Provisional and clinical diagnosis. Doctors can not make a diagnosis, where to go? Accurately diagnose but

Our body often gives us certain signals about a disease. Absolutely any disease has a number of some signs, which are called. In order to correctly diagnose, you need to identify them. This process is called diagnosis.

General concepts of diagnosis

What does the concept of “diagnosis” mean in medicine? This is nothing but the recognition of an ailment. Moreover, this is not only the disease itself, but also the results of the patient's study, which allow the specialist to move from thinking to treatment.

When staging, the specialist is guided by the complaints of the applicant (symptoms), examination of the patient and the results of the tests. This takes into account gender, age, place of residence and other non-medical factors.

It is customary to distinguish several types of diagnoses in medicine: clinical, pathological-anatomical, forensic, epidemiological.

How to diagnose by symptoms?

Previously, only people who had a special medical education could make diagnoses, but after the Internet entered our lives, many of us began to diagnose ourselves and prescribe medications for ourselves. This is not good, because without being a professional in this matter, you can easily make a mistake in making a diagnosis, and because of this, there can be serious consequences.

First of all, you need to carefully monitor. Its rapid decline can signal many ailments, for example, hyperthyroidism (excessive secretion of thyroid hormones). This disease is very common in young women. As for the elderly, a sharp weight loss may indicate malignant tumors.

If you get sick, then watch how long the cough lasts. If this continues for more than 3 weeks, it may indicate a serious illness. For example, bronchial asthma, tuberculosis, pneumonia or other oncological diseases.

How to make a tongue diagnosis?

In a normal state, our tongue should be pink in color, have a small cover and a weak one, which can be removed with a toothbrush. If it begins to thicken over time, acquire a yellowish or gray tint, this indicates reduced immunity.

By the way, if you find a white-yellow coating in the morning and it can be easily removed with a brush, then this is not a reason to panic. And if this could not be done, then this may indicate a fungal infection, various diseases of the oral cavity or dysbacteriosis.

Pale plaque may indicate anemia, while another sign can also be distinguished: fatigue.
If you have a gray coating, then this may indicate that your body does not have enough iron.
When it is slightly enlarged and has a pale patina, and with low acidity, on the contrary, it is slightly reduced and drier.
A yellowish color may indicate liver pathologies.

You visited the doctor and described the symptoms to the best of your ability.

You may even have brought previous test results, X-rays, and opinions from other specialists.

This does not rule out misdiagnosis and treatment.

Cases are different.

Several doctors can express diametrically opposed opinions on the same pictures. Or to attribute the mysterious word "idiopathic", which in medical language means an unknown cause of the disease.

How to understand that the doctor made the wrong diagnosis?

All of the following should be taken critically, without rushing at the doctor with accusations based on Internet publications or bare intuition. Reading medical articles and forums is no substitute for six years in medical school and twenty years of clinical practice.

Life shows that in the vast majority of cases the attending physician is right. But only those who do nothing are not mistaken, and therefore be careful.

Possible signs of a misdiagnosis:

- Intuition tells: something is wrong

Sometimes you leave the doctor's office with a strange feeling. The information received seems inconsistent and confusing. You are not sure that the doctor listened carefully enough to the complaints. Every year, millions of patients are misdiagnosed.

Although everything is jumbled up after a serious diagnosis, don't write off your uncertainty as stress. Intuition (especially for chronic patients "with experience") is a weighty argument. It's part of the ancient survival instinct that everyone has.

What prevents you from contacting another specialist and checking your concerns?

- The doctor listens inattentively

"My doctor doesn't listen to me"- one of the most common complaints of patients in the world practice. Do you think our situation is better if many doctors are forced to see several dozen patients in six hours? This is where errors come from.

One of the founders of the Johns Hopkins Hospital in Baltimore, the father of American medicine, William Osler wrote: "Listen to your patient, he tells you the diagnosis".

It is rare for two different people to describe symptoms in exactly the same words.

The specialist gets used to identify categories, features, typical patterns. The problem is that he can listen but not hear you. If what is said does not fit into his category or typical clinical pattern, the disease may be underestimated.

Time and a huge line under the office put enormous pressure on the doctor to make clinical decisions faster than in the past. Even the most compassionate and skilled diagnostician can make an unintentional mistake.

How can you help your doctor? Be as precise, honest, and concise as possible.

Describe symptoms clearly, when and in what order they appear, know and share information about the health of relatives, report all medications taken.

- Internet search suggests a different diagnosis

I see a sarcastic smile on the faces of colleagues. For the sake of fairness, it is worth recognizing that Dr. Google is sometimes right. There are cases when a doubting patient, armed with a search engine and a thematic forum, found the right answer - and his doctor was wrong. Internet Treatment Requires Caution and Some Basic Knowledge. Since copywriters easily go to the creative distortion of medical information and write sometimes absurd custom-made articles, not every source is trustworthy.

To check your guesses, visit several professional sites, summarize the information received and consult other experts on this matter.

The doctor knows medicine better, but you know yourself better.

Correct diagnosis is the result of collaboration between doctor and patient.

- Pills, pills, pills...

If, in response to concerns and new symptoms, you leave the office with more and more appointments, that's a big red flag! Perhaps something is not going according to plan.

The more drugs, the more confusing the situation can become. The risk of unwanted interactions with other medicines, predicted and unexpected, increases. As a person ages, the functions of the liver and kidneys deteriorate, which complicates the process of neutralization and removal of drugs from the body.

All this adds health risks and ... new mysterious symptoms.

- You're not getting better

You strictly follow medical recommendations, take pills by the hour and do everything necessary, but no improvement is visible. There is only one answer: assignments do not work. Perhaps it is the nature of your disease. Or misdiagnosed.

Was the diagnosis made only on the basis of complaints? Have all the required analyzes and studies been carried out? Should I repeat the tests in another laboratory? Did you find errors, inconsistencies or incomplete information in the medical record?

The answers to these questions can save your health, and even life.

We are accustomed to viewing the medical worker as an "unshakable authority", and not an open partner in the diagnosis and treatment of the disease.

A compassionate and wise doctor will appreciate the patient's willingness to deal with the situation.

For him, the main thing is not to harm, and not to emphasize his innocence.

There are many strong professionals in Russia and abroad who encourage rather than discourage patient participation. Find them. Your life may depend on it.

Konstantin Mokanov

Doctors say that there are a lot of fairly serious diseases that are asymptomatic for the patient. Indeed, it often happens that a person does not suspect that he has a disease, leads a habitual (and often incorrect) lifestyle, eats harmful foods, and at a certain moment realizes that he is sick.

But is it possible to recognize alarming signs by seemingly unrelated things to pathology? Diagnosis by tongue is a sure way to determine that any unwanted changes and disorders are occurring in the body.

What can your language tell you?

This method can be carried out independently, at home. If you are sufficiently aware of how your organ may look against the background of a particular disease, there is a chance to recognize it in the early stages of development, which will help you seek qualified help in a timely manner and begin adequate treatment. Remarkably, doctors themselves often pay attention to the state of this organ, which helps them to make the most accurate and objective verdict.

Each person who is aware of its possible modifications in a particular ailment can make a diagnosis by language. Often, the presence of pathology is determined by the color of the organ, the presence of a dense plaque on it, the violation of its shape and structure.

It is advisable to carry out such events in the morning, on an empty stomach. Natural lighting is a must. Before examining your mouth, rinse it with warm water (you don't need to brush your teeth yet).

Turn around to face the window and take the magnifying mirror. Right now you will find out what diseases can progress or originate in your body, or make sure that your health is in perfect order.

Objective assessment of the shade and structure of the organ

The tongue of a healthy person looks like a smooth, pale pink or pink organ with an even fold and the presence of small papillary formations. There is no plaque on it, and its shade is almost completely uniform. Papillae are present on the surface of a healthy organ in both adults and children. At the tip they are small, barely noticeable, towards the middle they are larger, and on the spine they are the most massive.

In summer and late spring, they tend to have an intense red color. For this reason, in the warm season they are easiest to distinguish. In winter and autumn, they can become pale, yellowish or gray, as if “merging” with the surface. These very papillae represent a whole complex of thermal, taste and biochemical analyzers, which are most directly connected with the organs of the digestive tract and the central nervous system.

How to correctly diagnose by language?

First of all, you should be as objective as possible. Please note that there are many exogenous factors that can affect the visual state of the organ.

For example, if you have just drunk freshly squeezed carrot juice and your tongue has acquired the appropriate shade, you should not take this fact for the presence of a serious pathology.

Smokers' tongues also have their own characteristics - they almost always have a dense whitish or grayish coating. Yes, and the body itself can change color against the background of constant contact with nicotine and tar. If you brush your teeth with a paste or powder before the diagnosis, the organ may become pale, or even white. All these things cannot be assessed as potential signs of the disease.

Changing the color of the tongue can occur for the following reasons:

Eating too hot or cold food the day before;
The use of products with coloring natural pigments (blueberries, beets, carrots, oranges);
The use of wine and wine drinks;
The use of sweet carbonated drinks with dyes ("Coca-Cola", "Fanta", etc.);
Wearing dentures (moreover, the change in the shade of the organ directly depends on the quality and characteristics of the composite from which the artificial teeth are made);
Diagrammatic intake of certain medications;
Active smoking.

Before making an adequate diagnosis, make sure that all of the listed factors are eliminated. If you smoke, clean your tongue from plaque in the evening, and refuse cigarettes in the morning until you examine it.

We establish a preliminary diagnosis by the shade of the tongue

Making a self-diagnosis by the color of the tongue is a good way to identify the disease at an early stage of its development. If you suspect something is wrong, see a doctor and voice your thoughts. By the shade of the surface, it is possible to determine the presence of pathologies in both acute and chronic forms.

What does the unusual color say:

Raspberry - signals the presence of extensive intoxication, which is often accompanied by a persistent increase in body temperature. Also, this symptom may indicate an infectious process in the body, or severe forms of pneumonia;
Red - indicates possible pathologies in the respiratory or cardiovascular system, blood diseases, infectious invasions;
Dark red - speaks of the same disorders that occur with a red tint, but the situation is much more serious. The change may also be associated with severe renal and toxic disorders;
Bluish - warns of possible heart defects. If the blue tint is localized mainly in the lower part, this may indicate the presence of circulatory disorders associated with cardiopulmonary insufficiency. If the bluish tint falls on the middle or upper third of the tongue, this indicates the possible development of heart attacks in the future. Moreover, such a symptom appears long before the feeling of "heaviness" and pain in the heart, as well as sudden weakness, characteristic of an attack that has already begun;
Purple - indicates the presence of severe pathologies from the lungs or blood;
Black - may indicate a possible cholera infection;
Pale, "bloodless"- warns of the presence of anemia, and can also become a sure sign of general exhaustion of the body. A whitish hue in this case may indicate a clear deficiency of blood cells - red blood cells.

After you have determined the change in the shade of the tongue, it is important to observe its structure, as well as pay attention to the nature and density of the plaque that covers it. Any strange change in shape and texture is a sign of internal illness. And the sooner you begin to treat it, the more likely a favorable prognosis and outcome of therapy.

Structure and plaque

Carefully examine the plaque in the mouth, if any.

In a healthy person, the tongue is clean and smooth, without excessive accumulation of mucus on the surface of the organ. If you have a thin plaque, it means that pathology is just emerging in your body, or it is already passing in an acute form. If the plaque is too dense and loose, the disease has been occurring for a long time, and has already acquired a chronic form.

Plaque also comes in different shades, and each of them indicates fundamentally different disorders in the body.

Establishing a diagnosis based on the state of the tongue and plaque on it should also be as objective as possible.

Plaque can have a variety of character:

If it covers the entire tongue, this indicates that there is an accumulation of toxins in the human stomach and intestines;
If it is localized mainly on the root, one can assume the presence of chronic pathologies of the kidneys or intestines;
If it is thin and well removed, and also gives off a metallic taste, this almost always signals the development of gastroenteritis. In this case, it is important to see a doctor as soon as possible. Chronic gastroenteritis is characterized by a sticky coating of a grayish hue with a putrid odor;
If it is oily and "silty", this indicates the accumulation of mucus and stagnation of food in the digestive tract;
If it is foamy and localized on the lateral parts of the organ, this may signal the presence of chronic bronchitis;
If it has a bluish tone, this may indicate the presence of typhus or dysentery;
If it is whitish, and located mainly at the root, the patient may suffer from chronic enterocolitis;
If it is brown, it makes sense to talk about severe diseases of the lungs and organs of the digestive tract in a chronic form;
If it is yellow, it indicates the presence of problems with the liver, spleen or gallbladder;
If it is located mainly in the middle third of the organ, it makes sense to check the condition of the duodenum.

Try to approach the examination of the tongue as adequately and carefully as possible, taking into account external factors. Be healthy!

The tradition of formulating a medical diagnosis is a legacy of the "interpretation of signs" from the time of Hippocrates and the later "epicrisis". The legislation does not define this term. The most widespread and widely used is the following definition: “A medical diagnosis is a doctor’s conclusions about the state of health of the subject, about an existing illness (injury) or about the cause of death, expressed in terms provided by the classifications and nomenclature of diseases.”

According to I.V. Davydovsky medical diagnosis has three categories:

underlying disease
Complications of the underlying disease
Concomitant diseases

For many decades of existence, the formula of medical diagnosis has confirmed its logical and practical value.

“The attending physician establishes a diagnosis, which is based on a comprehensive examination of the patient and drawn up using medical terms, a medical report on the disease (condition) of the patient, including that which caused the death of the patient. The diagnosis, as a rule, includes information about the underlying disease or condition, concomitant diseases or conditions, as well as complications caused by the underlying disease and concomitant disease, ”noted in paragraphs 5 and 6 of article 70 of the Federal Law of November 21 2011 No. 323-FZ "On the basics of protecting the health of citizens in the Russian Federation".

And part 2 of Article 14 of the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” determines that the powers of the federal executive body that develops state policy and legal regulation in the field of healthcare, includes, among other things: 11) approval of the procedure for organizing a document management system in the field of health protection, unified forms of medical documentation, including in electronic form. Thus, only the specified executive authority determines in which paragraphs of the unified forms of medical documentation (outpatient card, dispensary observation card, sanatorium card, certificates, extracts, etc.) and in what form the diagnosis is formulated. Order of the Ministry of Health of Russia dated December 15, 2014 No. 834n “On approval of unified forms of medical documentation used on an outpatient basis and the procedure for filling them out” approved: form No. 025 / y “Medical record of a patient receiving medical care on an outpatient basis”, form No. 043- 1/y "Medical record of an orthodontic patient", form No. 030/y "Control card of dispensary observation", Form No. 070/y "Reference for obtaining a voucher for spa treatment", form No. 072/y "Sanatorium-resort card" ; form No. 076/u "Sanatorium and resort card for children" according to; form No. 079 / y “Medical certificate for a child leaving for a sanatorium health camp”; form No. 086 / y "Medical certificate (medical professional advisory opinion)". These documents emphasize the important role of the earliest and most complete formulation of the diagnosis, which is why records of the primary examination of the doctor, examination of other specialists, the head of the department, consultation of the medical commission and generalization of the clinical examination data by the attending physician without fail ends with the diagnosis. On the first page of the outpatient card, diagnoses of all diseases for which dispensary observation is being carried out are indicated. On the second page, all first or re-established final (refined) diagnoses are recorded.

In Russia, the International Classification of Diseases (ICD) is considered the International Statistical Classification of Diseases and Related Health Problems of the 10th revision (1995), adopted by the Forty-third World Health Assembly (Order of the Ministry of Health of the Russian Federation dated May 27, 1997 No. 170 “On the transfer of healthcare bodies and institutions of the Russian Federation on the International Statistical Classification of Diseases and Related Health Problems, Revision X). It is according to this classification that the diagnosis should be established. Do not forget that the ICD is primarily a statistical classification. You can read more about the classification in the article "".

Undoubtedly, a progressive step in 2015 was the publication of the Order of the Ministry of Health of the Russian Federation of July 7, 2015 No. 422an "On approval of criteria for assessing the quality of medical care" (hereinafter - Order No. 422an). The criteria for the quality of medical care established by this order affect not only the process of providing medical care, but also issues related to the formulation and execution of a diagnosis. The document separates the requirements for the formulation and execution of a diagnosis in an outpatient and inpatient setting. Thus, paragraph 3 states that a preliminary diagnosis is established by the attending physician during the initial admission of the patient when providing medical care on an outpatient basis, no later than 2 hours from the moment of treatment, and a clinical diagnosis is established within 10 days from the moment of treatment. The latter should be made out with an appropriate entry in the outpatient card and be based on anamnesis, examination, data from laboratory, instrumental and other research methods, and the results of consultations of medical specialists. The entire volume of diagnostic measures should be provided for by the standards of medical care, as well as clinical guidelines (treatment protocols). If it is difficult to make a diagnosis, a consultation of doctors is held with an appropriate entry in the outpatient card signed by the head of the outpatient department of the medical organization. If it is necessary to provide medical care in a hospital, a referral to the hospital is issued indicating the clinical diagnosis.

When providing medical care in inpatient and day hospital conditions, a preliminary diagnosis is established by the doctor of the admission department or the doctor of the specialized department (day hospital) or the doctor of the department (center) of anesthesiology-reanimation of a medical organization no later than 2 hours from the moment the patient enters the medical organization. Establishment of a Clinical diagnosis should be made within 72 hours from the moment the patient enters the profile department (day hospital) of the medical organization, and when the patient is admitted for emergency indications, no later than 24 hours. Clinical diagnosis in the hospital is based on the same criteria as in the outpatient setting. In case of difficulty, the clinical diagnosis is established by the decision of the council of doctors with the execution of the protocol and making an entry in a special section of the hospital card, with the signature of the attending physician and the head of the department. We remind you that these criteria are used for the purposes of assessing the quality of medical care, which is currently carried out only within the framework of compulsory medical insurance. You can learn more about this in the articles: "", "".

From July 1, 2017, new criteria for assessing the quality of medical care, approved by the Order of the Ministry of Health of Russia dated July 15, 2016 No. 520n, will come into force(hereinafter - order No. 520n).

Note that, unlike the norm contained in Order No. 422an, Order No. 520n does not contain a time limit for making a preliminary diagnosis by the attending physician during the initial appointment of the patient. Read more about this in the article " » .

We remind you that these criteria are used for the purposes of assessing the quality of medical care, which is currently carried out only within the framework of compulsory medical insurance. You can learn more about this in the articles: "", "".

Order of the Federal Compulsory Medical Insurance Fund No. 130 dated July 21, 2015 “On Amendments to the Procedure for Organizing and Carrying out Control over the Volumes, Terms, Quality and Conditions for the Provision of Medical Assistance under Compulsory Medical Insurance, approved by Order No. 230 of the Federal Compulsory Medical Insurance Fund dated December 1, 2010” in the list of grounds for refusing to pay for medical care (reducing the payment for medical care) due to defects in the provision of medical care introduced the presence of a discrepancy between clinical and pathological-anatomical diagnoses of categories 2-3. For the first time, an expert opinion (a protocol for assessing the quality of medical care) includes diagnostic criteria: an assessment of the wording, content, time of diagnosis, and justification of the negative consequences of errors in diagnosis.

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A unified classification of types of diagnoses has not yet been established. In clinical practice, the customs of business medical circulation include several definitions of the diagnosis: differential diagnosis, laboratory, immunological, preliminary final. Differential diagnosis is rather part of the rationale and method of medical thinking. Data from laboratory and immunological tests, as objective signs and symptoms, may be under the heading "underlying disease". The preliminary diagnosis and the final diagnosis can be called "preliminary clinical diagnosis" and "final clinical diagnosis", but they should not be distinguished as types.

The most reasonable should be recognized as the judgment that the type of medical diagnosis is determined by the functions that it performs. The following types of diagnosis are distinguished: clinical, pathological-anatomical, forensic, sanitary-epidemiological diagnosis.

Clinical diagnosis- this is a diagnosis established by a patient in a hospital or long-term outpatient observation, which contributes to the treatment and further prevention of diseases. A preliminary diagnosis (incomplete) is made during the initial examination, and on its basis a plan of examination and treatment is drawn up, it can be symptomatic, syndromic, nosological. A detailed diagnosis (complete) is formulated in a certain time period on the basis of anamnesis data, examination, laboratory, instrumental and other research methods, the results of consultations of medical specialists provided for by the standards of medical care, as well as clinical recommendations (treatment protocols), contributes to complex treatment and secondary prevention, it can be syndromic or nosological.

Pathological and anatomical diagnosis- the final part of the autopsy protocol, in which the pathologist, based on the analysis of morphological data and clinical materials, formulates a synthetic conclusion about the nosological form, the dynamics of the disease (or diseases) and the immediate cause of death. The procedure for its registration is regulated by the Order of the Ministry of Health of Russia dated June 6, 2013 No. 354n "On the procedure for conducting pathological and anatomical autopsies."

Forensic diagnosis- this is a special conclusion on the nature of the damage (disease), the condition of the subject or the causes of death, drawn up on the basis of a forensic medical examination to resolve issues that arise in forensic investigative practice, and expressed in terms accepted in forensic medicine. Order of the Ministry of Health and Social Development of the Russian Federation dated May 12, 2010 No. 346n “On Approval of the Procedure for Organizing and Performing Forensic Medical Examinations in State Forensic Expert Institutions of the Russian Federation” establishes the procedure for conducting examinations and making a forensic medical diagnosis.

Sanitary-epidemic diagnosis- this is a formula for the conclusion of an epidemiologist about the epidemic nature of an infectious disease, the properties of the epidemic focus and the features of the epidemic process, expressed in terms provided for by the nomenclature and classifications adopted in epidemiology. The sanitary-epidemic diagnosis does not directly concern the patient, but is aimed at identifying the features of the emergence, formation and spread of the epidemic focus.

Misdiagnosis can result in both criminal and civil liability.

On the basis of clause 9, part 5, article 19 of the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, the patient has the right to compensation for harm caused to health during the provision of medical care to him. An incorrectly diagnosed diagnosis is always associated with incorrect, incomplete, and sometimes simply harmful treatment and can lead to complications of the disease, deterioration, disability and even death, which is undoubtedly a hazard to health, which has numerous confirmations in judicial practice. Thus, in the Appellate Ruling of the Moscow Regional Court dated May 18, 2015 in case No. 33-11200/2015, the role of an incorrect diagnosis as a reason for poor-quality medical care was emphasized “due to the fact that the fracture of the acetabulum was not diagnosed and appropriate treatment was not performed , as well as the patient was recommended to become more active, moving on crutches, there was an aggravation of the injury due to the formation of a dislocation of the femoral head, which subsequently required an additional operation aimed at eliminating the dislocation of the femoral head ... In the event that a fracture of the acetabulum would have been diagnosed in D.I.H. in the Sergiev Posad hospital, the treatment would have been more likely to have been carried out conservatively, that is, without the operation of osteosynthesis of fragments of the acetabulum and reduction of the dislocation of the femoral head .... due to shortcomings in the provision of medical care, he was misdiagnosed , which subsequently led to surgical interventions. On December 1, 2013, he was recognized as a disabled person of the second group. The jurisprudence is clear on this issue. Thus, in the Appellate Ruling dated May 18, 2015 in case No. 33-4519, the Perm Regional Court noted that “In accordance with clause 9, part 5, article 19 of Federal Law No. 323-FZ dated November 21, 2011 “On Health Protection citizens in the Russian Federation” the patient has the right to compensation for harm caused to health during the provision of medical care. In accordance with Article 150 of the Civil Code of the Russian Federation, health is an intangible good. In accordance with Article 151 of the Civil Code of the Russian Federation, if a citizen has suffered moral harm by actions that violate his personal non-property rights, the court may impose on the violator the obligation of monetary compensation for moral harm. In accordance with 1068 of the Civil Code of the Russian Federation, a legal entity or a citizen compensates for the harm caused by its employee in the performance of labor (official, official) duties. .. Late diagnosis did not contribute to the interruption of the pathological process and could worsen the prognosis of the disease. The panel of judges concludes that poor-quality provision of medical services, associated due to its specificity with the need for the plaintiff to use drugs that are not aimed at treating a real disease for a long time, the lack of medical care in the treatment<...>, the presence of physical suffering during the period of treatment due to an incorrect diagnosis undoubtedly caused the plaintiff non-pecuniary damage.”

Criminal liability may arise when:

official forgery - the introduction by an official of knowingly false information into official documents, as well as the introduction of corrections into these documents that distort their actual content, if these acts are committed out of mercenary or other personal interest (in the absence of signs of a crime under Part 1 of Article 292.1 of the Code ) (Article 292 of the Criminal Code of the Russian Federation);
falsification of evidence in a civil case by a person participating in the case, or his representative (Article 303 of the Criminal Code of the Russian Federation).

In case of an incorrect diagnosis, criminal liability may also be imposed under Art. 109; 118 of the Criminal Code of the Russian Federation and not only, depending on the consequences resulting from an incorrect diagnosis (causing serious bodily harm, death to a patient).

Summing up, we can conclude that the diagnosis (in terms of terms, types, form, grounds) is currently regulated by law, and work in this direction continues. Currently, these criteria are widely used in judicial practice to assess the harm caused.

The next stage of the diagnostic process is the establishment of a diagnosis based on the synthesis of the results of the examination and the differential diagnosis.

The correct and methodologically competent construction of the diagnosis is of paramount theoretical and practical importance. According to the degree of reliability, diagnoses are divided into preliminary, clinical and final.

Preliminary diagnosis- this is a subjective medical report in form, expressing the hypothesis of the objective nature of the disease in this patient (V.A. Germanov, 1981). A preliminary diagnosis is made on the basis of the initial examination of the patient and is based on the results of the questioning, the patient's medical records and physical examination. The preliminary diagnosis serves as the starting point for building a plan for further detailed examination. The preliminary diagnosis can be confirmed and refined, it can become the basis of a clinical one, but it can also be

rejected; it is a hypothesis and has a probabilistic value. A preliminary diagnosis is established in the very first hours of the patient's admission to the hospital. In this case, the analogy method is always used, when the recognition of the disease is possible by identifying the similarities and differences in the symptoms observed in a particular patient with the symptoms of known diseases.

Nosological unit- this is a structural and functional damage (disease) that has a certain etiology, pathogenesis or a characteristic clinical and anatomical picture, posing a threat to working capacity and life, requiring treatment and allocated as an independent statistical rubric at this stage of development of medicine and health care in order to study morbidity, mortality and more effective prevention and treatment.

Clinical diagnosis- this is a full-fledged subjective conclusion obtained in the course of a differential diagnosis, which is an objective relative truth, which, as our knowledge accumulates, approaches absolute truth, never reaching the absolute value of the latter. Clinical diagnosis is always determined by a certain degree of certainty, which continuously increases in the process of monitoring the patient.

A clinical diagnosis must be made within a period not exceeding 3 days of the patient's stay in the hospital, and must be placed on the title page indicating the date of its installation and the signature of the doctor who made the diagnosis. The date of the clinical diagnosis and the date of its justification in the medical history must match. If the diagnosis is not in doubt already during the initial examination of the patient (especially in cases of frequent hospitalization of the patient in this department), then the clinical diagnosis can be substantiated and formulated on the day the patient enters the hospital.

When substantiating and formalizing a clinical (and preliminary) diagnosis, the following requirements must be observed:

1. The diagnosis should be formulated on the basis of the nosological principle and at the same time provide a uniform and complete encryption, taking into account the International Classification of Diseases of the latest revision. Terms and expressions that allow dual, contradictory encryption should be avoided. Eponymic (named) designations of diseases and syndromes are also undesirable.

2. Clinical diagnosis must be complete. For a more complete disclosure of the features of this case, greater information content of the diagnosis, it is necessary to use generally accepted classifications with additional intranosological characteristics (clinical form; syndrome; type of course; degree of activity; stage; functional disorders).

3. Justification of the diagnosis should be carried out according to each fragment of the formulated diagnosis. As criteria for substantiating the diagnosis, use the most significant, significant symptoms and signs, as well as the results of the differential diagnosis, indicating the diseases included in the range of differential diagnosis. The recognition path should be the most economical.

4. Clinical diagnosis in the course of observation and treatment should be critically reviewed, supplemented and refined, reflecting the dynamics of structural and functional damage, changes in the patient's condition (change of phases, stages, degree of compensation), addition of complications, intercurrent diseases, as well as favorable and unfavorable consequences of treatment and rehabilitation (including complications of therapy).

5. The diagnosis must be timely and delivered in the shortest possible time.

6. When formulating a clinical diagnosis, they consistently indicate: in the first place - the underlying disease, in the second - complications of the underlying disease, in the third - concomitant diseases.

Main Of the several diseases present in patients, a nosological unit should be considered, which itself or as a result of complications causes a priority need for treatment at this time due to the greatest threat to working capacity and life and becomes the direct cause of death.

Complication of the disease– this is a secondary structural and functional damage, pathogenetically associated with the current underlying disease, or its corresponding therapeutic and diagnostic effects, or a manifestation of the underlying disease, which has independent significance. Complications significantly aggravate the clinical picture, increase the likelihood or degree of disability; contribute to death or are its direct cause; require a significant change or addition to treatment.

Concomitant disease– this is a nosological unit that is not etiologically and pathogenetically related to the underlying disease, does not significantly affect its course, is significantly inferior to it in terms of the degree of influence on the ability to work and the danger to life, the degree of need for treatment, and does not matter in thanatogenesis.

underlying disease– This is a nosological unit that contributes to the onset or unfavorable course of the underlying disease, increasing its danger to work capacity and life, or contributes to the development of severe complications and death, and therefore requires treatment at this time along with the underlying disease.

Associated diseases and injuries– these are nosological units that are simultaneously available in a certain patient, which in this combination cause the occurrence of disability, severe complications and death due to the summation of structural and functional damage, the impossibility of using effective methods of treatment (contraindicated in connection with one of these diseases), the adverse effects of therapy for one from diseases to the course of another, while separately each of these diseases could not lead to similar complications or death at a given time.

competing diseases one should name the nosological units that are simultaneously present in a particular patient, independent of each other in etiology and pathogenesis, but equally meeting the criteria for the underlying disease.

Examples of formulating a complete clinical diagnosis can be:

1. Ischemic heart disease. Widespread transmural myocardial infarction of the anterior wall of the left ventricle, acute stage. Stenosing atherosclerosis of the coronary arteries. Acute pericarditis. Atrioventricular block II degree (Samoilov-Wenckebach periods). Circulatory insufficiency II "B", IV FC according to NYHA. Diabetes mellitus type 2, moderate severity, decompensated. Psoriasis.

2. Chronic obstructive pulmonary disease, stage IV, bronchitis variant, exacerbation. Chronic respiratory failure 3 tbsp. Chronic cor pulmonale, decompensated. Relative insufficiency of the tricuspid valve. NK II "A" according to the right ventricular type. Sliding hernia of the esophageal opening of the diaphragm.

The doctor, having completed the formulation of the diagnosis, must ask himself whether he is mistaken. A thoughtful doctor always checks himself with the consciousness of the high responsibility of medical diagnostics.