From Big Medical Encyclopedia

DIAGNOSIS (grech, diagnosis recognition) — the medical certificate about morbid condition of the health inspected about the available disease (injury) or about a cause of death, expressed in the terms provided by the accepted classifications and the nomenclature of diseases. Can be D.'s maintenance also special fiziol, conditions of an organism, napr, pregnancy, a climax, etc., and also the conclusion about epid, the center.

D.'s establishment diseases makes a final part of process diagnoses (see) at any stage or upon termination of purposeful inspection of the patient. Knowledge of diagnostic methods, the principles of creation and D.'s registration is essential for medical practice since the formulated D. is justification to the choice of methods of treatment of the patient and preventive actions. Correctness, timeliness and D.'s validity in each case surely find reflection in the main medical documents — the out-patient card, case histories (see), the dispensary card (see. Medical examination ), etc.

In system of the Soviet health care the wrong D.'s cases or performing the therapy which is not corresponding to the put D. are carefully analyzed (see. Medical errors) can also become a subject of legal consideration. Therefore in all medical documents negligent registration of D., an erasure in the text, etc. are inadmissible; each correction of the text of D. if it is necessary, is made out date and the signature of responsible persons.

Depending on the purposes of diagnosis, character of the inspected object and the applied diagnostic methods distinguish main types of D.: clinical (intravital), pathoanatomical, epidemiological and medicolegal.

The clinical diagnosis

shall reflect features of a disease In the most perfective aspect of D. at inspected, determined by its individual reactivity, age, the constitution, living conditions etc. In that case speak about «the diagnosis of the patient», opposing it to D. diseases. «The diagnosis of the patient» is the highest step of medical D. though its registration has no precisely depicted scheme. Most closer the conclusion about the nature, essence, the main manifestations and disease formulated in the history of a disease in shape a wedge approaches requirements of «the sick diagnosis» epicrisis (see). However such form D. is a little suitable for studying of the general patterns in dynamics of structure of incidence and mortality, a cut is based on the statistical accounting of diseases, their complications and outcomes. Besides, the general principles of diagnostic methods, treatment and prevention are developed also in relation to a type of a disease that does not exclude reasonable derogations from these principles in specific cases. Therefore D. of a disease makes the essentialest part of the doctrine about D. and is the basis for documentary registration of diseases in medical practice, and also a scientific and medico-statistical research in all developed countries.

In D.'s creation is leading nozol, the principle, according to Krom shall contain the name of a certain disease (an injury, a cause of death) provided by the existing nomenclature (see. Nomenclature and classification of diseases ). In communication about these the doctrine about D. is closely connected with the doctrine about a disease — nosology (see), the level of development the cut at each stage defines the general principles of classification and the nomenclature of diseases on the basis of knowledge of their etiology, pathogeny, patol, anatomy, forms of a current, etc. According to this knowledge of D. of a disease includes not only designation of its essence (most often reflected in the name nozol, forms), but also, whenever possible, the nature of a disease (etiol, a component D.), a pathogeny of its main manifestations or complications (a pathogenetic component D.), pathoanatomical expression (morfol, a component D.), character and extent of disturbances of activity separate fiziol, systems (a functional component D.).

The etiological component characterizes feature nozol, forms of a disease, connected with its reason. The reasons can be various. The instruction in D. of the nature of a disease in some cases is necessary since it substantially can define medical tactics. So, D. «acute pneumonia» is insufficient for final therapeutic conclusions while «acute bacterial pneumonia» or «acute viral pneumonia» allows to determine by D. bulk to lay down., preventive, epidemiol, actions, and the exact instruction in D. of a disease-producing factor (e.g., «acute staphylococcal pneumonia») allows to develop the most optimum system of treatment.

Many nozol, forms, especially among infectious and parasitic diseases, are obligatno connected with one reason or specific known activators (e.g., malaria, syphilis, tuberculosis); in D. of such diseases the additional indication of an etiology becomes excessive (the etiology matches a nosology).

The pathogenetic component characterizes features of a pathogeny of a disease and its complications presenting to hl. obr. polypathogenetic patol, processes and states. Most often the pathogenetic characteristic is applied to definition of qualitative features of recognizable pathology (e.g., «iron deficiency anemia», «hron, obstructive bronchitis»), and also to specification of communication between patol, the states or processes specified in D., napr, «a menorrhagia, hron, posthemorrhagic anemia». In the latter case a side in definition of a component D. as pathogenetic or as etiological becomes less accurate: the pathogenetic characteristic of a complication of a disease comprises also the instruction on its reason.

The morphological component reflects essence and localization of the main pathoanatomical changes in bodies and fabrics and can be a component both the intravital, and established posthumously pathoanatomical. In some cases morfol. Completely matches nomenclature definition the main nozol, forms or substantially is reflected in its name (e.g., «a polyp of a gullet», «atherosclerosis of an aorta», «cirrhosis»). Except anatomic essence patol, process, morfol, the component D. can characterize the qualitative features of disease connected with a morphogenesis (e.g., «the abscessing pneumonia»), to reflect prevalence and depth patol, changes (e.g., «a transmural myocardial infarction of a front wall of a left ventricle and interventricular partition...») or to specify on morfol, a basis of functional disturbances (e.g., «rheumatic heart disease: stenosis of the left atrioventricular opening; circulatory unefficiency...»).

The functional component informs on the disturbances of the major connected with a disease fiziol, functions, most often with the quantitative characteristic of functional insufficiency on degrees. In some cases this component D. substantially defines the made treatment planning and has crucial importance for examination of working ability of the patient and for assessment of the forecast of a disease. So, D. «hron, pneumonia of the II stage, a phase of remission, insufficiency of function of external respiration of the 3rd degree» indicates serious condition of the patient while lack of respiratory insufficiency allows the patient at the same stage hron, pneumonia to perform the usual work practically in all cases. Sometimes extent of functional frustration has a criteria .znacheniye for the characteristic of stages of a disease, and in that case it is determined by the stage specified in D. E.g., at the II stage of an idiopathic hypertensia, unlike the I stage, disorders of function of regulation of the ABP are characterized by his more permanent increase demanding obligatory use of antihypertensives. Or, e.g., D. «emphysema of lungs, the III stage», on Segal and Dalfano's classification (M. of S. Segal, M. of J. Dulfano, 1953), testifies to heavy degree of respiratory insufficiency with disturbance of gas composition of blood though dysfunctions of external respiration specially are not specified in D.

Formulation wedge. Is made by uniform rules (the appendix 7 to the order No. 4 M3 of the USSR of January 3, 1952), according to the Crimea are consistently specified in D.: on the first place — a basic disease, on the second — complications of a basic disease, on the third — the accompanying diseases.

The disease (injury) is considered the basic, a cut in itself or by means of the complication was the reason of the request for the medical help, the reason of hospitalization or death. It is specified in D. in the form of defined nozol, forms and cannot be substituted for a syndrome or transfer of symptoms.

A complication of a basic disease call patol, the processes and states pathogenetic connected with a basic disease, but creating wedges, syndromes, anatomic and functional changes, qualitatively other than its main manifestations. E.g., hron, the posthemorrhagic anemia which developed owing to repeated helcomenias of a stomach is a complication of a peptic ulcer while ulcer bleeding shall be regarded as one of manifestations of a basic disease. However in some cases differentiation between display of a disease and its complication is very difficult as manifestations (e.g., a heart attack of a brain at an idiopathic hypertensia, acute massive bleeding at stomach ulcer) create qualitatively new kliniko-anatomic complexes.

The diseases which are available for the patient are not connected with a basic disease etiologically, pathogenetic and having other nomenclature rubrifikation are considered as associated diseases.

Both the basic, and associated diseases represent separate nozol, units included in the statistical classification of diseases, injuries and causes of death accepted in the USSR and based on the international classification of diseases. At D.'s formulation it must be kept in mind that statistical classification is used by hl. obr. for definition and the correct rubrifikation nozol. forms, but it does not cancel a wedge, the classifications developed and accepted in the USSR (e.g., classifications of an idiopathic hypertensia by G. F. Lang and A. L. Myasnikov, a mitral stenosis according to A. N. Bakulev).

The relative positioning of separate components in D. of a basic disease has no strictly certain order. The etiological component at its existence in D. is most often put at the beginning of designation nozol, forms, for a cut the morphological component follows; the characteristic of functional frustration completes D. The pathogenetic component can be present at any part D. of a basic disease and its complications. An example of creation full the wedge, the diagnosis can be following: «Basic disease: hron, pneumonia of the II stage, phase of remission. Diffusion peribronchial pneumosclerosis, emphysema of lungs. Hron, respiratory insufficiency of the 3rd degree of obstructive type. Complications: hron, pulmonary heart. Relative insufficiency of the three-leaved valve. Circulatory unefficiency 26 degrees. Associated diseases: the sliding hernia of an esophageal opening of a diaphragm. Psoriasis».

Process of establishment of D. is not identical to different cases, conditions of inspection, opportunities of consultation with narrow specialists etc. Taking into account this D. characterize on a way and time of its statement, on degree of validity and other signs.

On a way of establishment distinguish the direct D. established on typical set of signs or on existence of symptoms, pathognomonic for a disease (see. Diagnosis , Semiotics ), and differential D. (diagnosis differentialis) based on establishment of distinctions in displays of this disease with displays of all diseases at which it is possible similar a wedge, a picture. At this D. it can be established by an exception of everything, except one, the diseases (diagnosis per exclusionem) on the basis of distinctive signs including revealed at purposeful diagnostic inspection or in the course of overseeing by a course of a disease (diagnosis ex observatione) assumed possible.

The important party of D. is its timeliness allowing to apply necessary treatment in an initial phase of a disease before development of its complications. In this regard allocate early D. (diagnosis praecox) established in doklin. stages or at initial displays of a disease, and overdue, or late, D. established in a phase of a heat a wedge, manifestations or in later stages of a disease. Sometimes the correct D. is established only after the analysis of disease for the long period (retrospective D.), including according to the analysis of effect of the carried-out treatment (diagnosis ex juvantibus), or only on the basis of data of pathoanatomical opening (posthumous D.).

On degree of validity distinguish reasonable D. which is often characterized as final, and hypothetical, presumable D. (diagnosis probabilis) which is regarded as preliminary. At small probability of confirmation of a diagnostic hypothesis sometimes speak about D. «questionable».

Reflect certain stages of diagnosis in medical documents of the concept «preliminary», «clinical» and «final» D. Preliminary D. is made out directly at the request of the patient for medical aid. He often is presumable, but maybe quite reasonable; anyway it determines the volume of primary diagnostic inspection and initial therapeutic tactics. Within three days from the beginning of inspection of the patient rather full clinical D. shall be formulated, on the basis to-rogo further therapeutic and diagnostic tactics is developed.

Final D. is formulated at completion of inspection of the patient (i.e. when D. is reasonable) or in connection with its departure or death. On different circumstances a wedge. Specified in medical documents as final can be insufficiently reasonable, even wrong what cases of discrepancy between a wedge, and pathoanatomical testify to, e.g. Therefore D. specified in medical documents as final should not be considered unchangeable. On the contrary, at a possibility of further observation (out-patient, dispensary) for the patient correctness of the established D. shall be checked; D. is specified in process of accumulation of new data.

At desirability of change of the formulation of D. established at the previous stages of medical inspection it is necessary to consider, in addition to a picture of a disease, and a labor orientation and psychology of the patient. Proceeding from the principles of a deontology, such changes of D. should be made only on the essential bases since they can injure psychologically the patient, deprive of it trust to the medical conclusions (see. Deontology medical ).

The pathoanatomical diagnosis

the Pathoanatomical diagnosis is a result of the final stage of the diagnostic process (after the death of the patient) specifying intravital D.; additions and amendments are made to it, sometimes it changes radically. Pathoanatomical D. is established by the pathologist on the basis of found morfol, changes. In the presence the wedge, the data reflected in the history of a disease, the out-patient card to lay down. to the book, etc., the analysis of these changes shall be kliniko-anatomic since results of intravital observations often promote clarification of dynamics morfol, changes, their communication and interdependence, a role and value in emergence of the processes which caused death of a disease.

According to the current situation pathoanatomical D., as well as clinical, is based on nozol, the principle and includes a basic disease, its complications and associated diseases. The disease is considered the basic, a cut in itself or by means of the complications was a cause of death. The names of diseases specified in pathoanatomical D. shall correspond to their list in the International classification of diseases and causes of death, and their definition — the formulation provided in explanations to filling of the certificate on death. According to this formulation the main reason for death and a basic disease — concepts identical.

In pathoanatomical D. into place nozol, forms can be put the medical actions which caused death if these actions were undertaken according to the wrong diagnosis or were carried out incorrectly (surgery, introduction of strong means, incompatible blood and so forth).

At the statistical accounting of diseases and causes of death in each case only one, basic disease is registered. However in practice two or several diseases from which to distinguish a basic disease often quite often are found in one patient can be difficult. In this regard, according to methodical recommendations M3 of the USSR about holding kliniko-anatomic conferences, it is recognized reasonable to enter into diagnostic definitions such concepts as «competing» the «combined» and «background» diseases, and to apply definition «the combined basic disease».

Two diseases found in the patient at the same time are called competing, each of which separately could be a cause of death. Combined call such diseases, each of which is not deadly, but, developing at the same time, led the patient to death. Background it is offered to call a disease, a cut was important in an etiology or a pathogeny of a basic disease or caused its special weight and played a role in emergence and an adverse current of complications. Understand the diagnostic definition used in the presence of the competing, combined or background diseases as the combined basic disease. At the same time for statistical coding only one of entered the combined basic disease nozol, a form gets out. About it the mark in the pathoanatomical epicrisis placed in the protocol of opening and in the history of a disease of the dead becomes.

After the name of a basic disease in pathoanatomical D. the most characteristic are listed its, visible it is macroscopic morfol, manifestations.

Complications are brought in the diagnosis in the sequence, edges are reflected by their interrelation. Some authors suggest to distinguish the complications of a disease and a complication which arose in connection with to lay down. actions; the last are brought in the diagnosis after the first.

Differentiation between manifestations and complications of a basic disease in pathoanatomical D. is also difficult, as well as in intravital. Substantially it is connected with insufficiently accurate maintenance of the concept «complication» in relation to a disease. More definitely this concept is formulated in relation to an injury, in particular fighting. M. F. Glazunov suggested to consider a complication of a fighting injury qualitatively, and often and etiologically the new process which arose owing to an injury, but directly with it not connected. From this point of view, e.g., deadly primary blood losses), caused by wound of a large vessel, it is necessary to regard as a direct consequence of an injury while the secondary bleeding connected with an arrosion of a vessel, unimpaired at an injury, in a zone of phlegmon around a wound is regarded as a complication. Also all infectious complications of an injury were regarded.

In the analysis of diseases this principle, in fact correct, is not always observed, and in D. both intravital, and pathoanatomical a complication often call displays of the disease.

Associated diseases call all diseases found during the opening or their effects which had no significant effect on a current of a basic disease or its complications. Before introduction to practice of the concept «background disease» quite often it was necessary to carry to associated diseases also those diseases which could play a role in an adverse current of a basic disease; it led to insufficiently objective assessment of the diseases found during the opening in their complex. At registration of an associated disease, as well as at a basic disease, the main are listed morfol, manifestations and its complications.

After pathoanatomical D.'s formulation the kliniko-anatomic epicrisis in which necessary explanations are provided to D. is formed: need of registration of the combined basic disease is proved, relationship between the main and background diseases is specified, the pathogeny of complications is analyzed, influence on a current and morfol, the displays of a disease applied during lifetime of medical actions and medicines is noted. Shall find assessment and a wedge in an epicrisis, diagnosis of a disease, its correctness and timeliness. This part of an epicrisis in disputable cases is formed after discussion at a kliniko-anatomic conference. The important, usually completing part of an epicrisis is the tanatogenetichesky conclusion, i.e. the analysis of the reason and the mechanism of death (see the Thanatogenesis). Such conclusion in cases of sudden, sudden death, death on the operating table, after reception of strongly operating means or after medical manipulations is especially important (injections, endoscopies, catheterizations of vessels and so forth) as it is required to establish whether mattered and what the specified actions in the death of a disease. The Tanatogenetichesky conclusion in the most part of cases can be made only with the assistance of the attending physician, the resuscitator, other doctors observing the patient in recent days, hours and minutes of his life since the mechanism of death is usually connected with a complex of functional frustration biochemical, shifts which are not defined during the opening and even at detailed microscopic examination. In certain cases for clarification of a thanatogenesis can have crucial importance bacterial., biochemical, a blood analysis and the urine withdrawn from a corpse.

In not clear cases demanding additional researches after opening preliminary pathoanatomical D. and an epicrisis is formed. The certificate on death in these cases also has preliminary character. After obtaining necessary additional data are made changes in D., the protocol of opening, a case history of the dead and the certificate on death.

Correctly made pathoanatomical D. and a kliniko-anatomic epicrisis give complete idea of all diseases found during the opening of a role and value of everyone patol, process in their general interrelation and in a thanatogenesis. The uniform principles of drawing up D., uniform understanding and the use of diagnostic definitions and terms allow to compare intravital and pathoanatomical D., promote identification of shortcomings of intravital diagnosis, and sometimes and treatments that is of great importance for professional development of doctors. The materials received from pathoanatomical D. make a basis of statistical data on causes of death at each nozol, a form, and also about their role in mortality of the population.

The epidemiological diagnosis

the Epidemiological diagnosis — the conclusion about the reasons and features of emergence epid, the center with the characteristic like epidemic, its development, a current and fading, with instructions of the struck contingents of the population taking into account intensity of mutual communication, a community in food and water consumption of the diseased.

Epidemiol, inspection for the purpose of identification of the reasons and conditions in which there is a center is the main method of a research in epidemiology. In process epidemiological inspection (see) reveal a source of an infection, a way and spreading factors of the activator, establish borders of the center and number of the susceptible persons considered as perhaps caught, etc.

On the basis of established epidemiol. Is formed the plan protivoepid, the actions directed to localization and elimination of the center. Epidemiol, overseeing by the center before its elimination allows to estimate both efficiency of the held events, and correctness put epidemiol.

the Medicolegal diagnosis

the Medicolegal diagnosis — the special conclusion about essence of damage (disease), a state inspected or about a cause of death, made on the basis court. - medical examinations for the solution of the special questions arising in judicial and investigative practice. Court. - medical D. is made out court. - the medical expert or the doctor of other specialty, carrying out court is entrusted to Krom. - medical examinations, in the terms and formulations accepted in forensic medicine. It reflects, in addition to the main damage (disease) and pathogenetic the related complications, also an origin of the found painful changes. Court. - medical D. depends on character of an object of examination and is more whole than it: surveys of the victim, the defendant, the defendant, a research of a corpse at violent death or at suspicion on it, drawing up the conclusion according to medical documents and materials of preliminary or judicial examination etc. The tasks which are put at the same time are defined by properties and features of the investigated event or the incriminated act. In case of a research of a corpse at creation court. - medical D. allocate: a) the main damage (disease) which was a cause of death, or pathogenetic the related complication, caused approach of death; b) the main complication caused by the main damage (disease); c) the additional complications caused by the main damage (disease); d) other damages or diseases which are not connected with the main damage (disease). At surveys of the victims, defendants, defendants establishment of nature of injuries is obligatory under article 79 Code of Criminal Procedure of RSFSR (and to the relevant articles Codes of Criminal Procedure of federal republics). Court. - the medical expert puts D. of damage, defines its danger to life at the time of causing and related duration of treatment and emergence (or absence) temporary or permanent disability. The established D. shall meet the requirements of articles 108, 109, 112 UK RSFSR (and the articles of the Criminal Code of federal republics corresponding to them) and to the «Rules of definition of weight of injuries» existing in each federal republic. At the surveys made in connection with establishment of sexual states or investigation of sexual crimes under articles 117, 119, 120, 121 UK RSFSR (and to the articles of the Criminal Code of federal republics corresponding to them), registration court. - medical D. is coordinated with the existing «Rules of medicolegal obstetric and gynecologic examination» and the «Rules of forensic medical examination of sexual conditions of men» approved by M3 of the USSR.

In court. - medical practice quite often there is a need for drawing up the conclusion according to medical documents (a case history, the out-patient card, the protocol of opening, etc.), and also on materials of preliminary and especially often judicial examination. The medical data which are available in documents and materials which form a basis court are subject to the expert analysis. - the medical D. answering questions of the investigation and court.

See also Diagnosis donozologichesky .

Bibliography: Avtandilov G. G. The international statistical classification of diseases, injuries and causes of death in work of the pathologist, Arkh. patol., t. 33, No. 8, page 66, 1971; Vasilenko V. of X., etc. Propaedeutics of internal diseases, M., 1974; Davydovsky I. V. Medical errors, Owls. medical, No. 3, page 3, 1941; Kaliteevsky P. F. From the point of view of the expert prosector, Arkh. patol., t. 33, No. 6, page 78, 1971; About with and p about in I. N. and Kopnin P. V. Main questions of the theory of the diagnosis, Tomsk, 1962; Errors of clinical diagnosis, under the editorship of S. S. Vail, L., 1969; N. K. Residents of Perm. Notes concerning A. V. Smolyannikov's article «The pathoanatomical diagnosis and an epicrisis at the present stage», Arkh. patol., t. 33, No. 7, page 72, 1971; Smolyannikova. B. The pathoanatomical diagnosis and an epicrisis at the present stage, in the same place, t. 32, No. 8, page 49, 1970; Stepanov A. D. A problem of a disease in the light of works I. V. Davydovsky, Gorky, 1973, bibliogr.; Hazanov A. T. O proximate causes of death, Arkh. patol., t. 30, No. 5, page 59, 1968; Khmelnytskyi O. N. O of a design of the pathoanatomical diagnosis, epicrisis and kliniko-anatomic comparisons, in the same place, t. 33, JVa 2, page 60, 1971; Tsaregorodtsev G. P., Krotkov E. A. and Bogolyubov V. M. About a concept of a nosological form of a disease, Rubbed. arkh., t. 48, No. 1, page 55, 1976.

See also bibliogr, to St. Diagnosis .

A. A. Kedrov; V. N. Kryukov, V. M. Smol-yaninov (court. medical), A. V. Smolyannikov (stalemate. An.), A. A. Sumarokov (epid.).