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Dear Reader! You read the whole book. We hope that the information contained in it helped you develop clinical thinking, i.e. the ability to correctly collect the necessary information and process it into a detailed clinical diagnosis. It is well known that the achievements of science and technology of recent times have significantly improved the recognition of internal diseases and deepened understanding of many issues of their clinic and pathology. However, despite the large number of additional research methods, the doctor still experiences significant difficulties in diagnosing certain diseases. This is due to a number of subjective and objective difficulties, the knowledge of which will greatly help to overcome diagnostic difficulties.
Errors in the diagnosis of internal diseases are based on many reasons that can be classified.
Errors having an objective cause:
a) the complexity, atypicality or severity of the disease, making it difficult to recognize;
b) the imperfection of medical science;
c) lack of necessary conditions for diagnosis. Errors with a subjective cause:
a) insufficient preparation of a doctor;
b) features of the personality and character of the doctor (the peculiarity of his thinking). The complexity, atypicality, or severity of the disease can be expressed in many different ways.
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 stage III circulatory failure substantially erases the nosological signs of the disease, which led to the development of decompensation. The patient has a significant increase in heart, noise of 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 “cardiac” cachexia). Against this background, it is very difficult to determine the nosological affiliation of the disease: valvular defect, cardiomyopathy, severe diffuse myocarditis, postinfarction cardiosclerosis (often with the development of aneurysm), cardiac amyloidosis. The data of additional research methods reveal only significant dilatation of the heart and signs of severe hemodynamic impairment, as well as changes in organ function in conditions of circulatory failure. Significant help in this situation can be provided by the results of stage I of the diagnostic search. However, there are cases when there is no significant data in the history, so the patient can not report anything valuable for the 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 underlying disease that led to impaired renal function are largely erased (chronic glomerulonephritis, pyelonephritis, amyloid kidney disease). Similarly, with the development of severe bronchial 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.
At the onset of the disease, diagnosis is also difficult. So, many diffuse diseases of the connective tissue can manifest themselves as joint syndrome and the patient is treated for a long time for rheumatoid polyarthritis (with more or less success). Extreme complication is the debut of the disease in the form of a fever of unclear origin or an isolated increase in ESR, the appearance of anemia, and unmotivated weight loss. The range of differentiable diseases is extremely large, and it often turns out that the correct diagnostic conclusion can be made only with dynamic monitoring of the patient, when the characteristic signs of a disease are determined.
Objective diagnostic difficulties should also include cases when the defeat of any one organ or system comes to the fore in the clinical picture of the disease, and the rest of the pathology seems to go to the “second” plane, and the whole situation is regarded differently. A classic example is glomerulonephritis, which makes systemic lupus erythematosus or infective endocarditis. Such a patient is regarded as suffering only with glomerulonephritis (acute) and appropriate treatment is carried out. Meanwhile, time goes on, the disease develops, while in one case it is necessary to prescribe glucocorticosteroids as early as possible, and in the other - massive antibiotic therapy.
Similarly, damage to the cardiovascular system, such as the heart, in systemic scleroderma can significantly prevail in the clinical picture, while skin manifestations, Raynaud's syndrome, swallowing disorders, and articular syndrome can be practically not expressed. In a similar 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 can 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 missed).
The objective diagnostic difficulties are also associated with a longer life span of the population and the development of atherosclerosis, which in itself gives a very varied symptomatology (depending on the predominant location of the affected vessels).
A typical situation is the development of infectious endocarditis in the elderly: the existing auscultatory picture of heart damage is explained by its atherosclerotic lesion, and the increase in body temperature, sweating, changes in blood counts are explained by sluggish 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 normalizes, 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.
The conclusion follows from all this: even, it would seem, in the most typical situation, it must be remembered that the observed clinical picture of the disease can have a double meaning - to be an independent pathology or part of another disease.
The imperfection of medical science also causes errors in diagnosis. So, with a number of diseases there are no clear "dividing lines." It is well known the difficulty of differentiating dilated cardiomyopathy and diffuse severe myocarditis, the hypertensive form of chronic glomerulonephritis and hypertension with kidney damage. When conducting diagnostics in such cases, already at the first stage of the diagnostic search, the range of differentiable diseases is very large, for any number of suspected diseases they “overlap” each other, i.e. have the same similar symptoms and syndromes. In such cases, the question arises: is it possible to accurately diagnose at this particular moment? (we are not talking about the diagnosis in the process of more or less prolonged observation of the patient, when the whole clinical picture gradually "unfolds"). Fundamentally, of course, it is possible provided that the “substrate” of the disease itself is examined: tissue of the heart, liver, kidneys, bone marrow, lymph node. However, this is not always possible due to purely technical reasons (in this medical institution this method of research is not mastered), the patient categorically refuses biopsy or organ puncture and, finally, even the pathomorphological and cytological examination itself does not in all cases illustrate a specific picture characteristic just for a specific disease. For example, with a liver biopsy, you can get a picture of active chronic hepatitis, which is often a syndrome in a number of diseases, for example, 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; the clinical picture of the disease does not have its main signs (for example, with undoubted myocardial infarction in patients with malignant tumors, there are no typical ECG changes or they are nonspecific). In the same way, considerable difficulties arise in the diagnosis of secondary infectious endocarditis, which develops against the background of existing rheumatic heart disease (neither the clinical picture, nor laboratory data provide grounds for an accurate diagnosis).
The absence of the necessary conditions for diagnosis is a situation that is very understandable for each doctor (the inability to conduct a number of laboratory and instrumental research methods in a medical institution, for example, fibrogastroscopy, scanning with radioactive isotopes, ultrasound imaging, computed tomography, some load tests, etc.).
Errors due to a gap in the knowledge of the doctor are the most numerous. The situation is quite simple: if a 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” to avoid diagnostic errors: if the clinical picture of the disease does not fit into the picture familiar to the doctor, you need to think about some other disease (or variant of the course of the disease known to the doctor) and try to get information about it from literature or by contacting a more experienced clinician. It would be a big mistake to “declare” any deviation from the usual picture of the disease as a variant of the course (or an atypical course). In this case, you should definitely think about a disease syndromically similar to the observed clinical picture.
You met some of the difficulties of diagnosis in IV and V courses. On the VI course, you will become acquainted with the complexities of diagnosis in their entirety, and this will continue throughout life. In this regard, the development of solid skills for examining a patient and clinical thinking is absolutely necessary for a doctor of any specialty.
Mistakes of a subjective nature are associated with the personality of the doctor, the level of qualification, the peculiarity of character and the characteristics of thinking, the ability to examine the patient, the desire to improve their knowledge.
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