Divergence of diagnoses. Immediate cause of death, terminal

Comparison of clinical and pathoanatomical diagnoses is one of the forms of control over the quality of diagnostic and medical work, an important way to influence the organization of medical care, the possibility continuous improvement physician qualifications.

1. Comparison is carried out according to three headings, which should contain the final clinical and final pathoanatomical diagnoses: a) the underlying disease; b) complications; c) comorbidities. The comparison is based on the nosological principle.

The underlying disease ("initial cause of death" according to ICD-10) is a disease or injury that caused a chain of disease processes that directly led to death.

Complications are pathological processes and syndromes that are pathogenetically associated with the underlying disease, significantly aggravating the course of the disease and contributing to death.

A concomitant disease is a nosological unit, a syndrome, etiologically and pathogenetically not related to the underlying disease, which does not affect its course.

Clinical and pathoanatomical diagnoses should reflect the etiology and pathogenesis of the disease, a logically justified temporal sequence of changes, intranosological characteristics (type of course, degree of activity, stage). When formulating, use modern terms and classification schemes, and coding is carried out in accordance with the headings of ICD-10. The term for establishing a clinical diagnosis is reflected on the title page and in the epicrisis of the medical history. The diagnosis should be as complete as possible, include the whole complex of pathological changes, including those caused by medical influences, be not formal, but "diagnosis of a particular patient."

2. The main clinical and pathoanatomical diagnoses may include one or more nosological entities. In the latter case, the diagnosis is called combined, and when it is formulated, the following are distinguished:

Competing diseases - two or more diseases, each of which in itself could lead to death;

Combined diseases - not fatal in themselves, but in combination, developing simultaneously, aggravating the course of the disease and leading to death;

Background diseases are nosological units that played a significant role in the occurrence and adverse course of the underlying disease and contributed to the occurrence of severe, sometimes fatal, complications.

3. In accordance with the requirements of the ICD and other regulatory documents, individual syndromes and complications can be presented as the main disease in the diagnosis. It's about mainly about cerebrovascular disease (CVD) and coronary disease heart disease (IHD) due to their special frequency and social significance as the most important reason disability and mortality of the population (at the same time, hypertension and atherosclerosis should not disappear from the diagnosis). The foregoing also applies to cases of iatrogenic category III.

4. Comparison of clinical and pathoanatomical diagnoses, as a rule, regardless of the length of stay in a health facility, should be carried out jointly by the pathologist and the attending physician, for which the presence of the latter at the autopsy is mandatory. The result of the comparison of diagnoses should be a statement of the following facts:

The main clinical and pathoanatomical diagnoses coincide or do not coincide. If there is a discrepancy, there is a discrepancy in the diagnoses of the underlying disease;

The diagnoses in the headings "background diseases", "complications" and "comorbidities" coincide or do not coincide. There are discrepancies in the diagnoses for these rubrics.

The following options are included in the discrepancy section by underlying disease:

1) Divergence of diagnoses according to the nosological principle, according to the etiology of the process, according to the localization of the lesion (including in the absence of indications of the topic of the process in the clinical diagnosis).

2) Non-recognition of one of the diseases included in the combined diagnosis.

3) Substitution of a nosological form by a syndrome, complication (except for CVD and IHD).

4) Incorrect formulation of the clinical diagnosis (non-observance of the etiopathogenetic principle, lack of rubrication, evaluation of the complication as the underlying disease or the underlying disease as a concomitant process).

5) Non-recognition during life of iatrogenic category III. The results of comparing the diagnoses are entered by the pathologist in the clinical and pathological epicrisis, brought to the attention of the attending physician and discussed collectively at the meetings of the clinical and anatomical conference, medical commission and commissions for the study of lethal outcomes (KILI).

5. Having established the fact of discrepancies in diagnoses for the underlying disease, the category of discrepancy should be determined.

Category I includes cases in which the disease was not recognized at previous stages, and in this medical facility it was impossible to establish the correct diagnosis due to the severity of the patient's condition, the short duration of the patient's stay in this institution and other objective difficulties.

Category II includes cases in which the disease in this institution was not recognized due to shortcomings in the examination of the patient; it should be taken into account that correct diagnosis would not necessarily decisive influence on the outcome of the disease. However correct diagnosis could and should have been set.

Only II and III categories of discrepancies between clinical and pathoanatomical diagnoses are directly related to the health facility where the patient died. I category of discrepancies in diagnoses refers to those health facilities that provided medical care to the patient in more than early dates his illness and before hospitalization in a medical facility, in which the patient died. The discussion of this group of discrepancies in diagnoses should either be transferred to these institutions, or the medical staff of the latter should be present at a conference in the hospital where the patient died.

After comparing the main diagnoses, a comparison is made on the most important complications and concomitant diseases. If the most important complications are not diagnosed, the case should be interpreted precisely as a discrepancy in diagnoses for this section, and not as a statement of an unrecognized complication with a coincidence in the diagnosis of the underlying disease.

6. Of no small importance in assessing the level of diagnosis is the time factor. Therefore, it is advisable, along with the comparison of diagnoses, to clarify whether the main clinical diagnosis was timely or not, whether complications were diagnosed in a timely manner or late, whether the late diagnosis affected the outcome of the disease. A short stay of a patient in a hospital is conditionally considered a period of less than 24 hours (for urgent patients, the period is reduced and individualized).

7. Determination of the category of discrepancy between clinical and pathoanatomical diagnoses must necessarily be accompanied by the identification of the causes of the discrepancy, often defects in the work of the attending physician.

The reasons for discrepancies in diagnoses are divided into 2 large groups: objective and subjective. Objective reasons include cases when it was impossible to establish a diagnosis (the short duration of the patient's stay in the hospital, the severity of his condition, the atypical course of the disease, etc.). Subjective reasons include defects in the examination of the patient, insufficient experience of the doctor, incorrect assessment of the results of laboratory and other studies.

8. The final judgment on the category of discrepancy between clinical and pathoanatomical diagnoses, its causes belongs to the KILI and the medical commission. At the same time, the diagnosis is discussed not only by the clinician, but also by the pathologist, because objective and subjective errors diagnostics can also be admitted during pathomorphological examination. In this case, the reasons for objective errors include the impossibility of conducting a full detailed autopsy, the inability to microscopic examination sectional material and other analyzes - bacteriological, biochemical, etc. The subjective causes of errors include insufficient qualification of the dissector, incorrect interpretation morphological features, technically illiterate or incomplete autopsy, lack of necessary additional research(microscopic, bacteriological, virological, biochemical) under conditions when they are available for execution. This also includes the underestimation of clinical data, the reluctance to consult with a more experienced specialist, the desire to "adjust" the pathoanatomical diagnosis to the clinical one.

In disputable situations, when the opinions of clinicians and pathologists do not coincide, and after analyzing the case at the medical commission, the point of view of the pathologists is officially adopted. For further discussion, materials can be transferred to the main and leading specialists of the relevant profile.

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I took the cell phone. The voice of the interlocutor was lifeless and slow, like a man who has resigned himself to defeat.

Hello, professor, it's the head physician of the hospital *** who is bothering you. I must report that our plans for joint work it will not come true - we are finalizing until the end of the year and closing.
- And why, dove? It seems that everything was fine, even the ministry was supposed to finally give a tomograph to neurology the other day?
- I was there. Reprimanded. They said we weren't working well and were shutting us down. So tonight we have a meeting of the labor collective.
- It's like a bad job?
- A large proportion of discrepancies in diagnoses.
- What?
- This is their new fashion. They began to write that our doctors have 30% discrepancies in diagnoses, which means that they themselves ruined 30% of patients. Now everyone in the ministry is running around, yelling, demanding a reduction. They raised our reporting ... now, and they are closing it ...
- But, my dear, those 30% that they like to quote are from a report at a conference on healthcare organization, where it was said that 30% are discrepancies not just in diagnoses, but in a diagnosis and a post-mortem diagnosis. And after all, it was clearly told there that these 30% are the world average, and they are often explained by the fact that physicians write diagnoses based on symptoms, and pathologists write diagnoses based on the cause of death. For example, if a drug addict is called for an overdose, then the ambulance writes “acute heart failure” in the cause of death, since she cannot write anything else, having no tests.
- I know, but have you tried to explain it to "them"?
- Yeah, that means they’ve come up with a new magic indicator and now they’re screwing for it ... So, my dear, immediately go to the ministry, and sign a protocol of intent there stating that you undertake to have in the hospital, starting from the moment the tomograph is installed there, the percentage of discrepancy between the main diagnoses not higher than 5%, otherwise you do not mind the immediate closure without protests and compensation ...
- Professor - Are you out of your mind?
“I’ll explain later, time is precious, we need to be in time before the previous decision is issued by order. And I'll go to the hospital to meet you. Just do not forget - the agreement is in writing, and that there are discrepancies in the main diagnoses. And don’t worry about 5% - and you won’t get it ...

=================
Two hours later, I was sitting at a meeting of the labor collective and listened with interest as the chief accountant, personnel officer and lawyer told doctors in three voices that they would be closed for the poor work of doctors, that a fool would make a correct diagnosis with a tomograph for a stroke patient, and if you are a good the doctor, then he should just make a diagnosis and determine the correct treatment ... Finally, my mobile phone chimed, the head physician reported that he had done everything exactly, and I took the floor.

Dear colleagues! According to my joint plan with the head doctor, he just signed a paper in the ministry that we, that is, you, will be immediately closed if your main diagnoses differ by more than 5%. And if there is less, then, accordingly, they will not close ...

There was silence in the hall. I continued.

So - what is the reason for the high frequency of discrepancy between the main diagnoses? As you understand, this is a formal indicator, so the fewer basic diagnoses you use, the better. I propose to leave three diagnoses ...
- And how to treat? – there was a question from the audience.
- In order to avoid problems with insurance companies, we treat not only the main diagnosis, but also related ones ...
- Is it like "an ankle sprain complicated by acute cerebrovascular accident and a fracture of the arm"? – someone in the hall guessed.
- Exactly!
- And how to make the main diagnoses? Without a tomograph, with our frail laboratory facilities?
- And we put the main diagnosis on the length of the surname. If the surname consists of 4, 7, 10, 13 and so on letters, then we make the diagnosis No. 1. If 5, 8, 11, 14 and so on - then number two. And if the number of letters in the surname is divided by three, then we make the third diagnosis.

In the right wing of the hall, where the staff of the psychiatric ward was sitting, there was a slight movement. The orderlies began to get up, but the doctor, who knew me, reassured them. I continued.

Thus, there will be no discrepancies within the hospital. And in order to avoid discrepancies with other institutions, these diagnoses must meet the following criteria:
1. They can be delivered or not delivered to any person, regardless of his condition,
2. For its setting, no laboratory or instrumental studies are required,
3. The presence of this diagnosis does not require any special treatment,
4. It is impossible to find out whether a cure has occurred or not.
Due to this, discrepancies between the main diagnosis and those that will be made outside the hospital walls are impossible in principle.

The hall began to stir. The therapists tried to explain something to the surgeons on their fingers, the anesthesiologists went into a normal state, that is, they calmed down, relaxed and fell asleep, the ultrasound doctor giggled, the junior medical staff took out cosmetic bags and began to preen, and the head. The ENT department began picking his nose intently. This seemed to be the most effective way to collect his thoughts, as he stood up and asked:

And what are these three magical diagnoses that can be made to anyone just like that and cannot be refuted?
- Sorry, colleagues, I forgot. So, starting today, the hospital makes only the following three diagnoses: dysbacteriosis, depression and vegetative-vascular dystonia.

Dedicated to the True Teacher of Truth.

The percentage of discrepancy is one of the main indicators of the quality of medical care. Last years there has been a downward trend.

The Pathological Anatomical Service under the Moscow Department of Health analyzed how correct diagnoses are made by the capital's doctors. The diagnosis is clinical - it is made by doctors when the patient is alive. And there is a pathoanatomical diagnosis - it is made at the autopsy of the body of a deceased patient. The percentage of discrepancy is one of the main indicators of the quality of medical care. In Moscow, the figures are the same.

As you can see, the number of incorrectly diagnosed diagnoses by doctors is decreasing, but still remains quite significant. It turns out that now every twelfth patient who died was misdiagnosed. And before, doctors incorrectly treated every seventh.

What are the mistakes

The details are also interesting. Errors are divided into three types. The first type is objective reasons. For example, a patient was taken to the hospital at a very early serious condition and there was little time to make a diagnosis. Or the case was very complex, confusing, the disease did not proceed according to the rules.

This option is possible: the patient was given misdiagnosis at previous stages of treatment. Because of this, the treatment was delayed and did not work. And in the hospital where he died, they simply entered this wrong previous diagnosis on the card, because there was no time to figure it out. Be that as it may, errors of the first type in Moscow in 2016 accounted for 74% of all cases.

The second type is subjective reasons ( insufficient examination, incorrect formulation of diagnoses, etc. - in general, flaws). This may not significantly affect the outcome of the disease, that is, the patient would still die (in 2016, 26% of cases). Or it can affect - that is, the patient died precisely because of an incorrect diagnosis.

According to the Pathological Anatomical Service, there were no such cases in 2016. But there is another organization that keeps the same statistics - the Bureau forensic medical examination at the same metropolitan health department. According to them, in 2016 there were still 2 cases (1.4%) when patients died precisely because of an incorrect diagnosis. And in 2015 there were 15 such cases.

In total, the specialists of the service perform about 40 thousand autopsies per year (in 2015 - 43.7 thousand, which is 36% of all deaths).

Distorted statistics

Yan Vlasov, co-chairman of the All-Russian Union of Patients, noted that the discrepancy between intravital and pathoanatomical diagnoses reaches 25%.

During the examinations of the Compulsory Medical Insurance Fund (Compulsory Medical Insurance Fund. - Note. Life) for every 10 examinations carried out, 6 show violations in the diagnosis. About 50 thousand deaths annually occur due to the fault of doctors. The percentage of disability due to the fault of the health care system is estimated at 10–35% by various experts.

All discrepancies in the diagnoses of doctors and pathologists are divided into three categories: objective circumstances that did not allow a correct diagnosis; there were such opportunities, but the wrong diagnosis did not play a significant role in the death of the patient; and the third category - the divergence of diagnoses led to incorrect therapeutic actions and death, - the expert said.

As the president said Russian Society pathologists Lev Kaktursky, discrepancies of the first category (when there were objective circumstances that did not allow a correct diagnosis) are 50–60%, the second - 20–35% (there were opportunities to make a correct diagnosis, but the wrong diagnosis did not play a significant role in the death of the patient) . Speaking about the third category (when exactly the wrong diagnosis led to the death of the patient), he noted that compared to the USSR, the number of such discrepancies has decreased: before it was 5-10%, now in Moscow it is less than 1%, and in Russia their number ranges from 2 to 5%. But many cases of medical negligence, due to which the patient died, may remain a secret, the expert added.

There is an order from the MHIF, according to which, if the second and third categories differ, the institution is not paid the funds spent on the patient, and a fine is imposed, - explained Lev Kaktursky. - This is a terrible order, which under the root cuts the entire control function of the opening. The pathologist simply obeys the order of the chief doctors, who do not want to spoil the indicators. Now the lion's share of all discrepancies in diagnoses are discrepancies of the first category, the most unpunished. But this is a distorted statistic.

An autopsy will show

The autopsy method remains the most reliable in determining the cause of death. But it is not always carried out: it is not uncommon for relatives of the deceased to different reasons(religious, aesthetic, etc.) refuse to autopsy - which means that it will not work to find out exactly what the patient died from. Now, according to health protection law , the opening is carried out in without fail in 12 cases. Among them are suspicions of death from an overdose of drugs, suspicions of violent death and death from cancer.

According to Lev Kaktursky, Soviet time opened 90-95% of patients who died in hospital, now this figure in Russia is about 50%.

On the one hand, it is bad that there are fewer autopsies, but, on the other hand, there are objective reasons for this, namely, the improvement in the ability to diagnose a patient's diseases during his lifetime. Medicine is improving, and where during his lifetime he was installed accurate diagnosis, probably, it makes no sense to conduct an autopsy, - the expert explained.

Dear Patients

If the patient managed to survive after being misdiagnosed, he can go to court. A striking example- the case with the Muscovite Maxim Dorofeev, about which Life. He p sued doctors from the Institute of Surgery. A.V. Vishnevsky. Two years ago, he went to the clinic complaining of insomnia and high blood pressure. The doctors said that Maxim had a malignant tumor in the brain, and they scheduled an operation. After it, it turned out that the tumor was benign and the diagnosis was incorrect. Doctors mistook a congenital formation for a malignant tumor, which was completely removed.

According to the victim, he actually did not need the operation and it caused serious harm to his health. Surgical intervention led to the fact that for two years the man could not walk and move independently. Now he has become an invalid of the first group.

The more difficult the diagnosis, the more profitable the patient is for the hospital. The more money the hospital will receive from the insurance company, explains Dr. Director of Research Institute of Health Organization and Medical Management Enta David Melik-Guseinov. - In some directions this problem was overcome - tariffs were changed. For example, previously complicated births cost more than ordinary ones. Now they've been leveled. And the number of complicated births began to decrease, because there is no interest and no benefit in writing that the births ended with ruptures. On other points now they are also trying to find a solution.

According to Melik-Guseinov, the problem with incorrect autopsy results for the sake of earning money exists due to the fact that in Russia the pathoanatomical service is directly subordinate to the clinical one. In America, for example, the situation is different: pathologists do their work, they receive money separately. And there are fewer cases of discrepancies in diagnoses - the two services control each other's work, respectively, doctors diagnose better, and pathologists provide truthful autopsy data.

Our chief physician is the immediate supervisor of the pathologist, so he can influence the results of the autopsy for selfish purposes, - the expert added. - There is such a problem, so the statistics are really not quite correct. And everything is important, even one case. Behind any such case is a human life.

RULES OF COMPARISON (COMPARATING) OF THE FINAL CLINICAL AND PATHOLOGOANATOMICAL DIAGNOSIS.

3.1. The concepts of "coincidence" or "discrepancy" of clinical and pathoanatomical diagnoses are applicable only for comparison (comparison) of the headings "Main disease" (initial cause of death). Comparison of diagnoses according to other headings, in particular, according to complications, according to a fatal complication (immediate cause of death), main concomitant diseases, is carried out separately and, if there is a discrepancy, is not recorded as a discrepancy in diagnoses, but is indicated additionally, for example, in the clinical and anatomical epicrisis: the diagnoses coincided, but no fatal complication (or comorbidity) recognized.

3.2. When comparing diagnoses, only the final clinical diagnosis, which is placed on the reverse side, is taken into account. title page medical history, or listed as final in outpatient card deceased. Unclassified or with a question mark clinical diagnoses do not allow their comparison with the pathoanatomical one, which is considered as a discrepancy between diagnoses in category II (subjective reasons - incorrect formulation or formulation of a clinical diagnosis).

3.3. When deciding on the coincidence or discrepancy between diagnoses, all nosological units indicated in the composition of the underlying disease are compared. With a combined underlying disease, any of the competing, combined, background diseases that are not diagnosed, as well as their overdiagnosis, represent a discrepancy in diagnoses. and vice versa). This should be avoided and, in cases of overlapping diagnoses, the order adopted in the final clinical diagnosis should be left. However, if there is a convincing objective reason for changing the order of nosological forms in the diagnosis, but all nosological units included in the combined underlying disease are the same, the diagnoses match, and the reason for the change in the structure of the diagnosis is substantiated in the clinical and anatomical epicrisis.

3.4. A discrepancy in diagnoses is a discrepancy between any nosological unit from the heading of the underlying disease in terms of its essence (the presence of another nosology in the pathoanatomical diagnosis - underdiagnosis, or the absence of this nosology - overdiagnosis), by localization (including in such organs as the stomach, intestines, lungs, head brain, uterus and its neck, kidneys, pancreas, heart, etc.), by etiology, by nature pathological process(for example, by the nature of the stroke - ischemic infarction or intracerebral hemorrhage), as well as cases of late (untimely) diagnosis. The fact of late (untimely) diagnosis is established collectively, during the clinical expert commission.

3.5. In case of discrepancies in diagnoses, the category of discrepancy (category of diagnostic error) and the reason for the discrepancy (one of the groups of objective and subjective) are indicated.

3.6. The categories of discrepancies in diagnoses indicate both the objective possibility or impossibility of correct intravital diagnosis, and the significance of a diagnostic error for the outcome of the disease.

I category of discrepancies in diagnoses - in this medical institution, the correct diagnosis was impossible, and a diagnostic error (often made during previous patient visits for medical care) no longer influenced the outcome of the disease in this medical institution. The reasons for the discrepancy between diagnoses in category I are always objective.

II category of discrepancy between diagnoses - in this medical institution, the correct diagnosis was possible, however, a diagnostic error that arose for subjective reasons did not significantly affect the outcome of the disease.

Thus, discrepancies in diagnoses in category II are always the result of subjective reasons.

III category of discrepancy between diagnoses - in this medical institution, the correct diagnosis was possible, and the diagnostic error led to erroneous medical tactics, i.e. led to insufficient (inadequate) or incorrect treatment, which played a decisive role in the fatal outcome of the disease.

The reasons for the discrepancy between diagnoses in category III are always subjective.

Cases of discrepancies in diagnoses, in particular, in category III, should not be equated with iatrogenics.

Objective reasons for discrepancies in diagnoses include the following:

1. Short stay of the patient in a medical institution (short stay). For most diseases, the standard diagnostic period is 3 days, but for acute diseases requiring emergency, urgent, intensive care, including cases of urgent surgery, this period is individual and can be equal to several hours.

2. Difficulty in diagnosing the disease. The whole range of available diagnostic methods was used, but atypicality, blurred manifestations of the disease and rarity this disease not allowed to make a correct diagnosis.

3. The severity of the patient's condition. Diagnostic procedures were completely or partially impossible, since their implementation could worsen the patient's condition (there were objective contraindications).

Subjective reasons for discrepancies in diagnoses include the following:

1. Insufficient examination of the patient.

2. Underestimation of anamnestic data.

3. Underestimation of clinical data.

4. Incorrect interpretation (underestimation or overestimation) of laboratory, radiological and other data additional methods research.

5. Underestimation or overestimation of the consultant's opinion.

6. Incorrect construction or design of the final clinical diagnosis.

7. Other reasons.

3.8. Only one should be specified main reason discrepancies in diagnoses, since a conclusion containing several reasons at the same time (a combination of objective and subjective reasons) makes subsequent statistical analysis extremely difficult.

3.9. Each clinical and anatomical epicrisis of the autopsy protocol must contain the conclusion of the pathologist about the fact of the coincidence or discrepancy between the diagnoses, as well as about the recognized or unrecognized complications(especially fatal) and major comorbidities. In case of discrepancies in diagnoses, the category and reason for the discrepancy should be indicated, and in case of coincidence of diagnoses, but unrecognized fatal complication or concomitant diseases, the causes of diagnostic errors. This conclusion is submitted by the pathoanatomical department (bureau) to a meeting of the relevant clinical and expert commissions for the study of lethal outcomes, to clinical and anatomical conferences, where the pathologist or the head of the pathoanatomical department (head of the bureau) presents the results of his research.

3.10. The final clinical and expert opinion for each specific lethal outcome is accepted only collectively, by a clinical expert commission or a clinical and anatomical conference. In case of disagreement of the pathologist or other specialist with the conclusion of the commission, this is recorded in the minutes of the meeting, and the issue is referred to a higher commission. On the basis of a collegial (commission) decision, in exceptional cases, it is allowed to reclassify cases of discrepancy (or coincidence) of clinical and pathoanatomical diagnoses into the category of coincidence (or, accordingly, discrepancy).

3.11. For community-acquired mortality - for those who died at home, the comparison of the final clinical and pathoanatomical diagnoses has its own characteristics. The post-mortem epicrisis and the final clinical diagnosis should be formulated in the outpatient card. The absence of a final clinical diagnosis in the outpatient card is noted as a comment on the issuance of this card in the clinical and anatomical epicrisis and a design defect. medical records submitted for consideration by the clinical expert commission.

In cases where it was not possible to formulate a final clinical diagnosis and the body of the deceased was sent for a post-mortem autopsy to determine the cause of death, no comparison of diagnoses is made and such cases are allocated to a special group for analysis at clinical expert commissions and for annual reports.

If there is a final clinical diagnosis in the card of an outpatient and when it is compared with the pathoanatomical pathologist, the pathologist establishes the fact of coincidence or discrepancy between the diagnoses. In case of discrepancy between diagnoses, the category of discrepancy is not determined (it is applicable only for patients who died in hospitals). Among the objective and subjective reasons for discrepancies in diagnoses, only those that do not imply hospitalization of the patient are indicated (such a reason as the short stay in the hospital is excluded).

Appendix 2

Examples of final clinical and post-mortem diagnoses, medical death certificates

As examples, the final clinical and pathological diagnoses (as well as medical certificates of death) of the most common diseases from the group of diseases of the circulatory system, neoplasms and alcohol-related diseases are presented.

Examples of diagnoses are given in abbreviated form, in practice a detailed one is always needed, complete diagnosis, involving the results of additional research methods.

Nosology - the study of diseases (from the Greek. nosos- sickness and logos- doctrine), which allows solving the main task of private pathological anatomy and clinical medicine: knowledge of structural and functional relationships in pathology, biological and medical basics diseases. Its content consists of problems without which neither the theory nor the practice of medicine is possible.

Nosology consists of the following teachings and concepts.

◊ Etiology - the study of the cause of diseases.

◊ Pathogenesis - the study of the mechanisms and dynamics of the development of diseases.

◊ Morphogenesis - morphological changes that occur during the development of diseases.

◊ Clinical and morphological manifestations of diseases, including their complications and outcomes.

◊ The doctrine of the nomenclature and classification of diseases.

◊ Diagnosis theory, i.e. identification of diseases.

◊ Pathomorphosis - the doctrine of the variability of diseases under the influence of various factors.

◊ Medical errors and iatrogenies - diseases or pathological processes caused by the actions of medical personnel.

The beginning of nosology was put by D. Morgagni. In 1761, he wrote a six-volume work "On the location and causes of diseases discovered by dissection", creating the first scientific classification and nomenclature of diseases. Currently, nosological units are distinguished in accordance with nosology. These are specific diseases with a specific etiology and pathogenesis, a typical clinical picture, consisting of a combination of characteristic symptoms and syndromes.

Symptom- a sign of a disease or pathological condition.

Syndrome- a set of symptoms associated with certain disease and associated with a single pathogenesis.

Disease- a complex concept that does not have an exhaustive formulation, but all definitions emphasize that illness is life. The concept of disease necessarily implies a violation of the interaction of the organism with the external environment and a change in homeostasis.

Each definition of disease emphasizes only one side of this condition. So, R. Virchow defined the disease as "life under abnormal conditions." L. Aschoff believed that "a disease is a dysfunction resulting in a threat to life." The Great Medical Encyclopedia gives the following definition: “A disease is a life disturbed 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 particular decrease in adaptability to the environment and restriction of the patient's freedom of life. "This cumbersome, but the most complete definition, however, is largely vague and does not fully exhaust the concept of the disease.

In the understanding of the disease there are provisions of an absolute nature.

◊ Illness, like health, is one of the forms of life.

◊ Illness is the general suffering of the body.

◊ A certain combination of external and internal environmental factors is necessary for the occurrence of a disease.

◊ In the occurrence and course of the disease, the most important role belongs to the compensatory and adaptive reactions of the body. They may be sufficient for a cure or insufficient, but their participation in the development of the disease is mandatory.

◊ Any disease causes morphological changes in organs and tissues, which is associated with the unity of structure and function.

ETIOLOGY

Etiology (from the Greek. aitia- the reason logos- doctrine) - the doctrine of the causes and conditions for the occurrence of diseases. The question of why diseases arise has been of concern to mankind throughout history, and not only doctors. The problem of cause-and-effect relationships has always occupied philosophers of various directions. Philosophical aspect Problems are also very important for medicine, since the approach to treating a patient depends on the understanding of cause-and-effect relationships. Highest value have theories of causalism (from lat. causalis- causal) and conditionalism (from lat. condicio- condition).

The doctrine of etiology goes back to Democritus (IV century BC) - the founder of causal thinking, who saw the causes of diseases as violations of the movement of atoms, and Plato (IV-III centuries BC) - the founder of objective idealism, who explained the causes of phenomena by the relationship between the soul and the body (the philosophical basis of modern psychosomatics). The beginning of the doctrine of the causes of diseases - belief in demonic forces that inhabit a person, and the teachings of Hippocrates (IV-III centuries BC) about 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 . Most of the doctrines of etiology have now lost their significance, but two of them - causalism and conditionalism are still interesting.

Causalism. Causalists, in particular, the well-known pathologist and physiologist C. Bernard (19th century), believed that every disease has a cause, but manifests itself only under certain objective conditions. From the 70s of the nineteenth century. there was a rapid development of the doctrine of microorganisms, associated primarily with the name of L. Pasteur. This led to the idea that any disease has only one cause - a bacterium, and the conditions for the development of the disease are secondary. So a kind of causalism arose - monocausalism. However, it soon became clear that the presence of a microorganism is not enough for the onset of a disease (the concept of bacillus carrying, a dormant infection, etc.), that, under equal conditions, two people react differently to the same microorganism. The study of the reactivity of the organism and its influence on the onset of the disease began. During the development of the doctrine of reactivity, the idea of ​​​​allergy appeared. Causalism as a doctrine of the causes of diseases began to lose its supporters.

Conditionalism, which arose against this background, completely denies the causes of diseases and recognizes only the conditions for their occurrence, and only subjective ones, excluding, for example, socio-economic conditions. The founder of conditionalism, the German philosopher M. Verworn (19th-20th centuries), believed that the concept of causality should be excluded from scientific thinking and instead introduce abstract representations, as in mathematics. In this case, the occurrence of the disease is associated with various conditions. Verworn wrote that the doctor must know three things: the conditions of health in order to maintain them, the conditions for the development of diseases in order to prevent them, and the conditions of recovery in order to use them. Denying such an understanding of causal relationships in the development of diseases, modern medicine, nevertheless, often takes the position of conditionalism, especially when the cause of the disease is unknown, but the conditions for its development are known.

The modern view of the problems of medicine lies in the understanding that a disease occurs when, under the influence of a cause, homeostasis is disturbed under specific conditions, i.e. the balance of the organism with the external environment, in other words, when the adaptability of the organism to changes in environmental factors becomes insufficient. External environment - social, geographical, biological, physical and other environmental factors. Internal environment - conditions that have arisen in the body itself under the influence of hereditary, constitutional and other features. The external and internal environment constitute the conditions of life.

Thus, from modern positions, the concept of etiology is interpreted more broadly - as a doctrine of the complex processes of interaction between the human body and the cause of the disease and the complex of additional conditions necessary for the implementation of this interaction. Hence the main point modern medicine- without a cause there can be no disease, and the cause determines its specificity, i.e. qualitative features of a particular disease

Etiology answers the question of the cause of a particular disease. Many diseases can be caused by external influences. environment, and disorders that occur in the body itself, for example, genetic defects or birth defects organs. More often, the causes of diseases are environmental factors that depend on a variety of conditions. The etiology of many diseases, such as most infectious, endocrine diseases or injuries, is known. However, a number of diseases have a still unknown etiology (for example, mental illness, malignant tumors, atherosclerosis, sepsis, sarcoidosis, etc.). Without fully knowing the causes of the disease, it can be successfully treated by influencing the mechanisms of development. Thus, the clinical signs, course, complications and outcomes of appendicitis are well known, hundreds of thousands of appendicitis are removed annually in the world, but the etiology of appendicitis has not been established. The causes of diseases act on a person in specific conditions of the internal and external environment, depending on these conditions, some people develop a disease, while others do not. Knowing the causes of the disease greatly facilitates the diagnosis and allows for etiological treatment, i.e. aimed at eliminating these causes.

PATHOGENESIS

NOMENCLATURE AND CLASSIFICATION OF DISEASES

The most important parts of nosology are medical nomenclature (a list of agreed names of diseases and causes of death) and medical classification (grouping of nosological units and causes of death to achieve certain goals). Both the classification and the nomenclature are constantly supplemented and modernized as knowledge about the diseases included in the nomenclature changes, or when new diseases appear. Modernization of the nomenclature is carried out by World Organization health (WHO), receiving information on diseases and causes of death from all countries - members of the UN. The WHO Expert Committee analyzes this information and compiles the International Classification of Diseases (ICD) - a system of headings reflecting the incidence and causes of death in the population. Periodically, the WHO expert committee holds assemblies and takes into account all changes in the understanding of the etiology and pathogenesis of diseases over 8-10 years, revising the existing classification and nomenclature of diseases, and compiling new ones, 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 10th revision (1993). After this document is compiled, it is translated into the languages ​​of the countries that are members of the UN and introduced as a mandatory guide to action for all medical institutions and medical workers every country. Medical diagnoses must comply with the ICD, even if the name of the disease or its form does not correspond to national ideas. Unification is necessary in order to world health could have a clear idea of ​​the medical situation in the world and, if necessary, provide special or humanitarian assistance to countries, develop and implement preventive measures on a regional or continental scale, and train qualified medical personnel for different countries. The international classification and nomenclature of diseases reflects the level of medical knowledge of society and determines the direction of research for many diseases.

ICD-10 consists of three volumes.

Volume 1 is a special list for statistical development.

Volume 2 is a collection of instructions for using the ICD-10.

Volume 3 - alphabetical index diseases and injuries by their nature, including the following sections:

∨ index of diseases, syndromes, pathological conditions and injuries that led to seeking medical attention;

∨ pointer external causes injuries, description of the circumstances of the event (fire, explosion, fall, etc.);

∨ list of medicinal and biological means, chemical substances that caused poisoning or other adverse reactions.

The alphabetical index contains the main terms or keywords denoting the name of the disease, injury, syndrome, iatrogenic pathology, subject to special unified coding. To do this, there are alphanumeric code numbers containing 25 letters of the Latin alphabet and four-digit codes, where the last digit is placed after the dot. Each letter corresponds to up to 100 three-digit numbers. Various medical associations have created additional International classifications for individual medical disciplines (oncology, dermatology, dentistry, psychiatry, etc.) included in the ICD. As additional classifications, they are coded with additional digits (fifth and sixth).

DIAGNOSIS

Diagnosis (from the Greek. diagnosis- recognition) - a medical conclusion about the state of health of the subject, about the existing disease (injury) or about the cause of death, expressed in terms provided for accepted classifications and disease nomenclature. The diagnosis can be preliminary or final, histological or anatomical, retrospective or forensic, etc. In clinical medicine, there are clinical and pathoanatomical diagnoses. Establishing a diagnosis, i.e. Recognition of the disease is one of the main tasks of the doctor. Depending on the clinical diagnosis, treatment is prescribed, it can be adequate and effective only if the diagnosis is correct. But it can be ineffective and even cause fatal consequences for the patient if an erroneous diagnosis is made. Formulating a diagnosis allows you to trace the doctor's thinking in recognizing and treating a disease, to find a diagnostic error and try to understand its cause. A good doctor is, above all, a good diagnostician.

No less important is the pathological diagnosis. It is formulated by the pathologist after the autopsy of the corpse of the deceased patient on the basis of the detected morphological changes and data from the medical history. Comparing the clinical and pathoanatomical diagnoses, the pathologist establishes their coincidence or discrepancy, this reflects the level of diagnostic and therapeutic work medical institution and his individual physicians. Errors found in diagnosis and treatment are discussed at clinical and anatomical conferences of the hospital. Based on the pathoanatomical diagnosis, the cause of death of the patient is determined, which allows medical statistics to study the issues of mortality of the population and its causes. And this, in turn, contributes to the implementation of state activities aimed at improving the health care of the country and developing measures social protection population.

In order to compare clinical and pathoanatomical diagnoses, they must be drawn up according to the same principles. Uniformity in the nature and structure of the diagnosis is also required by the ICD, since the diagnosis is the basic document for all subsequent medical documentation. The fundamental principle of making a diagnosis is the presence of three main headings in it: the underlying disease, complications of the underlying disease, concomitant disease.

underlying disease usually represents a nosological unit, and the concomitant is a pathological background that contributes to the development of the underlying disease. In clinical diagnosis, the underlying disease is a condition that required treatment or examination of the patient at the time of seeking medical help. In the pathoanatomical diagnosis, the underlying disease is a disease that, by itself or through its complications, caused the death of the patient. According to the underlying disease, the cause of death is coded in the ICD system.

Complication- a disease pathogenetically associated with the underlying disease, aggravating its course and outcome. In this definition, the key concept is "pathogenetically related", this connection is not always easy to grasp, and without it, the disease cannot be a complication. Resuscitation complications are an independent line in the diagnosis. They describe the changes that have occurred due to resuscitation, and not the main disease, and therefore are not associated with it pathogenetically.

The principles of formulating a diagnosis are illustrated by the following examples.

Patient I., 80 years old, developed croupous pneumonia, which caused his death. The main disease is croupous pneumonia, the pathoanatomical diagnosis begins with it. This disease arose in an elderly person with reduced reactivity, who, even before the development of pneumonia, suffered from atherosclerosis with a predominant lesion of the heart vessels. Atherosclerosis coronary arteries caused chronic progressive hypoxia, which led to a violation of the metabolism of the heart muscle, the development of diffuse small-focal cardiosclerosis and reduced the functionality of the myocardium. This, in turn, caused compensatory processes in the heart, including hyperfunction of other muscle fibers. Hyperfunction of the myocardium in combination with hypoxia led to the development of protein and fatty degeneration in cardiomyocytes, which allowed the heart to work in conditions of relative health of the patient. Involutive processes in an elderly person led to the development of pulmonary emphysema, a decrease in the level of gas exchange and, as a result of a combination of these factors, diffuse pneumosclerosis. As long as a person was relatively healthy, changes in the heart and lungs allowed them to function at a life-sustaining level. However, the occurrence of extreme conditions (pneumonia) contributed to a decrease in the respiratory surface of the lungs, increased hypoxia, and general intoxication of the body, which aggravated fatty degeneration myocardium. At the same time, the functional load on the heart and lungs increased sharply, but the adaptive and compensatory capabilities of the body are largely exhausted, metabolism and reactivity are reduced. Under these conditions, the heart could not cope with the load, and it stopped.

When formulating a pathoanatomical diagnosis, the main disease is croupous pneumonia, since it caused the death of the patient. In this case, it is necessary to indicate the localization, prevalence of the inflammatory process and the stage of the disease. The beginning of the diagnosis: the main disease is left-sided lower lobar lobar pneumonia in the stage of gray hepatization. In the heading "comorbidities" it is necessary to indicate atherosclerosis with damage to the heart vessels (atherocalcinosis with stenosis of the lumen of the left coronary artery by 60%), diffuse small-focal cardiosclerosis, myocardial fatty degeneration, senile emphysema, diffuse pneumosclerosis. Thus, the concept of "croupous pneumonia" received a deeper content in the description of concomitant diseases. Such a diagnosis allows us to understand the cause of death of this patient.

If the same patient suffering from lower lobar lobar pneumonia develops an abscess in the area of ​​fibrinous inflammation, this will significantly worsen the patient's condition. As a result of severe intoxication, a sharp decrease in the patient's reactivity and the appearance of abscesses in other lobes of the lung are possible. Putrefactive bacteria can enter the affected lung through the bronchi, causing gangrene of the lung and death of the patient. In this case, in the diagnosis after the main disease - left-sided lower lobar lobar pneumonia, there should be a heading "complications", it will indicate multiple abscesses and gangrene of the left lung. Associated diseases - the same. Lung abscess is pathogenetically associated with the underlying disease, this is its complication.

It is far from always possible to describe the entire pathology found at autopsy as one underlying disease. Often there are several diseases considered as the underlying disease. To describe such a situation in the diagnosis, there is a heading "combined underlying disease", which allows us to name several diseases that led to the death of the patient as the main ones. In relation to each other, these diseases are defined as competing or combined.

Competing diseases- two or more diseases, each of which, by itself or through its complications, could lead the patient to death. This situation can be explained with the help of a frequently occurring situation.

An elderly patient was hospitalized for stage IV gastric cancer with multiple metastases and tumor decay. There is no doubt that the patient is dying and it is no longer possible to help him. The tumor causes a restructuring of many processes in the body, including an increase in blood clotting. At the same time, the patient has pronounced atherosclerosis of the coronary arteries, against this background, thrombosis of the descending branch of the left coronary artery, extensive myocardial infarction of the left ventricle, and acute heart failure develop. The patient died 12 hours after the infarction. What is considered the main disease that caused the death of the patient? He was supposed to die of cancer, but in this state he still lived and, perhaps, would have lived for a few more days. The patient, of course, could die from a myocardial infarction, but myocardial infarction does not always lead to death. Thus, each of the two diseases could play a fatal role. There is a competition between two deadly diseases. In this case, the underlying disease is combined and consists of two competing diseases. The diagnosis should be written as follows.

◊ The main combined disease: cancer of the antrum of the stomach with tumor decay and multiple metastases in the perigastric The lymph nodes, liver, greater omentum, bodies of V and VII thoracic vertebrae. Cancer cachexia.

◊ Competing disease: infarction of the anterolateral wall of the left ventricle, atherocalcinosis and thrombosis of the descending branch of the left coronary artery.

◊ Complications and comorbidities should then be described.

Often, a patient develops several serious diseases at the same time.

For example, in an 82-year-old patient suffering from widespread atherosclerosis with a predominant vascular lesion lower extremities, coronary arteries of the heart and arteries of the brain develop atherosclerotic gangrene right foot. He was hospitalized for her. In the clinic, against the background of increasing intoxication with hemolysis of erythrocytes, suprahepatic jaundice, impaired hematopoietic function of the liver, the patient develops myocardial infarction. Two days later, against the background of increasing cardiovascular insufficiency, ischemic stroke in the brain stem and the patient dies. What was the main disease that led to death? According to ICD-10, atherosclerosis is not considered as a nosological form, it is only a background for the development of myocardial infarction or cerebrovascular diseases. Each of three diseases could cause the death of the patient. The main disease is combined and includes three competing nosological forms: gangrene of the right foot, myocardial infarction of the left ventricle and ischemic stroke in the brainstem. The background of all competing diseases is atherosclerosis in the stage of atherocalcinosis with a predominant lesion of the vessels of the lower extremities, coronary arteries and arteries of the brain. As a complication, intoxication and its morphological manifestations, as well as edema and swelling of the brain with wedging of its stem part into the foramen magnum, should be considered. Then they describe concomitant diseases: senile emphysema, gallbladder stones.

Combined diseases- 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 to the death of the patient.

An example of combined diseases is the situation when an elderly woman fell and broke her femoral neck. On this occasion, she went to the hospital, where she underwent osteosynthesis. After that, the patient spent three weeks in the ward in a forced position on her back. Bilateral focal confluent lower lobe pneumonia developed and the patient died. However, there is no pathogenetic connection between a femoral neck fracture and pneumonia, since pneumonia might not have occurred or it would not have led to death if the patient had been given breathing exercises, massage, appropriate drug therapy and so on. congestive pneumonia cannot be considered a complication of a hip fracture. The fracture of the femoral neck itself could hardly have been the cause of death. It is also impossible to consider that these two diseases are not related to each other, if only because they arose at the same time, and the body simultaneously reacted to trauma and pneumonia. A fracture of the femoral neck as the main disease is not in doubt, since the patient sought medical help and received treatment for this disease. What is pneumonia, which arose later than the fracture, but was of significant importance in the death of the patient? Pneumonia cannot be the main disease, the main disease is a hip fracture. Pneumonia could not be a competing disease either, since a hip fracture was unlikely to cause death. For such situations, there is the concept of a combined underlying disease. In the example, the diagnosis should be written as follows.

◊ The main combined disease: fracture of the neck of the left femur, condition after osteosynthesis.

◊ Combined disease: bilateral lower lobe focal confluent pneumonia.

◊ This is followed by the heading "complications", 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 indicated, for example, atherosclerosis with a primary lesion of the heart vessels, chronic coronary artery disease, etc.

underlying disease- a disease that played a significant role in the occurrence and adverse course of the underlying disease, the development of fatal complications. It may be included under the heading "underlying disease". The concept of a background disease was introduced by decision of the WHO in 1965; at first it was used when formulating the diagnosis of myocardial infarction. Now this rubric is used for many diseases.

The introduction of the concept of "background disease" has its own history. Until the middle of the last century, myocardial infarction as a complication of atherosclerosis or hypertension was not recorded in the WHO statistics, which takes into account only the underlying disease. Meanwhile, myocardial infarction has become the world's leading cause of death. To develop measures for its prevention and treatment, it was necessary to have statistics on morbidity and mortality from myocardial infarction. Therefore, in 1965, the WHO Assembly adopted a special resolution: in order to develop measures for the prevention of acute coronary artery disease, consider myocardial infarction as the main disease and start writing a diagnosis from it. However, realizing that myocardial infarction is pathogenetically a complication of atherosclerosis and hypertension, the concept of background diseases and as such began to consider atherosclerosis and hypertension. This principle of writing a diagnosis gradually began to be used when writing a diagnosis of cerebrovascular disorders, since they are also complications of atherosclerosis or hypertension and are associated with stenosis of the cerebral arteries with atherosclerotic plaques. However, arterial atherosclerosis occurs not only in these diseases. Diabetes mellitus with severe atherosclerosis, also began to be mentioned in the diagnosis as underlying disease. Currently, any diseases that precede the development of the underlying disease and aggravate its course are often considered background.

polypathy- a group of major diseases, consisting of etiologically and pathogenetically related diseases ("family of diseases") or a random combination of diseases ("association of diseases"). Polypathies can consist of two or more competing, combined and background diseases. In such cases, the immediate cause of death is taken as the underlying disease.

Thus, in the clinical and pathoanatomical diagnosis, the heading "main disease" may consist of one nosological form, a combination of competing or combined diseases, a combination of the main and background diseases. In addition, the equivalent of the underlying disease, according to the ICD, may be complications of treatment or errors in medical manipulations (iatrogeny).

Cause of death. Completes the pathoanatomical diagnosis "Conclusion on the cause of death". It can be initial and immediate.

The initial cause of death is a disease or injury that caused a succession of disease processes that directly led to death. In the diagnosis, the primary cause of death is the underlying disease, which is in the first place.

immediate cause death occurs as a result of a complication of the underlying disease.

Outcome of the disease can be favorable (recovery) and unfavorable (death). A favorable outcome may be complete or incomplete.

Full favorable outcome - full recovery, repair of damaged tissues, restoration of homeostasis, the possibility of returning to normal life and work.

An incomplete favorable outcome is the occurrence of irreversible changes in the organs, disability, the development of compensatory and adaptive processes in the body.

For example, about cavernous tuberculosis The patient underwent a lobectomy at the top of the right lung. There was a cure for cavernous tuberculosis, i.e. the outcome of the disease is generally favorable. However, in the middle lobe of the right lung, a rough postoperative scar, in the middle and lower lobes - compensatory emphysema, and in place of the former upper lobe sprawl has occurred connective tissue. This led to a deformity of the chest, curvature of the spine and displacement of the heart. Such changes undoubtedly affect the labor prognosis and lifestyle of the patient.

DIFFERENCE OF DIAGNOSES

The pathoanatomical diagnosis must be compared with the clinical diagnosis. The results of the autopsy and the diagnosis are usually analyzed together with the attending physician. This is necessary for the final clarification of the etiology, pathogenesis and morphogenesis of the disease in this patient. Comparison of diagnoses is an important indicator of the quality of work of a medical institution. A large number of coincidences of clinical and pathoanatomical diagnoses indicates the good work of the hospital, the high professionalism of the staff. However, there is always one or another percentage of discrepancies between clinical and pathoanatomical diagnoses. Diagnosis can be hampered by the patient's severe condition or inadequate assessment of his feelings. There may be errors in laboratory studies, incorrect interpretation of x-ray data, insufficient experience of the doctor, etc. The discrepancy between clinical and pathoanatomical diagnoses is inevitable, we are talking about the number of such discrepancies.

The reasons for the discrepancy between the clinical and pathoanatomical diagnoses can be objective And subjective.

objective causes of diagnostic errors: the patient's short stay in the hospital, his severe, including unconscious state, which does not allow performing necessary research, the difficulty of diagnosing, for example, a rare disease.

subjective reasons: insufficient examination of the patient if possible, incorrect interpretation of laboratory and radiological data due to insufficient professional knowledge, an erroneous conclusion of a consultant, an incorrect construction of a clinical diagnosis.

The consequences of a diagnostic error and the doctor's responsibility for it can be different. Depending on the nature, causes and consequences of errors, discrepancies in diagnoses are divided into three categories. Additionally, the discrepancy in the underlying disease, complication of the underlying disease, and localization of the pathological process is taken into account. If there is a discrepancy between the clinical and pathoanatomical diagnoses, it is necessary to indicate the reason for the discrepancy.

A 65-year-old patient in an unconscious state was urgently delivered to the clinic. Relatives reported that he suffered hypertension. The available clinical examination, including puncture of the spinal canal and consultation with a neurologist, made it possible to suspect a cerebral hemorrhage. Were held necessary measures in accordance with the diagnosis, however, they were ineffective, and 18 hours after admission to the intensive care unit, the patient died. The section revealed lung cancer with metastases to the brain and hemorrhage in the area of ​​metastasis. There is a discrepancy in diagnoses. But doctors cannot be blamed for this, because. they did their best to establish the underlying disease. However, due to the severe condition of the patient, doctors could only determine the localization of the pathological process that caused clinical symptoms and tried to save the patient. This is a discrepancy between diagnoses according to the nosological form of category 1. The reasons for the discrepancy are objective: the severity of the patient's condition and the brevity of his stay in the hospital.

◊ For example, in the clinic, a patient was diagnosed with cancer of the head of the pancreas, and cancer of the major duodenal papilla was found in the section. There is a divergence of diagnoses according to the localization of the pathological process. The reason for the discrepancy between the diagnoses is objective, since the symptoms in both tumor localizations in the terminal stage of the disease are identical, and the diagnostic error did not affect the outcome of the disease.

◊ Another situation is possible. A 82-year-old patient is admitted to the department with a diagnosis of "Suspicion of gastric cancer". Upon admission, she underwent a laboratory examination, an ECG was performed, establishing the presence of chronic coronary artery disease. On fluoroscopy of the stomach, there was insufficient evidence for the presence of a tumor. They planned to repeat the study in a few days, but did not. Nevertheless, stomach cancer for some reason did not cause doubts and the patient was not further examined. On the 60th day of her stay in the department, the patient died, she was given a clinical diagnosis: "Cancer of the body of the stomach, metastases to the liver." On the section, a small cancer was indeed found, but of the fundus of the stomach, without metastases, and, in addition, an extensive myocardial infarction of the left ventricle at least three days ago. Consequently, there are competing diseases - stomach cancer and acute infarction myocardium. Failure to recognize one of the competing diseases is a discrepancy in diagnoses, since each of the diseases could cause death. Given the age and condition of the patient, it was unlikely that a radical surgical treatment gastric cancer (gastrectomy, esophago-intestinal anastomosis). However, myocardial infarction should have been treated, and the treatment could be effective, although this cannot be said. An analysis of the medical history showed that the rounds of the attending physician and the head of the department were of a formal nature, no one paid attention to the fact that laboratory tests and ECG were not repeated for 40 days. No one noticed that the patient had symptoms of myocardial infarction, so the necessary studies were not carried out, which led to a diagnostic error. This is the 2nd category of discrepancy between clinical and pathoanatomical diagnoses for a competing disease, but the reason for the discrepancy in diagnoses is subjective - insufficient examination of the patient, although there were all conditions for this. An error is a consequence of the negligent performance of their duties by the doctors of the department.

Category 3 discrepancies in diagnoses - a diagnostic error led to an incorrect medical tactics which had fatal consequences for the patient. This category of discrepancy in diagnoses often borders on a medical crime, for which the doctor may be held criminally liable.

For example, a patient with a diagnosis of " interstitial pneumonia", but the symptoms of the disease are not quite typical, the treatment is ineffective. A consultant phthisiatrician is invited. He suspected pulmonary tuberculosis and prescribed a number of diagnostic studies, including tuberculin skin tests, repeated sputum examinations, a tomographic examination of the right lung. However, the attending physician performed only one recommendation: he sent sputum for analysis, received a negative result and did not examine the sputum again. The doctor did not fulfill the rest of the recommendations, but continued to conduct ineffective treatment. Three weeks after consulting a phthisiatrician, the patient died. In the clinical diagnosis, the main disease was called interstitial pneumonia of the lower and middle tuberculous caseous pneumonia of the right lung, which caused severe intoxication and death of the patient. misdiagnosis, and without objective reasons led to incorrect, ineffective treatment and death of the patient. By following the recommendations of a consultant phthisiatrician, the diagnosis could be made correctly, the patient could be transferred to a phthisiatric clinic, where special treatment. Thus, this is a discrepancy between diagnoses of the third category, when incorrect clinical diagnosis led to incorrect treatment and a fatal outcome of the disease. The reason for the diagnostic error is subjective, it became possible as a result of insufficient examination of the patient and non-compliance with the recommendations of the consultant.

Diagnostic errors require a comprehensive analysis in order not to repeat them again. For such an analysis, clinical and anatomical conferences are needed, which should be held in each hospital once a quarter in the presence of the chief physician and head of the pathoanatomical department. All doctors of the hospital participate in the conferences. The cases of discrepancy between clinical and pathoanatomical diagnoses are discussed, clinicians and pathologists report. In addition, an opponent is necessarily appointed - one of the most experienced doctors of the hospital, who had nothing to do with the case under consideration. A general discussion helps to reveal the causes of a diagnostic error, and, if necessary, the hospital administration takes appropriate measures. In addition to diagnostic and therapeutic errors, clinical and anatomical conferences discuss rare cases especially if they are correctly diagnosed. Clinico-anatomical conferences are an essential professional school for all hospital doctors.

IATROGENIA

Iatrogenia - diseases or complications of diseases associated with the actions of medical personnel. In the diagnosis they are included in the heading "underlying disease". Iatrogenic (from the Greek. iatros- doctor and genes- arising, damaged) - any adverse effects of preventive, diagnostic, therapeutic interventions or procedures that led to impaired body functions, disability or death of the patient. Iatrogenia associated with the actions of doctors can be attributed to medical errors and medical misdemeanors, or crimes.

medical error- conscientious error of a doctor in the performance of his professional duties, it cannot be foreseen and prevented by this doctor. A medical error is not related to the doctor's negligent attitude to his duties, ignorance or malicious act. Medical error - in most cases, a consequence of insufficient professional experience, lack of necessary laboratory or instrumental capabilities for proper diagnosis and treatment.

Medical misconduct occurs when, having every opportunity to foresee and prevent the consequences of a disease or injury and to provide assistance to a patient, a doctor, due to neglect of his professional duties or out of selfish motives, conducts treatment that has led to a severe, sometimes fatal outcome of the disease. The fact of a medical crime or misdemeanor can only be established by a court.

Iatrogenia can be the result of tactical or technical errors of the doctor.

Tactical mistakes: incorrect choice research methods due to underestimation of the degree of risk of manipulation (age of the patient, history data, individual reaction manipulation), wrong choice of indications for surgical intervention or administration of medications, preventive vaccinations and so on.

PATHOMORPHOSIS

Pathomorphosis (from the Greek. pathos- sickness and morphosis- formation) - persistent change in clinical and morphological manifestations disease under the influence of environmental factors. Knowledge and understanding of pathomorphosis is important, since a change in the picture of the disease leads to a change in its diagnosis, treatment and prevention. This requires the development of new diagnostic methods and drugs, in turn, affecting pathogens. The result may be a change in the epidemiology of the disease and, consequently, a change in the epidemiological and preventive measures carried out on a scale of the entire health care system.

Pathomorphosis can be true and false.

True pathomorphosis They are divided into general (natural), consisting in changing the general panorama of diseases, and private, reflecting changes in a specific disease.

General pathomorphosis is associated with the evolution of the outside world, including changes in pathogens, their interaction with humans and animals, the emergence of new pathogens, new factors affecting humans (radiation, accumulation of various chemicals in the atmosphere, etc.). This changes the overall panorama of diseases. So, in the nineteenth century. the epidemiological picture in the world was characterized by bacterial infections, in the 20th century - by cardiovascular and oncological diseases, in the 21st century. promises to be the age of viral infections. However, the natural general pathomorphism occurs over the course of centuries and is therefore hardly noticeable.

Private pathomorphosis can be natural (spontaneous) and induced (therapeutic).

◊ Spontaneous partial pathomorphosis is a consequence of a change in the external causes of the development of the disease, which are not always known. For example, it is not known when and why cholera occurs, why Asiatic cholera, which devastated the globe for hundreds of years, was replaced by cholera caused by El Tor vibrio, which proceeds less catastrophically. Private spontaneous pathomorphosis may be the result of a change in the constitution of a person, i.e. internal causes of illness. It reflects the same patterns as general pathomorphosis, but with respect to a specific disease.

◊ Induced (therapeutic) pathomorphosis is of much greater importance in everyday life. This is an artificially induced change in a specific disease with the help of various measures or certain drug therapy. Thus, long-term anti-tuberculosis vaccination of children immediately after birth led to a shift in the incidence of tuberculosis from the age of 4-5 years to the age of 13-14 years, i.e. to the period when the formation is almost completed immune system, and tuberculosis lost its fatal significance. In addition, the most acute tuberculous sepsis and tuberculous meningitis. A wide arsenal of specific drugs has dramatically reduced mortality from acute forms diseases, the life expectancy of patients increased markedly, but chronic forms of tuberculosis began to predominate. It was possible to reduce the number of massive pulmonary hemorrhages, but more often cirrhotic forms tuberculosis with the development of pulmonary heart failure and amyloidosis. Under the influence of preventive measures, there has been a change in the epidemiology and symptoms of many childhood infections, etc. 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 socio-economic standard of living of the population, the collapse of the pharmaceutical industry, a sharp decline in healthcare capabilities, including the sanitary and epidemiological service, the cessation of preventive vaccinations for children and other difficulties, has shown that if induced pathomorphosis is not constantly maintained, then he disappears. For example, the destruction of the anti-tuberculosis service of the country led to the return of tuberculosis to its epidemiology and clinic, characteristic of the early twentieth century. as a result, it approached the indicators indicating an epidemic of this disease.

False pathomorphosis- apparent change in the disease. For example, among the diseases of young children, rubella and congenital deafness are known. However, as knowledge about the infection deepened, it became clear that deafness is not an independent disease, but a complication of rubella suffered by the fetus in the prenatal period. At early diagnosis and the treatment of rubella, congenital deafness disappeared. The disappearance of congenital deafness as an independent disease is a false pathomorphosis.

Thus, the main provisions of nosology allow us to understand the patterns of development of diseases, which is the key to their successful diagnosis and treatment. Nosology forces the use of international rules necessary for the interaction of the international medical community.