and understanding of pathomorphism is important because it is about changing the picture of the disease, and therefore about changing its diagnosis, treatment and prevention. This entails the development of new diagnostic techniques, new drugs, which, in turn, can affect the causative agents of the disease. And this can already entail a change in epidemiology and, consequently, a change in the epidemiological and preventive measures carried out throughout the entire health system. Pathomorphosis is divided into two large groups - true and false. In turn, true pathomorphosis is divided into general pathomorphism, which consists in changing the general panorama of diseases, and particular pathomorphosis, which reflects a change in a certain nosological form, i.e. specific disease. General pathomorphosis is associated with natural changes in the environment in which humanity lives, with the evolution of the external world, and therefore, including changes in pathogens of diseases, with a change in the nature of their interaction with humans and animals, with the emergence of new pathogens, new factors, influencing a person, for example, the appearance of radiation, the accumulation of many chemical factors in the atmosphere, etc. In this regard, the frequency of a disease changes, the age of the patients, characteristic of these and other diseases, changes, the general panorama of diseases changes. So, for example, in the XIX century. the general epidemiological picture in the world was characterized by bacterial infections, in the XX century. - cardiovascular and oncological diseases, and the XXI century. - promises to be a century of viral infections. However, it should be emphasized that natural general pathomorphosis occurs over the centuries, i.e. for a very long time, and therefore not so noticeable. Private pathomorphosis, in turn, can also be spontaneous or natural, but it can also be induced or therapeutic. Private spontaneous pathomorphosis, as the name says, is a consequence of a change in the external causes of the development of the disease, which are far from always known. For example, we do not know when and why cholera appears, why the Asian cholera, which has devastated the globe for hundreds of years, has been replaced by cholera caused by the vibrio Eltor and proceeding far less catastrophically. It can also be a consequence of a change in the constitution of a person, i.e. internal causes. In fact, spontaneous private pathomorphism reflects the same patterns as general pathomorphism, but it concerns a specific disease, a specific nosological form. In everyday life, private induced, or therapeutic, pathomorphosis, i.e. artificially caused by various measures or a specific drug therapy, change in a particular disease is of much greater importance. Thus, long-term tuberculosis vaccination of children immediately after birth led to a shift in tuberculosis infection from 4-5 years to the age of 13-14 years, i.e. to the period when the formation of the immune system is almost over, as a result of which tuberculosis has lost its fatal value. In addition, such forms of the disease as acute tuberculosis sepsis and tuberculous meningitis have disappeared. A wide arsenal of specific drugs sharply reduced mortality from acute forms of the disease, the life expectancy of patients significantly increased, but its chronic forms began to prevail in the picture of tuberculosis. The number of complications in the form of massive pulmonary hemorrhages decreased, but cirrhotic forms of tuberculosis with the development of pulmonary heart failure and complications in the form of amyloidosis began to prevail. Under the influence of preventive measures, the epidemiology and clinic of many childhood infections have changed, for example, scarlet fever, the first period of which began to occur in the form of a mild catarrhal sore throat, without a “burning pharynx”, without serious complications in the form of noma, etc. However, the number of patients with a second period of scarlet fever increased. characterized by kidney damage. Significantly easier, without the development of croup, diphtheria began to flow, and much more often adults began to suffer from it. Special antibiotic therapy for croupous pneumonia led to the fact that this disease began to proceed in the form of an abortive form, stopping at the stage of high tide, sometimes at the stage of red hepatitis and thereby lost its tragic significance. Thus, artificial pathomorphosis is a reflection of the success of preventive and clinical medicine. However, the experience of our country, which has suffered a decline in the standard of living of the population, the collapse of the pharmaceutical industry, a sharp decrease in the potential of healthcare, including the sanitary-epidemiological service, the cessation of vaccinations for children and other difficulties associated with the transition from one socio-political system to another, has shown that the induced pathomorphism is not fixed for even a long time and, if it is not constantly maintained, it disappears. An example of this is the situation with the same tuberculosis. The collapse of the country's anti-tuberculosis service system, in almost all its links, turned back to the epidemiology and tuberculosis clinic, characteristic of the beginning of the 20th century, and resulted in an epidemic of this disease, the level of which in Russia caused concern of other countries and required assistance from international health care. There is also a false pathomorphosis - an apparent change in the disease. So, for example, such an infectious disease of young children as rubella has long been known. Another childhood disease is known - congenital deafness. However, as knowledge of the infection deepened, it became clear that deafness was not an independent disease, but a complication of rubella, which the fetus carries in the form of otitis in the prenatal period. They learned to diagnose and treat rubella early, and congenital deafness disappeared. But this is not a true pathomorphism, it simply became clear that rubella is the disease that is complicated by deafness. Consequently, the disappearance of congenital deafness, as an independent disease, is a false pathomorphosis. These are the main provisions of nosology that allow us to understand the laws of the development of diseases, which is the key to their successful diagnosis and treatment, as well as those international rules, without which the international medical community could not interact.
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INTRODUCTION TO NOSOLOGY. TEACHING ABOUT DIAGNOSIS. PRINCIPLES OF CONSTRUCTION OF CLINICAL AND PATHOLOGICAL DIAGNOSIS. REASONS AND CATEGORIES OF DIAGNOSIS DIVERSION. The concept of iatrogenism
- Shalyga I.F., Martemyanova L.A., Turchenko S.Yu. Postmortem diagnosis. Diagnosis discrepancies and their analysis, 2012
- STRUCTURE OF THE CLINICAL AND PATHOLOGICAL DIAGNOSIS, RULES FOR COMPARISON OF DIAGNOSIS
Clinical and pathoanatomical diagnoses are the stages of a single diagnostic process, although during a stay in a hospital, the lifetime clinical diagnosis of the disease can change (for example, a patient was treated for a long time for liver cirrhosis and died of myocardial infarction). Therefore, when formulating a final clinical diagnosis (ZKD), it is necessary to isolate the disease that caused
- Discrepancies in diagnoses. Definition Types of diagnosis discrepancies
It is necessary to dwell on such a concept as a discrepancy of diagnoses, which can be revealed by comparing the clinical and pathological diagnosis. In each medical institution, a comparison of clinical and pathological diagnoses is mandatory. This allows you to evaluate the quality of diagnosis in clinical and outpatient departments, regardless of the opinion and influence of medical
- The basic principles of diagnosis
The clinical diagnosis presented to the patient is clearly categorized and includes the following sections, set out in strict sequence: - The underlying disease (simple or combined). - Complications of the underlying disease. - Accompanying illnesses. Examples of diagnosis: The underlying disease is defined as the condition that causes the patient to seek treatment.
- Requirements for the comparison (comparison) of clinical and pathological diagnoses
When comparing ZKD and PAD, the concepts of “coincidence” or “discrepancy” are used to compare only the heading “underlying disease” (the initial cause of death). A separate comparison is made between the diagnoses of a fatal complication (the immediate cause of death) and the main concomitant diseases, which is recorded when they do not coincide as an unrecognized fatal complication
- Principles for preparing a pathoanatomical diagnosis and medical death certificate
The principles of interdisciplinary understanding of clinicians and pathologists should be based on a clear nosological identification of sepsis with the indispensable use of ICD-10 codes: • sepsis as a complication of local inflammatory processes, surgical interventions, injuries; • sepsis as an independent nosological unit - the initial (main) cause of death; • sepsis as a manifestation
- Basic principles for the design of a pathological diagnosis in pediatric practice
One of the very difficult issues is the interpretation of morphological changes in the corpse and the construction of a pathological diagnosis in the prenatal and perinatal periods. In these age periods, the pathology and cause of death of the fetus and newborn is largely due to the complex of causes of the mother-fetus interaction. Some of them are installed at the autopsy of the fetus, which has certain
- Registration of a pathoanatomical diagnosis
In connection with the successful development of theoretical and practical medicine, the improvement of the theory of diagnosis is of great relevance. Of particular importance are the general principles of pathoanatomical diagnosis, the wording and structure of the pathoanatomical diagnosis, as the final stage in the knowledge of a disease, syndrome, pathological process or pathological condition [Abrikosov AI, 1947;
- Building an obstetric diagnosis
1. In the first place is the presence of pregnancy and its duration: "Pregnancy - 38 weeks." 2. Further indicate the presentation of the fetus - the head or pelvic presentation and its variants: "Head (occipital) presentation" or "Pelvic (purely gluteal) presentation." 3. In the third place, the period of labor is noted: the "first period of labor" and its phase (latent or active phase). 4. Pay attention to integrity or
- Registration of the autopsy protocol, pathological diagnosis, clinical and pathological epicrisis, conclusion and death certificate
Registration of the autopsy protocol, pathological diagnosis, clinical and pathological epicrisis, conclusion and certificate of
- PRESENTATION OF DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
The process of recognizing features of the state of an object is called diagnostics. In medicine, such an object is a person. The main task of diagnosis is to identify deviations from the average normal indicators. In medicine, diagnostic tasks are reduced to recognition of pathological processes, congenital malformations and their consequences. It is important not only to detect deviations, but also
- Diagnosis. Diagnosis structure
The diagnosis (from the Greek. Diagnosis - “recognition”) - a medical opinion on the nature of the disease and the condition of the patient, expressed in accepted medical terminology and based on a comprehensive systematic study of the patient. In medicine, there are 4 main types of diagnoses: clinical, pathological, forensic and epidemiological. Construction of a clinical and pathoanatomical
- Clinical Diagnosis Requirements
Currently, the following requirements for the diagnosis are formulated: - correctness - timeliness - validity - completeness - logical construction - compliance with the accepted classification approaches. The correctness of the diagnosis is determined, first of all, by the accuracy of reflection of the essence of the disease. So, if a patient’s cause of hypertension is hyperaldosteronism due to
- 5. DIRECT CLINICAL DIAGNOSIS.
Direct is a method for constructing a diagnosis in those cases when, when examining a patient, one diagnostic hypothesis arises and it is confirmed at the end of the examination. If you approach strictly, in any case, the doctor differentiates the clinical symptoms, syndromes, and the more the more he knows, however, this is done as if unconsciously. The solution comes quickly, as if naturally,
- Diagnosis and differential diagnosis.
When making a diagnosis, general data on the sanitary and zoo-hygienic conditions of rearing young animals and the maintenance and feeding of mothers are taken into account. Pay attention to the behavior of the animal in the room, while walking on its general condition, take into account clinical signs and pathological changes. X-ray examination finds various degrees of pulmonary dimming
- . Clinical diagnosis
The veterinarian makes the diagnosis based on the clinical picture, medical history and laboratory data. The diagnosis is confirmed by fluoroscopy of the stomach and the study of gastric contents. The first, most constant sign of chronic gastritis and what draws the attention of the owners is vomiting of undigested food. Since chronic gastritis cannot occur without some
- 4. METHODOLOGY OF CLINICAL DIAGNOSIS.
The compound word “methodology” can be divided into the terms “method” and “science”. The science of the research method, or theoretical justification of the method. The content of this term answers the question why such a combination of research methods is used, why so, and not otherwise. Diagnosis is one of the forms of cognition. She uses research and thinking methods common to all sciences: historically