Initial examination of the patient

1.1. The patient's appearance

The first impression of a patient is an important stage in the diagnostic process, at which both sensory-figurative (intuitive) and rational knowledge of the disease are included. In this regard, a comprehensive and detailed study of the characteristics of the patient's appearance with their reflection in the medical history is necessary. In particular, the following should be taken into account: neatness - untidiness (general, in clothes), indifference to clothes - emphasized neatness and pretentiousness, brightness of clothes, peculiarities of caring for appearance (face, hairstyle), addiction to jewelry, perfumes, and also - features facial expressions and pantomimes (adequate, expressive, lively, restless, agitated, confused, sluggish, inhibited, frozen), the nature of the gait - how he entered the office (willingly - reluctantly, silently - in speech excitement, independently, with the help of the medical staff, brought in on a stretcher ).

Already by the appearance of the patient, his facial expressions, posture, according to preliminary anamnestic data, it is often possible to assume in a first approximation a syndrome, and sometimes a disease. This allows you to vary the nature and form of the conversation with the patient (the content of the questions asked, their volume, brevity, the need for repetition, the degree of complexity).

A certain difficulty in creating even a provisional diagnostic hypothesis based on some characteristics of the appearance may be due to the fact that many of its features (stage information, according to Argelander, 1970) are the least amenable to objectification, since they depend on the level of culture, tastes, upbringing, ethnic and professional features.

To classify the features of appearance as psychopathological phenomena and to distinguish them from everyday, social, cultural non-psychotic analogs, it is necessary to take into account the suddenness, unexpectedness of their appearance, caricature, flashiness, psychological lack of motivation, aimlessness. It must be taken into account the extent to which these features cause surprise, ridicule, indignation of others, shock them, contradict the tastes and customs of the environment, the level of culture of the individual, his usual appearance and behavior. As a rule, external signs do not appear in isolation, but are combined with a change in the patient's entire lifestyle.

1.2. Features of the patient's contact (communication with others and the doctor)

It is necessary not only to describe the features of the contact (easy, selective, formal), but also to try to find out the reasons for its difficulty. The reasons for the violation of the patient's contact with others can be darkening, confusion, narrowing of consciousness, mutism, negativism, an influx of hallucinations and illusions, delusional mood, apathy, autism, deep depression, fear, agitation, drowsiness, aphasia, as well as taking some psychotropic drugs, alcohol, drugs. Of course, in some cases it is difficult to immediately establish the reason for the absence, difficulty or limitation of contact, then only assumptions can be made.

In order to obtain benign information in a conversation with a manic patient, it is advisable to carefully, without interrupting with questions, listen and record his statements. It is almost impossible to remember them, and the manic patient is not able to repeat his statements. In severe manic speech confusion, it is advisable to use a tape recording. It is important to pay attention to the change in the patient's mood depending on the topic of the conversation, to the patient's interest in certain topics. It is necessary to find out whether the external situation affects the structure of speech production or the latter is predominantly reproductive in nature. As the conversation progresses, attempts should be made to at least limited control of the patient's behavior and speech production, the focus of his attention, skillfully correct the attempts of the manic patient to completely suppress the interlocutor's activity and take the initiative of the conversation into their own hands. With severe manic confusion and angry mania, contact with patients can be difficult, unproductive, and sometimes even impossible. It is necessary to patiently endure inappropriate jokes, ridicule, witticisms, remarks of manic patients, skillfully distracting and switching the conversation to other topics. The doctor should refrain from joking remarks, avoid sexual topics, as there is a risk of being included in overvalued, delusional and delusional ideas of erotic content.

When talking with patients in a manic state, it is not recommended to show disagreement with them, contradict them, challenge their opinions, statements and incriminate them in mistakes, lies, deceit, as this can cause a violent emotional outburst with aggression directed at the “offender” in case of angry mania ".

In all patients, including patients in a manic state, it is necessary to describe the peculiarities of keeping the distance, which are peculiar depending on the structure of the syndrome. Maintaining a distance is determined by a complex highly differentiated ethical feeling, the violation of which is of great diagnostic value. In the peculiarities of its manifestation, the state of the emotional sphere, intellect, the level of critical assessment of the situation, the state of one's health (partial criticism, anosognosia), premorbid personality traits reveal themselves. Manic patients are characterized by an ironic-mocking, ironic-patronizing, mocking, familiar, familiar attitude towards the interlocutor, often combined with sexual ambiguity in statements, pantomimic swagger and obscenity. Quite typical addiction to flat (banal) inappropriate jokes in patients with chronic alcoholism and patients with mori-like disorders. Depressive patients are characterized by a timid, dependent, sad-humiliated attitude towards the doctor and other medical staff. There are features of contact in patients with epilepsy (viscosity, sugaryness or malice, hypocrisy, mentoring), schizophrenia (indifferent passivity, fencing off), paranoia (thoroughness, pressure, expectation of understanding, obsequiousness alternating with arrogance), atherosclerosis of cerebral vessels (incontinence memory defects), progressive paralysis and syphilis of the brain (gross absurdity, impudence, swagger), in patients with the consequences of traumatic brain injury (manifestation of "ceremonial" hyperesthesia, irritability, tearfulness) and so on.

In a conversation with an anxious patient, it is necessary to verbally probe the "sore spot" - the source of anxiety, determining which issues increase the anxiety. In delusional and anxiously delusional patients, these are most often questions concerning the wife, husband, children, apartment, pension, the nearest sad fate of loved ones and the patient himself; in patients with reactive depression - questions related to a traumatic situation; in patients with involutional depression - questions of marital and apartment-property relations. In a sparing aspect, it is advisable to move from an alarming, disturbing topic to an indifferent everyday topic, and then return to the first one to clarify the details of interest and its emotional significance.

In a conversation with depressed patients, one should not lose sight of the fact that they often have complaints not of melancholy, but of somatic malaise (insomnia, general weakness, lethargy, decreased performance, lack of appetite, constipation, etc.). To clarify the question of the intention to commit suicide, the doctor should proceed as a last resort and only in a tactful, careful, sparing form, given the psycho-traumatic nature of the very clarification of this topic. Conversation can increase sadness and anxiety in such patients, but sometimes their verbal response reduces the severity of depression and suicidal tendencies. It is advisable to adapt to the slow pace of the conversation, pauses, laconic answers in a quiet voice, silence, to the exhaustion of patients. It is necessary to pay attention not only to the content of responses, complaints and descriptions of experiences, but also to the expressive side of the manifestation of emotions (facial expressions, gestures, sighs, posture, moaning, wringing of hands, special speech modulation).

Autism, negativism, mutism, stupor of the patient should not stop the doctor from trying to contact the patient, since by the peculiarities of the posture, its change, facial expression, gestures, autonomic reactions, it is often possible to determine the patient's reaction to the doctor's words. In some such cases, the use of barbamil-caffeine disinhibition is indicated. Enough characteristic feature autistic contact is that it is not eliminated by barbamil-caffeine disinhibition. Sometimes you can get the patient's answers to questions asked in a low voice and laconic. It is advisable to alternate questions addressed to painful experiences with neutral (indifferent) questions. It is important to carefully study the characteristics of the patient's posture (its naturalness, compulsion, duration and variability during the day, increase or decrease in muscle tone, whether the patient resists attempts by the staff to change his posture, passive or active actions express this resistance, whether the patient changes an uncomfortable posture, reacts pantomimically to external stimuli, pain, food offer). Attention should be paid to the facial expression of the substuporous and stuporous and the patient, to the presence of vegetative and somatic disorders, whether the patient is neat in natural discharges.

When describing the features of the patient's contact, it is necessary to indicate the presence of selective interest in some questions and the nature of the reaction to them, hyperactivity in contact (intercepts the initiative of the conversation), indifference, lack of interest, negative attitude, anger, exhaustion during the conversation. Patients with lethargy and negativism should not point out, make comments in a loud, categorical, imperative form - this usually not only does not improve contact, but can completely destroy it. The best contact is achieved if you communicate with them quietly, calmly, in the form of a request. In a conversation with delusional patients, prone to dissimulation, it is not recommended to directly "head on" raise questions about the patient's excitement, but hidden painful experiences. Patients with relatively intact intellect and the core of the personality are often sensitive to the doctor's attitude to their delusional experiences and therefore prefer not to talk about them. In the course of a conversation on neutral, abstract topics, vigilance, self-control of the subject is reduced and individual experiences, especially judgments related to a hidden delusional or other psychopathological complex may appear. It should be borne in mind that by hiding delusional products from the doctor, the patient can report it to the middle and junior medical personnel, patients, relatives and other persons. Delusional production with its thoroughness, detailing, paralogical, symbolic judgments and other thinking disorders can be reflected in the written production and drawings of the patient. It is advisable to identify delusional ideas not by the method of continuous (non-sample) polling in terms of trial and error, but after obtaining preliminary information about probable, suspicious, possible delusional stories with an emphasis in the conversation primarily on them. When trying to identify delirium in a dissimulating patient in a conversation on alleged "delusional topics" in cases where the patient does not respond to them verbally, one should observe the expressive (non-verbal) manifestations (facial expressions, pantomime, voice timbre, glitter of eyes, etc.). Sometimes dissimulating patients give an especially intense refusal reaction precisely to the inclusion of a "delusional topic" in the conversation. Such delusional patients are characterized by unevenness, electiveness of contact: they are much better at telling about events that are not related to delusion, and become secretive, evasive, formal when the conversation turns to events associated with delusional experiences. After revealing in the patient uncriticality to delusional judgments, one should not try to dissuade him of their erroneousness. This is not only a waste of time, but also a real danger of worsening contact with the patient. The conversation should be conducted in such a way that the patient was confident that the doctor recognized the truth of his explanations, messages, concerns and fears. Only a careful check of the possibility of correcting delusional constructions and their persistence for the purpose of differential diagnosis with delusions, overvalued and delusional ideas is allowed. At the same time, the doctor should direct the edge of his arguments to the logically weak links of erroneous judgments, forcing the patient to justify them again. When talking with patients, it is not recommended to be distracted by talking with others, talking on the phone, making notes, keeping a medical history on the table, as this can increase alertness, fears in anxious and some delusional patients. In some cases, a skillful psychotherapeutic relationship regimen (Konstorum I.S.) can significantly improve contact with a delusional patient.

1.3. Complaints

The patient's complaints often reflect a subjective assessment of the changed state of health, vital tone, fear of loss of health, working capacity, well-being and even life. In them, as a rule, emotional stress is expressed, the elimination of which is the first and necessary task of the doctor. Subjective complaints are signs of a disease, symptoms in which a pathological process reveals itself, sometimes inaccessible to clinical and paraclinical research methods. Relatively often, the manifestations of the disease and the characteristics of the patient's personal response to it appear in subjective complaints no less than in objective symptoms. Underestimation of the significance of subjective complaints is inappropriate and is, in addition, ignoring the specifics of a person with his articulate speech, ability for reflection, introspection, and interpersonal contact. Taking into account the nature of the patient's complaints, the manner in which they are presented and described can help to choose the heuristic focus of the conversation when obtaining anamnestic information and examining the patient's mental state.

A conversation with a patient usually begins with the identification of complaints. This is the usual relationship between a doctor and a patient, and therefore the identification of complaints contributes to the establishment of natural contact between them. It should be borne in mind that the verbal design of complaints is often poorer than the available sensations and behind complaints, for example, insomnia, headaches, dizziness, a whole complex of various disorders can be hidden. So, dizziness patients often call a feeling of instability, lightheadedness, darkening in the eyes, general weakness, nausea, slight intoxication, double vision. But even with adequate use by the patient of terms such as headache, dizziness, weakness, and others, it is necessary to strive for their careful detailing, which allows maximum use of the clinical features of each symptom for topical and nosological diagnosis. For example, when clarifying complaints about a headache, it is necessary to find out the nature of pain sensations (acute, dull, pressing, aching, and so on), localization (diffuse, local), persistence, duration, conditions of occurrence, methods of elimination or mitigation, combination with other symptoms. This can help in resolving the issue of her muscular, vascular, hypertensive, psychogenic, mixed or other nature.

It is advisable to build a conversation in such a way that the patients independently and freely express their complaints and only then it is permissible to carefully clarify them and clarify the presence of painful manifestations missed by the patients. This will avoid or reduce the risk of being suggested by the doctor. On the other hand, it must also be remembered that the verbal description of some symptoms and syndromes (for example, senestopathies, psychosensory disorders) is difficult, so the doctor must carefully (taking into account possible suggestions) and skillfully help the patient in their adequate definition.

Apparently, it is more reasonable and expedient to move from the identification of complaints of patients to the history of the disease, and not to the history of life, as is usually accepted in the schemes of the medical history. Asking about the patient's life after complaints and anamnesis of the disease will make him more focused and productive, will allow you to pay attention to many necessary details, facts, because the doctor's questioning about the patient's life will take place taking into account the primary diagnostic hypothesis. It is important, however, that the hypothesis be provisional, one of the possible, and not biased, final, unshakable. This will avoid the danger of suggesting facts and symptoms to the patient and attracting them to the diagnostic hypothesis. In many cases, it is useful to play several hypotheses, while the doctor's thinking should be flexible to such an extent that, under the pressure of accumulating facts that contradict the primary diagnostic hypothesis, be able to abandon it and switch to another hypothesis that more successfully explains the totality of the obtained clinical facts. A diagnostic hypothesis should not bind the doctor's thought, it should be a working tool, help to obtain facts, facilitate their organization and comprehension, and be stepping stones to the final well-founded clinical diagnosis. Diagnostic hypotheses should not be gloves that are easily thrown away, just as they should not be rags, which for some reason they hold on to, despite their uselessness.

1.4. Anamnesis

Several attempts have been made to assess the practical value of each of the diagnostic methods. So, the anamnesis, according to Loud (1952), in 70% of cases, and according to R. Hegglin (1965), in 50% of cases leads to a justifiable assumption about the diagnosis. According to Bauer (1950), in 55% of cases, diagnostic questions can be correctly resolved thanks to examination and anamnesis, moreover, these methods contribute to the correct further direction of the diagnostic search.

Obtaining reliable anamnestic information from a patient and his environment is not a one-step short-term procedure. Often this is a long, laborious process of identifying, clarifying and supplementing the necessary information, repeatedly returning to it to create, sift, polish and substantiate diagnostic hypotheses. When establishing trusting contact with the patient and those around him, obstacles associated with prevailing prejudices, fears, fear, mistrust of psychiatrists are eliminated, inadequate ideas about mental illnesses, the fatal role of heredity in them are corrected, and often only after that the patient's relatives and other persons from his entourage gives more detailed and reliable amnestic information.

In a number of cases, it turns out to be advisable to use special techniques to revive the most significant associative connections in memory, because they are not in a chaotic form, but have a certain order (for example, the use of emotional associations, the strength of which usually depends not on repetition, but on individual significance).

At the beginning of the conversation, patients should be given the opportunity to freely present anamnestic information, while avoiding suggestions and leading questions. The danger of the latter increases significantly in the presence of memory gaps, with some individual characteristics of the patient (childhood, the phenomenon of psychophysical infantilism, hysterical personality, increased suggestibility). The questions asked during the examination should only activate, stimulate the patient to an open, frank presentation of the medical history, family history and life history. An example of this kind of question is: “What childhood memories did you have of your father? Mother? About past illnesses? " Other variants of questions are possible, in particular, alternative questions (offering a choice). Example: "Were you the first or last student in school?" In order to check the doctor's assumption about the presence of a particular disorder, active-suggestive questions are possible, in which the answer "yes" or "no" is already laid down in advance. For example: "Did you hear male or female voices when you entered the department?" Actively paradoxical suggestive questions are used (seeming denial of a fact, the existence of which is assumed in the patient). For example: “Have you ever had conflicts with your parents? Brother? Wife? " When using the last two options, affirmative answers must be carefully detailed and re-checked.

It is also necessary to follow the sequence of the study, as far as possible, starting with a free survey. The importance of the first conversation is especially great, which is often unique, inimitable. The second and subsequent conversations usually proceed differently, but the prerequisites for their productivity are laid already in the first conversation.

At the beginning of the conversation, the psychiatrist takes a somewhat passive position - he listens carefully. This part of the conversation can be indicative, preliminary, can help to establish contact with the patient. In the second half of the conversation, the doctor uses all the options for filling in gaps, gaps in information, clarifying ambiguities. When receiving anamnestic information from relatives about the present disease, the patient's life has to rely mainly on their involuntary memorization. Previously it was believed that it is not always complete and accurate, but this is not entirely true. Involuntary memorization may be more accurate and reliable than voluntary, but unlike the latter, it requires active work of the doctor with the respondent. It is important to avoid leading, suggestive questions. However, it is necessary and permissible to use clarifying, complementary, detailing, reminding, and controlling questions. One should strive to obtain confirmation of statements made by patients and relatives with specific facts and examples. Subsequently, when observing relatives of the patient in the process of visits, medical leave, in remission, the doctor can turn on the deliberate (voluntary) memorization of relatives, giving them a certain observation scheme. Obtaining anamnestic information in a psychiatric clinic has its own specifics. In a significant number of patients upon admission to the hospital and during their stay in it, it is generally not possible to obtain anamnestic information at all due to the peculiarities of their mental state (syndromes of stupefaction, confusion and narrowing of consciousness, catatonic and apathetic sub-stupor and stupor, various types of excitement, severe depressive syndromes ). In other patients, anamnestic information can be obtained in an inaccurate or deformed form (patients with Korsakov, psychoorganic, dementia syndrome, oligophrenia, gerontological mentally ill, children). In such cases, the role of an objective anamnesis increases immeasurably, which sometimes has to be limited.

When receiving anamnestic information in a conversation with a patient, his relatives, the degree of detailing of certain sections of the anamnesis depends on the alleged diagnosis (on the preliminary diagnostic hypothesis). So, in patients with some forms of neuroses and psychopathies, a detailed study of the features of family education, sexual development is necessary, in people with endogenous diseases it is important to pay special attention to the genealogical history, in people with oligophrenia, epilepsy, organic diseases, the data of early childhood (including prenatal and antenatal) history. Each nosological form has its own priorities for the sections of anamnestic research.

The specific gravity, value of subjective and objective anamnestic information in comparison with the data of mental, neurological and other studies for various diseases differ significantly. The value of an objective history is especially great in patients with alcoholism, drug addiction and substance abuse, psychopathy, in patients with epilepsy with rare seizures and without personality changes. An objective anamnesis provides otherwise unattainable data about the personality structure, its social adaptation, because when talking with a doctor and in a hospital, patients often hide, dissimulate many personal characteristics, features of their behavior in order to show themselves from their best side. It is desirable to obtain an objective history from many individuals (relatives, friends, acquaintances, employees, and others). They characterize the patient from different angles, from different points of view, at different age periods, in different situations, circumstances. This creates the possibility of verification of anamnestic information.

1.4.1. History of present illness.

Possible pathogenic factors that preceded the onset of the disease or its recurrence are identified and described: acute and chronic infectious and somatic diseases, intoxication, pathology in childbirth, nutritional disorders, external and internal conflicts in everyday life, family, at work, loss of loved ones, fear, change of work , place of residence and others. It should be borne in mind that confusion of random factors that preceded the onset of psychosis or its relapse with the causes of the disease is often allowed. And this leads to the termination of the search for true causal factors. For example, the formation of a preneurotic radical from the first years of a child's life is overlooked, the importance of such unconscious factors as the course of intrapsychic personality conflicts and the possibility of a latent period of intrapersonal processing of a traumatic situation (from several days to many years) is underestimated.

It is very important to find out the time of the onset of the disease. This is helped by asking the following questions: “Until when did you feel completely healthy? When did the first signs of the disease appear? " It is necessary to clarify what signs the patient has in mind. This should be followed by careful identification and detailed description the first signs of the disease, the order of development and change of symptoms, clarification of the patient's attitude to symptoms.

Upon re-hospitalization, the medical history should briefly reflect (using archived medical records and an outpatient card of a psychiatric dispensary) the clinical picture of the disease at all admissions, the dynamics of the disease, the nature of light gaps and remissions, the formation of a defect, data from paraclinical studies (EEG, CT and others) , number of relapses, inpatient and outpatient therapy. It is advisable to pay attention to the entire arsenal of previously used means of biological therapy and its other types, to the doses of drugs, to the results of treatment, adverse reactions and complications, on their nature, severity, duration and outcome. When studying remissions and light gaps, it is necessary to reflect in the history of the disease their quality, depth and clinical features, difficulties in labor and family adaptation, to clarify their causes, as well as the characteristics of characterological changes that interfere with family and labor adaptation. The state of the patient's home is of interest, especially in patients with senile, vascular psychosis, progressive paralysis and other progressive diseases.

It is necessary to find out the reasons for admission to the hospital, especially the behavior of the patient on the way, in the emergency room, pay special attention to suicidal tendencies.

In cases where obtaining detailed anamnestic information upon admission of the patient to the hospital is impossible due to mental disorders (depression, amentia, mutism and others), the anamnesis should be collected during the examination at the hospital. With all the importance of careful collection of anamnestic information, it is necessary to strive so that the conversation with the patient is not excessively lengthy, and the record contains the maximum of the necessary information with the utmost brevity of presentation. For example, when a patient develops dementia in old age there is no need to obtain detailed information about early childhood, the development of motor skills, speech, feeding habits, and the like.

1.4.2. Family history (data from both subjective and objective research are used).

It usually begins with a genealogical study, which involves clarifying the following questions. The presence of a patient among the relatives (in a straight line - great-grandfather, grandfather, father; great-grandmother, grandmother, mother; siblings, children, grandchildren; on the side line - great-uncles, grandparents, uncles, aunts, cousins, sisters, nieces, nephews; by maternal or paternal line) cases of deformities, left-handedness, delays and defects in intellectual development, in the development of speech, oligophrenia, outstanding ability to do something, epilepsy, psychosis, suicide, degenerative diseases nervous system, migraine, narcolepsy, diabetes, syphilis, alcoholism, dipsomania, drug addiction and substance abuse and other nervous or severe somatic diseases. The presence and degree of parental relationship with each other is revealed; the age of the parents at the patient's birth; with twins - qualification of monozygosity or dizygosity, the study of diseases in the second twin. It is important to get detailed information about the personal characteristics of the father, mother, other close relatives, about the social, economic, professional, educational status of the father and mother.

It is advisable to draw up family pedigrees that allow us to assess the nature and type of inheritance: autosomal dominant, autosomal recessive, sex-linked, multifactorial, and others. When compiling family pedigrees and their interpretation, it is necessary to take into account the possibility of different degrees of severity (expressiveness of the pathological gene) and manifestation (penetrance of the pathological gene) of inherited signs of the disease, the diversity (clinical and type of heritability) of the same disease in relatives, as well as the possibility of phenocopies of mental diseases , the possibility of developing endogenous mental illness in adulthood and later life (Alzheimer's disease, Pick's disease, Huntington's chorea, epilepsy, and others). A pronounced predisposition to mental illness is usually inherited to varying degrees, and mental illness manifests itself under the influence of certain external factors (mental trauma, infection, alcoholism, and others), mainly at a certain age (usually in critical age periods: pubertal, maturity, involutional). The disease can be clearly detected in only one family member (with incomplete penetrance), transmitted through generations, or manifest only in persons of a certain sex. When compiling pedigrees, it is important to obtain anamnestic data on an extremely large number of persons who are related to the patient. It is desirable to obtain the results of paraclinical studies of the patient's relatives (biochemical, cytogenetic studies, EEG and others). In some cases, it is necessary to examine certain relatives to detect the syndrome of multiple anomalies (malformation).

Table 1.1

Conditional genealogical designations of traits

A legend should be drawn up to the pedigree (explanation of abbreviations and conclusions about the type and nature of inheritance of pathology).

Pedigree example:

Legend: the grandmother of the proband on the maternal side had seizures, the aunt of the proband on the maternal side suffers from epilepsy, the mother of the proband suffers from migraine. The data of clinical and genealogical research indicate the dominant nature of the inheritance of epilepsy in the proband.

The following data, important for diagnostics, about the patient's parents and features of his natal period are clarified. At what age did the mother begin menstruation and the nature of their course. She has somatic pathology (kidney disease, diabetes, congenital malformation and other heart diseases, arterial hypertension or hypotension, endocrine diseases, toxoplasmosis), alcohol abuse, drug use, smoking, chemical intoxication, the use of hormonal and psychotropic drugs, antibiotics and others medicines, exposure to radiation (including X-ray irradiation), vibration, the effects of heavy physical labor, and so on. The mother has a burdened obstetric history (infertility, narrow pelvis, repeated miscarriages, multiple pregnancies, stillbirth, prematurity, death of newborns). Features of the patient's conception and the course of the mother's pregnancy to them: conception in a state of intoxication, undesirability of conception, stressful conditions during pregnancy, infectious diseases in the first third of pregnancy (toxoplasmosis, rubella, cytomegaly, etc.), severe toxicosis of the first and second half of pregnancy, pathology of the placenta and polyhydramnios, Rh incompatibility, undermaturity (less than 37 weeks) or overmaturity (more than 42 weeks) of the fetus. The nature of childbirth: protracted, rapid, with the imposition of forceps, Werbov's bandage, birth in premature twins, intrauterine hypoxia, umbilical cord prolapse, premature detachment of the placenta, cesarean section and other surgical interventions. Child's pathology in childbirth: asphyxia, cerebral hemorrhage, hyperbilirubinemia, the need for revitalization. It is necessary to pay attention to the following features of the neonatal period: deviation from the norm in body weight at birth, skin color, the presence of jaundice, sucking disorder, decreased muscle tone, "twitching", convulsive manifestations, diseases (especially meningitis, encephalitis), the presence of trauma, congenital defects development. An indirect indicator of damage to the nervous system in a newborn can be a late attachment of the child to the breast (on the 3-5th day), discharge from the hospital later than 9 days (not because of the mother's illness). The age and state of health of the father at the time of conception is also found out: alcohol abuse, the presence of radioactive and X-ray irradiation, somatic and nervous diseases. Attention should be paid to the indications of pathological abnormalities during paraclinical examination of the mother, fetus and newborn (according to medical documentation).

1.4.3. Anamnesis of life (patient biography).

The study of anamnestic information is at the same time the study of the personal profile of a given individual before the illness, since the personality structure is reflected in the characteristics of the biography, professional path and activity, in the peculiarities of relations in microsocial groups (family, school, production, military service), in the peculiarities of acquiring and manifesting bad habits, as well as in the peculiarities of adaptation to stressful and psycho-traumatic circumstances. It should be borne in mind that insignificant, at first glance, facts from the anamnesis may turn out to be significant for a holistic synthetic assessment of the patient. They may be necessary to understand the etiology and pathogenesis of the disease in a particular patient (assessment of the role of past diseases, the impact of certain harmful effects on the occurrence of this disease - "trace reactions", according to Ya. P. Frumkin and SM Livshits, 1966; " the principle of the second blow ", according to A. A. Speransky, 1915). This especially applies to the occurrence of reactive psychoses, epilepsy, late traumatic psychoses, psychosis on the basis of previously transferred encephalitis, some forms of alcoholic psychoses.

An important etiological factor in the development of a number of mental illnesses can be traumatic, depriving complexes that were formed in childhood as a result of the following factors: a sharp separation of the child from the mother and sending him to a nursery school, hospitalization without a mother, acute feelings of fear (including fear of death) , loss of loved ones (care, death) and beloved animals, blockade of physical activity, conflict situations between parents, lack of love and attention from parents, presence of a stepfather, stepmother, psychophysical defects, discrimination from peers, difficulties in adaptation in a mass school, collective, especially adolescent self-affirmation, etc. Information is needed about the personality characteristics of the parents, their education, profession, interests. It is necessary to evaluate the nature of the family in which the patient was brought up: harmonious, inharmonious, destructive, disintegrating, disintegrated, rigid, pseudo-solidary family (according to Eidemiller E.G., 1976). The peculiarities of upbringing in the family are noted: by the type of "rejection" (undesirable child by gender, undesirable to one of the parents, birth at an unfavorable time), authoritarian, cruel, hypersocial and egocentric upbringing. It is necessary to take into account the peculiarities of the formation of preneurotic radicals: "aggressiveness and ambition", "pedantry", "egocentricity", "anxious syntony", "infantility and psychomotor instability", "conformity and dependence", "anxious suspiciousness" and "isolation", "contrast ", With tendencies to auto- and heteroaggressiveness, to" overprotection "(according to V. I. Garbuzev, A. I. Zakharov, D. N. Isaev, 1977).

Attention should be paid to the peculiarities of the child's development in the first years of life: deviation from the norm of the rate of formation of statics and motor skills (sitting, standing, walking). With late development of speech and its defects, it is necessary to clarify whether such manifestations were in relatives, to find out the dynamics of these disorders (progressive or regreduated course, increased in puberty). You should also take into account the peculiarities of crying, the development of an orienting reflex, attention, attitude towards the mother and other relatives. It is necessary to pay attention to the peculiarities of interest in toys, their choice, the dynamics of play activity, the presence of excessive, aimless activity or its lack, decrease, deviations in the development of self-service skills. The following indicators are also taken into account: compliance of the child's psyche development with 4 stages - motor (up to 1 year old), sensorimotor (from 1 year to 3 years), affective (4-12 years old), ideational (13-14 years old); sleep features: depth, duration, anxiety, sleepwalking, dreaming, night fears; the presence of diseases of the child and their complications, vaccinations and reactions to them. When raising a child outside the family (nursery, kindergarten, from relatives), you should find out the age of separation from his mother and the length of his stay outside the family, especially his behavior in the children's team.

It is important to pay attention to children's deviant behavioral reactions: refusal, opposition, imitation, compensation, overcompensation and others. Taken into account: age at school entrance; interest in school, academic performance, favorite subjects, repetition, how many classes I have finished; peculiarities of relationships with peers, behavior at school; manifestations of acceleration or retardation, including infantilism. Adolescent deviant behavioral reactions should be noted: emancipation, grouping with peers, hobby reactions and reactions caused by the emerging sexual attraction (Lichko AE, 1973); forms of behavior disorder: deviant and delinquent, escapes from home (emancipatory, impunitive, demonstrative, dromomanic), vagrancy, early alcoholization, deviations of sexual behavior (masturbation, petting, early sexual activity, adolescent promiscuity, transient homosexuality and others), suicidal behavior ( demonstrative, affective, true). Identifying features child development especially important in the diagnosis of neuroses, mental infantilism, minimal cerebral dysfunction, psychosomatic disorders, pathocharacterological development, personality accentuations, psychopathy.

The following facts of the patient's biography are of interest: studies after school; features of military service; reasons for exemption from military service; lifestyle (interests, hobbies, activities); work activity: compliance with the position held by education and profession, promotion, frequency and reasons for changing jobs, attitude of the team, administration, work environment before the disease; features of living conditions; past illnesses, infections, intoxication, mental and physical trauma; when I started smoking, the intensity of smoking; alcohol consumption (in detail): when he started drinking, how much and often he drank, drank alone or in a company, the presence of hangover syndrome, and so on; drug use.

The need to take into account the allergic factor in the treatment of certain mental illnesses determines the importance of the drug history: intolerance to psychotropic, anticonvulsant drugs, antibiotics and other drugs, allergic reactions to food products... In this case, the forms of reactions should be indicated: urticaria, Quincke's edema, vasomotor rhinitis, other reactions. It is advisable to obtain anamnestic information on these issues and in relation to the next of kin.

1.4.4. Sexual history.

The peculiarities of sex education in the family, as well as the peculiarities of the patient's puberty are taken into account: the age of the appearance of secondary sexual characteristics, in men - the onset of wet dreams, erotic dreams and fantasies; in women - the age of menarche, the establishment menstrual cycle, regularity, duration of menstruation, well-being in the premenstrual period and during menstruation. The features of libido, potency, the beginning and frequency of masturbation, homosexual, masochistic, sadistic and other perverse inclinations are noted.

The specifics of sexual activity (regularity, irregularity, etc.), the number of pregnancies, the nature of their course, the presence of medical and criminal abortions, stillbirths, miscarriages are specified; the age and duration of the formation of menopause, its influence on the general state of health, subjective experiences during this period.

If pathological deviations are found in one of the above points, a detailed clarification of the nature of the pathology is necessary. In some cases, it is advisable to consult a gynecologist, andrologist, sex therapist, endocrinologist and other specialists. Sexual history is especially important for the diagnosis of some psychopathies, pathological personality development, neuroses, personality accentuations, endocrinopathies, endogenous psychoses. Sexual history in cases of revealing signs of paraphilia should contain information about sexual characteristics and abnormalities in the patient's relatives.

The following facts of the sexual history are also of interest: the age of the patient's marriage; features of maternal and paternal feelings; whether there were divorces, reasons for them; family relationships, who is the leader in the family. One should get an idea of \u200b\u200bthe type of family ("family diagnosis", according to Howells J., 1968): a harmonious family, an inharmonious family (actually an inharmonious family, a destructive family, a disintegrating family, a broken family, a rigid, pseudo-solidary family according to Eidemiller E.G., 1976). If the patient is lonely, then the reason for the loneliness and the attitude towards him are found out. It is established whether there are children, what is the relationship with them, the reaction to their growing up and leaving home, the attitude towards grandchildren.

It is necessary to find out whether the patient had breakdowns in social adaptation, whether he had losses of loved ones and what is the reaction to them.

It is advisable to obtain characteristics for patients from the place of study, work, which would reflect: attitude to study and official duties, promotion, characterological characteristics, relationship with the team, bad habits, behavior features.

Anamnestic information should be collected in such a volume and so carefully that it becomes possible to determine the characteristics of the personality and character before the onset of mental illness and changes in personality and character during the period of the illness, up to the moment of examination.

In some cases, identifying the onset of the disease presents significant difficulties due to the mild nature of the manifest symptoms, the onset of the disease in the form of "masked" depressive, neurotic and other syndromes, as well as difficulties in distinguishing the manifestation of the disease from premorbid personality traits, especially during periods of age crises.

1.4.5. Forgotten history and lost history(Reinberg G.A., 1951).

A forgotten anamnesis refers to events, incidents, harmful factors that took place in the past, thoroughly forgotten by the patient and his relatives, but which can be identified with the persistent efforts of the doctor. For example, if there are clinical manifestations characteristic of the consequences of traumatic brain injury and there is no history of indications of such an injury, it is necessary to reanalyze in detail and purposefully the features of ontogenesis, including the intrauterine, prenatal, perinatal and postnatal periods. At the same time, it is important to adhere to a special "sterile" survey technique so as not to evoke suggestively conditioned "memories" in the patient and his relatives. A lost anamnesis is events, facts, the impact of pathogenic factors in the patient's past life, which he himself does not know about, but they can be identified by a doctor with sufficient skill and persistence from relatives, friends, from medical and other documentation, as well as that information, which is lost to the doctor forever. Lost information can significantly complicate diagnostic work. Forgotten and lost anamnesis are of particular importance for the diagnosis of mental disorders in the long-term period after traumatic brain injury and encephalitis. The forgotten and lost anamnesis includes not only external ordinary and exquisite etiological factors, events, harmfulness, but also often overlooked data on heredity, on erased, latent, atypical forms of pathology in relatives, especially in the ascending generations and in the children of the patient. Forgotten and lost anamnesis is rarely found in a continuous, schematic, non-targeted survey, usually it is revealed only if the doctor has a clear diagnostic hypothesis developed during the examination of the patient, with good contact with the patient and his environment.

Collecting anamnesis is not a simple thoughtless stenographic registration of information, facts with their subsequent diagnostic assessment, but an intense, dynamic, constantly creative thought process. Its content is the emergence, struggle, screening of diagnostic hypotheses, in which both rational (conscious, logical) and intuitive (unconscious) forms of the doctor's mental activity are involved in their indissoluble unity. The intuitive aspect of the diagnostic process should not be underestimated, while keeping in mind that it is based on previous experience and must undergo the subsequent maximum logical refinement and extremely precise verbalization in special psychiatric terminology. But when sifting through hypotheses, one should not forget about the so-called "economy of hypotheses", choosing the simplest ones that explain the largest number of discovered facts (Occam's principle).

1.5. Features of the personality structure

Personal characteristics (emotions, activity, intellectual development and others) in puberty, adolescence, youthful, mature, involutionary, senile periods are revealed. Personality is a human individual with all biological and social characteristics inherent in him as a subject of social relations and conscious activity. The personality structure includes hereditary somatotypes that correlate with certain mental characteristics. In psychiatry, the classification of physiques by E. Kretschmer (1915) is usually used, in which asthenic, pycnic and athletic somatotypes are distinguished.

The asthenic type is characterized by: a narrow chest with an acute epigastric angle, poor development of the musculoskeletal and fatty components, pronounced supra- and subclavian fossae, long thin limbs with narrow hands and feet, a narrow face with a sloping chin, a long thin neck with protruding thyroid cartilage and seventh cervical vertebra, thin pale skin, coarse hair ("Don Quixote type"). This type of somatoconstitution correlates with schizothymia: uncommunicativeness, secrecy, emotional restraint, introversion, craving for loneliness, a formal approach to assessing events, a tendency to abstract thinking. In addition, there is restraint in manners and movements, a quiet voice, fear of causing noise, secrecy of feelings, control over emotions, a tendency to intimacy and solitude in difficult times, difficulties in establishing social contacts (Kretschmer E., 1930; Sheldon V., 1949).

The pycnic type is characterized by: relatively large anteroposterior size of the torso, a barrel-shaped chest with an obtuse epigastric angle, a short massive neck, short limbs, a strong development of adipose tissue (obesity), soft hair with a tendency to baldness ("Sancho Panza type"). The picnic type correlates with cyclothymia: good nature, gentleness, practical mentality, love of comfort, thirst for praise, extroversion, sociability, craving for people. Also typical are such signs as relaxation in posture and movements, socialization of nutritional needs, pleasure from digestion, friendliness with others, thirst for love, a tendency to gallant treatment, tolerance for the shortcomings of others, spinelessness, serene satisfaction, the need to communicate with people in difficult times ( Kretschmer E., 1915; Sheldon V., 1949).

The athletic type is characterized by: good development of bone and muscle tissue with a moderate development of the fat component, a cylindrical chest with a right epigastric angle, a wide shoulder girdle, a relatively narrow pelvis, large distal extremities, a powerful neck, a face with pronounced brow ridges, dark skin, thick curly hair ("Hercules type"). The athletic type correlates with personality traits such as confidence in posture and movement, the need for and pleasure in movement and action, decisive demeanor, a propensity to take risks, energy, desire for leadership, perseverance, emotional callousness, aggressiveness, love of adventure, in a difficult moment, the need for activity, for activity (Sheldon V., 1949).

Even E. Kretschmer (1915) revealed the predominance of individuals with an asthenic physique among schizophrenic patients, and among patients with affective pathology, people with a pycnic physique are more common. There are indications that individuals with an athletic somatotype often suffer from epilepsy (E. Krechmer, 1948). Among patients with paranoia, an athletic body type is also relatively common.

The biological basis of personality is also such a hereditary factor as temperament or a type of higher nervous activity (the phenomena coincide to a certain extent). The type of higher nervous activity is the innate features of the main nervous processes (their strength, balance and mobility are a biological type that determines the structure of temperaments, as well as the ratio of the level and degree of development of the first and second signaling systems - especially the human, social type). The type of higher nervous activity is a genetically determined personality framework. On the basis of this framework, under the absolutely necessary influence of the social environment and, to a lesser extent, the biological environment, a unique psychophysiological phenomenon is formed - the personality. Psychodiagnostics of personality is possible on the basis of family and personal anamnesis (biography), as well as an indicative study of the type of higher nervous activity using a personality questionnaire developed by B. Ya. Pervomaysky (1964), an abbreviated version of which is presented below.

Table 1.2

An abbreviated version of the personality questionnaire for determining the type of higher nervous activity.

1. The power of the excitatory process:

1) performance;

2) endurance;

3) courage;

4) determination;

5) independence;

6) initiative;

7) self-confidence;

8) gambling.

2. Force of the braking process:

1) excerpt;

2) patience;

3) self-control;

4) secrecy;

5) restraint;

6) distrust;

7) tolerance;

8) the ability to refuse what you want.

3. The mobility of the excitatory process:

1) how quickly do you fall asleep after worries?

2) how quickly do you calm down?

3) how easy is it for you to interrupt work without finishing it?

4) how easy is it to interrupt you in a conversation?

4. Inertness of the excitatory process:

2) to what extent do you achieve what you want by all means?

3) how slowly do you fall asleep after worries?

4) how slowly do you calm down?

5. Mobility of the braking process:

1) assessment of the speed of motor and speech reactions;

2) how quickly do you get angry?

3) how fast do you wake up?

4) the degree of propensity to move, excursions, travel.

6. Inertia of the braking process:

1) how slow is typical for you?

2) the degree of inclination to comply with the rules and prohibitions after their abolition;

3) how slowly do you wake up?

4) the degree of expression of the feeling of expectation after accomplishing the expected?

7. State I signaling system:

1) the degree of practicality in everyday life;

2) expressiveness of facial expressions and speech;

3) a penchant for artistic activity;

4) how vividly can you imagine something?

5) how direct do people think you are?

8. State II of the signaling system:

1) how forward-looking are you?

2) the degree of inclination to carefully think over their actions,

relationships with other people;

3) how much do you like conversations and lectures on abstract topics?

4) the degree of propensity for mental work;

5) how self-critical are you?

9. Instructions for research and processing of its results:

A person himself assesses personal qualities on a five-point scale.

Then the arithmetic mean (M) is calculated in each of the eight columns: M1, M2, M3, etc.

1. Power of type VND: if (M1 + M2): 2\u003e 3.5 - strong type (Sn); if (M1 + M2): 2< 3,5 - слабый тип (Сн).

2. Equilibrium type of VND: if the difference between M1 and M2 is 0.2 or less - balanced type (Ur), 0.3 or more - unbalanced type (Hp) due to the nervous process that turned out to be greater: Hp (B\u003e T) or Hp (T\u003e B).

3. Mobility of the excitatory process: if M4\u003e M3, the excitatory process is inert (Vi), if M3\u003e M4 or M3 \u003d M4, the excitatory process is mobile (Bn).

4. The mobility of the braking process: if M6\u003e M5, the braking process is inert (Ti), if M5\u003e M6 or M5 \u003d M6, the braking process is mobile (Bp).

5. Specially human type of IRR: if the difference between M7 and M8 is 0.2 or less - medium type (1 \u003d 2), 0.3 or more for M7\u003e M8 - artistic type (1\u003e 2), for M7< М8 - мыслительный тип (2>1).

Formula of type VND: example - 1\u003e 2 Cn Nr (B\u003e T) VnTp.

Personality traits the patient is advisable to check with relatives and other close people. At the same time, it is desirable that the patient's personal characteristics be illustrated with specific examples. Attention should be paid to personality traits that interfere with adaptation in the social and biological environment.

The diagnostic value of elucidating the structure of personality can hardly be overestimated, since psychiatric pathology is a pathology of personality (Korsakov S.S., 1901; Krepelin E., 1912 and others). Endogenous psychoses are personality diseases per se. In the structure of a premorbid personality with them, initially, as if in a preformed form, there are “rudiments” of typical psychopathological symptoms, in which a predisposition to this psychosis is manifested (as patos - Snezhnevsky A.V., 1969). In exogenous psychoses, the structure of the personality largely determines the clinical form of psychosis.

1.6. Mental health research

The so-called subjective testimony is as objective as any other for someone who knows how to understand and decipher them.

(A. A. Ukhtomsky)

Whatever experience a psychiatrist has, his study of the mental state of a patient cannot be chaotic, unsystematic. It is advisable for each doctor to develop a specific scheme for researching the main mental spheres. We can recommend the following sequence, which is fully justified in the study of mental spheres: orientation, perception, memory, thinking and intellect, feelings, will, attention, self-awareness. At the same time, the study and description of mental status, its documentation is usually carried out in a relatively free narrative form. A definite disadvantage of this form is its significant dependence on the individual characteristics of the doctor himself. This sometimes complicates the quantitative and qualitative assessment of symptoms, communication (mutual understanding) between doctors, scientific processing of case histories.

A qualified examination is possible only if there is sufficient knowledge of the phenomenological structure of the main psychopathological symptoms and syndromes. This enables the doctor to develop a typified and at the same time individual manner of communication with the patient, depending on the registration of the information received and the nosological unit. It is also necessary to take into account the age of the patient (children, adolescence, adolescence, young, mature, elderly, senile), his sensorimotor, emotional, speech and ideational characteristics.

In the medical history, it is necessary to clearly separate the information received from the patient and information received about him from other persons. A prerequisite for a productive conversation with a patient is not only professional competence, erudition, experience, a vast amount of psychiatric information, but also the manner of communication with the patient adequate to the mental state of the patient, the nature of the conversation with him. It is important to be able to "feel" into the patient's experiences, while revealing sincere interest and empathy (this is of particular importance for patients with neuroses, psychosomatic diseases, psychopathies and reactive psychoses). The doctor is faced with the task of identifying healthy personality structures in order to use them, appeal to them, and strengthen them. This is important for successful treatment and especially for psychotherapy.

During a conversation with a patient and observing him, it is necessary to understand and remember (and often immediately record) what and how he said, to capture the non-verbal (expressive) components of the message, to qualify the nature and severity of psychopathological and neurotic symptoms, syndromes and their dynamics. Interviewing a patient in the study of his mental status should be delicate, "aseptic" (not be traumatic in nature). Essential (clinically significant) questions should be hidden (alternated, interspersed) among standard and indifferent ones.

To increase the reliability of the identified symptoms of the disease, it is recommended to double and triple check them - by the same and different methods (Obraztsov V.P., 1915; Pervomaisky B. Ya., 1963; Vasilenko V. X., 1985). The essence of this rule in psychiatry is that the doctor, along with the extreme detail of the symptom, returns two or three times to identifying and confirming it, using different formulations of questions. One should strive for confirmation clinical signs objective observation, objective anamnestic information (obtained from the words of other persons). In this case, it is necessary to take into account the nature of the correspondence between the patient's mental status and the history data, as well as the deforming effect on the symptomatology of the psychotropic drugs taken by him.

The clinical picture of the disease can be significantly distorted by an incorrect assessment of the so-called psychological analogues of mental disorders. Very many psychopathological phenomena correspond to the psychological phenomena observed in healthy people. At the same time, painful signs - psychopathological symptoms - seem to grow out of psychological phenomena, acquiring not always immediately and clearly distinguishable qualitative difference. Below are some of the most common psychological analogues of mental disorders.

Table 1.3

Correlation of psychopathological phenomena and their psychological analogues

The study of the mental state is hampered by the insufficient knowledge of the differential differences of externally (phenomenologically) similar symptoms of the disease and syndromes (depression and apathy, illusion and hallucinations, mild stunning and abortive amentia, and others). An even greater danger is the so-called psychologizing of psychopathological phenomena, in which there is a tendency to "explain", "understand" psychopathological symptoms from an everyday and psychological standpoint. For example, finding out the fact of marital infidelity with a delusion of jealousy, explaining the symptom of family hatred by the peculiarities of the puberty period, and so on. In order to avoid such mistakes, it is necessary, firstly, to remember about their possibility, and secondly, to carefully study the history of the disease. In this regard, it is important to study symptoms and syndromes from an evolutionary point of view, in age dynamics (which increases the importance of studying psychology and the foundations of the currently emerging synthetic science of man - "Human Science").

In a psychopathological study, it is necessary to give a detailed description not only of pathological disorders, but also of the "healthy parts" of the personality. It should be borne in mind that the constant synchronous recording of the information received, the results of the patient's observation can violate the freedom and naturalness of the patient's messages. Therefore, during the conversation, it is advisable to record only individual characteristic phrases, formulations and short expressions of the patient, since recording "from memory", as a rule, leads to inaccuracies, loss of valuable information, to smoothing, combing, impoverishment, and dehydration of documentation. In some cases (for example, to fix speech confusion, resonance, thoroughness of thinking), it is optimal to use a tape (dictaphone) recording.

It is extremely important to strive for a concrete description of symptoms and syndromes, to reflect the objective manifestations of clinical signs, to accurately register statements (neologisms, slippage, resonance and others), and not be limited to an abstract qualification of symptoms and syndromes - "sticking psychiatric labels." A thorough description of the mental state often makes it possible, using anamnestic data, to reconstruct a more or less complex, sometimes long-term sluggish or inconspicuous course of the disease.

Monitoring in a psychiatric clinic should be specially organized, thoughtful, purposeful. It should implicitly contain elements of theoretical thinking and should be aimed at finding the meaning of the observed. Observation is not devoid of subjectivity, for the observed facts can be seen in the spirit of the observer's expectations, depending on his conscious and unconscious attitude. This requires rejection of hasty, premature conclusions and generalizations, control by other methods to increase the objectivity of observation.

A properly conducted conversation between a doctor and a patient in identifying complaints, collecting anamnestic data and in a psychopathological study has a psychotherapeutic effect (such as cathartic), helps to relieve or alleviate fears, fears, internal tension in a number of patients, gives real orientation and hope for recovery. The same applies to the conversation with the patient's relatives.

Notes:

Features of expressive manifestations of the psyche (facial expressions, gestures, eye expression, posture, voice modulation, etc.) in various mental illnesses and their differential diagnostic value are presented in the section "Mimics, pantomimics and their pathology".

Preventive examination is an important measure in medicine, which is necessary to help citizens to maintain and maintain their health. Timely passage of such an examination allows you to prevent the development of many diseases, as well as to reveal their latent forms. It is carried out in accordance with the order of the Ministry of Health No. 1011m dated 06.12.2012. What is included in a preventive medical examination and what kind of preparation is needed to pass it, we will tell in this article.

Objectives of a preventive medical examination

The main task of preventive examination is to preserve and maintain the health of citizens, as well as prevent the occurrence and development of diseases. In addition, this medical event has other purposes:

• Detection of chronic noncommunicable diseases;
• Establishing a health group;
• Implementation of short preventive counseling (for sick and healthy citizens);
• Implementation of in-depth preventive counseling (for citizens with high and very high total risk of cardiovascular diseases);
• Establishment of a group of dispensary observation of citizens, as well as healthy individuals with high and very high total cardiovascular risk.

The inspection is carried out once every two years. At the same time, it is not carried out in the year of the medical examination. At the same time, citizens involved in hazardous and hazardous work (production) are required to undergo compulsory medical examinations at certain periods according to their own schedule and in accordance with the Order of the Ministry of Health of the Russian Federation of 12.04.2011 No. 302n, are not subject to preventive medical examination.

What does a preventive medical examination include?

Medical preventive examination includes examinations and tests. These procedures are mandatory elements of a medical examination for both males and females. A complete list of necessary studies for a preventive medical examination is reflected in Table 1.

Table 1 - List of examinations included in the preventive medical examination

Study type	Name	Note
Interview	Questionnaire	It is carried out before the start of the examination, the purpose is to identify factors influencing the deterioration of health (infectious diseases, smoking, alcohol abuse, unhealthy diet, increased body weight, etc.)
Measurement	Anthropometry	Includes measurement of the patient's height, weight and body mass index, waist circumference; The data obtained make it possible to identify excess body fat content
	Arterial pressure	It is one of the main methods for diagnosing arterial hypertension.
Analysis	Determination of the level of total cholesterol in the blood	Allows you to diagnose a number of serious diseases
	Determination of blood glucose
	General clinical blood test	A basic blood test to determine the concentration of hemoglobin in erythrocytes, the number of leukocytes and ESR
Diagnostics	Determination of the total cardiovascular risk	Held for citizens under the age of 65
	Fluorography of the lungs	Respiratory system diseases are detected
	Mammography	Held for women aged 39 and over
Analysis	Fecal occult blood test	Held for citizens aged 45 and over
Diagnostics	ECG (electrocardiogram)	Determination of the rhythm and conduction of the heart
Inspection	Reception of a therapist	It is carried out to determine the health status group and the dispensary observation group, as well as to conduct brief preventive counseling

The results obtained reveal the main indicators of a person's health and are mandatory entered into his medical record. On their basis, in the future, the doctor will determine the need for additional research or in-depth preventive counseling.

If a citizen has on hand the results of examinations that were carried out during the year preceding the month of the preventive medical examination, then the decision on the need for a repeated examination is made individually, taking into account all the available results and the state of health of a particular citizen.

Preparation for inspection

A preventive medical examination requires preparation from every citizen who will face it. At the same time, there are certain recommendations for both men and women. The preparation includes two sequential stages, which are reflected in table 2.

Table 2 - Stages of preparation for a preventive medical examination

Stage	Stage content	Note
On the day of inspection	Morning urine collection	Collection rules: Restrictions: Menstruation in women;
	Morning feces collection
Preparatory (before examination)	Lack of meals 8 hours before the examination	Preventive examination is carried out on an empty stomach
	An exception physical activity on the day of the examination (including morning physical exercises)	This rule is necessary for reliable measurement of the patient's pulse and heart rate.
On the day of inspection	Morning urine collection	The volume of biological material is 100-150 ml. Collection rules: Thorough hygiene of the external genital organs before the procedure; Collection is carried out a few seconds after the start of urination Limitations: Menstruation in women; Eating carrots or beets 24 hours before harvesting (these vegetables affect the color of urine); The period after one and a half hours after urine collection (after this time, the biomaterial is not suitable for research); Transport temperature is below zero (at low temperatures, a precipitate of salts contained in the urine occurs. It can be misinterpreted as a manifestation of renal pathology)
	Morning feces collection	The material is transported in a special container (sold in pharmacies); hygiene measures must be taken before the collection procedure

These preparation stages are mandatory for all patients, regardless of their gender and age. Due to the observance of these recommendations, the research results will more accurately and more reliably reflect the state of the body. Along with this, there is special training, which is carried out only by a certain category of citizens, depending on age indicators, as well as on a gender basis. Features of preparation for the study are presented in table 3.

Table 3 - Special preparation for preventive examination

Category of citizens	Preparation for research
Persons (men and women) from 45 years	It is necessary to refrain from eating three days before the examination: Meat; Iron-containing foods (beans, spinach, apples, etc.) and medicines; Ascorbic acid; Vegetables containing enzymes such as catalase and peroxidase (found in cucumbers, cauliflower, etc.). In addition, it is worth giving up laxatives and the use of enemas. These restrictions are necessary for the correct study of feces for occult blood.
Women	Restrictions for women in which the procedure for taking a smear from the cervix is \u200b\u200bnot performed: Menstruation; Infectious and inflammatory diseases of the pelvic organs; Sexual intercourse two days before the study In addition, any vaginal drugs, spermicides, tampons and douching should be canceled.
Men over 50	7-10 days before the examination, you should exclude: Rectal examination; Prostate massage; Enemas; Sexual intercourse; Treatment with rectal suppositories; Other effects on the prostate gland of a mechanical nature

Compliance with the recommendations above will significantly increase the likelihood of detecting existing diseases, increase the accuracy of test results, and also make it possible to provide more accurate recommendations for the patient.

Conclusion

The main active medical care aimed at early diagnosis or detection of any diseases is a preventive examination. All citizens must pass it at least once every two years. As a result of this examination, citizens are assigned a health group (1,2 or 3), and all the results of analyzes and diagnostics are compulsorily entered into the patient's card. Before being examined, citizens must undergo special training prescribed by a doctor.

Another option for the template (form) of the examination by a therapist:

Examination by a therapist ​

Inspection date: ______________________
FULL NAME. patient:_______________________________________________________________
Date of Birth:____________________________
Complaints pain behind the breastbone, in the region of the heart, shortness of breath, palpitations, interruptions in the work of the heart, edema lower limbs, face, headache, dizziness, noise in the head, in the ears ___________________________________________________________________

_
_______________________________________________________________________________

Medical history:___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________

Information about diseases, injuries, operations (HIV, hepatitis, syphilis, tuberculosis, epilepsy, diabetes, etc.): __________________________________________________________________

Allergic history: not weighed down, weighed down ________________________________
_______________________________________________________________________________

The general condition is satisfactory, relatively satisfactory, moderate, severe. The position of the body is active, passive, forced
Body type: asthenic, normosthenic, hypersthenic _____________________
Height __________ cm, weight __________ kg., BMI ____________ (weight, kg / height, m²)
Body temperature: ________ ° С

Skin: color pale, pale pink, marble, icteric, redness,
hyperemia, cyanosis, acrocyanosis, bronze, earthy, pigmentation _____________________
_______________________________________________________________________________
Skin moist, dry _____________________________________________________________
Rash, scars, stretch marks, scratches, abrasions, spider veins, hemorrhages, swelling _______________________________________________________________________________

Oral mucosa: pink, hyperemia ____________________________________

Conjunctiva: pale pink, hyperemic, jaundice, porcelain white, edematous,
the surface is smooth, loosened ___________________________________________________

Subcutaneous adipose tissue expressed excessively, poorly, moderately.

Subcutaneous lymph nodes: not palpable, not enlarged, enlarged __________
_______________________________________________________________________________

The cardiovascular system... The tones are clear, loud, muffled, muffled, rhythmic, arrhythmic, extrasystole. Murmurs: no, systolic (functional, organic), localized at the apex, including Botkin, above the sternum, to the right of the sternum ________________
_______________________________________________________________________________
Blood pressure ________ and ________ mm Hg Heart rate ________ in 1 minute.

Respiratory system... Shortness of breath is absent, inspiratory, expiratory, occurs when _________________________________________________________. Respiratory rate: ________ in 1 minute. Percussion sound clear pulmonary, dull, shortened, tympanic, boxy, metallic ___________________________
____________________________. Borders of the lungs: unilateral, bilateral descent, upward displacement of the lower borders ______________________________ In the lungs during auscultation, breathing is vesicular, hard, weakened on the left, right, in the upper, lower sections, on the front, back, lateral surfaces ____________________________. Wheezing is absent, single, multiple, fine- medium- large-bubble, dry, wet, wheezing, crepitant, stagnant on the left, right, on the front, back, lateral surface, in the upper, middle, lower parts _____________________
_________________________________. Sputum_____________________________________.

Digestive system... Smell from the mouth ____________________________________. Tongue moist, dry, clean, coated with a coating __________________________________________
The abdomen ____ is enlarged due to p / fatty tissue, edema, hernial protrusions ___________________________________________________________, on palpation it is soft, painless, painful _____________________________________________________
There is a symptom of peritoneal irritation, no ___________________________________________
Liver along the edge of the costal arch, enlarged ___________________________________________,
____ painful, dense, soft, smooth, bumpy surface _____________________
_______________________________________________________________________________
The spleen ____ is enlarged ______________________________________, ____ is painful. Peristalsis ____ disturbed _________________________________________________.
Defecation ______ once a day / week, painless, painful, formalized, liquid, brown stool, without mucus and blood ____________________________
____________________________________________________________________________

urinary system... A symptom of tapping on the lower back: negative, positive on the left, right, on both sides. Urination 4-6 times a day, painless, painful, frequent, rare, nocturia, oliguria, anuria, light straw urine _______________________________________________________________
_______________________________________________________________________________
Diagnosis:_______________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

The diagnosis was established on the basis of the information obtained during the questioning of the patient, data from the anamnesis of life and disease, results of physical examination, results of instrumental and laboratory tests.

Survey plan(consultations of specialists, ECG, ultrasound, FG, OAM, OAC, blood glucose, biochemical blood test): ______________________________________________
_______________________________________________________________________________

Treatment plan:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Signature _______________________ Full name

See the full version of the document in the attachment to the message

Every woman should clearly know which stages of a complete preventive examination should be followed in consultation with a gynecologist. It would seem, why should the patient worry about the specialist's compliance with all the nuances of his work? However, the harsh reality confirms the fact that when examining in a district consultation is not always carried out in full due to the large number of patients and saving time. We in no way want to belittle the professionalism of any doctors, but often women spend a lot of time in front of the computer, worrying about only one question: where to find a good gynecologist? It is sad to realize that, in the minds of many, high-quality services are associated with a paid consultation of a gynecologist. So, a good gynecologist will conduct an examination according to the following algorithm.

1. Conversation with a gynecologist

If nothing bothers you, you can come to a consultation with a gynecologist for a simple preventive gynecological examination. By the way, you need to do this 2 times a year so that the doctor can exclude your asymptomatic course. various diseases... If you have any complaints, then this is a serious reason to seek help and advice from a gynecologist. First (unless, of course, this is an emergency), the gynecologist asks you a series of questions to fill out a medical record. A standard set of questions, usually including clarification of your individual characteristics of the body, clarification of complaints and problems, the presence of diseases (including chronic or hereditary ones), sometimes the questions may be related to sexual life. You need to answer all these questions in detail, do not hesitate, since it is about your health. If necessary, do not be afraid to ask your doctor questions (it is better to make a written list of all the questions that interest you in advance).

2. External gynecological examination:

• pressure measurement,
• determination of weight,
• examination of the mammary glands,
• external gynecological examination of the female genital organs on a special gynecological chair for the presence of inflammatory elements or neoplasms, etc.

3. Internal gynecological examination

Various techniques are used to examine the cervix. Most often, a classic examination of the vagina is performed using disposable mirrors. The gynecologist examines the organ for secretions and other pathological processes. Next, a manual (manual) vaginal examination is performed through the anterior abdominal wall... Thus, the doctor notes the shape, size, position, mobility, soreness of the uterus and appendages. The presence of painful sensations is a signal for the doctor, as this may be a sign of a gynecological disease.

The most modern and informative way of examining the cervix and vagina is video colposcopy. The colposcope is an optical device with 30x magnification that allows the doctor to examine in detail the condition of the patient's vagina and cervix. The camcorder allows you to display the image in digital format on the monitor screen. The data can be stored in memory, so you can not only qualitatively examine the patient, but also hold consultations with several doctors or, for example, do a comparative analysis of the dynamics after a certain therapy.

Extended video colposcopy - examination of the cervix to rule out suspicions of cervical cancer. The neck is treated with a 3% solution of acetic acid and the state of the epithelium is recorded using a video colposcope, after about 4 minutes the Schiller test is performed (lubricated with 3% Lugol's solution). In the cells of healthy unchanged squamous epithelium of the neck, iodine stains glycogen in a dark brown color. If there are atrophic age-related changes, as well as dysplasia of the cervical epithelium (precancerous condition), then the cells are poorly stained. In such a simple and absolutely safe way, the gynecologist discovers the zones of pathologically altered epithelium. A cervical biopsy is done only when needed.

4. Taking a smear on flora (internal gynecological examination)

Examination of a smear of gynecological discharge is a bacteriological examination. With laboratory alanisis, the number of leukocytes is counted (more than 10 in the field of view may indicate the presence of infection). According to the results of bacteriological research, you can find:

• pathogens of infection,
• mushrooms (candidiasis),
• "Key cells" (bacterial vaginosis),
• changes in the normal flora in the secretions.

5. Taking a smear for cytology (internal gynecological examination)

Cytological examination (cytology) is a mandatory stage in the early diagnosis of oncological pathology of the cervix. Annual scraping of the cervix during a preventive examination is a guarantee of early diagnosis of cancer in case of its asymptomatic course.

6. Ultrasound examination of the pelvic organs (ultrasound in gynecology)

An ultrasound scan can be the culmination of a gynecologist's examination, since only after this the initial examination can be considered as comprehensive and as complete as possible. This safe technique allows the gynecologist to obtain comprehensive information about all organs of the small pelvis, including the uterus and ovaries, and makes it possible to determine the causes uterine bleeding, menstrual irregularities, abdominal pain, pathological discharge not visible during a routine gynecological examination. Paid pregnancy management also involves regular ultrasound examinations. If the doctor has any reasons for the examination, he may offer to do an ultrasound. Gynecology and ultrasound research methods are closely related.

At the second appointment, the gynecologist informs the woman about the test results taken during the first gynecological examination. Further development of events develops according to an individual algorithm. The full treatment program (in case of detection of any gynecological disease) is signed by the gynecologist after the diagnosis.

A - before examining the respiratory tract in patients with trauma, it is necessary:

1.immobilize the cervical spine with a cervical splint (collar), as until proven otherwise, it is believed that a patient with extensive injuries may be injured in the cervical spine;

2. check if the patient can speak. If yes, then airways passable;

3. to identify the blockage (obstruction) of the airways caused by the tongue (the most common obstruction), blood, lost teeth or vomit;

4.Clear the airway by applying pressure to the jaw or lifting the chin to maintain immobilization cervical.

If the blockage is caused by blood or vomit, cleaning should be done with an electric pump. If necessary, insert the nasopharyngeal or oropharyngeal airway. Remember that the oropharyngeal airway can only be used on unconscious patients. The oropharyngeal airway induces a gag reflex in conscious and semi-conscious patients. If the nasopharyngeal or oropharyngeal airway does not provide sufficient air supply, the patient may require intubation.

B - in case of spontaneous breathing, it is necessary to check its frequency, depth, uniformity. Blood oxygen saturation can be checked using oximetry. When examining, you need to pay attention to the following points:

1.Does the patient use additional muscles when breathing?

2. Are the airways audible bilaterally?

3.Is there a deviation of the trachea or swelling of the cervical veins?

4. Does the patient have an open chest wound?

All patients with extensive trauma require hyperoxygenation.

If the patient does not have spontaneous free breathing or is breathing ineffectively, a respirator mask is used prior to intubation.

C - when assessing the state of blood circulation, it is necessary:

1. check for the presence of peripheral pulsation;

2. determine the patient's blood pressure;

3. pay attention to the patient's skin color - is the skin pale, hyperemic, or other changes have occurred?

4. Does your skin feel warm, cool, or damp?

5.Does the patient sweat?

6.Is there any obvious bleeding?

If the patient has severe external bleeding, apply a tourniquet above the bleeding site.

All patients with extensive trauma need at least two IVs and may require large amounts of fluids and blood. A solution heater should be used whenever possible.

If the patient has no pulse, perform CPR immediately.

D - for neurological examination it is necessary use scale coma Glasgow (W.C. Glasgow, 1845-1907), which determines the basic mental status. You can also use the principle of TBGT, where T is the patient's anxiety, G is the response to the voice, B is the response to pain, O is the lack of response to external stimuli.

It is necessary to preserve the immobilization of the cervical spine before the X-ray is taken. If the patient is conscious and allows it mental condition, then you should go to the secondary inspection.

E - to inspect all damage it is necessary remove all clothing from the patient. If the victim is shot or stabbed, it is necessary to keep clothing for law enforcement.

Hypothermia leads to numerous complications and problems. Therefore, the victim needs to be warmed and kept warm. To do this, cover the patient with a woolen blanket, warm up solutions for intravenous administration. Remember that the initial examination is a quick assessment of the condition of the victim, aimed at identifying violations and restoring vital functions, without which it is impossible to continue treatment.

Initial evaluation of trauma patients.

Secondary inspection

After the initial inspection, a more detailed secondary inspection is performed. During it, all the injuries suffered by the victim are established, a treatment plan is developed and diagnostic tests are performed. Firstly, breathing, pulse, blood pressure, temperature are checked. If a chest injury is suspected arterial pressure measured on both hands.

- establish observation of cardiac activity;

- receive pulse oximetry data (if the patient is cold or has hypovolemic shock, the data may be inaccurate);

- use a urinary catheter to monitor the amount of fluid being sucked in and out (the catheter is not used for bleeding or urination);

- use a nasogastric tube to decompress the stomach;

- with the help of laboratory tests, the blood group, the level of hematocrit and hemoglobin are determined, toxicological and alcohol screenings are carried out, if necessary, a pregnancy test is performed, the level of electrolytes in serum is checked. Assess the need for family presence. Relatives may need emotional support, the help of a clergyman, or a psychologist. If any of the family members wishes to be present during the resuscitation procedures, explain all the manipulations performed to the victim.

Try to calm the patient down. The victim's fears can be ignored through haste. This can worsen the victim's condition. Therefore, it is necessary to talk with the patient, explaining what examinations and manipulations are performed for him. Encouraging words and kind tone can help calm the patient. To improve the patient's condition, anesthesia is also done and sedatives... Listen carefully to the patient. Collect as much information as possible about the victim. Then carefully examine the victim from head to toe, turn the patient over to check for back injuries.