Diagnostics as a process of medical knowledge. Features of scientific knowledge in medicine

In generalory plan, when analyzing and evaluating diagnostics, there are two approaches. One of them considers the diagnosis as a recognizable, algorithmic process, which is performed in advance by the well-known rules. Supporters of such a look essentially understand the diagnosis as recognizing the already known, not containing new knowledge about the object. Recognition is a complex mental process, involving penetration into a certain extent in the essence of the studied. Apply the diagnosis of recognition, they emphasize the special detection of recognition as such from scientific knowledge, research.

In fact, the diagnosis is not a conventional recognition process, i.e. identification of the studied disease with those knowledge that are contained in textbooks, monographs. The famous knowledge of the desired, alleged illness is only landmarks on the complex way to find a true individualized diagnosis of the disease.

The recognition process in honey diagnostics has some non-typical features, appearing as a peculiar form of knowledge of an unknown or little-known and individual in the known one. In particular, this is the identification of an atypically developing disease.

In general, scientific knowledge, regardless of the science profile, cannot do not rely on the famous. Often, new scientific discoveries are a kind of hybrid already known and open new. Also in the diagnosis, recognition of the already known and opening new - a single process. Based on the famous, the doctor to strive when the diagnosis of the disease is to know the unknown, specific. Recognizing the typological in a particular patient, the doctor is often faced with the individual characteristics of the disease. Individualized diagnosis is not only a consequence of recognition, but also the discovery, the cognition of something new, not occurring previously or substantial change of typical. The typological, nosological diagnosis is mainly the result of recognition, and the specific, individualized (diagnosis of this patient) is largely a consequence of knowledge, i.e. Acquisition of new knowledge. Thus, it can be concluded that the diagnosis is not just a recognizing process. Based on the main provisions of the theory of knowledge, the diagnosis should be considered as a specific form of cognition, in which its general patterns appear at the same time.

The diagnostic process has no chronological, nor spatial demarcation faces separating sensory and logical knowledge. Collecting anamnesis, laboratory and instrumental examination most accurately to the sensual stage of knowledge. But already when collecting anamnesis, the doctor is guided by those or other theoretical provisions, clinical principles, thereby grouping and classifies "sensual material". The specificity of the diagnosis as a form of cognition strengthens the significance of sensual contemplation. In diagnostic activities, the doctor constantly has to deal with objective and subjective data and testimony. From one or another understanding of the ratio of objective and subjective, their role and specific gravity in the development and course of pathological processes depend on the accuracy and adequacy of the diagnosis. With the so-called subjective examination of the patient, i.e. When familiarizing with the patient's complaints to its condition, the doctor in one way or another learns the objective state of the patient, the pathological foundations of the disease. In addition, an objective study is not exhausted only by laboratory and instrumental methods. Objective methods include conventional classical physical methods: palpation, percussion, auscultation. And when using the latter, the possibility of subjective assessment and interpretation of certain objective testimony is very large. Thus, any type of patient's knowledge can be simultaneously objective in its content and subjective in form. This is because the information obtained using instrumental methods is decoded and explained by narrow specialists with a different level of training, often not familiar with the patient's painful state directly.

Diagnosis is the main form of cognitive activity of the doctor. "The diagnosis establishment is a complex cognitive process, the essence of which is the reflection of objectively existing patterns in the mind of the doctor. In front of him, it is essentially the same task as before any other researcher - the establishment of objective truth, "the theorists of the medicine, philosophers of the kartegorodtsev G.I. And Erokhin V.G.

The diagnostic process consists of the following steps: Survey of the patient, analysis of the facts received and the creation of a synthetic picture of the disease in this patient, building a diagnosis, verification of the truth of the diagnosis and its refinement during the treatment of the patient, the forecast of the disease and its outcomes.

Prior to the start of diagnostic measures, the doctor based on patient polling (history) and their own observations related to professional knowledge is formed by the diagnosis hypothesis, in which elements of objective and subjective knowledge are closely intertwined. Further diagnostic measures are aimed at the maximum approximation of hypothetical knowledge of the diagnosis to true knowledge based on objective data.

The doctor, "starting to inspect and objective examination of the patient, assigning additional laboratory tests and research, it essentially already has a certain survey plan in the head and some set of hypotheses relative to a possible diagnosis of illness. ... at the stage of understanding the data obtained, in the process of differential diagnosis, the doctor does not at all as a "pure" theorist. It constantly overshadows his own point of thought with objective indicators of the development of the disease, analyzes the dynamics of changes in the symptoms of the disease, is looking for new empirical evidence of its hypothesis. "

At each of these stages, there is a close interaction of the sensual and rational side of knowledge, the objective and subjective in the picture of the disease of a particular patient appears.

"The diagnostic process has some specific features that distinguish it from other types of cognitive activity. First of all, the diagnosis, as follows from the very meaning of the term "diagnosis", there is a recognition process ", i.e. This is the process of establishing a private manifestation of the pathological process of a certain type. In the individual picture of the disease, there are both common and private, specific characteristics of a particular disease.

The same disease occurs in different people with a different combination of symptoms characteristic and uncharacteristic for him. Each patient has a specific disease proceeds not "strictly according to the rules", but taking into account the individual characteristics of his body, his personality. In medical practice, "atypical" cases are often found. This is a manifestation of general in an individual, specific. The complexity of the diagnosis is manifested primarily in the individual to see the general and apply the necessary methods and funds taking into account both in general, and individual. "Essentially ..." Art "of diagnosis is an individualization of the diagnosis of the nosological form of the disease, taking into account the characteristics of the patient and other specific circumstances."

"Weave the most different external and internal, sometimes random circumstances turns diagnostic activities in a truly creative act."

The diagnosis may have a different degree of truth, i.e. Knowledge of the disease has a different degree of completeness and compliance with objective reality. This problem of medical knowledge is directly related to the problem of medical errors.

The problem of medical errors is the designation of the problem of errors committed in their professional activities with medical workers.

Currently, it is customary to distinguish between errors caused by objective and subjective reasons. The basis of such a unit is the difference between the delusion and its own error. For example, if a doctor faces in his practice with a new, unknown science of the disease and not knowing this, trying to explain it with the help of his knowledge and ideas, he is mistaken. The causes of misconception in this case are neither of them or anyone independently depend. When the doctor acts incorrectly due to gaps in its formation or inability to correctly appreciate the objectively difficult situation, they talk about a medical error.

All sources of diagnostic errors are associated with the process of interaction of a learning entity (medical worker) with a certain object of medical knowledge. Therefore, "the division of mistakes for objective and subjective fully refers to the activities of the subject of knowledge - a separate physician."

There are no such professions whose specialists would not be mistaken in their practical activities. More Ancient Romans formulated their observation of mistakes in the form of axioms: "Every person is mistakenly mistaken" (Errare Humanym EST). Is mistaken, of course, medical workers. But a distinctive feature Medical errors are that their consequence is the damage caused to health, and in the broad sense and the life of another person.

To subjective sources of professional mistakes medical workers These include: insufficient training, the presence of gaps in professional knowledge, exaggeration of the meaning of the testimony of its own senses, inability to think to think, illegal generalizations and conclusions, preconceived convictions, pressure of someone else's opinion, unfair attitude towards their professional duties, etc.

To objective reasons for medical, including diagnostic errors include everything related to the overall level of medical knowledge, with the real possibilities of diagnosis, i.e. All those conditions that do not depend on the will and knowledge of individual people.

Associate and highly qualified specialists, and here the causes of another nature: the complexity of the course of the disease, lack of knowledge on this issue in the most medical science. And in these cases, a creative approach to solving the existing problem, professional intuition of a specialist becomes great importance.

In medical ethics there is a notion of "medical error". It still remains in many respects, and in conditions of modern medicine is filled with new ethical and philosophical and legal content.

The negligence, negligence, lack of professional knowledge and skills, which caused damage to the patient's health (and in extremely death) in different historical periods of the existence of medicine had various consequences for a doctor (or other medical worker).

In the laws of King Hammurapi, which was ruled in the middle of the 2nd millennium BC, listed penalties for erroneous treatment. For example, if, as a result of an unsuccessful operation, the patient was delayed, then the doctor was deprived of the hands. Thus, the society cultivated the responsibility of the physician for their professional actions.

In the early stages of the formation of domestic medicine, the doctor's action was equal to witchcraft, to "wicked - sorcery." During the period of Petrovsky reforms, a decree was issued, which the obligatory opening of the corpses was introduced into the duty of doctors in the deaths of the person. This was the first step towards scientific understanding of the correctness of the diagnosis and treatment of patients, the establishment and analysis of doctors errors.

In recent decades, the 20th century In connection with the expansion of citizens' rights, an increase in the value of human life is becoming increasingly distributed by a system of legal punishment of medical professionals for damage to the patient's health.

A sample of a doctor's attitude towards their professional mistakes is considered to be the attitude towards them an outstanding physician and scientist N.I.Pirogov. He believed that the doctors should extract the maximum instructive of their professional mistakes enriching both their own experience and the cumulative medicine experience. Only such a path meets the requirements of professional medical ethics, and only such life position Can compensate the "evil of medical errors."

An outstanding domestic doctor I.A.Kassirsky rightly noted: "... Medical errors are serious and always actual problem Healing. It must be admitted that no matter how well the medical case was delivered, it is impossible to imagine a doctor who already has a large scientific and practical experience, with an excellent clinical school, very attentive and serious, which in its activities could unmistakably determine any disease and so It is unmistakable to treat it, to do perfect operations. "

A peculiar milestone in the history of the formation of modern ideas about medical errors was the work of I.V. Dodovovsky. New emphasis in the content of the concept of "medical errors" by I.V. Dvalovsky is reduced to the following:

1. "Medical errors are an annoying marriage in medical activities." Unfortunately, it is impossible to imagine a doctor who would not commit diagnostic and other professional mistakes. Case in the extraordinary complexity of the object.

2. The relevance of the problem of medical errors has objective prerequisites. First of all, it should be noted the abruptly increased "activity" modern methods treatment and diagnosis, as well as the negative aspects of progressive specialization in medicine.

3.Registration, systematization and study of medical errors should be carried out systematically and everywhere. The main purpose of such activities within each clinical institution should be pedagogical concern for the growth of professionalism, hospital doctors.

4. It is fundamentally important when analyzing medical errors is the differentiation of ignorance from ignorance, in other words: a doctor - the entire Lin man, a measure, his responsibility for professional mistakes (not only in legal, but also in the moral and ethical) should have some objective criteria. If the doctor does not know the elementary basics of anatomy, physiology and clinic - it must be removed from work.

The narrower meaning of the term "medical error" was acquired in subsequent in forensic medicine. All adverse outcomes of treatment caused by the actions of the doctor, it shares the criminal acts, medical errors and accidents. Indeed, the life and human health is under the sewn of criminal law law. To be consistent, then each case of adverse outcome of treatment should be subject to criminal proceedings. Obviously, this is socially not expedient, almost impracticable, finally meaningless. "Medical mistakes" are apologizing for any objective and subjective circumstances, the conditions inherent in medical practice.

The thesis about the "right of the doctor's wrong mistake" is also in terms of logic, and from the point of view of the worldview.

From the point of view of logic: it is impossible to lend for due, professional lips of doctors - "annoying marriage" - happen by virtue of the circumstances uncontrolled by the doctor, and not right.

From the point of view of the worldview: if the professional activity of the doctor, obviously focuses on errors, it loses its humanistic nature. The idea of \u200b\u200b"the right to mistake" demoralizes the doctor.

The exceptional attention of clinicians, pharmacologists, all health workers deserve complications of drug treatment.

The concept of "medical error" emphasizes more subjective side of the professional activity of the medical worker, his ability to apply the general provisions of medical science to certain cases of diseases, an assessment of erroneous professional actions from the position of responsibility (moral, legal).

The concept of "yatrogenation" is largely correlated with the concept of "medical error". Currently, this concept means .........................

The cause of iatrogenies are professional errors of medical workers.

Professional miscarriage errors due to their extreme importance for other people should be of the negative experience, which should be comprehensively analyzed to prevent his repetition in the future. Each error should be appreciated by its own conscience of a person-specialist. This is a professional debt of a medical worker. L.N. Tolstoy wrote: "Try to fulfill my duty, and you will immediately learn what you are standing."

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Diagnostic Survey Methods or Diagnostic Technology

Methods of diagnostic observation include medical observation and examination of the patient, as well as the development and application of special methods for the study of morphological, biochemical and functional changes associated with the disease. Historically, the most early diagnostic methods include the main methods of medical research - anamnesis, inspection, palpation, percussion, auscultation.
There are 3 types of patient surveys: a) asked, b) inspection, percussion, palpation, auscultation, that is, direct sensual research and c) laboratory and to-mental examination. All three types of surveys are simultaneously both subjective, and objective, but the most subjective is the abstract method. Conducting the patient, the doctor must be guided by a certain system and strictly adhere to it. This survey scheme is trained in medical institutes and, first of all, in the departments of propedevics.
Subjective examination.
The patient's survey begins with listening to its complaints and questioning, which are the most ancient diagnostic techniques. The founders of domestic clinical medicine attached great diagnostic importance to the patient's complaints, his story about illness and life. M. Ya. Wisers for the first time in Russia introduced a planned questioning of patients and the history of the disease. Despite the seeming simplicity and publicity, the method of questioning is difficult, requires a significant skill and special preparedness of the doctor. Collecting anamnesis, it is necessary to identify the sequence of development of certain symptoms, a possible change in their severity and nature in the course of deploying a pathological process. In the first days of the disease, the complaints may be little pronounced, but intensify in the future. According to B. S. Shklyar (1972), ".. The sick, his sensations are reflected in his consciousness of the objective processes occurring in its organism. The ability to solve these objective processes for the verbal complaints of the patient with the knowledge and experience of the doctor. "
However, often complaints of patients have a purely functional origin. In some cases, due to increased emotionality, patients are inadvertently distorting their inner sensations, their complaints are acquired inadequate, distorted character, are purely individual severity. At the same time, there are complaints that are common, but inherent in certain diseases, for example, heart pain with irradiation in the left hand under angina, etc. The main complaints are those that determine the underlying disease, they are usually most constant and racks. , intensify as the disease develops. M. S. Maslov (1948) emphasized that there is a proper analysis of the anamnesis and symptomatology of the disease, there are alpha and omega of medical activities, and in the diagnosis of pylorosenosis in infants, anamnesis is crucial. Of great importance is the history and in the diagnosis of round peptic peptic ulcers of the stomach, the ulcers of the 12-rosewoman in children. M. S. Maslov believed that in a number of diseases of childhood history - all, and an objective study - only a small addition and the diagnosis is often ready by the time of the end of the collection of anamnesis. M. S. Maslov persistently emphasized that in pediatrics the diagnosis should be made primarily on the basis of anamnesis data and such simple methods of objective examination as inspection, percussion, palpation, auscultation, to the complex examination methods specifying the diagnosis, should be resorted only then When the doctor has a certain idea of \u200b\u200bthe disease.
Having heard the complaints and asking the patient, the doctor should not forget that the patient is not only an object, but also a subject, therefore, before proceeding to a detailed question, you should familiarize yourself with the personality of the patient, to figure out the age, the profession transferred earlier diseases, image and living conditions and living conditions and etc., that it will help to better understand the identity of the patient and the nature of the disease. The doctor must always remember that the patient is a person. Unfortunately, students at the institutes emphasize this position, and the personality of the patient should constantly increase. An underestimation of the individual comes from the wrong understanding of the role of biological and social in man. Only as a result of a comprehensive approach to the patient, as an individual, the extremes of both biologism and vulgar sociologist can be avoided. The range of impacts of the medium on the human body is large, but it largely depends on the individual characteristics of the body, its hereditary predisposition, the state of reactivity, etc. As a person is a reasonable, possessing the highest nervous activity, then the patient's asked is one of the methods of studying the psyche, clarification The states of the highest nervous activity, and the abundance itself should be attributed to the category of specific methods of examination. I. P. Pavlov The abrasion method considered the objective method of studying human mental activity.
The intellectual development of patients is different, therefore the doctor must already in the survey process, to develop the most acceptable communication for this patient. It happens that some doctors of coarse in conversation, others - fall into the shroud-satellite tone ("Milka", "Friendly"), others resort to a deliberate-primitive, pseudo-octic conversation manner with patients. Bernard show somehow noticed that there are 50 ways to say "yes" or "no", but only one way to write them. The doctor must constantly keep up the tone of his conversation with the sick. Fake tone does not have a patient to an open conversation with a doctor. It should be remembered that the patient during the abrasion in turn examines the doctor seeks to find out the degree of its competence and reliability. Therefore, in sympathy listening to the patient, the doctor must be able to find golden middle Communication, lying between a strictly objective official manner of behavior and exaggerated sentimental care. A good doctor is the one with whom you can speak in any vein: from a slight uncomfortable conversation up to a deep serious exchange of opinions. The word "doctor" comes from the ancient Russian word "lie", which means "talk", "talk". In an older, the doctor had to be able to "talk" the disease. In diagnosis, an important role is played by the immediate impression, the impression of the "first look".
A feature of human thinking is that it is never isolated from other manifestations of psyche and primarily from emotions, so not all truths can be proved by using only formal logical means (V. A. Postovit, 1985). The processing of information in the brain is carried out using 2 programs - intellectual and emotional. Through close psychological contact with the patient, the doctor seeks the patient's bed to find out the most characteristic, most importantly, relating to the personality and the disease itself. The philosopher Plato was surprised that the artists, creating good works, do not know how to explain their forces, from here I went myth about the "shepherd intellect" of artists. In fact, apparently we are talking About harmony in art, inaccessible to still systematic analysis.
The abrasion is a difficult and complex examination method, for mastering which you need to work a lot and versatile. Unfortunately, part of the graduates of our medical universities cannot be interested in and carefully listen to patients. It is important to listen to the patient with a stethoscope, but it is even more important to be able to just listen to it, calm. The reason for this
Inability lies in a weak other practical preparedness of young doctors, in the insufficient practice of their communication with patients in student years. The psychoneurologist M. Kabanov complained that for 6 years of study, students of medical universities study human body 8000 academic hours, and the human soul (psychology) is about 40 hours ("True" from 28-V-1988).
Currently, in connection with the technicalization of the diagnostic process and treatment, the principle of an individual approach to the patient is increasingly lost. At times, the doctor begins to forget that the sick person underestimates the psychology of the patient, and after all, it is pretty much to be treated to manage the patient's personality. Therefore, at the institute, the intention of medicine cultivated since the time of hippocrat should be maximally.
It is noticed that the lower the qualifications of the doctor, the less he speaks with the sick. Anamnesis can be quite complete when there is a complete psychological contact between the doctor and the patient. Different doctors patients can tell differently about their disease. So, for example, women are often talking about themselves about themselves and about the disease, depending on the doctor a woman or a man. The more experienced doctor, the more data it receives when the patient is asked.
The patient's complaints play a leading role in the formation of the diagnostic direction of the doctor's thinking. It is from the complaints of the patient depends on the primary diagnostic "sorting". The patient sets out first of all those complaints that attracted his attention and seem to him the main ones that, however, far from always and, moreover, many symptoms escape the patient's attention or even unknown to him. Therefore, the clarification of the complaints should not be reduced to their passive listening, the doctor is obliged to actively ask the patient and, thus, this survey process consists, as we have already mentioned, from two parts: the passive-natural story of the patient and the actively skillful, professional question of the doctor. Recall that even S. P. Botkin pointed that the collection of facts should be made with a certain guidance idea.
Conducting an active clarification of the patient's complaints, the doctor should strive to maintain complete objectivity and in no way put questions to the patient, in which a certain answer has already been prompting in advance. To the formulation of such issues, doctors are often resorted to the prejudice diagnosis and seeking artificially to bring the facts under the diagnosis invented by them. In these cases, the unhealthy desire of a doctor shine to the patient or the surrounding allegedly volatility. There are and easily impressed patients who seek the location of the doctor and pleased to him. The diagnosis should not be biased.
In the 50s in the Kiev Medical Institute, he worked as far away, an experienced associate of the therapist, inclined to some boasting. Once, looking together with the students of the 6th course of the patient, respectable age Ukrainian peasant, and not finding the belly of the "lanes of pregnant" on the skin, he did not say to students without a barraffication that the patient had no children and asked her to confirm it. The patient confirmed, but after a certain pause, during which the associate of the victoriously looked around the students added: "Bulo three sons are all three hanging on the Wine." It turned out to confuse, which many learned about.
After clarifying the complaints of the patient, they begin the most important part - asked, anamnesis. Anamnesis is a memoratory of a patient, his story about the start and development of the disease in his own understanding of the patient. This is "history of illness." But there is also a "history of life" - this is a story of a patient about his life, about the suffering diseases.
G. A. Rainberg (1951) allocated the "Forgotten Anamnesis" - the active identification of the patient for a long time and already forgotten events and the so-called "lost history" - identification of last Life Patient of such events that he himself does not know essentially. As an example of the "lost anamnesis" G. A. Rainberg describes a patient who was discovered by visceral syphilis on the basis of the existing indirect signs - a non-heaven fracture, and he did not know the patient about his disease. However, the proposals of G. A. Reinberg did not get distribution. "Forgotten anamnesis" is essentially a history of life, and the allocation of "lost anamnesis" is artificially artificially.
The value of the anamnesis in the diagnosis is difficult to overestimate, although in various diseases and not evenly. As G., A. Rainberg (1951) indicates, at the end of the XIX century, the XX century there was a dispute between the therapists of Moscow and St. Petersburg: the Moscow School, the main importance in the formulation of the diagnosis was attached to an anamnesis, St. Petersburg - an objective examination. Life has shown that only a skillful combination of data of a subjective and objective examination allows the most fully recognized disease. Experienced doctors know that a good history is half a diagnosis, especially if the patient is fully fully and accurately transferred the symptoms and they are specific, and the doctor is dealing with the disease, in the clinical picture of which subjective symptoms prevail.
Collecting anamnesis, as mentioned earlier, consists of a relaxed story of the patient about the start and development of the disease and directed asking for a doctor, during which he assesses a significant and insignificant in the story, while simultaneously observing the neuropsychiatric state of the patient. That is, we emphasize once again that the question is not a passive process of mechanical listening and recording information about the patient, but a planner, organized by the doctor's doctor.
The methodology of the history of the history was perfectly developed in the Moscow clinics of the founders of domestic therapy G. A. Zaharine and A. A. Ostrumov. G. A. Zaharin constantly stressed the need to adhere to the strict scheme of examination of patients and in his clinical lectures (1909) indicated: "The novice doctor, if he did not assimilate my methods ... asks how it fell ... he was fond of the first impression ... hopes quickly Solve the case, offering a patient somewhat related questions, but without having exhausted the question of the entire body ... The only true although a slower and difficult path is observing completeness and known once taken about the procedure in the study. " G. A. Zaharin brought the Anamnese method to virtuosity, the objective symptoms paid a little less attention. In his opinion, history allows you to get a more reliable idea of \u200b\u200bthe disease than the well-known physical ways of research.
There are various history schemes, which are trained in medical institutes, but no schemes adhere to the doctor, it is necessary that they provide sufficient completeness of the patient surveys and did not allow you to miss anything important for the diagnosis. Therefore, when collecting anamnesis, it is impossible to retreat from the plan of questioning, the ability to hear the patient is not a simple wish, we sometimes listen, but we do not hear, look, but we do not see. The consistent dimensions give a huge number of information that often replacing complex diagnostic studies, and sometimes determines the diagnosis. R. Hugglin (1965) believes that, on the basis of the data of the anamnesis, the diagnosis is established in more than 50% of cases, according to physical examination, in 30%, and in laboratory data - in 20% of patients. V. X. Vasilenko (1985) pointed out that almost in half cases anamnesis allows you to correctly diagnose. The famous English cardiologist P. D. White (1960) said that if a doctor cannot collect good history, and the patient cannot tell him well, then both of them are in danger: the first - from the appointment, the second - from the use of unsuccessful treatment. P. D. White (1960) emphasized that the history of the patient often contains many keys to resolve diagnosis and treatment issues, but it is often precisely this part of the examination of the patient most of all doctors neglect. Sensity and lack of a systematic survey are usually the causes of such disregard. Collecting anamnesis requires more time than other types of surveys, but the doctor should not save time on history.
The accepted procedure for examination of the patient, when there is a question earlier, and then an objective examination cannot be absorbed, but absolutely, it is often necessary, as one or another symptoms are found, the need arises to return to history, specifying or complementing its various sides, considering and evaluating them. from new positions. According to N. V. Elstein (1983), the main mistakes in therapists when collecting anamnesis are the following: a) the underestimation of the characteristic complaints, the absence of the desire to find out the relationship of symptoms, time, the frequency of their appearance, b) the underestimation of the difference between the beginning of the disease and the beginning of its exacerbation , c) underestimating epidemiological, "pharmaco-allergological" history, d) underestimation of household conditions, family relationships, sex life. The abrasion method should be considered as a strictly objective and scientific method of examination of the patient, with the help of which, as well as clarifying the nature of patient complaints, the doctor is an initial idea of \u200b\u200bthe picture of the disease as a whole, forming a preliminary diagnosis.
Objective examination.
The diagnostic techniques of the great clinicians of the past, along with questioning, observation, were also the simplest physical methods such as Palpation, percussion, auscultation. Hippocrates indicated that judgments about the disease arise through the view, touch, hearing, smell and taste. Hippocratic belongs to the first attempt of the auscultation of patients. Physical methods of surveys of patients retained their meaning and at present, despite the fact that they have already exhausted their capabilities regarding the establishment of new scientific facts. The development of science and medical equipment has given the opportunity for ordinary physical examinations methods to strengthen and supplement new tools and devices, which significantly increased the level of diagnosis.
But now the main diagnostic method is a clinical method, the essence of which is to directly examine the patient with the help of the sense of the doctor and some simplest devices that increase the resolution of the sense organs. The clinical method includes the analysis of patient complaints, history, inspection, palpation, percussion, auscultation, observation in the dynamics of the disease.
It is impossible to talk seriously about the diagnosis if the doctor does not have enough examination methods and is not sure about the reliability of its survey. If the doctor does not own the clinical method, he cannot be considered a practical doctor. The doctor, like a musician, must perfectly own the patient's survey technique.
Separate the clinical method of examination of the patient is not as simple as it seems at first glance - for this requires great work and years. Although physical methods (inspection, palpation, percussion, auscultation) and refer to the simplest methods, but the term "simplest methods" must be understood according to the fact that these methods are simultaneously simple and complex: simple - because they do not require complex equipment, but complex - For mastering them requires a long and serious training. Fisical methods sometimes give more information than instrumental. The symptoms of the disease detected using the clinical method are the primary actual material, on the basis of which is diagnosed. First ofnder effective application Clinical research methods is technically correct ownership of them, the second is strictly objective use of them and the third - completeness of the survey of the patient "from the head to items" even when the diagnosis is allegedly clear at a glance. Even a young and inexperienceful doctor in good faith, without a rush, examined the patient, knows him better than having watched his more experienced specialist.
Starting the patient examination, the doctor must avoid bias the opinions about the diagnosis, so the survey itself is being carried out, and then familiarization with certificates, extracts and conclusions of other medical institutions. M. S. Maslov (1048) emphasized that mainly the diagnosis should be made on the basis of anamnesis data and simple inspection methods, percussion, palpation and auscultation. Based on his many years of practical experience, we believe that after the patient examination, it is already possible to put an allegedly allegedly, and in some cases a reasonable diagnosis. If the clinical method does not make it possible to make a diagnosis, then resort to additional and more complex methods of examination. With a clinical examination of the patient, according to I. N. Osipov, P. V. Kopnin (1962), wider than all the vision is used, with which an inspection is carried out. The visual irritations have a very low threshold, in view of which even very small irritation is already able to cause visual perceptions, which, as a result of a minor difference threshold, make it possible to distinguish the growth or decrease in light irritation on a very small amount.
Percussion and auscultation are based on auditory perceptions, palpation and partially immediate percussion - on touch, which makes it possible to determine the humidity and temperature of the skin. Some meaning in the diagnosis may also have an olfactory, and the doctors of antiquity even discovered the presence of sugar in the urine during diabetes. Most of the symptoms detected through vision, somehow skin color, body, coarse changes in the skeleton, rash on the skin and mucous membranes, the expression of the face, brilliance of the eyes and many others belong to the category of reliable signs. No wonder the outstanding pediatrician N. F. Filatov Sometimes for a long time, it was silent for a long time at the bed of a child, watching him. The second place of reliability, after the symptoms, detected visually, occupy symptoms detected by palpation by touching, especially during examination of the lymphatic and musculoskeletal system, pulse, abdominal organs, etc. It should be noted that the tactual abilities of the fingers of the hands from various doctors should be noted. Not the same, which depends on both congenital characteristics and experience gained. Many made a lot to improve the Palpation method Outstanding domestic clinicians V. P. Designs, N. D. Strazhessko et al. These percussions and auscultations based on auditory perceptions have only relative accuracy, since many sounds we do not perceive. No wonder they say that it is better to see once, than to hear a hundred times, and, probably, this saying does not sound anywhere so realistic as in the field of practical medicine. A person's ear distinguishes the sounds from 16 to 20,000 oscillations in 1 C, but with maximum sensitivity it has to sounds with the oscillation range from 1000 to 3000, the sensitivity to the sounds with the oscillation range up to 1000 and over 3000 - sharply decreases and the higher the sound, the higher It is worse perceived. The ability to distinguish the height and duration of sound very varies individually, which depends on the age of people, the degree of their training, fatigue, the development of hearing organs, therefore percussion and auscultation often discover only the symptoms of probable, having a relative importance, due to which they need to be more careful To the symptoms obtained by inspection or palpation.
The human senses are not so perfect so that with their help it was possible to detect the manifestations of all pathological processes, therefore, with a dynamic observation of the patient, repeated research is necessary.
The state of many organs and patient systems is not directly research, so clinical medicine constantly seeks to overcome the limitations and relativity of sensual perceptions. Medical perception also depends on the objectives of the examination, namely: a specialist, thanks to his experience and skill, enshrined in the conscious and subconscious spheres, can see what others do not notice. But you can watch and not understand, feel and not perceive - only thinking eyes can see. Without sensations, no knowledge is impossible. The French clinician Trusso called to constantly observe the sick and memorize images of the disease.
The priority task of an objective examination is to identify the main complex of data that determine the main disease, the defeat of a system or another. V.I. Lenin so determined the role of the feeling as the first reflection of the objective reality in the consciousness of a person: "The feeling is a subjective image of the objective world" (Poly. Cons. Op. T. 18, p. 120). However, to own only the patient's examination technique is not enough, it is necessary to seek to know the pathogenesis of each symptom, to understand the connection between the symptoms because the feeling is only the first stage of knowledge, in the future the content of sensations with thinking should be transformed into concepts, categories, laws, etc. It will not be subjected to appropriate processing of thinking, they can lead to erroneous judgments in diagnosis. If using the clinical method, it is not possible to make a diagnosis or it needs to be clarified, then resort to laboratory and instrumental methods of examination, in particular to biochemical, serological, radiological, ECG and EEG studies, functional (spirometry, dynamometry, etc.) and other research methods, as well as to follow the patient's observation.
The widespread introduction into the clinical practice of various instrumental and laboratory research methods, significantly increasing the effectiveness of the diagnosis, at the same time increased the possibility of side effects on the patient's body. In this regard, there was a need to generate and certain criteria for the usefulness and safety of diagnostic methods. Studies should be safe, accessible, cost-effective, reliable and accurate, should be the stability and uniqueness of the resulting results with a minimum number of deviations. The smaller the number of erroneous results, the higher the specificity of the research methodology. The patient's survey should be targeted, organized, and not a natural, for which the doctor must have a specific survey scheme and the assumption of the essence of the disease. Speaking about the direction of the diagnostic examination, two ways should be distinguished: the first - is the movement of medical thoughts from studying the symptom to the diagnosis, the second - called methodological or synthetic, is a comprehensive examination of the patient "from head to pack", with full accounting of the history of the anamnesis, objective and laboratory surveys, regardless of the severity and nature of symptoms. The second path is more laborious, it is resorted to it even when the diagnosis seems clear "at first sight." This method of examination of patients is usually trained in medical institutes. Modern condition Science allows you to study the functional-structural condition of the person at the following levels: molecular, cellular, tissue, organ, systemic, organized, social, environmental. It should be borne in mind that the nenection of pathological changes in the body is the same objective fact as the identification of certain symptoms.
A certain orientation should exist, and when conducting laboratory studies. It should not be prescribed too many laboratory tests, and if they also give not very clear results, they not only do not clarify the diagnosis, but even confuse it. Laboons, endoscopists, radiologists can also be mistaken. And yet many analyzes and instrumental studies are more useful than dangerous if they are carried out correctly, in accordance with indications and non-invasive methods.
At the same time, numerous studies that are appointed or interpreted incorrectly, unsymptic, with an insufficient understanding of their clinical significance, and in case of an erroneous assessment of the results obtained, a weak opportunity to associate the results, reassessment of some and underestimation of other studies. Let us give an example. Somehow our clinic of viral hepatitis for one week began to receive an alarming conclusions about very low figures in a number of patients of the prothrombin index, which was explicitly contradiction with the general condition and other biochemical indicators from most of them. It turned out that the laboratory makers allowed a rough technical error in the study of blood. But a sharply reduced prothrombin index in such patients is one of the formidable indicators of hepatic insufficiency requiring the use of urgent and special therapeutic measures. The data of laboratory research should be treated sober and critically, one should not overestimate laboratory and instrumental data in the examination of patients. If, after examining patients and with the help of laboratory and instrumental methods, it is not possible to diagnose, then they are resorted (if the patient's condition allows) to follow the observation. Subsequent observation of the development of the pathological process, especially in infectious diseases that differ in cyclic flow (with the exception of sepsis), it often makes it possible to come to the correct diagnostic conclusion. On the subsequent observation, as a diagnostic method, I knew Avicenna and widely recommended it to the introduction into practice: "If the disease is difficult to determine, then do not interfere and do not hurry. Truly, or the creature (person) will take the top of the disease, or the disease will be determined! " (Cyt. According to Vasilenko V. X., 1985, p. 245-246). I. P. Pavlov constantly demanded "to observe and watch!". The ability to observe should be brought up in itself from school bench, develop visual sharpness, which is especially in the diagnostic process. The outstanding clinicians of the past were distinguished by the ability to observe. The ability to observe requires a large patience, concentration, alpostly, which usually comes with experience.
My teacher, a well-known professor infectiousist Boris Yakovlevich Padalka, possessed enviable patient and thoroughness in the study of patients and persistently instilled these qualities to his employees and students. He did not get tired of listening to the patients's complaints, their stories about their illness, often confused, fragmentary, and sometimes ridiculous, incoherent. We, employees who participated in the trafficking, were sometimes very tired physically and sometimes defeated the professors for him, as it seemed to us, petty meticulousness. But over time, we were convinced of the usefulness of such a thorough examination of the patients, when the clarification of small facts and symptoms helped to make a diagnosis correctly. Boris Yakovlevich, regardless of the severity of the patient and the nature of his illness, always examined in detail the patient, did it slowly and strictly consistently, systematically examining the condition of all organs and patient systems.
In 1957, being on a business trip, in the city of W., I was invited to consult a highly aggressive patient of the Middle Ages with an unclear diagnosis. Among the patient who observed in the hospital were experienced diagnosticians, so I decided to inspect the patient, like my teacher - as much as possible and thoroughly. And so, in the presence of several local professionals, few believers believe in my luck, I started slow and strictly consistently and methodically examine the patient. Surveying the cardiovascular system, the gastrointestinal tract, the urinary system, I could not "catch up" for anything explaining the patient's condition, but when it came to the respiratory authorities, then at percussion it was possible to identify the presence of fluid in the pleural cavity and diagnose exudative pleurisy. In the future, the diagnosis was fully confirmed, the patient recovered. The diagnosis turned out to be at all difficult and was viewed by local doctors not by ignorance, but by inattentive. It turned out that in the past two days before my inspection, the patient was not examined by the attending physician, and for this period, the basic accumulation of fluid in the pleural cavity occurred. In the diagnosis, it is better to be honest and courageously confessing in his ignorance and declare "I don't know" than to speak in a manner, inventing fake diagnoses and harm the patient, discrediting the medical title.
It should be noted that the most characteristic clinical symptoms and most adequate laboratory studies correspond to a certain stage of the disease. For example, in the abdominal title, the hemoculture is easier to highlight the sickness in the 1st week, while the reaction of the agglutination of Vidal gives positive results from the beginning of the 2nd week, when specific agglutinins accumulate in the blood. Using technical innovations in the diagnosis, it is impossible to fall into naked technicalism, remembering that the diagnosis technology does not replace direct clinical examination of the patient, but only helps him. M. S. Maslov (1948) emphasized the conventionality of functional, biochemical and instrumental research methods, warned against the danger of fetishization of numbers.
Getting Started by a survey of a patient, the doctor must remember the impression that he produces at him already at the first meeting, so you can not examine the patient in the presence of outsiders. In the room where the survey is conducted only two: the doctor and the patient, and if the sick child, then only his close - in essence this is the main meaning of the "medical office". If the first meeting of the doctor and the patient fails, then the proper psychological contact between them may not arise, and during this meeting the doctor should get acquainted with the patient as a person, to make a favorable impression on him, win his trust. The patient should feel in the doctor of his true friend, to open him, to understand the need to be frank with him, in turn, the doctor should be able to internally collect. The doctor needs to work out a professional ability to switch entirely and delve into his thoughts into his work as soon as it turns out to be at his workplace. Only in case of establishing a good psychological contact between the doctor and the patient, you can count on the completeness of the patient's survey, the subsequent formulation of the correct diagnosis and the appointment of individualized treatment. Only as a result of the immediate communication of the doctor with a patient, which cannot be fixed on paper, you can get a complete picture of the disease and the state of the patient.
In conclusion, I would like to emphasize once again that a well-assembled history, skillfully and thoroughly conducted an objective study, correctly meaningful examination data enable the doctor in most cases to put the correct diagnosis. And although this trivial truth is known to everyone, but it is constantly underestimated. Being a very young doctor, I somehow, together with the same inexperienced colleague, tried to make a diagnosis at the situation-based patient of the middle-aged, distinguished by silence and closedness. After examining the patient, we did not find any changes that could explain the presence of a temperature reaction. Left after the working day in the clinic, we went through dozens of diseases, built not one diagnostic hypothesis, but they did not come to a certain conclusion. The next morning we asked the opposite of our department, an elderly and a very experienced infectiousnessist, to see our mysterious patient. We have never doubted that a patient will present certain difficulties for our senior comrade. Associate Professor, asking the patient, threw back the blanket and immediately discovered a patient from the sick focus of the grinding inflammation, but we looked at the patient only to the belt and did not pay any attention to the legs. My young colleague with my young colleague (later a professor-therapist) were brutally disgraced, but they made an unequivocal conclusion for themselves: the patient should always be examined by just- "from the head to the fifth"!
Human genius created " Divine comedia"," Faust "," Don Quixote "," Evgeny Onegin "and other great creations that everyone says, but few people read or reread and the meaning of the methods of clinical diagnostics are known to everyone, but not all of them quite fully Use.
Machine diagnostics.
Achievements of science and technology have penetrated various areas of knowledge, including clinical medicine, facilitating the solution of many research and practical tasks. Machine diagnostics is a tool of knowledge and clinical medicine should boldly join the union with mathematics, mathematical logic. Therefore, it is impossible to refuse the benefits of industrialization and in the field of clinical diagnostics, striving at the same time to preserve the personal contact of the doctor with the patient. However, technician, whatever perfect it, cannot replace the doctor in the study of the patient as a person. All prominent and authoritative clinicians constantly emphasize the leading role of the clinic and a practical doctor in recreating a picture of the disease based on subjective and objective data, as well as a clinical analysis of the results of laboratory research. The cybernetic machine cannot operate with dialectical logic, without which it is unthinkable to formulate the individual diagnosis or diagnosis of the patient. Cybernetic diagnostic methods are the processes of processing information by a certain algorithm, in the development of which three main stages distinguish: a) collect information about the patient and storage of information, b) analysis of the information collected, c) data assessment and diagnosis. It should be remembered that the task for the computing machine is a person, and not a car, the man "puzzles" the car and the diagnostic effect will depend on how correctly the program for the machine was made.
Diagnosis logic.
One of the most complex areas of cognitive activity is the diagnostic process in which objective and subjective, reliable and probabilistic are intertwined. The diagnosis is special species cognitive process. "Cognition" means compassion for knowledge. This is a socio-historical process of creative activity of a person who form his knowledge, on the basis of which the goals and motives of human actions arise. In the theory of knowledge, there are two main directions - idealism and materialism.
Idealism gives knowledge of the self-knowledge of the "World Spirit" (Hegel), to the analysis of the "complex of sensations", the denying the possibility of knowledge of the essence of things. Materialism proceeds from the fact that knowledge is the reflection of the material world, and the reflection is the universal form of adaptation of the body to external causal relations in the residence environment. The dialectic and materialistic theory of knowledge considers practical activities as the basis of knowledge and criterion of the truth of knowledge. The method of knowledge should be only one - the only correct dialectic and materialistic one.
Dialectics, if she claims success, should be closely related to the materialistic theory of knowledge and dialectical thinking methodologies. The dialectic involves a high culture of dialectical thinking of a doctor. All stages and sides of knowledge in any region are dialectically interconnected, permeate each other. Contemplating an object, a person seems to "impose" historically formed the skills of its processing and use, and thus this object appears in front of a person and as a purpose of its action. The living contemplation of objects is thus the moment of sensual practical activities carried out in such forms, as a feeling, perception, representation, etc.
The diagnosis methodology is a set of cognitive funds, methods, techniques used in the recognition of disease. One of the sections of the methodology is the logic - science on the laws of thinking and its forms, the beginning of which was still written by Aristotle. Logic studies the course of reasoning, conclusions. The logical activity of thinking is carried out in such forms as a concept, judgment, conclusion, induction, deduction, analysis, synthesis, etc., as well as in creating ideas, hypotheses. The doctor must have an idea of \u200b\u200bvarious forms of thinking, as well as distinguish the skills and ability, since the conscious nature of human activity is determined by the knowledge system, which in turn is based on the system of skills and skills that are the basis for the formation of new skills and skills. Skills are called those associations that make up the stereotype, as much as possible and quickly reproduce and require the smallest costs of nervous energy, while the skill is already the use of knowledge and skills in these specific conditions.
The concept is the idea of \u200b\u200bsigns of objects; With the help of concepts are allocated and secured in words (terms) similar and significant signs of various phenomena and objects. Categories of clinical concepts include symptom, symptom complex, syndrome.
The judgment is a form of thought in which it is approved or denied something relative to objects and phenomena, their properties, connections and relationships. The judgment about the origin "of any disease requires knowledge not only the main causal factor, but also many living conditions, as well as heredity.
The conclusion is a form of thinking, as a result of which a new judgment is obtained from one or several well-known concepts and judgments containing new knowledge. One of the types of conclusions is an analogy - the conclusion of the similarity of two items on the basis of similarity of individual signs of these items. The conclusion by analogy in classical logic is the conclusion about the belonging of this subject matter based on its similarity in essential features with another single subject. The essence of conclusion by analogy in the diagnosis consists in comparing similarities and differences in the symptoms in a particular patient with symptoms of known diseases. M. S. Maslov (1948) noticed that "differently can only be suspected of being suspected" (p. 52). Diagnosis by analogy is of great importance in recognizing infectious diseases during epidemics. The degree of probability of conclusion by analogy depends on the materiality and number of similar signs. I. N. Osipov, P. V. Kopnin (1962) warn of the need to comply with caution and criticality in diagnosis by analogy. Dangerous in this method is the lack of a permanent plan of systematic comprehensive examination of the patient, since the doctor in some cases examines the patient not in a strictly defined order, but depending on the leading complaint or the symptom. At the same time, the method of an analogy is a relatively simple and frequently used method in the recognition of disease. In clinical medicine, this method is almost always applied, especially at the beginning of the diagnostic process, but it differs in limited, does not require the establishment of comprehensive relations of symptoms, identifying their pathogenesis.
An important place in diagnostics occupies such a logical reception as a comparison with which the similarity or distinction of items or processes is established. Comparison is a widespread cognitive technique to which even during the hypocratic times, doctors often resorted to the empirical period of medicine. You can compare various subjects, processes, phenomena, both in high-quality and quantitative terms and in different ways. For the diagnosis, it is valuable not any comparison, so it should be carried out according to certain rules, including A. S. Popov,
V. G. Kondratyev (1972) include the following: a) determine, at least approximately, the circle of the most likely diseases with which a comparison will be carried out; b) to highlight the disease leading symptoms or syndromes from the clinical picture; c) determine all the nosological forms in which this symptom or syndrome is available; d) compare all signs of a particular clinical picture with signs of an abstract clinical picture; e) exclude all kinds of diseases, except for one, most likely in this case.
It is easy to note that the consistent comparison of a particular disease with an abstract clinical picture, according to the indicated rules, makes it possible to carry out differential diagnosis and is its practical essence. Disease recognition is essentially differential diagnosis, for a simple comparison of two paintings of the disease - an abstract, typical, contained in the doctor's memory, and a specific - in the patient's surveyed, and is a differential diagnosis.
Comparison methods and analogies are based on the detection of the greatest similarity and the smallest difference in symptoms. In cognitive diagnostic work, the doctor meets with such concepts as an essence, phenomenon, necessity, accident, recognition, recognition, etc.
Essence is the inner side of the subject or process, the phenomenon characterizes the outer side of the subject or process.
The need is something that has the cause in itself and naturally follows from the most essence.
Accident is something that has the basis and reason in another, which follows from external or cork ties and in view of this may or may not be, can occur, but may also be different. The need and chance with a change in conditions go into each other, the accident at the same time is a form of manifestation and addition to it.
The prerequisite for any cognitive process, including diagnostic, is the recognition and recognition of studied and related, as well as similar phenomena and their parties in a wide variety of options (K. E. Tarasov, 1967). The act of recognition is limited only by fixation and the basis of the holistic image of the object, subject, phenomena, its general view One or more signs. The recognition is associated with specific sensual activities, is a manifestation of memory comparable to the designation process, and not only a person, but also to the highest animals. Thus, the recognition is limited to the reproduction of a holistic image of an object, but without penetration into its internal essence. The act of recognition is a more complex process that requires penetration into the hidden inner essence of the phenomenon, object, object, establishing on the basis of a limited number of external signs of a specific structure, content, causes and dynamics of this phenomenon. Recognition is comparable with the installation process, disclosure of the object value, taking into account its internal and external relations and relations. However, recognition should not be identified with scientific cognition, since it is subject to the objectives of practical change, the transformation of the subject and in each area has its own characteristics.
The general for recognition and recognition is that the course of thought comes from a sign of a phenomenon based on preliminary knowledge, exploring the phenomenon as a whole and its most common specific signs. However, acts of recognition and recognition in practical life are not manifested, they are combined, complementing each other. When making a diagnosis, by analogy, first of all resort to simple method The recognition and in the studied symptoms of the disease recognize the signs of an already previously known abstract disease. When conducting a differential diagnosis and especially individual diagnosis (i.e. the diagnosis of the patient), the doctor also uses the recognition method, since more in-depth penetration is needed into the essence of the disease, it is necessary to find out the relationship between individual symptoms, to know the identity of the patient.
Thus, in diagnostics, two types of knowledge of the cognition process can be distinguished, of which the first is the easiest and most common, based on analogy and recognition, when the doctor recognizes what he is already known, and the second is more complex, based on the act of recognition when it happens The knowledge of the new combination of elements, that is, the individuality of the patient is learned.
Even more complex methods in the gnoseological process are induction and deduction. Induction (Latin. Inductio - Guidance) is a research method, which consists in the movement of thought from the study of private to the formulation of general provisions, that is, the conclusion coming from private provisions to the general, from individual facts to their generalizations. In other words, diagnostic thinking in the case of induction moves from individual symptoms to their subsequent generalization and establishment of a disease, diagnosis. The inductive method is based on primary hypothetical generalization and subsequent verification of concluding on the observed facts. The output obtained inductive way is always incomplete. V.I. Lenin pointed out: "The most simple truth, the most simple inductive way received, is always not complete, because it is always not over" (cit. T. 38, p. 171). Conclusions obtained by induction can be checked in practice with a deductive path.
Deduction (Latin. Deductio - elimination) - This is a conclusion, moving, in contrast to induction, from knowledge of a greater degree of community to knowledge of a lesser degree of community, from the perfect generalization to individual facts, to parties, from 1 general provisions for special cases. There are a number of forms of deductive conclusion - syllogisms (Greek - SylLogismus - getting output, derivation of consequences); The construction of a row of various divisory syllogisms gives the analytical work of a physician strict and consistent nature. If the deduction method is resorted to the diagnosis, then medical thinking moves from the alleged diagnosis of the disease to individual symptoms expressing the disease and characteristic of it. The great importance of deductive conclusions in The diagnosis is that with their help previously unnoticed symptoms are detected, it is possible to predict the emergence of new symptoms characteristic of this disease, that is, using a deductive method, you can check the correctness of the diagnostic versions in the process of further observation of the patient.
In diagnostic practice, the doctor must also contact induction, and to deduction, exposing inductive generalizations of deductive verification. Using only induction or deduction can lead to diagnostic errors. Induction and deduction are closely related to each other and there are no "clean" induction, nor "clean" deduction, but in various cases at various stages of the gnoseological process, then one, then another reasoning is predominant.
Of the three sections of diagnostics - semiology, methods of research and medical logic - the last section is the most important, for semiology and medical techniques have a subordinate value (V. A. Postovit, 1989). Each doctor by nature is a dialectic, but dialectics are natural and firmly standing at the scientific positions of Marxist-Leninsky dialectics. The doctor is obliged to own scientific dialectical thinking. The ability to apply dialectic, which distinguishes dialectics from non -ialectics. Dialectic materialism makes it possible to penetrate the sick person's secrets, correctly recognize the nature of the disease. Unlike agnosticism, denying the cognitiveness and its internal laws, dialectical materialism, based on the data of science and the world-historical practice of mankind, strongly denies the existence of the principle of non-recreationality and approves the ability of science to limitless development. There is no unrecognizable in pathology, and there is only an unknown, which will be good for medical science. Life irrefutably testifies that as clinical knowledge expands, new facts are opened, new information about the patterns of development of pathological processes.
Knowledge of dialectics, as the foundations of the materialistic worldview and the method of knowledge of the surrounding world, as V. M. Syrnev, S. Ya. Chikin (1971), it is necessary to students of any higher educational institution and especially physicians and doctors, since everyday medical work Constantly related to dialectical thinking. Unfortunately, the familiarization of students and young doctors with a dialectical method is often carried out in detachment from practice, too trapped and therefore poorly mastered, and the logic - science on the laws of thinking and its forms is particularly important for the doctor - neither in high school, nor in the medical institute Not studied at all. In the few manuals and manuals on the logic diagnostics, there is little, besides, it is sometimes quite primitive that it creates a distorted representation and causes the doctors a negative attitude to this type of science. M. S. Maslov (1948) gives the following recommendations for the use of a dialectical method in clinical diagnostics: and in history, and in symptoms to allocate a decisive link, taking into account the real, specific living conditions and the surroundings of the patient. To keep in mind that social, economic and household factors affect the causes and course of the disease, which, depending on the conditions of the medium, the patient's reactivity changes. For diseases, the whole system of organs is almost always amazed and often the entire body, so based in the diagnosis and forecast only on morphological data and only on certain organs, isolated, without taking into account the whole organism, is clearly not enough and must be complemented by learning functions.
To the modern principles of general diagnosis of V. X. Vasilenko (1985) refers the following: a) the disease is the local and general reaction, b) the body's reactions depend on many factors - transferred in the past disease, genetic moments, reactivity changes, etc. , c) the patient's body - the whole, organs and systems, including the highest nervous activities, are closely interrelated, therefore, not only local, but also common phenomena, d), the body should be studied in its unity with an external environment. It may contribute to the emergence and development of the disease, e) when studying the body, it is necessary to take into account the role of higher nervous activity, temperament, changes in the neurohumoral regulation of vital processes, e) the disease is not only somatic, but also mental suffering. There are several forms of logic: formal, dialectical and mathematical logic. But perhaps those authors who recognize the existence of only one logic that has 3 aspects: formal, dialectical and mathematical or symbolic logic. Formal logic is a science that studies the forms of thought - concepts, judgments, conclusions, evidence. The main task of formal logic is to formulate laws and principles whose compliance is a prerequisite for the achievement of true conclusions in the process of obtaining output knowledge. The beginning of formal logic was made by the works of Aristotle. Thus, formal logic is a science of forms of thinking, but without the study of their occurrence and development, therefore V. I. Lenin called such forms by "external", compared with the deep essence of dialectical logic. F. Engels indicated that formal logic is only a relatively faithful theory of the laws of thinking, called it the logic of "ordinary", the logic of "household" (F. Engels. Dialectic nature).
Medical thinking, as well as any other, are inherent in universal logical characteristics, logic laws. The theory of the knowledge of Marxism-Leninism reveals the basic principles and the most common patterns of knowledge regardless to which the area there is cognitive activity. The diagnosis should be considered as a peculiar, specific form of cognition, in which its general patterns are also manifested.
A. F. Bilibin, G. I. Tsoregorodtsev (1973) emphasized that the diagnostic process does not have chronological and spatial boundaries separating sensory and logical knowledge. Training in the university students, methodological examination of patients by authorities and systems, we thus teach their techniques for formal logic. Formal logic is not a special methodology, although it is used as a method to explain the new results in the process of thinking. When the physician's logicality of the doctor's reasoning is evaluated, then it is above all in mind the formal logical association of its thinking, that is, formal logic. However, it would be an incorrect logical mechanism of medical thinking to reduce only for the presence of formal logical connections between thoughts, in particular between concepts and judgments.
One-sidedness, deficiency of formal logic, as S. Gilyarovsky, K. E. Tarasov (1973), is that it is distracted by the content of scientific concepts, the degree of accuracy, the completeness and depth of reflection in them objective reality. Last century L. Bogolepov (1899) tried to submit the laws of medical thinking based on the principles of formal logic and allocated the following types of diagnostic thinking: 1) the method of intuitive, 2) method is simple, 3) Differential method, 4) Exception method, 5) method Specific difference, 6) Deductive method and 7) Method of analytical. The above classification of L. Bogolepova is quite formal and schematically, the presented types of diagnostic thinking are not listed logically, do not complement each other and do not reflect the actual process of diagnostic medical thinking. The foregoing is an example of how to ignore the laws of dialectics makes lifeless in general, not deprived of meaning classification. Despite limited capabilities, formal logic is necessary and useful for mastering dialectical logic.
Dialectical logic, being highest compared to formal, studies the concept, judgment and conclusion in their dynamics and relationships, exploring their epistemological aspect. The main principles of dialectical logic are the following: objectivity and comprehensiveness of the study, study of the subject in development, disclosure of contradictions in the very essence of objects, the unity of quantitative and qualitative analysis, etc.
V. I. Lenin formulated the basic 4 requirements of dialectical logic: 1) to study the subject studied comprehensively, opening all its connections and mediation; 2) take the subject in its development, "self-expression" of changes in Hegel; 3) include in the full definition of the subject as the criterion of truth, practice; 4) Remember that there is no "abstract" truth, the truth is always concrete "(full. Coll. Cit. T. 42, p. 290).
Karl Marx emphasized: "Concrete is concrete concrete that it is the synthesis of many definitions, therefore, unity is diverse. In thinking, it is therefore acting as a synthesis process, as a result, and not as the initial item, although it is a valid source point and, as a result, the initial item of contemplation and representation "(K. Marx and F. Engels. Op., Ed . 2nd, vol. 12, p. 727).
What does concrete in gnoseology mean? This is a system of concepts, formulations, definitions characterizing the specificity of the subject, its features logically interconnected. V.I. Lenin, determining the essence of dialectical logic, wrote: "The logic is a doctrine not about the external forms of thinking, but about the laws of development" of all material, natural and spiritual things, that is, the development of the entire particular content of the world and knowledge of it, t . e. The result, the amount, withdrawal of the history of the knowledge of the world "(full. Cons. Op. t. 29, p. 84) and further:" ... separate does not exist otherwise, as in the connection that leads to the total. The general exists only in a separate, through a separate "(full. Cons. Op. T. 29, p. 318). "To really know the subject, V. I. Lenin said, it is necessary to cover, examine all his parties, all connections and" mediation. " We will never achieve this completely, but the requirement of comprehension warns us from errors "(full. Cathed. Op. T. 42, p. 290). V.I. Lenin in his writings persistently emphasized: "The dialectic requires comprehensive accounting of relations in their specific development, and not pulling a piece of one, a piece of the other" (full. Coll. Cit. T. 42, p. 286).
The diagnostic process is a historically developing process. The examination of the patient is conducted throughout its stay under the supervision of a doctor in the clinic or outpatient conditions. M. V. Chernorutsky (1953) about the dynamic of the diagnostic process said: "The diagnosis is not complete, since the disease is not a state, but the process. The diagnosis is not a single, temporarily limited act of knowledge. Dynamic is dynamic: it develops together with the development of a painful process, with the course and course of the disease "(p. 147).
S. P. Botkin emphasized: "... The diagnosis of the patient has a more or less likely hypothesis, which must be constantly checking: new facts that can change the diagnosis or increase its probability" (the course of the clinic of internal diseases and clinical lectures. M. , Medgiz, 1950, vol. 2, p. 21). The diagnosis never ends while the patient continues the pathological process, the diagnosis is always dynamic, it reflects the development of the disease. S. A. Gilarhevsky (1953) believed that the restructuring of the diagnosis is possible under the following circumstances: a) when new conditions appear due to the evolution of the painful process, b) when the entire complex of symptoms was not expressed during the patient examination and therefore the diagnosis, despite its manifestations, It needs addition and clarification, c) when the patient has two diseases at the same time, but one of them, being pronounced, served as the basis for the initial diagnosis, and the second is weakly manifestized, recognized later, d) when the initial diagnosis was incorrect. The doctor should be able to correctly combine the data of its own and instrumental study with the results of laboratory tests in the dynamics of the pathological process with the results of laboratory tests, remembering that they change in the course of the disease. The correct diagnosis is the correct today in a few weeks and even days, and sometimes hours can become incorrect or incomplete. And the diagnosis of the disease, and the diagnosis of the patient is not a frozen formula, but change together with the development of the disease. The diagnosis is individual not only in relation to the patient, but also in relation to the doctor. The path to the diagnosis should be not through complex, but through simpler concepts.
The pathogenesis of the disease, which is a dialectical process, needs to study the source, nature and directions for the development of the pathological process. At the same time, the source is understood as the internal impulse of the "self-division" of the disease, the nature of the development is revealed by the law of transition of quantitative changes to qualitative, the direction is detected by the law of denying denial (S. A. Gilarhevsky, K. E. Tarasov, 1973). Matter self-governed according to the laws of dialectics, of which 3 laws are closely related, are universal: 1) the law of unity and struggle of the opposites, 2) the law of transition of the number in quality, 3) the law of denying denials. The doctor needs to constantly keep in mind that the body and healthy, and the patient is a single whole, all systems, organs and tissues of the holistic organism are in the prosestation and complex interdependence from each other.
A living organism is not an arithmetic amount included in it parts - it is a new quality resulting from the interaction of individual parts under certain conditions of the external environment. But, emphasizing the significance of the whole, it is impossible to be understood and the role of local, local, no wonder I. Pavlov said: "It goes without saying, there is a living organism, but how to deny item, it is nonsense, ignorance, misunderstanding" (quot. A . F. Bilibin, G. I. Tsoregorodtsev, 1973, p. 63).
Unfortunately, the doctor sometimes sees a separate liver, stomach, nose, eyes, heart, kidneys, bad mood, imperitiousness, depression, insomnia, etc. But it is necessary to cover the patient as a whole, to create an idea of \u200b\u200bthe person! At the same time, some doctors do not even want to hear about it, considering it by resonance, rhetorically asking the question: "What does personality mean? We always learn it! ". However, this is just an empty phrase! Doctors have long known that the state of the nervous system affects the course of somatic processes. M. Yasadrov noticed: "... Patients, suffering and despair, thereby deprive of life, and from one fear of death die." (Element. M., 1949, p. 107). The French surgeon Larray, claimed that the wounds of the winners heal faster than the defeated. Any somatic violation leads to a change in the psyche and vice versa - a modified psyche has an impact on somatic processes. The clinician doctor should always be interested in the mental world of man, his attitude to people, society, nature; The doctor is obliged to find out everything that forms a person and affects him. According to the ancient scientists of Greece, the greatest mistake in the treatment of disease was that there are doctors for the body and doctors for the soul, while both inseparable, "But this is just not noticing by Greek doctors, and only therefore from them So many diseases are hidden, they do not see the whole "(Cyt. V. X. Vasilenko, 1985, p. 49). Plato argued: "The greatest mistake of our days is that the doctors separate the soul from the body" (CIT. F. V. Bassin, 1968, p. 100). The unity of the functions and reactions of the body is due to interrelated mechanisms of nervous and humoral regulation. The highest center regulating vegetative processes is a hypothalamus, which has vascular and nervous bonds with the pituitary gland, forming a hypothalamic-pituitary system. M. I. Astanzagurov in 1934 reported that the presence of a body carrying out the primary relationship between mental and somatic functions was established. This organ is the ganglia of the intermediate brain - the auditorium and a striped body, closely connected with the vegetative system and are phylogenetic roots of primitive emotions. Due to the presence of the unity of the body functions, the local pathological process may become generalized. The functional unity of content and shape creates a certain integral structure, which is not just a set of individual elements, but also by the system of ties and interaction. It should be borne in mind that each structure can have several functions related to a single holistic system, therefore it is more correct to talk about the functional system, and not about the function. F. Engels pointed out: "All organic nature is one solid proof of identity and continuity of form and content. Morphological and physiological phenomena, the form and function determines mutually each other "(K- Marx and F. Engels. Op. Ed. 2, vol. 20, p. 619-620). Restress the function from the structure or structure from the function - metaphysically and contradicts the principles of dialectical thinking. Structural changes almost always lead to functional shifts, while the latter may occur without significant structural rearrangements, therefore, the mechanism of dependence of the function on the structure is more noticeable in life and less expressed the effect of the function on the structure. In this regard, the functional diagnosis is usually preceded by other types of diagnosis, in particular, morphological, uniting all kinds of diagnosis into a single integral detailed diagnostic concept of a single orientation and having an integrating universal value, while the value of the morphological, etiological and other diagnoses is more narrow.
A narrow specialization of doctors leads to the fact that they forget about the integrity of the human body, that he is a person. Deliching into the study of "molecular violations", which in itself is important and progressively, it is impossible to lose from the type of a holistic organism with its highly organized and subtle psyche. Therefore, a narrow specialization, on the one hand, very necessary, on the other, it turns out not always useful, since the understanding of the organism of the patient disappears, as a whole. The perception of even the simplest phenomenon occurs in the form of an image, a holistic, and not fragmented to separate components. V. X. Vasilenko (1985), speaking of the tasks of the doctor's doctor, indicated that his task "consists not only to determine the essence, patient's disease, but also to know its special features, i.e. his individuality, almost Just as the artist-portraitist depicts not a person at all, but a completely concrete person and personality; Without this data, there can be no medical art "(p. 35). Dialectical logic does not deny formal logic, and acts through it, based on a specific synthesis of its operations, overcoming the limitations of each of them.
Formal and dialectical logic are different stages of the historical development of human thinking. Formal logic, as the lower stage of thinking history, is included in dialectical logic, and the latter mediates modern formal logic, telling it new content in accordance with the requirements and demands of scientific thought. Therefore, it is impossible in the diagnostic process to artificially dismember the formal logic and dialectical, for at any stage of recognition, the doctor thinks and formally and dialectically. However, for the formulation of the methodologically reasonable final diagnosis, the doctor is not enough applications only of the laws of formal logic - they must be comprehended and supplemented with laws and categories of dialectical logic. The dialectical method of thinking exists and operates in each area of \u200b\u200bscientific episheology, but this, however, does not eliminate its specifics. Mathematical logic is not a special form of logic, and represents the modern stage of development of formal logic. The merit of mathematical logic is to create special logical systems (calculus) and in the development of formalization methods. Mathematical logic is even more formalistic than classical formal logic. However, the diagnosis is not an arithmetic amount of the patterns of a living biological system calculated using a computer, diagnostics - not a simple addition of symptoms of the disease, but a thin process of synthesis and creativity.
The diagnostic process is associated with obtaining, comprehending and processing numerous anamnestic and laboratory data, data of an objective study obtained sometimes obtained using complex instruments, and in some cases as a result of long-term monitoring of the patient, therefore, the processing of such information is possible only using methods not only formal , but also dialectical logic, and the latter is only available to the doctor, and not the car. Mathematical or symbolic logic is used when solving tasks with computers. One of the sections of mathematical logic is the probabilistic logic that attributing the judgments is not two, but many values \u200b\u200bof truth.
No special medical logic or special clinical gnoseology. All sciences logic is alone, it is universal, although it manifests itself somewhat differently, for it acquires some originality of the material and those goals with which the researcher deals. Methodology, gnoseology, logic in all spheres of human activity are common, but the fact that they are manifested differently generate the erroneous opinion that each science has its own logic.
The medical thinking is inherent in a single universal logic, its principles and laws whose application is an indispensable condition for the correctness of thinking and its effectiveness. The statement that for each science there is its own special logic, unfounded. But in logic, individual fragments can be allocated, which most of all are suitable for the logical form of this particular scientific or professional activity. It should be noted that the logic does not indicate the right paths as possible from incorrect, erroneous paths. In the diagnostic activity of the doctor there is a complex dialectic and categorical synthesis of inorganic and biological, biological and social, physiological and psychological, that is, there is a unique cognitive situation. At the same time, it should be borne in mind that the diagnosis logic is not limited to the development of the finished system of means of recognition of the disease. It can not be reduced to the logical designs of the perception of famous medical knowledge, to their deductive transformation. According to S. V. Cherkasova (1986), the logic of the diagnosis should contribute to the development of creative and structural abilities from a doctor to abstract and intuitive thinking, the ability to share the main and secondary. The active and creative nature of clinical thinking is not manifested in the fact that the doctor's thought ignore the logical correctness of creative constructions, and in the fact that adequately reflects the general pattern and the peculiarities of the disease in their dialectical unity.
What is thinking? "Thinking is an active process of reflection of the objective world in concepts, judgments, theories, etc., associated with the solution of certain objectives, with generalization and methods of mediated knowledge of reality; The highest product is specially organized by the matter of the brain "(Philosophical Dictionary, M., 1986, politicization, p. 295). Thinking is the process of interaction of a person with public labor and life practices, it is never isolated from other manifestations of psyche. Regarding the interpretation of the concept of "clinical thinking" there are various opinions. A. F. Bilibin, G. I. Tsoregorodtsev (1973) believe that this concept includes not only the process of explaining the observed phenomena, but also the attitude of the doctor to them, clinical thinking is based on a variety of knowledge, at imagination, memory, fantasy, intuition , skill, craft and skill. Next, these authors indicate that despite the fact that the doctor's thinking should be logical and to be controlled and inspected, it is still not mechanically identified with
Formally logical, philosophical and figurative-artistic. Clinical thinking along with the general possesses and unique in its kind of specificity. And the peculiarity of medicine is that it is always associated with people, and each person is always individual (V. A. Postovit, 1989, 1990). A. S. Popov, V. G. Kondratyev (1972) give such a definition of clinical thinking: "under clinical thinking it means the specific mental activity of a practical doctor who ensures the most efficient use of these theory and personal experience To solve diagnostic and therapeutic tasks with respect to a particular patient. The most important feature of clinical thinking is the ability to mental reproduction of the synthetic and dynamic inner painting of the disease "(p. 24-25). According to these authors, the specificity of clinical thinking is determined by three peculiarities: a) the fact that the object of knowledge is a person - a creature of emergency complexity, b) specificity of medical problems, in particular, the need to establish psychological contact with patients, studying it as a person in diagnostic and therapeutic Plans and c) Building a treatment plan. It should be borne in mind that the doctor is forced to often act in conditions of insufficient information and significant emotional stress, increasing a sense of permanent responsibility.
Clinical thinking is also a logical activity to clarify a specific personality, so clinical thinking is always an active creative process. S. V. Cherkasov (1986) notes that clinical thinking is not manifested in the fact that the doctor's thought ignores the logical correctness of theoretical constructions, but that adequately reflects the overall pattern and the features of the course of the disease in their dynamic unity. The symptoms of the disease are the symptoms of the disease. Symptoms of the disease are the symptoms and diagnostics. Clinical thinking provides for a creative approach of the doctor to each particular patient, the ability to mobilize all knowledge and experience to solve a certain task, to be able to change the direction of reasoning, to comply with the objectivity and determination of thinking, be able to act even in terms of incomplete information.
The culture of the doctor's thinking is of great importance in recognizing diseases, a doctor who does not have enough culture and experienced clinical thinking often takes probable conclusions for reliable.
In clinical activities, a lot of guesses, so-called hypotheses, so the doctor is obliged to constantly think and think about, given not only indisputable, but also difficult to explain phenomena. The hypothesis is one of the forms of the cognitive process. In the diagnosis of hypothesis are very important. By logical form of the hypothesis is a conclusion conclusion in which part of the parcels, or at least one, is unknown or probably. The doctor enjoys a hypothesis when it does not have sufficient facts to accurately establish the diagnosis of the disease, but implies its availability. In these cases, patients usually lack specific symptoms and characteristic syndromes, and the doctor has to follow the path of probable, presumptive diagnosis. Based on the identified symptoms, the doctor is building an initial hypothesis (version) of the disease. Already when identifying complaints and anamnesis, the initial hypothesis appears, and at this stage of the survey, the doctor must freely move from one hypothesis to another, seeking the most appropriate to build a study. A preliminary diagnosis is almost always more or less likely a hypothesis. The hypotheses are important and because during the continuing examination of the patient, they contribute to the identification of other new facts that can sometimes be even more important than those discovered before, and also encourage the inspection of the symptoms and conduct additional clinical and laboratory research. The importance of hypotheses in Knowledge pointed F. Engels: "The form of the development of natural science, since it thinks, is a hypothesis" (K. Marx, F. Engels. Op. 2nd ed., Vol. 20, p. 555). Claude Bernard said that science is a cemetery of hypotheses, and D. I. Mendeleev claimed: "It is better to hold such a hypothesis, which may turn out to be wrong with the time than any" (1947, vol. 1, p. 150). There are general and private or working hypotheses. In general or scientific, actual hypothesis, the assumption of the laws of natural and public phenomenaIn a private hypothesis - the assumption of the origin and properties of individual facts, phenomena or events. The working hypothesis provides one of the possible explanations or interpretations of the fact, phenomenon or events. The working hypothesis is usually advanced at the very beginning of the study and is rather the nature of the assumption that orient the study in a certain direction. If the general hypothesis is a form of development of purely scientific knowledge, then private - used not only by science, but has an applied value when solving practical problems. The overall hypothesis, although with known amendments, can give such an explanation of the phenomenon, which in some cases turns into reliable knowledge. The general hypothesis is always exposed to evidence, and the proven turns into a reliable truth. In order for the general hypothesis in the period of studying anamnesis and clarify the complaints of the patient turned into reliable conclusions about the diagnosis, it is necessary to obtain and take into account the data of an objective study.
The working hypothesis is an initial assumption that facilitates the process of logical thinking, helping to systematize and evaluate the facts, but not assigning a mandatory subsequent transformation into reliable knowledge. Each new working hypothesis requires new symptoms, so the creation of a new working hypothesis requires searches for additional, still unknown, signs that contributes to a comprehensive study of the patient, deepening and expanding the diagnosis. The probability of working hypotheses as they are shifted and the emergence of new, constantly increasing.
A. S. Popov, V. G. Kondratyev (1972) allocate the following rules for constructing diagnostic hypotheses: a) the hypothesis should not contradict firmly established and practically proven provisions of medical science; b) the hypothesis should be based only on the basis of proven, true, truly observed facts (symptoms) should not need to be built in other hypotheses; c) the hypothesis should explain all existing facts and none of them should contradict it. The hypothesis is discarded and replaced by a new one, if at least one important fact (symptom) contradicts it; d) When constructing and presenting a hypothesis, it is necessary to emphasize its probabilistic nature, remember that the hypothesis is only an assumption. Excessive passion for the hypothesis, combined with personal indiscrimination and non-critical attitude towards himself can lead to a rough mistake. V. X. Vasilenko (1985) emphasized that hypotheses should be affordable to check, and their number need to strive to reduce. Diagnostic hypotheses in practice are checked. When building hypotheses should avoid hasty in generalizations, not to give an unlikely hypothesis value of reliable truth, not to build hypotheses on unreliable symptoms, since the ultimate goal is to transform the diagnostic hypothesis to a reliable conclusion. The hypothesis is considered correctly formed in cases where it corresponds to the facts, it is based on them and it follows from them even if one, but a serious and reliable symptom contradicts a hypothesis, then such a hypothesis should be considered deprived of value and a doctor should be discarded it. In diagnostics, you need to be able to abandon the diagnosis in certain cases, if it turned out to be erroneous, which is sometimes given very difficult, sometimes it is even more difficult to form the diagnosis itself.
Critically belonging to the hypothesis, the doctor must simultaneously be able to and defend it by discussing with himself. If the doctor ignores the facts that contradict the hypothesis, he begins to take it for a reliable truth. Therefore, the doctor is obliged to seek not only symptoms confirming its hypothesis, but also the symptoms that disprove it contradictory it, which can lead to the emergence of a new hypothesis. Construction of diagnostic hypotheses is not an end in itself, but only a means to obtain the right conclusions when recognizing diseases.
The diagnosis is a cognitive process, the essence of which is to reflect in the minds of the doctor of objectively existing patterns caused by the pathological process in the body of the patient. The task of diagnosis in general is reduced to creating a mental picture of the disease in a particular patient, which would be possible a more complete and accurate copy of the disease itself and the state of the patient. If the doctor manages with the greatest completeness to achieve the identities of his thought from the true pattern of the disease and the state of the patient, the diagnosis will be correct, otherwise a diagnostic error occurs.
The cognitive diagnostic process takes place all the stages of scientific knowledge, following the knowledge of the simplest to the knowledge of complex, from knowledge of the shallow to deeper, from collecting individual symptoms to their comprehension, establishing the relationship between them and the design of certain conclusions in the form of a diagnosis. V.I. Lenin said: "The thought of man is infinitely deepened from the phenomenon to the essence, from the essence of the first, so to speak, of the order to the essence of the second order, etc., without the end" (full. Coll. Cit. T. 29, p. 227). The doctor seeks to recognize the disease, mentally moving from the part to the whole. Each of the stages of thinking is closely conjugate, followed and intertwined with it. The diagnostic process follows from a particular sensual to abstract and from it to a specific thought, and the latter is the highest form of knowledge.
The movement of knowledge in the diagnostic process takes place by the following 3 stages, reflecting the analytical and synthetic mental activity of the doctor: 1. Detection of all symptoms of the disease, including negative symptoms, with a clinical and laboratory examination of the patient. This is the phase of collecting incidence of incidence in a particular patient. 2. Comprehension of the detected symptoms, "sorting" them, evaluation according to the degree of importance and characteristics and comparison with the symptoms of certain diseases. This is the phase of analysis and differentiation. 3. Formulation of the diagnosis of the disease on the basis of identified signs, combining them into a logical integer. This is the phase of integration and synthesis.
Diagnostics begins with analysis, with studies of subjective data, from examining a patient for organs and systems in a known sequence and subsequent synthesis of collected facts. Condivating the analysis and synthesis, the doctor must comply with the rules of scientific observation that require:
1) objectivity, accuracy, survey accuracy,
2) completeness, methodological and systematic surveys,
3) the permanent comparison of the observed phenomena.
This testifies that clinical diagnosis refers to complex medical activities requiring the ability to analyze and synthesize not only the identified painful symptoms, but also the individuality of the patient, its features as a person. Clinical diagnosis is based on the study of the patient, on the knowledge and experience of the doctor, the ability to apply his knowledge in practice in various conditions. The success of the doctor in recognizing disease depends on the ownership of the foundations of logic-formal and dialectic. When conducting differentiation, the doctor seeks to come to a clinical diagnosis, when direct symptoms fit into the clinic of one particular disease. All symptoms that do not correspond to this disease will speak or against the diagnosis of this disease, or indicate the availability of complications.
The diagnostic process, in contrast to scientific research, assumes that the essence of the recognized object, that is, the symptoms of the disease is already known. In principle, the diagnosis consists of two parts of the physician's mental activity: analytical and synthetic and the main forms of thinking are carried out through the analysis and synthesis. Any human thought is the result of analysis and synthesis. In the work of the Clinician's doctor, the analysis is practically carried out simultaneously with the synthesis and the separation of these processes, as consistent, very conditionally.
Analysis is called mental dismemberment into separate parts the subject matter, phenomena, their properties or relations between them, as well as the allocation of its signs to study them separately, as united parts. It should be borne in mind that the disease is sometimes characterized by complex clinical manifestations and the doctor has to collect and analyze very extensive information about the patient, to conduct a serious analysis. The subject or process can be perceived as a whole without preceding analysis, but in this case the perception is more often superficial, shallow. The analysis process can be divided into a number of components, somehow: the transfer of information, the grouping of identified data, to the main and secondary, classification of symptoms for their diagnostic significance, the allocation of more or less informative symptoms. In addition, the analysis of each symptom is carried out, for example, its localization, high-quality and quantitative characteristic, communication with age, communication in time of appearance, frequency, etc. The main task of analysis is the establishment of symptoms, the definition of significant and insignificant, sustainable and Unstable, leading and secondary, helping to identify the pathogenesis of the disease. A. S. Popov, A. G. Kondratyev (1972) emphasize that the diagnostic informativeness and pathogenetic significance of the symptoms often do not coincide: so, for example, such "small" symptoms of diabetes mellitus as paradontosis, furunculosis, skin itch may be present in hidden Disease flow.
Synthesis - the process is more complicated than the analysis. Synthesis, in contrast to the analysis, is a compound of various elements, objects of the object, the phenomenon into a single integer. With the help of synthesis, all symptoms in the diagnostics are integrating into a single associated system - a clinical picture of the disease. Under the synthesis, mental reunion into a single integer component parts or object properties is understood. However, the synthesis process cannot be reduced to a simple mechanical addition of symptoms, each symptom should obtain an estimate in a dynamic connection with other signs of the disease and with the time of their appearance, that is, the principle of integral consideration of the entire complex of symptoms should be observed, in their relationship with each other. The mechanical addition of individual symptoms without taking into account their relationship and assess the dynamic significance of each of them leads to distortion of a holistic picture and an error in the diagnosis. In most cases, the identified symptoms are a reflection of only one disease, which is obliged to the doctor), although it is not eliminated by the possibility of several diseases. With the help of the synthesis, all identified symptoms are combined into a single pathogenetic picture by combining individual symptoms in syndromes, the initial establishment of individual sides of the diagnosis, the so-called "private diagnoses" and their subsequent synthesis to obtain a single picture of the disease with a single diagnosis. This is preceded by the release of a complex of decisive, leading symptoms and differentiation of them from the secondary.
If the doctor collects all the facts characterizing the disease in the first part of the diagnosis, then in the second - the large creative work According to the critical assessment of these facts, comparing them with others and formulating the final output. The doctor is obliged to be able and analyzed, and synthesize the obtained clinical and laboratory data. In the diagnostic process, there is unity of analysis and synthesis. M. S. Maslov (1948) emphasized that Alpha and Omegoic medical activity are the analysis and synthesis. F. Engels pointed out: "Thinking consists of the same in the decomposition of objects of consciousness on their elements, as in the combination of elements connected with each other into some unity. No analysis No synthesis "(K. Marx, F. Engels. Op. T. 20, p. 41). Analysis without subsequent synthesis may be fruitless. The analysis can give a lot of new information, but numerous details come to life only in their connection with a whole organism, that is, in the case of rational synthesis. Therefore, the simple collection of symptoms of the disease for diagnosis is completely insufficient: there are still mental processes and, in addition, the activities of the doctor, based on observation and experience, which contribute to the establishment of communication and unity of all detected phenomena. Thus, the diagnostic process consists of two stages: recognition and logical conclusion, on the basis of which the following 3 tasks are solved: 1) the detection of symptoms of the disease, 2) the correct interpretation of the identified signs of the disease, 3) implementation of the correct diagnostic conclusions.
In life there are doctors who perfectly know the propiance and symptoms of diseases, but, without possessing the ability to synthetic thinking, remain poor diagnosticities. Here we are not talking about knowing the doctor, but about its inability to diagnostic thinking. In this case, the doctor is likened to the bad mechanics, which, having all the separate parts of the machine, cannot collect it.
Clinical thinking has a dual character: the ability to record the well-known and ability to reflect on the specific identified when analyzing. The diagnostic process is permeated by the analytical-synthetic mental activity of the doctor. It should be borne in mind that not all the facts obtained during the examination of the patient are used in diagnosis. In the clinical picture, there are both random, insignificant and even "extra" signs that are not only not only helping the recognition of the disease, but even interfering diagnosis, who lead the thought of the doctor, especially inexplicable, from the main facts. The ability to select facts from redundant information indicate the diagnostic abilities of the doctor. When the doctor proceeds to the diagnosis, then revealing subjective and objective data on the disease, immediately wonders - what body or bodies are amazed? This is how an attempt to form a morphological diagnosis is formed. Then the second question arises - what is the reason for the defeat of this organ or organs? Reflecting in this direction, the doctor seeks to establish a etiological diagnosis. And, finally, when it seems, at least in general terms, the main localization of the pathological process and the most likely cause of the disease, the doctor begins to mentally create the overall picture of the disease, thus issuing a pathophysiological or pathogenetic diagnosis structure.
Creating a diagnosis, the doctor is obliged to firmly rely only on the facts, the course of his reasoning should be justified. The prominent Swiss clinician R. Hugglin pointed: "It is difficult to describe in words, but the fact that most importantly in the patient's bed is the ability to intuitively, as if inland look, cover the whole clinical picture as something as a whole and connect it with similar previous observations. This property of the doctor is called clinical thinking "(p. 19). The doctor is obliged to develop the ability to see the whole through the item and be able to project the part to the whole. A. S. Popov, V. G. Kondratyev (1972), not without reason, it is believed that the main in clinical thinking is the ability of a doctor to mention the synthetic pattern of the disease, to the transition from the perception of external manifestations of the disease to the recreatation of its pathogenesis. There is also a "inner picture of the disease", that is, the painting of the disease, which seems to be the patient himself, his subjective assessment of its disease. The task of the doctor is that the actual picture of the disease and the inner picture of the disease combine into one unit, try to analyze, discard all the unnecessary and use valuable and important. Clinical thinking on the way to creating a diagnosis passes consistently certain stages. V.I. Lenin formulated the path of knowledge of truth as follows: "... from living contemplation to abstract thinking and from him to practice - such is the dialectical path of knowledge of the truth, knowledge of objective reality" (full. Coll. Op. T. 29, with . 152). S. A. Garerevsky (1953), I. N. Osipov, P. V. Kopnin (1962), V. M. Syrnev, S. Ya- Chikin (1971), S. A. Gilar, K. E. Tarasov (1973) and others believe that the diagnostic process passes all three steps scientific knowledge, namely: sensual contemplation, abstract thinking, practice.
At the stage of sensual contemplation, the patient is examined, the subjective and objective data obtained are analyzed. This stage is not performed automatically and mindlessly, the doctor is already beginning to think about a possible diagnosis, so this stage goes in an inextricable combination with the second stage-abstract thinking.
At the stage of abstract thinking, the doctor synthesizes the results of the survey, builds a diagnosis, ponders the pathogenesis of each symptom and the disease as a whole, while finding out with the relationship between individual symptoms using clinical thinking. In the period of practice, on the basis of a formulated diagnosis, treatment begins, the forecast of the disease is determined, preventive measures are scheduled.
Practice in medical diagnostics most specifically performs in two basic forms: in a practical examination of the patient in order to recognize the nature of the disease and in the recommendations for treatment and prevention. Practice is the basis of the knowledge and criterion of truth. In this period, the doctor checks the correctness of its conclusions and recommendations, and the inspection is in the dynamics of the disease when observing the results of treatment. In a dialectical understanding, the stage of practice is connected with living contemplation, and with abstract thinking. In practice, as on the criterion of truth, the task of identifying and correction lies possible errorsallowed in the previous two stages of the cognitive process. Practice is a stimulus for knowledge, a new search. Crucial In diagnosis, it belongs to practice, because practical measures are followed by the diagnosis. Practice is the criterion of the truth of knowledge. Through practice, a person affects nature and knows reality as much as he can cultivate it and change it. Dialectic materialism in practice understands the activities of people through which they change phenomena, objects, reality processes. Therefore, the only criterion for the objective truth of diagnosis is practice. Practice itself is a developing process, which is limited at every stage of its production capabilities, its technical level. This means that the practice is also relative, by virtue of which its development does not give the truth to turn into a dogma, in a constant absolute.
Speaking of "live contemplation", and not just about "contemplation", we emphasize the active and methodological study of the patient, targeted action, and not a passive "contemplation" of the patient, not naked, mechanical picking facts. It is in this phase that a purposeful picking and registration of observed phenomena, facts, processes related to the disease occurs. All data obtained in the period of "living contemplation" should differ specificity and accuracy, since they are based on the next period of the cognitive process - the period of "abstract thinking". Incorrect judgments created at the second stage will lead to errors in the third stage of the cognitive process - practice.
F. T. Mikhailov (1965) notes that there is a tendency in the literature to submit a diagnostic process in the form of a peculiar design of the transition from living contemplation (inspection, palpation, percussion, auscultation) to abstract thinking, and from him to practice. However, such an approach, according to F. T. Mikhailov (1965), is a manifestation of "philosophical naivety", as the authors, forgetting the general nature of the main stages of knowledge reflected in the Leninist formulation, and trying to bring under this position and stages of the diagnostic process. , do not take into account one essential feature of the doctor determines the disease already known to science, therefore the diagnostic process cannot be identified with the universal process of cognition, which has the goal of the opening of a new one in nature and society. Scientific activity It is bound primarily with the discovery of a new phenomenon, and when diagnosing a diagnosis, the doctor establishes the already known, long-known science disease in a particular patient. Diagnosis, the doctor seems to reveal the disease, which is already known, highlighting the individual characteristics of a particular patient. The examination of the patient and the diagnosis is the cognitive task of a special kind, significantly different from scientific research. If the doctor meets with a completely new, yet an unknown disease (which in principle is not excluded, although it happens extremely rarely), then the diagnosis will not be established, because, as M. S. Maslov notes (1948), "Diagnose can only be What are suspected in advance, "(p. 52). Therefore, clinical diagnostics cannot be identified with a scientific study, as it sometimes is trying to do, equating the diagnosis to solve the research task.
It should be noted that the division of the diagnostic process into individual stages is purely conditional, in the real diagnostics, it is almost impossible to carry out a line between the stages of this process, to accurately determine where one ends and the second stage begins, especially since in some cases the diagnosis passes so quickly, That individual stages seems to merge into one continuous cognitive process. So between stage (phase) of "living contemplation" and "abstract thinking", it is very difficult to carry out the border, for already in the period of questioning the patient, the doctor begins to diagnose. G. A. Zaharin (1909), with a full basis, indicated: "It would be mistaken to think that recognition was made only after the study ... The data obtained by asked and an objective study inevitably excite the well-known assumptions that the doctor immediately tries to solve with testing issues and Objective studies ... Therefore, recognition is done during the research itself, "(p. 18). Thus, G. A. Zaharin emphasizes that it is mistaken to think that the diagnosis is carried out only after the patient's survey is completed - it is performed during the survey itself. However, in didactic, curriculous purposes, we adhere to a certain sequence and stratility in the analysis of the course of the diagnostic process, having remembered that the clear and consistent alternation of the phases of this process takes place only in parse patients for pedagogical and didactic purposes in teaching diagnostics with a methodological analysis of the most informative process. In practice, during the study of the patient, these steps are stored only in part in their logical and chronological sequence, more often they mutually intertwine and merge. Stages of knowledge of objective truth, including recognition of disease, so dialectically interconnected, which is almost impossible to divide them. Finding out the symptoms of the disease, classifying them on top and minic, the doctor simultaneously thinks about the diagnosis. It is difficult to allocate individual temporary stages when the doctor would be engaged only by the "sensual contemplation" or "abstract thinking" in the separation from practice.
Existing diagnostic methods have developed historically, arose and developed as logically related steps of a single process. Therefore, it is impossible to artificially disseminate a single holistic diagnostic process into separate parts, individual periods that begin to act as independent types of diagnoses, in particular, the diagnosis of the disease and the diagnosis of the patient. In real life, the diagnostic process is continuous, rigidly limited in time and no clearly defined periods and consistent transition of the thought process in it, therefore the doctor classifies the symptoms continuously, as if automatically during the patient's research itself.

The ideal model of the process of knowledge is to move it along the steps from the sensation, perception and ideas to the concept, judgment and conclusion, on the one hand, and from the empirical to theoretical one. The patterns of the real epistemological process of knowledge is definitely much more difficult.

In fact, in the process of cognition, empirical knowledge begins to form not from some observations, which are recorded in words and expressions in the form of so-called perceptual proposals. For example, diagnostic thinking, although it begins at first glance with observation, is not independent of the research process for two reasons. First, it is pretended. It would be a simplification to believe that research analysis begins with fixation of some multitude of facts or processes. The latter thanks to the logic of the cognitive process "are introduced" into a conceptually defined, historically determined logical and semantic scheme, which gives elements of objective reality, the status of a scientific fact. Secondly, it is a kind of output knowledge penetrating "on the other side" of concepts, measurement data, actions and actions of individuals.

Diagnostics as the process of cognition contains at least a research plant to choose the most important features and screening minor already when they are submitted under the symptom.

In medical sciences, knowledge justifies, perhaps, to more than any other science, on the gnoseological installation of the comprehension of truth, accuracy of knowledge and at the same time on the regulatory and value installations of the Company. Ideals of values \u200b\u200bhave a complex, complex nature here: on the one hand, there is a purely cognitive processes (and, accordingly, natural science, according to the advantage of the criteria of scientific relations), and on the other - regulatory reflective processes (having predominantly sociogumanitarian ideal of scientific relations). Of course, the health workers of the orientation on objective truth act as primary in relation to regulatory reflective processes.

Well-developed methodological and methodological principles of the organization of medical knowledge (empirical and theoretical levels, epistemological, regulatory and value character, etc.) are an important indicator of their grounds. Knowledge of these grounds is especially important due to the multi-faceted historicity of the object of this field of human resources, as well as with the expansion of the spectrum of means of impact on a person, a population and a social group for the purpose of prevention or treatment. Consequently, the measure of the substantiation of medical knowledge is directly related to the level of development of society, with the reflective capabilities of the subject and with the specific historical nature of the object itself and the subject of medicine as science. At the conceptual level, such grounds for knowledge, as the scientific picture of the world, ideals and norms of knowledge, various philosophical and methodological principles are essential. Common prerequisites, foundations and medicine can be considered with an emphasis on gnoseological preference, and not on an evident logical justification.

Diagnostics as a specific cognitive process remains in the era of high technologies closely associated with the "person's factor", activities in which the personal aspect of knowledge remains very significant. With some part of the convention, it can be argued that the task of any diagnostic study includes an accurate explanation of the established facts. The path to achieving this is the use of a logical apparatus, a language of medicine, understanding and interpretation and other techniques and methods of knowledge.

Diagnostics, as a reflective process detects syncretism of rationality and empiricism, structural modeling and functional analysis, meaning and meaning. In it, the epistemological and value aspects of reflection are not internal and external, but a single tissue of the creative process.

With the development of theoretical knowledge and growth of computer processing, more attention began to pay more attention to the accuracy and unambiguous knowledge in medicine. This is due to the fact that accuracy is one of the foundations of the truth of knowledge. Usually it acts as a problem of logic-mathematical and semantic accuracy. Accuracy has a specific historical character. Usually allocate formal and meaningful accuracy. The latter became particularly important in connection with the development of metatoretical studies and with the movement of the Center for Methodological Research with the direct analysis of the object and the ways of approaching experienced knowledge to it, on the study of the knowledge itself (logical structure, problems of grounds and broadcast knowledge, etc.), on language analysis medical science.

Medic inevitably goes beyond the clinic. This is inevitable, since the pragmatics and semantics are woven into its fabric in the form of the problem of "meaning" and accuracy of knowledge, for the logic of the diagnosis and clinic is not formal, but meaningful. Diagnosis As a disease recognition in a semiotic plan is the process of designation of the disease based on the knowledge of its signs in the patient. The diagnosis is to summarize the identified symptom complex under a certain nosological unit.

The ultimate goal of knowledge is the truth. True knowledge is the disclosure of objective laws of reality. Absolute knowledge of the object is a gnoseological ideal. Typically, in the process of knowledge, knowledge is obtained, which for one or another grounds are objective and at the same time relative truth. In general, the truth is the process and the result of knowledge, movement from relative to absolute truth.

In assessing the process of knowledge, the correctness of the diagnosis is a key role in practice, which is the initial point, the ultimate goal and the criterion of the truth of knowledge.

Diagnostics (Greek. Diagnō Stikos capable of recognizing) - section of clinical medicine, studying the content, methods and consistent steps of the process of recognizing diseases or special physiological states. In a narrow sense, the diagnosis of the disease recognition and evaluation of individual biological features and social status of a subject, which includes a targeted medical examination, interpretation of the results obtained and their generalization in the form of the established diagnosis.

Diagnostics As a scientific subject includes three main sections: semiotics; Diagnostic methods patient examination or diagnostic technique; Methodological foundations defining the theory and diagnosis methods.

The methods of diagnostic surveys of the patient are divided into basic and additional, or special. Historically, the most early diagnostic methods include the main methods of medical research - history, examination of the patient, palpation, percussion, auscultation. Special methods are developing parallel to the development of natural sciences and medical knowledge; They determine the high potential of diagnostic capabilities, including studies at the sub-cell level and processing medical data using computers. The practical use of special diagnostic methods is determined by modern requirements for a clinical diagnosis based on the nosological principle and comprising ethiological, morphological, pathogenetic and functional components, which with sufficient completeness should characterize the peculiarities of the occurrence and course of the disease. From special methods widespread x-ray diagnostics, radionuclide diagnostics , Electrophysiological studies (including electrocardiography, electroencephalography, electromyography), Functional Diagnostics Methods, Laboratory diagnostics (including cytological, biochemical, immunological studies, microbiological diagnostics). In large hospitals and diagnostic centers, highly informative modern special methods are used - computer tomography, ultrasound diagnostics Endoscopy. Laboratory technician, reagents and analyzes are subject to periodic special verification in order to control the quality of laboratory research. Diagnostic devices and devices should also be subjected to metrological control to ensure accuracy, reproducibility and comparability of the results of their application.

The use of special methods of diagnostic survey does not replace the diagnostic activity of the doctor. The doctor is obliged to know the possibilities of the method and avoid conclusions inadequate to these opportunities. For example, by changes in the ECG without taking into account the clinic, it is unlawful to such a conclusion as "reduction of blood flow in myocardium", for the blood flow and the blood supply to myocardium cannot be measured electrocardiographically. Available diversity and further development of special diagnostic methods involve the improvement of the diagnostic process only in connection with the mastering of its methodological foundations and subject to the relevant growth of the professional qualifications of doctors.

The methodological foundations of diagnosis are formed on the principles of the general theory of knowledge (gnoseology), on the methods of research and thinking common to all sciences. As a scientific method, diagnostics is based on the use of historically established knowledge, observation and experience, comparison, classification of phenomena, disclosure between them, constructing hypotheses and their verification. At the same time, diagnosis as a special area of \u200b\u200bgnoseology and an independent section of medical knowledge has a number of specific features, the main one is determined by the fact that the object of the study is a person with its characteristic complexity of functions, connections and interaction with it environmental. The feature of the diagnosis is also its relationship with the general theory of pathology, so historically the development of diagnosis as a form of knowledge was determined mainly by the refraction of common philosophical knowledge in specific questions Development of medical theory, in the ideas about health and illness, the body, its connection with the environment and the ratio of parts and the whole, in understanding the causality and laws of development diseases.

IN modern medicine The theory of pathology relies on the principles of determinism, the dialectic unity of the body and the medium (including its geographical, biological, environmental, social and other characteristics), historical, evolutionary conditionality of the body's reactions to damage, primarily the adaptation reactions.

In methodical terms, diagnosis also has a number of features. First, the complexity of the study object determines the existence in the diagnosis of a rare manifold for one science of research methods, both own and borrowed from almost all sections of physics, chemistry, biological sciences. This requires multilateral training of doctors and special systematization of knowledge of natural sciences designed specifically to solve various variants of diagnostic tasks.

Secondly, unlike other sciences, where the object of the study is recognized by significant and constant features, in medicine, the recognition of the disease is often based on insufficiently severely pronounced signs, and some of them often refers to so-called subjective symptoms, which, although reflecting objective The processes in the body depend on the features of the highest nervous activity of the patient and can be a source of diagnostic errors.

Thirdly, the diagnostic examination should not cause harm patient. Therefore, the direct and accurate, but potentially dangerous method for the patient a diagnostic study is usually replaced in practice with a variety of indirect, less accurate methods and diagnostic techniques. As a result, the role of medical conclusions, the so-called clinical thinking significantly increases in the diagnostic process.

Finally, the characteristics of the diagnostic process are determined by the limited time and opportunities for examination of the patient under states that require urgent treatment. In this regard, the diagnostic experience of the doctor, which determines the ability of rapid recognition of the leading pathology, on the basis of the similarity of the set of features with the already observed doctor earlier and therefore, which has a syndromic or even nosological specificity, which is not amenable to a physician, however, abstract description. It is in this sense that you can talk about the role in the diagnosis of the so-called medical intuition.

The process of establishing a diagnosis of the disease during the primary examination of the patient includes the analysis, systematization, and then a generalization of the symptoms of the disease in the form of a nosological or syndromic diagnosis or in the form of constructing a diagnostic algorithm.

The definition of the disease as a nosological unit is the responsible and most important stage of diagnosis. The nosological approach involves the establishment of a diagnosis depending on the coincidence of the entire picture of the disease with known clinical manifestations, typical of a certain nosological form (specific symptom complex), or by the presence of a pathognomonic symptom for it.

The syndromic diagnosis can be an important step to the diagnosis of the disease. But the same syndrome can be formed with different diseases under the influence of various reasons, which characterizes syndromes as a reflection of a certain pathogenetic entity, as the result of a limited number of typical reactions of the body for damage. In this regard, the syndromic diagnosis has the advantage that, being established with the smallest volume of diagnostic studies, it is at the same time sufficient to justify pathogenetic therapy or operational intervention.

The diagnostic algorithm is the prescription of the sequence of elementary operations and actions to establish the diagnosis of any of the diseases that are manifested by this set of symptoms or data syndrome (see Diagnostic algorithm). In its perfect form, the diagnostic algorithm is drawn up for cybernetic diagnostic methods involving the use of computers (see Cybernetics in medicine). However, the process of medical diagnosis is clearly or implicitly algorithmized, because The path to a reliable diagnosis even in the presence of highly specific (but not pathogenic) symptoms goes through an intermediate probable diagnosis, i.e. Construction of diagnostic hypothesis, and then checking its data of targeted patient reduction. In the process of diagnostics, the number of hypotheses should be minimized (the principle of "economy of hypotheses") in the desire to explain one hypothesis as possible large quantity Cash facts (symptoms).

In the primary identification of only nonspecific symptoms, diagnostic assumptions in the nosological sense are impossible. At this stage, the diagnostic process is general Definition The nature of pathology, for example, is there any infectious disease or exchange rate, inflammatory process or neoplasm, allergic or endocrine pathology, etc. After that, a targeted diagnostic preparation of the patient is prescribed to identify more specific features or syndrome.

Construction of diagnostic hypothesis based on symptoms is made by inductive conclusion, i.e. From knowledge of a lesser degree of community (individual symptoms) to knowledge of a greater degree of community (form of the disease). Checking the hypothesis is carried out by means of deductive conclusion, i.e. From the generalization made again to the facts - to the symptoms and results of the survey undertaken to verify the hypothesis. The deduction method allows to detect previously not observed symptoms of the disease, to foresee the emergence of new symptoms during the disease, as well as its very development, i.e. Determine the forecast of the disease. Thus, in the process of diagnosis, inductive and deductive methods with necessity complement each other.

The establishment of the syndrome or relatively specific set of symptoms is usually sufficient to build several diagnostic hypotheses, each of which is verified during the differential diagnosis.

Differential diagnostics It is based on the detection of differences between the manifestations of this disease and the abstract clinical picture of each of the diseases in which the same or similar signs are possible. For differentiation used as possible more Symptoms of each disease, which increases the accuracy of the conclusions. The elimination of the proposed disease is based on one of the three principles of differentiation. The first of these is the so-called principle of a significant difference, according to which the observed case does not belong to the compared disease, because It does not contain a constant feature of this disease (for example, the absence of proteinuria eliminates jade) or contains a symptom, never occurred with it.

The second principle is an exception across the opposite: this case is not an estheriad disease, because With it, it is constantly found by the symptom, which is directly opposed to the observed, for example, with Ahilia rejected the ulcer duel of the duodenum, because It is characterized by gastric hypersception.

The third principle is to exclude the alleged illness on the basis of the differences in the symptoms of one order in terms of quality, intensity, features of manifestations (the principle of signage of signs). All these principles do not have absolute value, because The severity of certain symptoms affects many factors, including the presence of concomitant diseases. Therefore, differential diagnosis involves additional testing of the diagnostic hypothesis, even if it seems the most reasonable of all hypotheses. The presumptive diagnosis of the practice of subsequent medical diagnostic measures arising from it, as well as monitoring the dynamics of the disease.

The conclusion of the diagnostic process is to transition from the abstract-formal diagnosis of the disease to a specific diagnosis (diagnosis of the patient), which in full form represents the combination of anatomical, functional, etiological, pathogenetic, symptomatic, constitutional and social recognition, i.e. Synthesis is the establishment of the unity of various sides of the state of this patient, its individuality. The diagnosis of the patient does not have generally accepted wording; In medical documents, a substantial part of its content is reflected in epicrise. The diagnosis of the patient serves as a substantiation of the individualization of treatment and conducting preventive measures.

Bibliography:Vinokurov V.A. Analogy in diagnostic thinking of the doctor, Vestn. Hir., Vol. 140, No. 1, p. 9. 1988; Leshchinsky L.A. and Dimov A.S. Is the concept of "diagnostic hypothesis"? Wedge. honey, vol. 65, No. 11, p. 136, 1987; Malkin V.I. The main causes of diagnostic errors in the therapeutic clinic, ibid, vol. 66, No. 8, p. 27, 1988; Popov A.S. and Kondratyev V.G. Essays of the methodology of clinical thinking. L., 1972, Bibliogr.