If a doctor does not make the correct diagnosis, this does not always indicate his lack of professionalism; sometimes the diagnosis depends on the patient. How can I help my doctor make a diagnosis?

A typical visit to the doctor most often looks like this: the patient describes his symptoms, gets tested and undergoes examinations, then the doctor analyzes the information and makes a diagnosis. The clinical picture is not always clear, so the diagnosis is a theory based on symptoms. There are often circumstances that make it difficult to make a correct diagnosis.

There are three types of error when making a diagnosis:

• Incorrect diagnosis - the doctor correlated the symptoms with the wrong disease and made a mistaken diagnosis;
• Delayed diagnosis - the diagnosis was made, but the doctor did not prescribe treatment until the symptoms became more clear;
• Missed diagnosis - the disease fits the symptoms, but the doctor did not make a diagnosis.

Many medical errors occur through the fault of the patient; for example, people often suppress certain facts, considering them insignificant. In order for the doctor to make the right decision, you must help him. Take this information seriously, as an incorrect diagnosis causes you to waste money and energy, and also undermines your trust in doctors.

Doctors make an incorrect diagnosis in approximately 10% of cases, and it does not matter the status of the doctor or the level of the medical institution.

High achievements in the field of medical technology play an important, but not decisive role. The findings of the most modern tomographs and the results of genetic tests will be interpreted by a person who may make mistakes. We are talking about the simplest and most common diagnoses; rare diseases, on the contrary, are most often diagnosed accurately.

First of all, you need to understand that the doctor is the same person as you, he can also be tired, distracted by serious problems at work or family, be hungry or sleep-deprived. No one is immune from medical errors, there is no need to react to them overly emotionally, your task is to follow several rules and help the doctor make a diagnosis.

Find an experienced and caring doctor

Doctors must be meticulous with their patients and patient when gathering information. If you have the idea that your doctor is neglecting additional examinations, then you need to find another specialist whom you trust.

Prepare for your visit

Before visiting a doctor, write down all your complaints on a piece of paper, as well as serious changes in your life recently, these could be severe psycho-emotional shocks, traveling abroad, physical activity, and more. Consider every factor that could somehow influence your condition. During your initial visit to the doctor, you need to prepare for him all the results of the latest tests and examinations, the opinions of other specialists, as well as a list of all the diseases that you have suffered from previously.

Tell us about all your symptoms

Just tell the doctor everything you feel, without missing a single symptom; perhaps a small detail will help the doctor build a logical chain. When describing pain, mention the nature of the pain when it first appeared. Speak voluminously and clearly, so that the doctor does not have to extract information from you or come up with it himself.

Ask about all the diagnostic options

Very often, doctors choose the most pronounced symptoms and select a diagnosis based on them, so don’t hesitate to ask the question, what other disease could there be with the same symptoms? A simple question will allow you to gain more information about your health, and will give the doctor the opportunity to look at your clinical picture from a different perspective.

Specify information about examinations

If the doctor has prescribed tests and examinations for you, then ask him about each of them, you need to understand why you should undergo this or that test, and at the same time, the doctor will justify the diagnosis for you.

Don't assume the absence of bad tests is good news

If all examinations and tests show normal values, then you should not be happy that you are not sick with anything. If you continue to feel unwell, tell your doctor and pay his attention to every sign of illness.

Respect the doctor's work

You should never enter into conflict with your doctor or react too emotionally to him, as this will only prevent him from making the correct diagnosis. When visiting a doctor, be calm and reasonable, do not spread negative emotions to the specialist, they will immediately affect you.

Know your role in making a diagnosis

A correct diagnosis can only be made through joint, well-coordinated work between the doctor and the patient. If you feel like you are not getting enough attention, consider looking for another specialist.

Gaevsky Yuri Germanovich, Doctor of Medical Sciences, Professor of the Department of Internal Medicine, Neurology and Psychiatry of NovSU

Throughout his entire medical life, starting from a rural district hospital and further in large clinics, in the process of working and teaching he was engaged in
issues of diagnostic methodology and teaching clinical diagnostic thinking skills.

What is disease diagnosis? This is the identification of the image of the patient’s illness with an abstract image of a particular disease. An abstract image of a disease may consist of signs that always occur in a given disease and do not occur in others.

That is, the sensitivity and specificity of these symptoms is one hundred percent. This symptom is the gold standard for diagnosis: if it exists, there is a disease. Without it, there is no disease. Unfortunately, such symptoms are few and far between. These may also be simple physical symptoms, for example, a diastolic murmur at the apex with mitral stenosis or a diastolic murmur at the aorta with aortic valve insufficiency. And complex hardware or laboratory facilities. Other symptoms always occur with this disease, but often occur with others - sensitive, but low specific.

An even larger part in the image of the disease is occupied by the symptoms that can only be present in a given disease, having low sensitivity and specificity - far less than one hundred percent. Identification of a patient's disease pattern is successful provided that the patient has all the symptoms that should be present. All other symptoms found in the patient may also be associated with this disease. The patient has no symptoms that are not described for this disease(1).

The search for the correct diagnosis is very close to the search in criminology. Perhaps that is why the prototype of Sherlock Holmes was the famous doctor.

Let us give an illustration of this.

Imagine that in a big city there is a search for a car that hit a passenger. According to witness testimony, the brand, series, color and presence of a dent are known. The car may have traces of blood or pieces of the victim's clothing. Simple “physical” symptoms are used to search. Five hundred cars were selected from the traffic police file, using color, make, and series. After examining them, they found thirty cars with a dent. Fifteen found traces of blood. In three of the spots the blood type matched the patient's blood type. One of them has a 100% alibi - he was in another city (that is, there is a symptom that should not exist). Genetic identification of the blood stains and the victim was carried out. In one case it's a coincidence. The culprit has been found. No match was found - the diagnosis fell apart. Reason: the witness mixed up the color of the car. A false positive symptom got into the version and ruined it like a Trojan horse. All symptoms participated equally in the search: at the first stage, simple, but highly sensitive. The last stage is complex, but with high specificity. Of course, it was possible to immediately check fifteen for genetic identification? But this is long and expensive. Although this is a symptom with one hundred percent sensitivity and specificity.

So, clinical diagnostics consists of the stage of collecting information and the stage of forming a diagnostic conclusion. The data can be divided into simple clinical ones: anamnesis and physical examination data. Routine hardware-laboratory and special. The most important principle of the culture of clinical diagnostics at this stage is the following: the value of a symptom is not determined by the modernity of the equipment with which it is obtained, but by its sensitivity and specificity. And also the reliability of its receipt. In this regard, the value of simple anamnestic and physical data is high and, along with routine and complex ones, they are equally involved in making a diagnosis. That is why it is so necessary to improve the art of taking anamnesis, examination, percussion, palpation, and auscultation.
In summary, simple clinical techniques for obtaining information are valuable for the following reasons.

• With an algorithmic and non-algorithmic approach, they help to narrow the range of possible diseases already at the very initial stage and provide direction in prescribing the only necessary special studies.
• Possession of them provides enormous advantages in emergency situations of night duty, emergency room and ambulance work.
• The low sensitivity and specificity of simple symptoms is compensated by their number. The probability is summed (4). This gives reliability to the diagnosis. Simple ones duplicate complex ones. Their coincidence makes the conclusion reliable. Their discrepancy forces us to double-check the data from special studies.
• They are also invaluable in terms of daily monitoring of the dynamics of the disease.
• Only the study of the dynamics of complaints, anamnesis and physical data makes it possible to create a complete spatial and temporal image of the disease.

Having this image makes it easier to handle second-hand information. Suspect and double-check it for false positives or false negatives in time and make the right diagnostic decision.

Example

A 41-year-old patient notes increasing shortness of breath during the year when walking. In the last month there have been two episodes of loss of consciousness while playing tennis. On auscultation there is a rough systolic murmur in the aorta. When conscripted into the army and before, no heart murmurs were found.

Preliminary diagnosis: aortic valve calcification with critical stenosis and syncope.

Echocardiography confirmed the diagnosis completely.

Simple physical findings and history provided an almost definitive diagnosis.

Example

The patient is 47 years old. There are no complaints, he was examined prophylactically. ECG is normal. There is a slight systolic murmur on the aorta.

Echocardiography revealed calcification of the aortic orifice with supposedly significant stenosis. This discrepancy between simple and special data forced a joint re-study.

The conclusion about stenosis was erroneous.

This is a good lesson: before the examination, look at the ECG, talk to the patient, listen to the heart.

Example

The patient is 16 years old, no complaints. During examination, a quiet, high-pitched, diastolic murmur was accidentally discovered at the Botkin-Erb point. The mild degree of aortic insufficiency did not raise any doubts. However, during the first echocardiographic study, aortic insufficiency was not detected. Repeated joint examination revealed a rare pathology - aortic valve prolapse with its insufficiency.

Auscultation of the heart is mandatory before echocardiographic examination.

Example

The patient is 38 years old. He was admitted to the intensive care unit with acute chest pain that began about five hours ago. ECG shows ST elevation in chest and standard leads by 2-3 mm. with shallow negative T waves. The troponin test is positive. It would seem that the diagnosis of myocardial infarction was not in doubt. However, attention was drawn to a rise in temperature to 37.4 degrees, which during a heart attack occurs no earlier than the second day of illness, and a close connection between pain and breathing (which cannot happen during a heart attack). This allowed us to make and later confirm the diagnosis of viral pericarditis.

Simple clinical symptoms played a decisive role in making the correct diagnosis.

Example

A 25-year-old patient was admitted with high fever, pain in the right side when breathing, percussion dullness on the right side under the scapula and bronchial breathing. The diagnosis of lobar pneumonia was not in doubt, but the attending physician was of the opinion that there was acute pyelonephritis, since the radiologist found no abnormalities, and there were leukocytes in the urine.

A joint review of the radiographs showed typical lobar pneumonia, which was not described due to a misunderstanding. Simple clinical data allowed us to avoid an annoying mistake.

Example

A 30-year-old patient was admitted with complaints of weight loss and constant pain in the right hypochondrium. On deep palpation, a dense, immobile formation under the right lobe of the liver was palpated uncertainly. An ultrasound examination revealed diffuse liver changes similar to chronic hepatitis. Repeated joint ultrasound examination revealed a tumor in the retroperitoneal space. False-positive information about hepatitis contradicted palpation data and this allowed us to avoid a fatal mistake.

Example

The patient is 50 years old. Suddenly, at work, I felt an acute pain in the chest, from which I lost consciousness for several seconds. The pain continued and he was taken to the emergency room. On the ECG, ST elevation in the precordial leads is 4-5 mm. Cardiac arrest occurred in the emergency room and successful resuscitation was performed.

The diagnosis of myocardial infarction was not in doubt, but attention was drawn to strange symptoms: the acute onset of the disease and the presence of a quiet diastolic murmur in the aorta. A dissecting aortic aneurysm was suspected. Hypotension was maintained. On the seventh day, the patient suddenly died from cardiac tamponade. The diagnosis of dissecting aneurysm was confirmed.

In the next article we will dwell in more detail on the second stage of diagnosis - direct diagnosis.

Yu. G. Gaevsky,
Doctor of Medical Sciences, Prof.

Each of us knows from our own experience, from friends, from books many reliable methods of treating certain diseases. Why, when we get sick, do we still go to the doctor? Yes, because we don’t know what we are sick with. Determining the disease and making the correct diagnosis is the first and most difficult task of medicine. V. V. Rassokhin, Candidate of Medical Sciences, head of the therapeutic department of MALO, secretary of the Association of Therapists of St. Petersburg, talks about how doctors today solve the problem of making a diagnosis, especially in difficult cases.

— Vadim Vladimirovich, what is a diagnosis, and is it possible to talk about the same diagnosis in completely different people?

— A diagnosis is a brief, one-sentence, statement of the essence of the disease that the doctor observes in the patient. The diagnosis implies the entire set of medical and other ideas about this disease, indicates a certain set of painful sensations or certain manifestations of the disease, and is made on the basis of examination data.

To say that any patient has his own diagnosis is an unjustified complication of the disease picture, although in each individual person the disease will naturally progress differently. The main thing is that we have now moved away from the method of treating the disease to the method of treating the patient. I do not agree that diagnostics is now completely different, that with the advent of new instruments and examination methods, medicine should move away from the patient and narrow down to the level of some kind of disease. The Russian school of medicine has always been based, first of all, on the approach to a specific person, and not to the disease in general. And modern examination methods only help with this.

— What does the examination include?

— The examination begins with personal contact between the doctor and the patient and includes, first of all, familiarization with the patient and a survey of complaints. This is followed by a survey on the medical history - what we call anamnesis: how the painful symptoms developed, how the person reached the current level of the disease, who dealt with it, what examinations were carried out. In addition, a real doctor always finds out when the patient was born, when and what he was sick with, what his parents were sick with, what genetic manifestations, characteristics and predispositions there are.

— Is it true that sometimes an experienced doctor just needs one look at a person to make a diagnosis?

- Yes, sure. For example, I usually ask a person, when he comes into my office, to return to the door and walk back to my desk. By the gait and nature of movements, by facial expressions, skin color, by the condition of the spine, by the position of the head, and by the general appearance, one can suspect some characteristic diseases. For example, with ankylosing spondylitis, a person over time acquires the so-called supplicant pose - the torso bent forward with the head raised up. This genetic disease affects mainly men and at a relatively young age. A person may never have seen a doctor about this disease, but the severe pathology of his spine is immediately visible.

Or liver disease: usually this causes a yellowish color of the skin and whites of the eyes. Anemia or anemia can be easily determined by pale skin color, and the color saturation of the sclera, that is, the inner surface of the lower eyelid, allows us to judge the severity of anemia. And if the patient also has tachycardia (rapid pulse), this only confirms the assumption.

Wet and cold palms in combination with weight loss, tachycardia and a special shine in the eyes are a sign that the patient most likely has increased thyroid function - hyperthyroidism. Wet and warm palms, if a person also reacts especially emotionally to stressful situations, is worried, is highly anxious, his blood pressure often rises paroxysmally, and some functional functions are disrupted - this indicates a violation of the vegetative-vascular complex.

- The second stage of the examination - laboratory tests?

— Having compiled a certain picture of the patient’s illness, the doctor develops a set of further studies. These are various tests of blood, urine, feces. If necessary, a blood sugar test. Or there’s a problem like osteoporosis, where early diagnosis is important: we see osteoporosis in women even at the age of thirty. In Scandinavian countries, there are social programs where, from the age of fifteen, women undergo a medical examination on this matter. We don’t have this yet, but we still strictly identify the risk group, for which we use tests for calcium and phosphorus levels in the blood, and for the level of parathyroid hormones. However, any woman can request that the district clinic refer her for such an analysis. However, the results of laboratory tests are sometimes insufficient, and the difficult diagnosis stage begins.

— In what cases is it difficult to make a diagnosis?

— If the initial acquaintance with the patient was detailed and complete, sometimes the difficulty of making a diagnosis disappears. But a narrow specialist does not have such an opportunity for a detailed interview, and an ordinary doctor, when conducting an initial examination of a patient, often cannot find out the cause of certain painful symptoms.

It happens that it is difficult for surgeons to make a decision: to operate or not. Hormonally active tumors, some early forms of tumor diseases, blood diseases - in all these and other cases, a specialist in difficult diagnosis must understand and direct patients in narrower directions. When a person is tormented by some main symptom of the disease - for example, chronic pain syndrome or chronic fatigue syndrome, prolonged fever of unknown origin with low-grade fever, unknown intoxication, unmotivated sudden weight loss, then it is necessary to isolate these main signs, observe “unclear” patients for a long time, step carry out the necessary examinations step by step. Only then is it possible to obtain a more complete picture of the disease and make a diagnosis.

— What modern methods are used in diagnostics?

— Nowadays medicine has many new medical technologies. Magnetic resonance imaging allows you to accurately diagnose diseases of the brain, spinal cord, and spine. Computed tomography is also indispensable in making some diagnoses. But for diseases of, say, hollow organs - the stomach, intestines - proven, highly informative diagnostic methods, such as x-rays and ultrasound, are indispensable. Oncology cannot do without them either: in some cases it is necessary to conduct a detailed step-by-step examination of many internal organs in order to accurately determine the primary tumor site. If the primary tumor is removed in time, metastases do not develop or are more easily amenable to chemotherapy and radiation therapy. The primary focus also needs to be eliminated in order to improve a person’s quality of life. For example, a large tumor of the stomach or intestines blocks the lumen. During surgery, it is removed, and the person lives normally - for as long as he is allotted.

— Please tell us about chronic fatigue syndrome.

“The range of medical problems here is unusually wide. In my opinion, chronic fatigue is not a disease, but an external manifestation of some basic process that occurs in the body and causes a whole complex of symptoms, that is, specific manifestations. For example, in addition to social, everyday and personal factors, the constant presence of a viral infection in the body, which is common to almost everyone today, plays a huge role in the manifestation of chronic fatigue syndrome. And if this virus periodically, albeit not too often, manifests itself in the form of influenza or herpes, then in the interval between attacks of the disease a person may experience chronic fatigue syndrome: a feeling of malaise, weakness, bad mood, because he carries that same virus within himself.

- So, even ordinary herpes deserves to be taken seriously?

- Yes, herpes should not be taken lightly. Its periodic exacerbations are the background for the development of various diseases: cardiovascular, autoimmune and even cancer. For example, the risk of developing malignant lymphoma in a patient who is constantly exposed to the virus is many times higher than in others, because this is a constant extra burden on the immune system.

But even if a person does not have external manifestations of a viral infection, then an accurate diagnosis must be made regarding his chronic fatigue syndrome. And there is no point in putting up with this, invigorating yourself with coffee and various biostimulants: this is a false, obviously vicious path. Chronic fatigue syndrome may also indicate the formation of some kind of organic autoimmune disease.

— What if patients say: “Everything hurts”, that is, pain in all muscles, “shooting” in the calves, forearms, it’s impossible to raise your arm, etc.?

- Muscle pain should be divided into primary and secondary - so-called myalgia. If muscle pain manifests itself in certain muscle groups, we can talk about a specific disease: polymyositis or polymyalgia. For example, it is difficult to raise your arm, which means that the paroxysmal (closest to the center) large muscle groups are affected. It is impossible to squeeze an object with your hand or respond to a handshake - this is one group of diseases, if the forearm does not work well - this is another group, here we can talk about a disease of the nervous system. Very often, patients with diabetes complain that their hands do not work well - due to vascular damage. On the contrary, rheumatic patients find it difficult to lift their arms or hips because large muscles hurt.

— How do you feel about taking painkillers for a headache or some other pain?

- I have a bad attitude. The newest painkillers, and there are more than a hundred of them on the market now, have all sorts of side effects - from internal gastric bleeding to various allergies, and a person does not even always know why he developed an allergy. Therefore, you should not just drown out the pain and haphazardly take painkillers; it is better to let the doctor make an accurate diagnosis and not interfere, but help him with this.

— What is the most important thing in making a diagnosis?

— In any matter of medical diagnostics, the main thing is the patient himself. A positive result primarily depends on his persistence, desire to get better, help himself, and understand what is happening to him. It is difficult to force a doctor to make a diagnosis if for some reason he cannot do this, but a persistent and sensitive patient will achieve this! Of course, this can be difficult: sometimes there is no doctor nearby who would direct the patient in the right direction, there is not enough time or money, but the solution to the problem often lies where you do not expect. Not everyone, for example, knows that doctors can solve a complex medical problem absolutely free of charge using the federal budget. Therefore, you need to go, ask questions, fight for yourself - act!

Interviewed by Alexander Volt

The presented online service “Diagnosis by Symptoms” of diseases operates on the principle of an intelligent medical reference book, indicating to the doctor possible options for diagnosing diseases. The operating principle compares the symptoms of diseases selected for a given patient and the symptoms of diseases in the directory database. A list of 589 symptoms allows you to convey in detail the clinical picture of the patient.

The list of 330 diseases describes all segments of practical medicine. As a result of the differential diagnosis, the doctor receives a list of disease diagnoses that are possible in the presence of a selected combination of symptoms, in which the disease diagnoses are sorted in descending order of probability.

The online diagnostic reference book for general practitioners, with elements of differential diagnosis of diseases, is intended for use by practicing physicians in clinics, emergency departments of hospitals and for doctors treating patients in hospitals. It can also be used as a teaching tool for diagnosing diseases in the training of students of medical institutes.

Selecting symptoms and performing analysis

Questions and answers about the service

Question:Hello, I am 18 years old, lately it has been very difficult to breathe (when inhaling) - it especially gets worse when lying down; constant yawning and feeling tired; The heartbeat is also very noticeable. What could it be?

Answer: There can be many reasons. You need an in-person consultation with a doctor for examination and examination.

Question:Hello! My mom's throat is on fire. And when it burns very strongly, a little blood appears. What could it be? ENT also had pharyngitis. The gastroenterologist diagnoses pancogastritis. They've been treating me for two months, but there's no point. Could these diagnoses cause blood during intense burning? Or maybe tell me something else. Thank you.

Question:Hello. Every evening I start with a sharp spasm in the lower back, nausea rises up and sudden vomiting of gastric juice begins. what could it be?

Answer: You need a face-to-face consultation with a therapist to prescribe the necessary examination.

Question:Hello! I am 28 years old. A month ago I had a stomach ache. Now severe diarrhea has begun. Sometimes even vomiting. The pain intensifies after eating. She didn't take any medications.

Answer: Gastrointestinal tract disease: gastritis, stomach ulcer, cholecystitis, etc. You need to be examined by a gastroenterologist.

Question:Can there be heaviness in the stomach and pain during abdominal pain?

Answer: This is possible, but cardiovascular and neurological signs are decisive.

Question:Hello! I have a formation on my gum with a white spot (hardens over time, and then softens again). Doesn't hurt, doesn't interfere. I consulted with many people, they say it’s a cyst. But I can’t rely only on the opinions of friends, can you tell me what it could be?

Answer: Only a dentist can answer this question during an in-person consultation.

Question:Hello. 10 days ago, while playing football, I collided with an opponent and was hit in the head. I went to the hospital about the injury, and they did an x-ray. They wrote that there was a bruise of the soft tissues of the frontal part. My head still hurts, less so, but it still hurts, which prevents me from working fully. What to do in such a situation?

Question:Hello, I’m 12, everything was fine with my health, but when I woke up last week, a lot of health problems appeared, a sore throat, temperature jumps up to (39 degrees), drool became stickier and thicker, my neck started to hurt when I get up from the couch, the first 2-3 seconds there is a sharp pain in my head, the medications hardly help. Make a diagnosis if possible, and whether it can be cured.

Answer: The cause of your condition can be many diseases (from the flu to more dangerous ones), so we recommend that you undergo a full medical examination. Start with a therapist.

Question:Hello, I have small blisters on my tongue at the base and sides, also a small white coating at the base of the tongue, itching on the tongue.

Answer: Possibly fungal stomatitis. Contact your dentist in person.