Leading syndrome and its rationale. Recognizing the cause of an emergency Determining the leading syndrome

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Chelyabinsk State Medical Academy

Department of Internal Medicine with a course of endocrinology

Head d.m.s. prof. Sinitsyn S.P.

Assistant PhD Ektova N. A.

EPICRISIS

FULL NAME.

Clinical diagnosis of the underlying disease:

Cirrhosis of the liver of mixed etiology, Child class B. Portal hypertension III stage. Ascites

Teacher:

Curator:_____________________

Group No.

Curation time:

Chelyabinsk 2008

Identification of the leading clinical syndrome

Ascites syndrome can be distinguished as the leading syndrome.

- the patient asked for help precisely because of the occurrence of an increase in the abdomen;

- ascites was the reason for hospitalization

Circle of diseases for differential diagnosis

Cirrhosis of the liver

Chronic heart failure metastatic lesion of the peritoneum (carcinomatosis)

Differential Diagnosis

Chronic heart failure at such a young age can be caused by a congenital defect, but auscultation of pathological tones does not reveal noise. It is also characterized by ascending edema, which this patient does not have, as well as inspiratory dyspnea. Therefore, the diagnosis of chronic heart failure can be ruled out.

With metastatic lesions of the peritoneum - there are no other manifestations of the tumor - cachexia, cancer intoxication, there are no symptoms from other organs in which the tumor could be located.

Preliminary diagnosis

Based on the patient's complaints (pain in the right hypochondrium and epigastric aching, abdominal enlargement, general weakness), medical history (periodic alcohol abuse, deterioration after the next episode), examination data (presence of a homemade tattoo, abdominal enlargement, dilatation of the saphenous veins of the abdomen , pain on palpation of the abdomen in the right hypochondrium and epigastrium, expansion of the boundaries of the liver and its pain on palpation, positive symptom the presence of free fluid in abdominal cavity) a preliminary diagnosis can be made:

Cirrhosis of the liver of unspecified etiology. Portal hypertension III stage. Ascites."

Plan of laboratory and instrumental methodsresearch

Complete blood count + platelets

General urine analysis

Biochemical blood test (ALT \ AST, creatinine, urea, thymol test, prothrombin index, total cholesterol).

Analysis for markers of viral hepatitis

Ultrasound of the abdominal organs

FGDS

Results of laboratory and instrumental research methods

1. UAC 12.03:

Erythrocytes 3.98 x 10^12

White blood cells 6.3 x 10^9

Platelets 270 x 10^9

Formula:

Eosinophils 2%

Band nuclear 1%

Segmented 48%

Lymphocytes 41%

Monocytes 8%

ESR 29

2. OAM 12.03 - no pathology

3. Biochemical blood test

Total bilirubin 44 mmol/l

Direct bilirubin 26 mmol/l

Thymol test 12

AST 112

ALT 42

total cholesterol 7.2 mmol/l

C-reactive protein 45

Albumins 38.5

Prothrombin index 93%

Fibrinogen 3.99

Creatinine 83.6 mmol/l

Urea 3.1 mmol/l

Viral hepatitis markers:

Core +++ (strongly positive)

NS++++ (strongly positive)

Viral hepatitis C detected

4. FGDS from 12.03

The esophagus is freely passable, the mucous membrane is pink, in lower third focally hyperemic. The socket of the cardia is closed, in the area of ​​the socket there is an erosion up to 3 mm in diameter with a coating of fibrin. In the stomach, mucus, the mucosa is focally slightly hyperemic, next to the pylorus there is a group of erosions up to 3-4 mm each, with a coating of fibrin. The folds are elastic, not thickened, peristalsis can be traced in all departments of the pylorus, the duodenal bulb is not deformed, the mucosa is focally hyperemic, edematous, there is bile in the lumen.

Conclusion: esophagitis, esophageal erosion, superficial gastritis. Erosion of the stomach. Duodenitis.

5. Ultrasound of the abdominal organs 10.03:

Hepatosplenomegaly, ascites.

Final Diagnosis

Based on the patient's complaints (pain in the right hypochondrium and epigastric aching, abdominal enlargement, general weakness), anamnesis data (periodic alcohol abuse, deterioration after the next episode), examination data (presence of a homemade tattoo, an increase in the abdomen, dilatation of the saphenous veins of the abdomen , pain on palpation of the abdomen in the right hypochondrium and epigastrium, expansion of the boundaries of the liver and its pain on palpation, a positive symptom of the presence of free fluid in the abdominal cavity), laboratory data (increase in total and direct bilirubin, total cholesterol, AST and ALT, the appearance C-reactive protein, positive reaction on Core and NS antigens, a decrease in the level of albumin) and instrumental (hepatosplenomegaly on ultrasound, diffuse changes liver parenchyma on ultrasound) can make the final diagnosis:

“Cirrhosis of the liver of mixed etiology (alcoholic and viral), Child class B, Portal hypertension stage III. Ascites.

Treatment

Mode - a complete rejection of alcohol. Complete rest, spa treatment. Diet - with a restriction of protein to 100 g per day, with its predominant production from plants. Due to the expediency of limiting table salt during cooking, it is not specially salted. To eliminate the temptation - salt should be absent on the table during meals by a patient with cirrhosis of the liver. Exclude and rich in sodium mineral water. Any products containing baking powder and baking soda are excluded (cakes, biscuit cookies, cakes, pastries and regular bread), as well as pickles, olives, ham, bacon, corned beef, tongue, oysters, mussels, smoked herring, fish and canned meat, fish and meat pate, sausage, mayonnaise, various canned sauces (except salt-free ones), all types of cheeses, ice cream. Preference should be given to salt-free products. To improve the taste of food (it should stimulate appetite), it is prepared with the addition of various spices and seasonings: lemon juice, orange peel, onion, garlic, pepper, mustard, sage, cumin, parsley, marjoram, bay leaf, cloves, etc. Of the products allowed for patients with cirrhosis of the liver, veal or poultry meat, rabbit up to 100 g per day, low-fat varieties of fish. One egg is equivalent to 50 g of meat. Milk is limited to 1 glass per day. Perhaps non-regular consumption of low-fat sour cream. Boiled rice is consumed only without salt.

Ethiotropicth treatment- hepatitis C therapy

Combination therapy with immunoglobulins and nucleoside analogues.

Pegiinterferon - once a week

Ribaverin - 1050 mg / day

Heptral - 0.4, 2 tablets / day

Vitamins B1, B2, B6, B12

Etiopathogenesis

Most common causes development cirrhosis liver chronic alcohol intoxication is recognized (according to various sources, from 40-50% to 70-80%) and viral hepatitis B, C and D (30-40%). The most important stages in the emergence of alcohol cirrhosis liver - acute alcoholic hepatitis and fatty degeneration of the liver with fibrosis and mesenchymal reaction. Alcohol-viral cirrhosis with rapidly progressive dynamics of the disease is characterized by a particularly severe course. They most often transform into hepatocellular carcinoma. Significantly less in development cirrhosis liver play the role of biliary tract disease (intra- and extrahepatic), congestive heart failure, various chemical and drug intoxications. Rare forms of liver cirrhosis are associated with genetic factors leading to metabolic disorders (hemochromatosis, hepatolenticular degeneration, a1-trypsin deficiency), and occlusive processes in the portal vein system (phleboportal cirrhosis). The cause of primary biliary cirrhosis remains unclear. Approximately 10-35% of patients etiology cirrhosis cannot be established. Such observations are referred to as cryptogenic cirrhosis, the causes of which are still unknown. The causes of liver cirrhosis are presented in Table 1.

The formation of cirrhosis of the liver occurs over many months or years. During this time, the gene apparatus of hepatocytes changes and generations of pathologically altered cells are created. This process in the liver can be characterized as immunoinflammatory. The most important factor in the genesis of alcoholic cirrhosis of the liver is damage (necrosis) of hepatocytes, due to the direct toxic effect of alcohol, as well as autoimmune processes. Sensitization of immunocytes to the body's own tissues is an important factor pathogenesis and with cirrhosis that develops in patients viral hepatitis B, C and D. The main target of the autoimmune reaction here is the hepatic lipoprotein. Dominant factor pathogenesis congestive cirrhosis of the liver - necrosis of hepatocytes associated with hypoxia and venous congestion.

A further stage in the development of the pathological process: portal hypertension is an increase in pressure in the portal vein system due to obstruction of intra- or extrahepatic portal vessels. Portal hypertension, in turn, leads to porto-caval shunting, splenomegaly, and ascites. Thrombocytopenia (increased deposition of platelets in the spleen), leukopenia, anemia (increased hemolysis of red blood cells) are associated with splenomegaly.

Ascites leads to restriction of diaphragm mobility (risk of pulmonary atelectasis, pneumonia), gastroesophageal reflux with peptic erosions, ulcers and bleeding from varicose veins of the esophagus, abdominal hernia, bacterial peritonitis, hepatorenal syndrome.

In patients with cirrhosis of the liver, hepatogenic encephalopathies are often observed.

The leading place in the origin of primary biliary cirrhosis of the liver belongs to genetic disorders of immunoregulation. To initial changes include the destruction of the biliary epithelium, followed by necrosis of the segments of the tubules, and at a later stage of the disease - their proliferation, which is accompanied by impaired bile excretion, the epithelium is infiltrated by lymphocytes, plasma cells, macrophages. In the evolution of the disease, 4 stages are traced: chronic non-purulent destructive cholangitis, ductular proliferation with destruction of the bile ducts, scarring with a decrease in the bile ducts and the development of large-nodular cirrhosis and cholestasis.

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Psychopathological syndromes

Relevance of the topic: One of the most important stages of diagnosis in psychiatry is the establishment of a leading psychopathological syndrome. The ability to correctly qualify the symptoms of mental disorders allows for the timely appointment of emergency therapy, as well as further diagnostic and therapeutic measures.

common goal: learn to identify the leading syndrome of mental disorders and provide adequate assistance to patients.

Theoretical questions:

1. Borderline non-psychotic syndromes, asthenic, neurotic (neurasthenic, obsessive-phobic, dysmorphophobic, hysterical), depressive, hypochondriacal, somatoform.

2. Psychotic syndromes: depressive, manic, paranoid, paranoid, dysmorphomanic, catatonic, hebephrenic, delirious, oneiric, amenoic, asthenic confusion, twilight state of consciousness, hallucinosis.

3. Defective-organic syndromes: psycho-organic, Korsakovsky amnestic, oligophrenia, dementia, mental insanity.

4. Major psychopathological syndromes childhood: neuropathy, childhood autism, hyperdynamic, childhood pathological fears, anorexia nervosa, infantilism.

5. Significance of the diagnosis of psychopathological syndrome for the choice of method
emergency treatment and further examination of the patient.

Psychopathological syndrome - This is a more or less stable set of pathogenetically related symptoms. The definition of the syndrome (syndromic diagnosis) is the initial stage of the diagnostic process, which is of great practical importance.

There are various classifications of syndromes: according to the predominant lesion of one or another mental function, according to the depth of the personality lesion.

Classification of psychopathological syndromes according to the predominant lesion of individual mental functions

1. Syndromes with a predominance of disorders of sensations and perceptions.

Hallucinosis syndrome (verbal, tactile, visual).

Syndromes of derealization and depersonalization.

2. Syndromes with a predominance of memory disorders

Korsakov's amnestic syndrome.

3. Syndromes with a predominance of thought disorders.

Paranoid syndrome (hallucinatory-paranoid, Kandinsky-Clerambault, hypochondriacal, dysmorphomanic, etc.);

paranoid;

Paraphrenic;

4. Syndromes with a predominance of intellectual disabilities.

Syndrome of infantilism;

Psychoorganic (encephalopathic) syndrome;

Oligophrenic syndrome;

dementia syndrome.

5. Syndromes with a predominance of emotional and effector-volitional disorders.

Neurotic (asthenic and neurasthenic, hysterical, obsessiveness syndrome);

Psychopathic;

Apatico-Abulic;

hebephrenic;

catatonic.

6. Syndromes with a predominance of impaired consciousness.

Non-psychotic syndromes (fainting; stupor; stupor; coma)

Psychotic syndromes (delirious; oneiroid; amental; twilight state of consciousness)

Classification of psychopathological syndromes depending on the depth of the personality lesion.

I. Nonpsychotic borderline syndromes:

1. Asthenic (astheno-neurotic, astheno-depressive, astheno-hypochondriac, astheno-abulic).

2. Apatico-Abulic.

3. Neurotic and neurosis-like (neurasthenic, obsessive-compulsive disorder, dysmorphophobic, depressive-hypochondriac).

4. Psychopathic and psychopathic.

II. Psychotic Syndromes:

1. Syndromes of clouding of consciousness:

1. asthenic confusion;

2. confusion syndrome;

3. delirious;

4. amental;

5. oneiroid;

6. twilight state of consciousness.

2. Depressive (psychotic variant);

3. Syndrome of hallucinosis (verbal, tactile, visual);

4. Manic;

5. Paranoid (including hallucinatory-paranoid, hypochondriacal, dysmorphomanic, Kandinsky-Clerambault mental automatism syndrome);

6. Paranoid;

7. Paraphrenic;

8. Hebephrenic;

9. Catatonic.

Sh. Defective organic syndromes:

1. Psycho-organic (explosive, apathetic, euphoric, asthenic variants);

2. Korsakovsky amnestic;

3. Oligophrenia;

4. Dementia (total and lacunar).

Psychopathological symptom is a single clinical sign mental disorders. Psychopathological syndrome - a set of pathogenetically related symptoms.

Asthenic syndrome(Greek a-lack, steno - strength) is manifested by a pronounced physical and mental fatigue that occurs after minor exertion. It is difficult for patients to concentrate and therefore they do not remember well. There is emotional incontinence, lability, increased sensitivity to sounds, light, colors. The pace of thinking slows down, patients experience difficulty in solving complex intellectual problems.

At astheno-neurotic conditions, irascibility, increased irritability, tearfulness, capriciousness join the described phenomena of asthenia.

At astheno-depressive states of the phenomenon of asthenia are combined with a reduced mood.

At astheno-hypochondriac - asthenic symptoms are associated with increased attention to their physical health, patients give great importance various unpleasant sensations coming from internal organs. They often have thoughts about the presence of any incurable disease.

At astheno-abulic Syndrome patients, starting any work, get tired so quickly that they practically cannot perform even the simplest tasks and become practically inactive.

Asthenic syndrome in various variants it occurs in all somatic, exogenous-organic, psychogenic diseases.

neurotic syndrome- a symptom complex, including the phenomena of instability of the emotional, volitional and effector spheres with increased mental and physical exhaustion, with a critical attitude to one's condition and behavior

Depending on the characteristics of the personality, the neurotic syndrome can have a neurasthenic, hysterical and psychasthenic character.

Neurasthenic syndrome(syndrome of irritable weakness) is characterized, on the one hand, by increased excitability, incontinence of affect, a tendency to violent affective reactions with volitional instability, on the other hand, by increased exhaustion, tearfulness, and lack of will.

hysterical syndrome- characterized by increased emotional excitability, theatricality of behavior, a tendency to fantasize and deceit, to violent affective reactions, hysterical seizures, functional paralysis and paresis, etc.

Obsessional Syndrome (Obsessive Syndrome)- manifested by obsessive thoughts, phobias, obsessive desires and actions. The phenomena of obsession arise, as a rule, suddenly, do not correspond to the content of the patient's thoughts at the moment, the patient is critical of them and struggles with them.

The syndrome of obsession occurs in neurosis, somatic, exogenous-organic diseases of the brain.

Dysmorphophobic Syndrome- Patients overestimate the importance of their physical defects, actively seek help from specialists, demand cosmetic surgery. Most often occurs at puberty by a psychogenic mechanism. For example, if adolescents are convinced that they are overweight, they severely restrict themselves in food (mental anorxia).

Depressive-hypochondriac syndrome-characterized by the appearance of thoughts in the patient about the presence of any severe even incurable disease, which are accompanied by a dreary mood. Such patients stubbornly seek help from doctors, require various examinations, prescription of drug therapy.

psychopathic syndrome- a symptom complex of emotional and effector-volitional disorders that are more or less persistent and determine the main type of neuropsychic response and behavior, usually insufficiently adequate to the real situation. It includes increased emotional excitability, inadequacy of voluntary actions and deeds, increased subordination to instinctive drives.

Depending on the characteristics of the type of higher nervous activity and the conditions of education, it can have an asthenic, hysterical, psychasthenic, excitable, paranoid or schizoid character. Is the foundation various forms psychopathy and psychopathic states of organic and other origin. Often accompanied by sexual and other perversions.

Delirious syndrome(from lat. delirium - madness) - hallucinatory stupefaction with a predominance of true visual hallucinations, visual illusions, figurative delirium, motor excitation while maintaining self-consciousness.

amental syndrome- gross clouding of consciousness with incoherent thinking, complete inaccessibility for contact, disorientation, jerky deceptions of perception and signs of severe physical exhaustion.

Oneiroid clouding of consciousness. Differs in extreme fantasticness of psychotic experiences. Characterized by duality, inconsistency of experiences and actions, a sense of global changes in the world, catastrophes and triumphs at the same time.

depressive syndrome characterized depressive triad: depressed, sad, melancholy mood, slowing down of thinking and motor retardation.

Manic syndrome - x typical manic triad: euphoria (inappropriately elevated mood), acceleration of associative processes and motor excitation with a passion for action.

hallucinatory syndrome (hallucinosis)) - an influx of profuse hallucinations (verbal, visual, tactile) against a background of clear consciousness, lasting from 1-2 weeks (acute hallucinosis) to several years (chronic hallucinosis). Hallucinosis may be accompanied affective disorders(anxiety, fear), as well as crazy ideas. Hallucinosis is observed in alcoholism, schizophrenia, epilepsy, organic lesions of the brain, including syphilitic etiology.

paranoid syndrome- characterized by the presence of unsystematized delusional ideas of various content in combination with hallucinations, pseudohallucinations. Kandinsky-Clerambault Syndrome is a type of paranoid syndrome and is characterized by phenomena mental automatism, i.e. sensations that someone controls the thoughts and actions of the patient, the presence pseudo hallucinations, most often auditory, delusional ideas impact, mentism, symptoms of openness of thoughts (feeling that the patient's thoughts are available to others) and nesting of thoughts(feeling that the patient's thoughts are alien, transmitted to him).

paranoid syndrome characterized by a systematic delirium in the absence of violations of perception and mental automatisms. Crazy ideas are based on real facts, however, the ability of patients to explain the logical connections between the phenomena of reality suffers, the facts are selected one-sidedly, in accordance with the plot of the delusion.

Paraphrenic syndrome - a combination of systematic or unsystematized delirium with mental automatisms, verbal hallucinations, confabulatory experiences of fantastic content, a tendency to improve mood.

Dysmorphomanic Syndrome characterized by a triad of signs: delusional ideas of physical deficiency, delusions of attitude, low mood. Patients actively seek to correct their shortcomings. When they are denied an operation, sometimes they themselves try to change the shape of their ugly body parts. Seen in schizophrenia.

catatonic syndrome- manifests itself in the form of catatonic absurd and senseless excitement or stupor, or a periodic change of these states. It is observed in schizophrenia, infectious and other psychoses.

hebephrenic syndrome- a combination of hebephrenic excitement with foolishness and fragmentation of thinking. It is observed mainly in schizophrenia.

Apatico-abulic syndrome- a combination of indifference, indifference (apathy) and the absence or weakening of motives for activity (aboulia). It is observed with debilitating somatic diseases, after craniocerebral injuries, with intoxication, schizophrenia.

Psycho-organic syndrome- characterized by mild intellectual impairment. Patients have reduced attention, fixation memory, they hardly remember events about their lives and well-known historical events. The pace of thinking slows down. Patients experience difficulty in acquiring new knowledge and skills. There is either a leveling of the personality, or a sharpening of character traits. Depending on which emotional reactions predominate, they distinguish explosive variant - patients have explosiveness, rudeness, aggressiveness; euphoric option (inadequate gaiety, carelessness), apathetic variant (indifference). Partial reversibility is possible, more often there is a gradual weighting and development of dementia syndrome. It is typical for exogenous-organic lesions of the brain.

Korsakov's amnestic syndrome-includes impaired memory for current events (fixation amnesia), retrograde and anterograde amnesia, pseudoreminiscences, confabulations, and amnestic disorientation.

dementia - persistent decline in intelligence. There are two types of dementia - congenital (oligophrenia) and acquired (dementia).

Schizophrenia, epilepsy, as well as organic diseases, in which atrophic processes take place in the substance of the brain (syphilitic and senile psychoses, vascular or inflammatory diseases brain, severe traumatic brain injury).

Confusion Syndrome It is characterized by a misunderstanding of what is happening, a misunderstanding of the questions asked, and not always adequate answers. The facial expression of the patients is confused, perplexed. They often ask questions: “what is it?”, “why”, “why?”. Occurs when leaving a coma, as well as in paranoid syndrome.

Frontal syndrome- a combination of signs of total dementia with aspontaneity, or vice versa - with general disinhibition. It is observed in organic diseases of the brain with a predominant lesion of the frontal parts of the brain - tumors, TBI, Pick's disease.

The clinical diagnosis should include a description of:

1) underlying disease. This is the disease that led to the last deterioration and for which the last hospitalization occurred. When making a diagnosis, one should be guided by the latest data, taking into account generally accepted classifications. For example, the main disease will be an exacerbation of chronic cholecystitis or myocardial infarction, etc.;

2) concomitant disease. This is a disease that has a different pathogenesis compared to the underlying disease, other causes. This may be a chronic disease that is currently in remission and does not pose a danger to the body, for example, chronic pancreatitis without exacerbation;

3) competing disease. This is a disease that competes with the main one in terms of the degree of danger to the patient, but is not associated with the main disease in terms of causes and mechanism of occurrence, for example, myocardial infarction and perforation of a stomach ulcer;

4) complications of the underlying disease. This is a complication that is pathogenetically associated with the underlying disease and is necessarily included in the structure of the diagnosis. For example, a complication peptic ulcer stomach is bleeding;

5) background disease. This is a disease that is also not associated with the main cause and mechanism of occurrence, but can have a significant impact on the course and prognosis of the main one. A classic example of an underlying disease is diabetes mellitus.

Any disease (main, concomitant, competing) should be reflected in the diagnosis according to a single plan. From the name of each disease, as a rule, it is possible to determine the affected organ and the nature of the pathological process.

So, the inflammatory nature of the pathology gives the name the ending “-itis”, for example, “gastritis”, “pleurisy”. The study pathological anatomy made it possible to clarify the diagnosis: myocardial infarction, spleen infarction, liver abscess, fatty hepatosis, etc. This was a reflection of the anatomical direction of medical science. Be sure to indicate the localization of the pathological process (for example, a lobe, segment or focus of inflammation in the lung with pneumonia). The discovery of many microorganisms after the invention of the microscope made it possible to identify the etiology of the disease.

The etiology of the disease must be indicated in the clinical diagnosis (for example, there are 3 main types of gastritis according to etiology - autoimmune, bacterial, chemical). Sometimes a certain syndrome is put into the diagnosis (for example, obstructive jaundice with inflammation of the gallbladder - cholecystitis). Active development and many discoveries in physiology made it possible to clarify the functional state of organs in the diagnosis (for example, respiratory failure indicating its degree, renal, hepatic insufficiency, uremia, hepatic encephalopathy). The diagnosis also necessarily includes the degree of disease activity (this is important for determining the prognosis and prescription of the treatment regimen), the severity of the pathological process (mild, moderate, severe), the phase of the disease (exacerbation or remission phase).

Direct clinical diagnosis is the easiest to establish, but the possibility of making a diagnosis in this way is rare. Each disease has a classic variant of the course, which corresponds to certain signs. When a patient comes to the clinic with certain complaints, the doctor, by the nature of the complaints, initially assumes damage to one or another organ system, the gastrointestinal tract, respiratory system, of cardio-vascular system etc. Typical symptoms, determined during questioning, palpation, percussion, auscultation, suggest a certain nature of the pathology. To confirm his hypothesis, the doctor needs to conduct a number of additional studies. After that, the results are evaluated. If the data obtained during the study, the objective symptoms, combined into syndromes, are similar to the classical picture of a certain disease, absolutely repeat it, then the disease in this patient is a disease that was originally assumed with the help of a hypothesis. This type of diagnosis is typical for acute surgical pathology, when one symptom allows you to immediately diagnose the disease. In addition, this diagnostic option is used for typical classical, uncomplicated variants of the disease. For example, if a patient, upon admission, complains of acute, extremely intense dagger pains in the epigastric region, the patient's condition is severe, and upon examination, muscular protection in the abdomen is detected, reaching a degree of board-like tension, the doctor immediately suggests perforation of the stomach ulcer. It is usually impossible to perform a detailed examination, therefore, an immediate diagnosis allows you to make a decision about surgical intervention which can save a patient's life.

However, this diagnostic method should be treated with a certain degree of caution, since it is not always possible to establish a diagnosis in this way. One or more initial symptoms can mislead the doctor and lead to an incorrect diagnosis.

In therapeutic practice, it is also possible to establish a diagnosis in this way. For example, if during the treatment the patient complains of pain behind the sternum of a pressing or squeezing nature that occurs after physical exertion or emotional stress, radiating to the left shoulder blade, shoulder, lower jaw that are successfully stopped by taking coronary lytics or on their own at rest, this immediately suggests the presence of coronary disease heart, angina pectoris, since the clinical manifestations of the classical picture are absolutely similar to the manifestation of the disease in this patient. But such a situation, when the manifestation of the disease in this patient is completely similar to the classical picture of the present disease, is extremely rare. In addition, this diagnostic method does not allow to identify concomitant diseases, complications, and the diagnostic process itself ceases to be creative, turns into a simple banal comparison.

When, when examining a patient, a doctor reveals certain symptoms that are pathogenetically combined into syndromes (one patient has a group of syndromes corresponding to not one, but two, and sometimes even several diseases), in such cases it becomes necessary to differentiate these diseases in order to establish the correct diagnosis. The differential diagnosis is made on the principle of exclusion from the group, assuming the most unlikely.

However, differential diagnosis requires much more qualification and theoretical training of the doctor, since the situation in this case is considered as a whole, taking into account the development of the disease, the individual characteristics of the patient. To identify pathological conditions between which a differential diagnosis is made, it is necessary to have enough knowledge to determine the range of diseases for differential diagnosis.

Its essence lies in the definition of a group of syndromes common to several pathological conditions. A comparison is made between these conditions and the presumptive disease. clinical picture.

The lack of similarity allows to exclude this disease. Of several syndromes, the one that is most specific and occurs in the fewest number of diseases is usually chosen.

The first phase is the search for that syndrome, in relation to which the circle of diseases is determined for differentiation. If the examination revealed several syndromes, the one that is most informative is singled out from them.

Second phase. For comparison, a detailed description of the leading syndrome is determined; in addition, it is necessary to create a complete picture of the disease, i.e., note all the symptoms identified during the examination.

The third phase is differentiation itself. The disease included in the presumptive diagnosis is consistently compared with all diseases from the proposed list. First, the nature of the manifestation of the underlying syndrome in the patient and in the classical picture of the alleged disease are compared. Then it is determined whether other symptoms characteristic of a differentiated disease are present or absent in the patient's clinical picture, and how they manifest themselves. In the process of this, the main signs of similarities and differences between diseases are determined.

The fourth phase is the most creative stage of diagnosis. At this stage, the main points of the analysis and synthesis of information take place. There are several principles according to which diseases are differentiated. The first principle is to compare the manifestations of a particular syndrome. Note the differences in the manifestation of symptoms in the patient and in the picture of a particular disease. Another principle says: if the syndrome that we assume has a certain specific sign, and in our case it is not noted, then this is a different syndrome. The last principle: if we suspect a disease, but the patient has a symptom that is directly opposite this disease means that the patient does not have this disease.

Fifth phase. Based on logical conclusions and the data obtained, all the least likely diseases are excluded, and a final diagnosis is made.

Autonomic dysfunction syndrome combines sympathetic, parasympathetic and mixed symptom complexes that are generalized, systemic or local in nature, manifested permanently or in the form of paroxysms (vegetative-vascular crises), with non-infectious low-grade fever, a tendency to temperature asymmetry.

Sympathicotonia is characterized by tachycardia, blanching skin, increased blood pressure, weakening of intestinal motility, mydriasis, chills, a feeling of fear and anxiety. With a sympathoadrenal crisis, a headache appears or intensifies, numbness and coldness of the extremities, pallor of the face occur, blood pressure rises to 150/90-180/110 mm Hg, the pulse quickens to 110-140 beats / min, there are pains in the area heart, there is excitement, restlessness, sometimes the body temperature rises to 38-39 ° C.

Vagotonia is characterized by bradycardia, shortness of breath, reddening of the skin of the face, sweating, salivation, lowering blood pressure, and gastrointestinal dyskinesias. A vagoinsular crisis is manifested by a feeling of heat in the head and face, suffocation, heaviness in the head, nausea, weakness, sweating, dizziness, urge to defecate, increased intestinal motility, miosis is noted, a decrease in heart rate to 45-50 beats / mi, a decrease in blood pressure up to 80/50 mm Hg Art.

Mixed crises are characterized by a combination of symptoms typical of crises, or by their alternate manifestation. There may also be: red dermographism, zones of hyperalgesia in the precordial region, "spotted" hyperemia of the upper half of the chest, hyperhidrosis and acrocyanosis of the hands, tremor of the hands, non-infectious low-grade fever, a tendency to vegetative-vascular crises and temperature asymmetries.

Syndrome of mental disorders - behavioral and motivational disorders - emotional lability, tearfulness, sleep disturbance, fear, cardiophobia. Patients with VVD have a higher level of anxiety, they are prone to self-accusation, and are afraid of making decisions. Personal values ​​prevail: great concern for health (hypochondria), activity decreases during the period of illness. When diagnosing, it is important to differentiate somatoform autonomic dysfunction, in which there are no mental disorders, and hypochondriacal disorder, which is also considered a somatogenic neurosis-like condition, as well as panic disorder and phobias, and other nervous and mental diseases.

Syndrome of adaptive disorders, asthenic syndrome - fatigue, weakness, intolerance to physical and mental stress, meteorological dependence. Data have been obtained that the asthenic syndrome is based on violations of transcapillary metabolism, a decrease in oxygen consumption by tissues and a violation of hemoglobin dissociation.

Hyperventilation (respiratory) syndrome is a subjective sensation of lack of air, chest compression, difficulty in breathing, need for deep breaths. In a number of patients, it proceeds in the form of a crisis, the clinical picture of which is close to suffocation. The most common causes that provoke the development of respiratory syndrome are physical exertion, mental stress, staying in a stuffy room, a sharp change in cold and heat, and poor transport tolerance. Along with the mental factors of shortness of breath, a decrease in the compensatory-adaptive capabilities of the respiratory function to hypoxic loads is of great importance.

Neurogastric syndrome - neurogastric aerophagia, spasm of the esophagus, duodenostasis and other disorders of the motor-evacuation and secretory functions of the stomach and intestines. Patients complain of heartburn, flatulence, constipation.

Cardiovascular syndrome - cardialgia in the left half of the chest that occurs during emotional, and not during physical exertion, is accompanied by hypochondriacal disorders and is not stopped by coronalists. Fluctuations in blood pressure, pulse lability, tachycardia, functional noise. On the ECG and ledergometry, sinus and extrasystolic arrhythmias are most often detected, there are no signs of myocardial ischemia.

Syndrome of cerebrovascular disorders - headaches, dizziness, noise in the head and ears, a tendency to faint. Their development is based on cerebral angiodystonia, the pathogenetic basis of which is the dysregulation of the vascular tone of the brain of a hypertonic, hypotonic or mixed nature. In some patients with persistent cephalgic syndrome, there is a violation of the tone of not only arterial, but also venous vessels, the so-called functional venous hypertension.

Syndrome of metabolic and peripheral vascular disorders - tissue edema, myalgia, angiotrophoneurosis, Raynaud's syndrome. Their development is based on changes in vascular tone and vascular permeability, disorders of transcapillary metabolism and microcirculation.

Cardiac syndrome

VSD of the cardiac type is the most common form. It is she who causes the overdiagnosis of organic pathology of the heart, which in turn is fraught with serious consequences: excommunication from physical education and sports, exemption from military service, warning about pregnancy and childbirth, frivolous removal of the tonsils, unnecessary prescription of thyreostatic, anti-inflammatory, antianginal and other drugs.

Among the leading cardiac syndromes, it is worth highlighting: cardialgic, tachycardial, bradycardic, arrhythmic, hyperkinetic.

Cardiac Syndrome

Cardiac Syndrome occurs in almost 90% of patients. Cardialgia is associated with increased susceptibility of the central nervous system to interoceptive stimuli; vegetologists regard them as sympathetic pain. Once having arisen, cardialgia is fixed using the mechanisms of self-hypnosis or a conditioned reflex. May be a form of dependence on psychoactive substances (eg, valocordin and other barbiturates). Pain can be of a different nature: constant aching or aching in the region of the apex of the heart, intense prolonged burning in the region of the heart, paroxysmal prolonged cardialgia, paroxysmal short-term pain or pain that occurs in connection with physical exertion, but does not interfere with the continuation of the load. In the diagnosis, the help of stress and drug tests is undeniable. With a change in the end part of the ventricular complex on the ECG, the stress test in the case of functional cardialgia leads to a temporary reversal of the T wave, and in patients with coronary artery disease it is aggravated. Drug tests in the first case also lead to a temporary reversion, in the second - no. For differential diagnosis, non-invasive methods are involved, the study of the dynamics of lactate during atrial stimulation. It is more difficult to differentiate between functional cardialgia and stress cardiomyopathy.

tachycardia syndrome

tachycardia syndrome characterized by an increase in the automatism of the sinoatrial node (SA node) with an increase in the number of heartbeats up to 90 or more per minute. More often, the syndrome is based on an increase in the tone of the sympathetic nervous system, less often - a decrease in tone vagus nerve.

Sinus tachycardia significantly limits the physical performance of patients, as evidenced by conducting tests with dosed physical activity. The heart rate reaches submaximal values ​​for a given age already when performing low-power work - 50-75 watts. With sinus tachycardia, the number of heartbeats at rest rarely exceeds 140-150 beats per minute.

bradycardia syndrome

bradycardia syndrome involves a slowing of the heartbeat to 60 per minute or less due to a decrease in the automatism of the SA node, due to an increase in the tone of the vagus nerve. The criterion for sinus bradycardia should be considered a decrease in the frequency of contractions to 45-50 beats per minute or less. The bradycardic variant is much less common. With more pronounced bradycardia, complaints of headaches and precordial pains, dizziness with rapid extension of the body or transition to orthostasis, a tendency to fainting and fainting are possible. Other signs of vagoinsular predominance are also determined: poor tolerance to cold, excessive sweating, cold hyperhidrosis of the palms and feet, cyanosis of the hands with a marble skin pattern, spontaneous dermographism. On the ECG, the appearance of "giant" ("vagal") T waves in chest leads, especially in V2-V4.

Arrhythmic syndrome

arrhythmic syndrome. In patients with VVD within the arrhythmic syndrome, extrasystole is more common, less often - supraventricular forms of paroxysmal tachycardia, extremely rarely - paroxysms of atrial fibrillation or flutter. Rhythm disturbances in functional heart diseases most often have to be differentiated from mild myocarditis (rheumatic and non-rheumatic), myocardial dystrophy, reflex effects on the heart (osteochondrosis, gallbladder pathology), hyperfunction of the thyroid gland.

Hyperkinetic Cardiac Syndrome

Hyperkinetic Cardiac Syndrome represents an independent clinical variety VSD. Like other cardiac syndromes, it belongs to the centrogenic autonomic disorders. The final link in its pathogenesis is an increase in the activity of myocardial beta-1-adrenergic receptors against the background and as a result of sympathadrenal dominance. As a result, a hyperkinetic type of blood circulation is formed with a characteristic hemodynamic triad: 1) an increase in shock and minute volumes heart, far exceeding the metabolic needs of the tissues; 2) an increase in the rate of expulsion of blood from the heart; and 3) a compensatory fall in total peripheral vascular resistance.

Treatment

Two approaches to treatment should be considered: the treatment of general disorders, which is carried out as part of the treatment, in the first place, of diseases in which VVD manifests itself, and individual treatment of specific cardiac syndromes.

Etiotropic treatment should start as soon as possible. In the case of the predominance of psychogenic influences on the patient, it is necessary, if possible, to eliminate the impact of psychoemotional and psychosocial stressful situations (normalization of family and domestic relations, prevention and elimination of hazing in the troops).

Antipsychotics have a powerful effect on the cardiovascular system and are able to give antiarrhythmic, hypotensive, analgesic effects, stop permanent autonomic disorders.

Other areas of etiotropic therapy: with an infectious-toxic form - sanitation of the oral cavity, tonsillectomy; with VVD associated with physical factors, including military labor (ionizing radiation, microwave field, etc.) - exclusion of occupational hazards, rational employment; with VVD against the background of physical overstrain - exclusion of excessive physical activity, the gradual expansion of physical activity.

Pathogenetic therapy consists in the normalization of disturbed functional relationships of the limbic zone of the brain, hypothalamus and internal organs.

Reception of herbs valerian, motherwort for 3-4 weeks has "stem effect"; tranquilizers (seduxen, relanium, mebicar - a daytime tranquilizer) relieve feelings of anxiety, fear, emotional and mental tension (duration of therapy - 2-3 weeks); belloid, bellaspon - "vegetative correctors", normalize the function of both parts of the autonomic nervous system: antidepressants (amitriptyline, azafen, coaxil) reduce feelings of anxiety and depression; nootropics, neurometabolites improve energy processes and blood supply to the brain; cerebrocorrectors (cavinton, stugeron, course of treatment - 1–2 months) normalize cerebral circulation; b-blockers reduce the increased activity of the sympathoadrenal system.

Physiotherapy, balneotherapy, massage, acupuncture - electrosleep, electrophoresis with bromine, anaprilin, novocaine, seduxen, water procedures (showers, baths), aeroionotherapy, acupressure and general massage.

Restorative and adaptive therapy recommended in the treatment of VVD in moderate and severe cases. It includes healthy lifestyle life, elimination bad habits, moderate physical activity, aesthetic therapy, therapeutic nutrition (fighting obesity, limiting coffee, strong tea), exercise therapy in combination with adaptogens, breathing exercises.

Of particular importance in some forms of VVD (asthenia, hypotonic forms, orthostatic disorders) is the intake of adaptogens, which have a tonic effect on the central nervous system and the body as a whole, metabolic processes and immune system: ginseng - 20 drops 3 times a day, eleutherococcus - 20 drops 3 times, lemongrass - 25 drops 3 times, zamaniha, aralia, pantocrine - 30 drops 3 times a day. The course of treatment is 3–4 weeks, 4–5 courses per year, especially in autumn, spring and after an influenza epidemic.

Spa treatment It has importance as a factor in the rehabilitation of patients with moderate VSD. The main resort factors are climatotherapy, mineral waters, sea bathing, exercise therapy, health path, balneotherapy, physiotherapy, nature. Individual treatment of patients with VVD consists in the treatment of specific cardiac syndromes. Cardiac Syndrome. Of the psychotropic drugs, the most effective is the use of mezapam, grandaxin, and especially "soft" antipsychotics - frenolon or sonapax.

Of secondary importance are classical sedatives, especially "valerian tea". Those who are already accustomed to barbiturates can use the sedative and analgesic effects of such drops as corvalol valocordin and others, although it is not recommended to prescribe such psychotropic drugs. The sublingual use of validol containing menthol relieves pain well. Local effects also bring relief: self-massage of the precordial region, mustard plasters, pepper plaster, applications with menovazine for persistent pain, physical methods of treatment - acupuncture, electroanalgesia, laser treatment, dorsonvalization.

In case of joining vegetative crises, an a-adrenergic blocker pyrroxan should be added at 0.015-0.03 g 2-3 times a day, anaprilin - 20-40 mg 2-3 times a day. To stop the crisis itself, Relanium is used - 2-4 ml of a 0.5% solution or droperidol - 1-2 ml of a 0.5% solution intravenously and pyrroxan - 2-3 ml of a 1% solution intramuscularly.

Tachycardia syndrome

Out of competition are b-blockers, they reduce the increased activity of the sympathetic nervous system (one of the methods pathogenetic treatment VSD). 2 drugs prescribed medium duration actions (6-8 hours) - propranolol (anaprilin, obzidan) and metoprolol (specicor, betalok) and 2 drugs of long-term (up to 24 hours) action - atenolol (tenormin) and nadolol (korgard). If treatment with b-blockers is difficult, you can use tincture of lily of the valley (strictly observe the dosage and duration of the course, for the prevention side effects take potassium supplements, control blood pressure). Courses of treatment - 1-2 months, maintenance therapy is possible.

bradycardia syndrome

Bradycardia less than 50 beats per minute, accompanied by cerebral or cardiac symptoms, matters. To restore vegetative balance, peripheral M-anticholinergics are used - atropine and belladonna preparations. The initial amount of atropine is 5-10 drops 3-4 times a day. If the result is not achieved, the dose is increased. The dose of belladonna tincture is the same. Tablets with dry extract of belladonna - becarbon are used. Well proven drug itrol 1/2 tablet (0.01 g) 2-3 times a day.

Tonic balneotherapy has a beneficial effect on neurogenic bradycardia: cool (22-30 ° C) coniferous or salt baths, radon baths with a low concentration of radon, carbonic and pearl baths, fan and especially circular cold showers. All patients are shown physiotherapy- from morning exercises to running, swimming and sports games.

Arrhythmic syndrome

For patients with functional heart disease, the use of antiarrhythmic drugs without psychosedative therapy is futile. Particularly indicated: mezapam, grandaxin, nozepam, which can help without antiarrhythmic drugs. The main indication for the treatment of extrasystoles is their poor subjective tolerance. With a clear sympathoadrenal predominance, that is, with “extrasystoles of tension and emotions”, especially against the background of a rapid rhythm, b-blockers (propranolol, metoprolol, atenolol, nadolol) are out of competition.

With "vagal" supraventricular extrasystoles, especially against the background of a rare rhythm, at the first stage it is advisable to use anticholinergic agents: atropine, belladonna preparations or itrol. With insufficient effectiveness, anticholinergics are replaced by b-agonists or combined with them. Strasikora and visken it is advisable to start treatment of the ventricular form of resting extrasystole. With the supraventricular form of extrasystole, verapamil can be prescribed, with the ventricular form, antiarrhythmic drugs deserve attention: ethmozine, etatsizin, and also cordarone. All antiarrhythmic drugs can cause arrhythmias, especially when combined, so organic pathologies should be an indication for their appointment.

It should be noted that VVD can be a manifestation of various diseases. It is especially important to differentiate somatoform autonomic dysfunction of the heart and cardiovascular system with both stress cardiomyopathy and post-traumatic stress disorder, panic disorder, phobias and other mental and behavioral disorders, including neuroses, as well as neurosis-like somatogenic conditions. Somatoform autonomic dysfunction of the heart and cardiovascular system is often combined with either neurological diseases or mesenchymal dysplasia. A comprehensive examination by therapists, cardiologists, endocrinologists, neurologists, hematologists, with the involvement of medical geneticists, if necessary, is necessary. Unfortunately, for example, pheochromocytoma in patients with VVD is usually diagnosed only posthumously - and this is evidence that patients with VVD are not properly examined.

The life of patients can be threatened by diseases in which the VSD syndrome is observed (stress cardiomyopathy, phobias, diabetes, parkinsonism, especially Shy-Drager syndrome, radiation sickness, etc.), and diseases, the prestage of which is manifested by the VSD syndrome. For example, somatoform autonomic dysfunction of the heart and cardiovascular system may be a precursor to essential hypotension, diffuse toxic goiter, hypertension, life threatening and health at hypertensive crises as a result of heart failure, kidney failure etc.

25.Traumatic brain injury(TBI) - damage to the bones of the skull or soft tissues, such as brain tissue, blood vessels, nerves, meninges.

Classification Brain concussion. It is characterized by a short-term loss of consciousness at the time of injury, vomiting (usually single), headache, dizziness, weakness, pain in eye movements, etc. neurological status focal symptoms are absent. Macrostructural changes in the substance of the brain during concussion are not detected.
Mild brain injury. It is characterized by loss of consciousness up to 1 hour after the injury, complaints of headache, nausea, and vomiting. In the neurological status, rhythmic twitching of the eyes when looking to the sides (nystagmus), meningeal signs, asymmetry of reflexes are noted. Roentgenograms may show skull fractures. In the cerebrospinal fluid - an admixture of blood (subarachnoid hemorrhage).
Moderate brain injury. Consciousness is switched off for several hours. Loss of memory (amnesia) for the events preceding the trauma, the trauma itself and the events after it is expressed. Complaints of headache, repeated vomiting. Short-term respiratory disorders, heart rate, blood pressure are detected. There may be mental disorders. Meningeal signs are noted. Focal symptoms manifest themselves in the form of uneven pupil size, speech disorders, weakness in the limbs, etc. Craniography often reveals fractures of the vault and base of the skull. Lumbar puncture showed significant subarachnoid hemorrhage.
Severe brain injury. It is characterized by a prolonged shutdown of consciousness (lasting up to 1-2 weeks). Gross violations of vital functions are revealed (changes in pulse rate, pressure level, frequency and rhythm of breathing, temperature). In the neurological status, there are signs of damage to the brain stem - floating movements eyeballs, swallowing disorders, changes in muscle tone, etc. There may be weakness in the arms and legs up to paralysis, as well as convulsive seizures. A severe contusion is usually accompanied by fractures of the vault and base of the skull and intracranial hemorrhages.
Brain compression. The main cause of brain compression in traumatic brain injury is the accumulation of blood in a closed intracranial space. Depending on the relationship to the membranes and the substance of the brain, epidural (located above the dura mater), subdural (between the dura mater and the arachnoid), intracerebral (in the white matter of the brain and intraventricular (in the cavity of the ventricles of the brain)) hematomas are isolated. there may also be depressed fractures of the bones of the cranial vault, especially the penetration of bone fragments to a depth of more than 1 cm.

Treatment

Treatment of traumatic brain injury can be divided into 2 stages. Stage one medical care and the stage of providing qualified medical care in a hospital.

In the presence of an episode with loss of consciousness, the patient, regardless of his current condition, needs to be transported to a hospital. This is due to the high potential risk of developing severe life-threatening complications.

After admission to the hospital, the patient undergoes a clinical examination, collects, if possible, an anamnesis, and clarifies with him or those accompanying the nature of the injury. Then a set of diagnostic measures is performed aimed at checking the integrity of the bone skeleton of the skull and the presence of intracranial hematomas and other damage to brain tissues.

The simplest diagnostic method is skull radiography, however, due to the peculiarities of the method, the effectiveness of such a method is relatively low even with the use of special styling, approximately 20-30% of the area of ​​​​the skull bones remain inaccessible for assessing their integrity. Same way this method does not allow assessing the state of brain tissue. The method of choice for this type of injury is CT scan. This technique allows you to get an image of all the bones of the cranial vault, and assess the state of the brain. The disadvantage of the technique is the high cost of computed tomography and, as a result, their low prevalence. As a rule, only relatively large clinics have such devices.

In Russia and the CIS countries, as a rule, the victims admitted initially with TBI are examined using radiography methods, and even in those cases when this technique does not give a clinically significant result, patients are referred for CT scan.

After the type of traumatic brain injury is established during the examination, the traumatologist decides on the tactics of treating the patient. Methods and schemes of therapy differ depending on the type of injury, but in general they pursue the same goals.

The main goal is to prevent damage to brain tissue, and as a result, maintain normal intracranial pressure and protection of the cerebral cortex from hypoxia. In some cases, trepanations are performed for this purpose in order to drain intracranial hematomas. In the absence of bleeding into the cranial cavity, patients are usually treated on conservative therapy.

Forecast

The prognosis of the disease largely depends on the nature and severity of the injury. With minor injuries, the prognosis is conditionally favorable, in some cases there is a complete recovery without medical care. In severe injuries, the prognosis is unfavorable, without immediate adequate medical care, the patient dies.

There are cases when even with serious traumatic brain injuries, doctors managed to save patients. A vivid example of this is the case of Carlos Rodriguez, who was left almost completely without the frontal part of his head.

26.Migraine- a neurological disease, the most common and characteristic symptom which are episodic or regular severe and painful attacks of headache in one (rarely in both) half of the head. At the same time, there are no serious head injuries, stroke, brain tumors, and the intensity and pulsating nature of pain is associated with vascular headache, and not with tension headache. Migraine headache is not associated with an increase or a sharp decrease in blood pressure, an attack of glaucoma, or an increase in intracranial pressure. (ICP).

Prevalence

Migraine is a chronic disease common in the population (10% of diagnosed patients, and another 5% of undiagnosed or misdiagnosed patients). Most often occurs in women, as it is transmitted mainly through the female line, however, often in men. The severity of the disease varies from rare (several times a year), relatively mild attacks, to daily; but, most often, migraine attacks are repeated at intervals of 2-8 times a month. Specific treatment is often expensive. Periodic or unpredictable incapacitation during and shortly after attacks may result in the need for a patient to be diagnosed with a disability due to the patient's inability to work enough hours per week or work at all.

When identifying the reasons contributing to the development emergency, two situations are possible - the causes of the emergency are known or the causes of the emergency are unknown.

In the first case, the situation can be clarified: impact of environmental factors; chronic diseases internal organs; the presence of anamnestic information - from the words of the patient, relatives, acquaintances, relatives or accompanying the patient (victim); information from medical institutions, etc.

For emergencies, which first appeared in "practically" healthy person, the doctor is in a more difficult position. However, in these cases, it must be remembered that emergency and urgent conditions are most often associated with damage to the cardiovascular system, abdominal organs (especially surgical pathology), then the pathology of the respiratory organs, the central nervous system follows in frequency.

When examining such patients, the doctor should adhere to all the rules of propaedeutics, and information must be collected quickly and the data obtained must be reliable, otherwise errors are inevitable. At the same time, the leading syndrome is singled out, which is confirmed (changed, rejected) by subsequent clinical and laboratory-instrumental methods of examining the patient.

The next stage of the doctor's work- "search" of conditions, diseases, accompanied by this syndrome, followed by differential diagnosis. So, in the syndrome of acute vascular insufficiency, we can talk about bleeding, poisoning, acute pancreatitis, ectopic pregnancy, rhythm disturbances, myocardial infarction, taking a large dose of antihypertensive drugs.

Diagnosis of emergency conditions, accompanied by symptoms - “harbingers”, is much more difficult and sometimes requires the participation of doctors of various specialties, dynamic monitoring of the patient, and the use of a wide arsenal of auxiliary research methods. At the core clinical diagnostics In such situations, the identification of the leading syndrome lies - this is the syndrome that has the greatest pathogenetic and clinical significance according to the principle of "greatest danger".

Assessing emergency symptoms, it must be borne in mind that such phenomena as vomiting, pain, and others are universal, i.e. are present in many diseases, and therefore they not only contribute to the diagnosis, but, on the contrary, make it difficult. If the doctor fixes his attention on this kind of universal symptoms and does not notice the hidden, most significant, although not so demonstrative, he can establish, for example, food intoxication where there is a myocardial infarction. Therefore, one should never overestimate a symptom, although very convincing at first glance (a negative symptom can become just as convincing), but one should always base oneself on the syndrome. Of course, the appearance of a reliable symptom decides diagnostic task. At the same time, the establishment of a diagnosis should not be delayed (“we will observe”, “we will see”, etc.), since you can miss the time necessary to provide effective assistance to the patient. Here it is appropriate to recall: “He who waits for fecal vomiting during intestinal obstruction- he will never make a mistake in the diagnosis, but he rarely saves the patient.

In the absence of a developed, "not formed" clinical picture of an emergency The principle developed by us - “think about a more severe pathology” can warn against a diagnostic error. So the syndrome acute abdomen”, consisting of 3 symptom complexes - abdominal pain, dyspeptic disorders, signs of peritoneal irritation - often develops gradually with a predominance of one or another symptom at various stages of the clinic. Therefore, in case of abdominal pain, the immediate task of the physician of the first contact should be the exclusion of surgical pathology.
In this way, in emergencies The main method of diagnosis is the method of differential diagnosis.

In all cases of detection causes of emergency importance should be attached to the so-called organizational measures for diagnostics, such as:
- thoroughly investigate the scene; carefully examine the patient's belongings (documents, medicines, etc.);
- timely send food, washing water, suspicious substances found in the patient for toxicological, bacteriological examination;
- one of the mandatory organizational principles for managing such patients is continuity, which includes a list and assessment of the main clinical syndromes, the sequence of their appearance, changes in the "quantitative" relation; a list of all studies carried out, etc.;
- when filling out a medical history, medical records it is necessary to monitor the emergence of new clinical manifestations, administration of drugs and their effectiveness, consultations of senior comrades and doctors of other specialties, etc.