Licensed books on medicine
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Dear reader! You have read the entire book. We hope that the information contained in it helped you to develop a clinical thinking, i.e. the ability to properly collect the necessary information and process it into a detailed clinical diagnosis. It is well known that recent advances in science and technology have significantly improved the recognition of internal diseases and deepened the understanding of many issues of their clinic and pathology. However, despite the large number of additional methods of research, the doctor is still experiencing significant difficulties in the diagnosis of certain diseases. This is due to a number of subjective and objective difficulties, the knowledge of which will in many ways help to overcome diagnostic difficulties.
Errors in the diagnosis of internal diseases are based on many reasons that can be classified.
Errors with an objective cause:
a) the complexity, the atypical nature or the severity of the disease, which make it difficult to recognize it;
b) the imperfection of medical science;
c) lack of necessary conditions for diagnosis. Errors with a subjective reason:
a) insufficient training of the doctor;
b) the personality and character of the doctor (the originality of his thinking). The complexity, atypical nature, or severity of the disease can be expressed in the most varied variants.
First of all, it should be remembered that difficulties in making a diagnosis arise, as a rule, in the final stage of the disease and in its debut. For example, the development of circulatory failure of stage III substantially “erases” the nosological signs of the disease that led to the development of decompensation. The patient reveals a significant increase in heart rate, relative valve insufficiency (mitral and tricuspid), rhythm disturbances (often atrial fibrillation), hepatomegaly with the development of fibrosis, massive edema and fluid in the abdominal and pleural cavities (or "heart" cachexia). Against this background, it is very difficult to determine the nosological status of the disease: valvular disease, cardiomyopathy, diffuse severe myocarditis, post-infarction cardiosclerosis (often with the development of aneurysm), amyloidosis of the heart. Data from additional research methods reveal only significant dilatation of the heart and signs of pronounced hemodynamic disturbances, as well as changes in the function of organs in conditions of circulatory failure. The results of the first stage of the diagnostic search can provide significant assistance in such a situation. However, there are cases when there is no significant data in the history, so the patient cannot report anything valuable for recognition of the disease. In this situation, the probability of a diagnostic error is high.
Another situation is the presence of renal failure syndrome, when the signs of the main disease that led to impaired renal function are largely erased (chronic glomerulonephritis, pyelonephritis, amyloid oz of the kidneys). Similarly, in the development of severe broncho-obstructive syndrome, respiratory and subsequent heart failure, it is difficult to determine what underlies the severe clinical picture: bronchial asthma, chronic obstructive bronchitis, pulmonary vasculitis, chronic specific or nonspecific lung diseases.
In the debut of the disease, diagnosis is also difficult. So, many diffuse diseases of the connective tissue can manifest articular syndrome and the patient is treated for a long time for rheumatoid arthritis (with more or less success). Extreme complications are the debut of the disease in the form of fever of unknown origin or an isolated increase in ESR, the appearance of anemia, unmotivated weight loss. The range of differentiated diseases is extremely large, and it often turns out that the correct diagnostic conclusion can be made only with dynamic observation of the patient, when the characteristic signs of a disease are determined.
The objective difficulties of diagnosis should also include cases where the clinical picture of the disease at the forefront is the defeat of any one organ or system, and the rest of the pathology seems to go to the "second" plan, and the whole situation is regarded differently. A classic example is glomerulonephritis, which debut systemic lupus erythematosus or infective endocarditis. This patient is regarded as suffering only from glomerulonephritis (acute) and is given appropriate treatment. Meanwhile, as time goes on, the disease develops, whereas in one case it is necessary to prescribe glucocorticosteroids as early as possible, and in the other - a massive antibiotic therapy.
Similarly, damage to the cardiovascular system, such as the heart, with systemic scleroderma can significantly predominate in the clinical picture, while skin manifestations, Raynaud's syndrome, swallowing disorders, articular syndrome can be practically not expressed. In this situation, the patient will be regarded as suffering from diffuse myocarditis and basic therapy will not be carried out. Another example: with systemic lupus erythematosus, the disease may debut with autoimmune hemolytic anemia or thrombocytopenic purpura. Enough time will pass before the doctor is convinced that these manifestations of the disease are nothing more than its syndromes (the time required for glucocorticosteroid therapy will be lost).
Objective difficulties of diagnosis are also associated with a longer life span of the population and the development of atherosclerosis, which in itself gives a very variegated symptoms (depending on the preferential localization of the affected vessels).
A typical situation is the development of infectious endocarditis in the elderly: the existing auscultatory picture of heart damage is due to its atherosclerotic lesion, and an increase in body temperature, sweating, and changes in blood parameters - slow pneumonia without clear radiological changes (or urinary tract infection, especially in women). -therapy improves the patient's condition: acute phase hematological parameters change, body temperature returns to normal, and the diagnostic concept seems to be s receives confirmation. However, infective endocarditis can not be cured, on the contrary, the disease progresses, the process involved and other organs of the system, and when the clinical picture is "classical", treat the patient (and cure) becomes difficult.
From all this it follows: even in the most typical situation, it would seem to be remembered that the observed clinical picture of the disease can have a double meaning - to be an independent pathology or a part of another disease.
Imperfection of medical science also leads to errors in diagnosis. So, with a number of diseases there are no clear "dividing lines". The complexity of differentiation of dilated cardiomyopathy and diffuse myocarditis of the severe course, the hypertensive form of chronic glomerulonephritis and hypertension with kidney damage is well known. When carrying out diagnostics in such cases, already at the first stage of the diagnostic search, the range of differentiated diseases is very large; have the same similar symptoms and syndromes. In such cases, the question arises: Is accurate diagnosis possible at this particular moment? (we are not talking about diagnostics in the process of more or less long-term observation of the patient, when the entire clinical picture is gradually “unfolding”). In principle, of course, it is possible under the condition that the very "substrate" of the disease is examined: the tissue of the heart, liver, kidneys, bone marrow, lymph node. However, it is not always possible to perform due to purely technical reasons (in this medical institution they do not have this method of research), the patient categorically refuses biopsy or puncture of the organ and, finally, even the pathomorphological and cytological studies do not in all cases illustrate the specific picture specifically for a particular disease. For example, with liver biopsy, we can get a picture of active chronic hepatitis, which is often a syndrome in a number of diseases, such as SLE, pulmonary tuberculosis, and others; At the same time, the patient may have chronic active hepatitis as an independent nosological unit. All this leads to the fact that in some cases the diagnosis is made with a greater or lesser degree of probability: there is no histological and cytological confirmation of the disease; in the clinical picture of the disease there are no major signs of it (for example, with undoubted myocardial infarction in patients with malignant tumors, there are no typical ECG changes or they are not specific). Similarly, significant difficulties arise in the diagnosis of secondary infectious endocarditis, which develops against the background of an already existing rheumatic heart disease (neither the clinical picture nor the laboratory data provide a basis for an accurate diagnosis).
The absence of the necessary conditions for diagnosis is a situation that is very understandable for each doctor (the impossibility in a medical institution of conducting a number of laboratory and instrumental methods of examination, for example, fibrogastroscopy, scanning with radioactive isotopes, echography, computed tomography, some stress tests, etc.).
Errors due to a gap in the knowledge of the doctor, the most numerous. The situation is quite simple: if the doctor does not know about the existence of a particular pathology, then he will never think about it. The following advice can serve as a “recipe” for avoiding diagnostic errors: if the clinical picture of the disease does not fit into the picture familiar to the doctor, you should think about some other disease (or a variant of the disease known to the doctor) and try to get information about it from literature or by contacting a more experienced clinician. It will be a big mistake to deviate any deviation from the usual picture of the disease as a variant of the course (or atypical course). In this case, you should definitely think about the disease, syndromically similar to the observed clinical picture.
You have got acquainted with some difficulties of diagnostics on IV and V courses. On the VI course you will get acquainted with the difficulties of diagnosis in their entirety, and this will continue throughout life. In this regard, the development of solid skills for examining the patient and clinical thinking is absolutely necessary for a doctor of any specialty.
Subjective errors are related to the personality of the doctor, the level of qualification, the peculiar nature and nature of thinking, the ability to examine the patient, the desire to improve their knowledge.
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