Propaedeutics and modern studies of internal medicine in 2 volumes
INTRODUCTION
Zachary Krastev
The first meeting between the patient and the doctor is essential for the course of the diagnostic process. In our fast-paced age, there is often not enough time left for warm, human relations, for building mutual trust. A modern approach to the doctor's classic weapons is also needed. Directing the patient's narrative accelerates the gathering of the necessary information. The clinical examination should be tailored to the patient's complaints and at the same time it should be possible to deduce from it data about some common diseases that are not always supported by corresponding complaints. According to the patient's age, sex, profession and heredity, an "individual screening" looking for socially significant diseases should be carried out.
We will try to oppose the hurried doctor or the narrow specialist, who has the opportunity and qualifications to brilliantly solve diagnostic tasks, but is prevented from losing sight of extremely important health problems. This is also helped by the significant change that has occurred in recent decades in the behavior of the patient, who, "prepared" by the mass media and the global network, by relatives and acquaintances, "competently" directs himself to a relevant specialist with a ready diagnosis and even treatment.
The change in life and work, in the health insurance of our population allows us today to evaluate the history taking from a different angle, without having any claims to change the classical approach.
Propaedeutics and modern studies of internal medicine in 2 volumes
1. "The ready-made diagnosis". In the office of the general practitioner or the internist, for example, we will see that upon entering, a significant number of patients provide the results of the already performed instrumental examinations, present their problem with a ready diagnosis ("I have pyelonephritis") and thus guide the doctor's thinking in a certain direction, which prevents him from building his own view of the history of the disease.
2. The guided history. The dynamics of our lives do not allow the patient's narrative to be left to flow on its own. It must be guided to extract useful information. In no case, however, should one go so far as to suggest certain complaints. It is better if the patient is left with the impression that the symptom we are interested in is missing. For example, by asking: "You don't wake up at night, do you?" we will have a more honest answer than if we ask "Do you wake up at night?"
Gathering information can be aided by the "four K" rule we use: "What?, When?, Where?, How much?". In this way, the anamnestic data acquires a quantitative character, which, in addition to assessing the severity of the complaints, also helps to build relative criteria for monitoring the effect of the treatment. ("How many stairs do you climb without getting tired? Where exactly does it hurt to breathe? When were you first diagnosed with high blood pressure? What has changed in your lifestyle?")
The conclusion of the history with active questions to check for omitted facts should be done according to some system accepted by the doctor. We use the direction from top to bottom: "Do you have headache, hypertension, impaired vision, shortness of breath, heart complaints, etc.?". A careful familiarization with the results of previous studies is desirable, but the attitude towards them should be critical. Sometimes a look at the evolution of the disease and taking the history in this vein — onset of complaints, development, present presentation — is more appropriate than starting with questions about the current complaints.
3. The special sections of the anamnesis. Recently, interest in the special sections of the anamnesis has increased: gynecological, hereditary, allergy, professional. The introduction of a section on trips abroad is also relevant.
Modern gynecological anamnesis necessarily includes the question of the method of contraception. Hormonal contraceptives can cause blood clotting disorders, metabolic diseases, liver and vascular damage. The long-term stay of the spirals is a prerequisite for inflammatory diseases of the genital organs and their appendages.
Family history takes on a new meaning today. The wording "unburdened" has no practical value, since the patient's problems are no longer limited to the current complaints. The doctor's active search for diseases with a known or suspected hereditary predisposition (diabetes mellitus, hypertension, ulcer disease, neoplasms, etc.) can change his behavior with a patient who sometimes comes for a minor reason. The data that can be obtained from the family and sexual history (for example, a recurrence of viral hepatitis) are often of great importance.
Propaedeutics and modern studies of internal medicine in 2 volumes
The change in classic production processes necessitates a specification of the nature of the work performed (for example, a driver who transports pesticides, a driver for cross-border transport). It is necessary to inquire whether the patient has not resided in countries where diseases uncharacteristic of Bulgaria can be encountered. The modern anamnesis cannot be completed without careful questioning about possible allergic reactions to household, occupational, medicinal and other factors. A meaningful anamnesis, including the disclosure of the patient's emotional and personality characteristics, will shorten the time until the diagnosis is made and make it cheaper.
It is not possible, and it is not necessary, to follow the model of clinical examination described in the manuals for every patient. Both history and status should be guided by the patient's complaints. However, this is only possible if the doctor has an excellent command of classical pro-needeutics.
1. What cannot the doctor afford at the first meeting with the patient? — Do not auscultate the lungs, do not measure arterial pressure, do not auscultate the heart, and do not check the abdomen for organomegaly or a tumor mass. In connection with the better possibilities of fighting breast cancer in its early detection, the doctor, and even better, the patient should perform a careful palpation on his advice.
2. Individual screening. Conducting mass screening (screening) for all diseases is not possible above all economically. Instead, it can be switched to individual screening, which will allow the timely diagnosis of diseases related to gender, age, profession, heredity, which have social significance for our country.
Under the concept of individual screening, we understand the search with minimal means of the most likely disabilities and diseases of the specific individual. It should be carried out in the usual health structures, where the person was admitted due to some complaint. It includes the methods of anamnesis, clinical examination, laboratory and some instrumental studies.
We can hypothesize some models for such screening that do not exhaust the clinical variety:
□ it is important to consider the "real" values of arterial pressure, not those under basal conditions;
□ it is necessary to plan the examination of the cholesterol level in all obese, diabetic, hypertensive patients;
□ actively look for signs of prostatic hypertrophy and cancer in older men;
□ to clarify the causes of accidentally detected anemia in women;
□ the establishment of iron deficiency in adults can help in the timely diagnosis of a neoplastic disease — for example, of the colon;
□ to look for latent hypothyroidism in adults;
□ in the case of neoplastic disease data, to plan targeted examinations of the relevant organ in the patient's relatives;
□ as a laboratory minimum for individual screening in persons over 40 years old, we can offer the examination of complete blood count, glucose, cholesterol, creatinine, urine.
Propaedeutics and modern studies of internal medicine in 2 volumes
The main tasks that the doctor should set himself at the first meeting with the patient are the following:
Creating conditions for real cooperation with the patient and his family, taking into account the characteristics of the disease and the personality of the patient.
Conduct a careful review and construct a research plan with a favorable cost/benefit ratio.
Use of tests that are harmless to the patient and can be performed quickly.
Perform individual screening.
3. Second meeting with the patient.
The first meeting with the patient should end with the construction of a real plan for his examination or with the determination of the probable diagnoses and the ways to achieve them, with a clear and accurate documentation of all tasks, even the upcoming ones, graded by complexity, cost or informativeness, and with appointment of the second meeting with the patient. It is usually much shorter and takes into account specific clinical and laboratory parameters. Even if it is held only to confirm the first impressions and the favorable effect of the treatment, the second meeting serves as a self-study for the doctor and strengthens the cooperation between doctor and patient. It helps to adjust the treatment plan. The second meeting with the patient makes sense even if the diagnostic and treatment measures fail. Otherwise, the patient will make a new "first appointment" with another doctor who may experience the same difficulties.
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