First of all, it is worth noting that the general practitioner conducts an external examination of the patient. By characteristic features he may suspect the patient has conditions such as anemia, jaundice, and high cholesterol.

An objective examination is carried out in two main ways: a thorough examination of the patient or establishing the functional characteristics of the body by studying its individual systems (circulatory, nervous, digestive, etc.).

Preliminary and visual examination by a general practitioner

Typically, a preliminary examination begins with an examination of the skin, superficial lymph nodes, visible mucous membranes, during which they can be identified skin rashes, swelling, hematomas, etc. Then the therapist palpates different parts of the body, assessing the firmness, elasticity and moisture of the skin, feels bones, joints, tumors, and blood vessels located near the surface.

If the patient cannot get to the clinic, then the therapist comes to the house and carries out a preliminary examination.

By tapping the chest and abdomen, the boundaries of organs or changes in their density are determined, and pathological compactions or fluid accumulations are detected. After this, using a stethoscope, the therapist listens to the sounds of the heart and lungs. Disorders of the heart are expressed in the appearance of pathological noises and rhythm disturbances. Diseases respiratory tract and lungs are often accompanied by the appearance of characteristic wheezing. By listening to the abdomen, the presence of peristalsis (movement) of the stomach or intestines is established, and in pregnant women, the fetal heartbeat.

Examinations at the clinic

In addition, modern clinics use temperature measurement (thermometry) and body parts (anthropometry), and examination of deep-lying organs using various mirrors and optical instruments.

At the end of the initial examination, the therapist usually measures blood pressure, examines hearing and vision, and measures the patient’s height and weight. When a qualified general practitioner needs confirmation of the diagnosis, he refers the patient for a special examination.

The range of modern diagnostic capabilities is very wide and includes studies such as measuring lung volume, assessing heart function (electrocardiography), and x-ray examination of various organs. Women may be advised to have a mammogram or a diagnostic scraping of the endometrial lining or a Pap smear (taking cells from the cervix for examination under a microscope). All these procedures are aimed at the early detection of cancerous tumors of the mammary glands and female internal genital organs.

At computer diagnostics a description of the patient’s symptoms and the results of all his examinations are entered into a computer, which, after processing the data, issues a conclusion. Typically, therapists use this diagnostic method in cases of rare diseases.

As a rule, during an objective examination a person does not feel much discomfort. At the end of the procedure, the therapist either informs the patient that everything is fine, or, based on the diagnosis, prescribes treatment and makes a prognosis for the course of the disease. of this disease. In this case, timely contact with a general practitioner is especially important, since identifying the disease in the early stages most often means the possibility of a complete cure.

II Stages of examination of a surgical patient.

I Features of examination of surgical patients.

1. The transience of the surgical disease (esophageal atresia, acute obstruction, purulent-septic diseases, etc.) is important.

2. The possibility of developing serious complications (peritonitis, phlegmon, abscess formation, etc.).

3. Presence of early and other local pathological changes.

4.Stages of examination of a surgical patient.

1. Initial examination of the patient(the examination is carried out in daylight or bright artificial light, the patient is completely exposed or the area about which the patient complains). They carefully examine the skin, mucous membranes, tissue turgor, function of the limbs, movements, the presence or absence of reflexes, and at the same time conduct a survey of the patient, identifying it complaints.

2. Additional examination of the patient. Based on the preliminary diagnosis made by the nurse, an additional examination plan is determined. These methods include laboratory diagnostic methods, which allow one to obtain information about the state of the body as a whole, as well as about the course of the pathological process.

Since ancient times, examination of a patient began with questioning about complaints, which in essence represent one of the dysfunctions of any organ or system.

Distinguish local complaints, associated with a specific anatomical area or part of the body, and general complaints , in the appearance of which such a connection is not visible. A common leading local complaint in surgical diseases is pain. There may be pain somatic and visceral the first arises in the nerve trunks of somatic structures, the second in the autonomic nerve fibers and reaches the subcortical centers.

Pain from the surface of the body is transmitted, as a rule, along myelinated (fast) fibers and inhibits slowly spreading irritations along non-myelinated (slow) fibers. Somatic pain is usually cutting or burning of a constant nature with a precisely defined starting point. Visceral pain is most often dull, manifests itself in the form of contractions, colic and is usually diffuse in nature. A methodologically correct and comprehensive study of complaints already at this stage of examination of a patient with a surgical disease usually makes it possible to form a prototype of a topical diagnosis of the disease.

When studying medical history, First of all, you should find out the general age of his (complaint) - i.e. determine how long the patient considers himself sick. A correctly and thoroughly collected anamnesis followed by analysis of anamnestic data allows one to get an idea of ​​the course of the pathological process. When studying the general anamnesis, it is advisable to highlight

Its three sections:

· anamnesis of life;

· family history;

· professional history.

Anamnesis of life includes information about the physical and mental development patient, previous diseases, allergic reactions, injuries and operations, etc.

Family history, in which a possible predisposition to the alleged disease, transmitted by inheritance, is determined.

Professional history, when studying which attention is paid to various kinds of static loads, physical inactivity, overheating, vibrations, ionizing radiation, etc. The next stage of the examination is carried out using the so-called objective research methods beginning with general examination of the patient, then carried out assessment of the condition of the disease site(status praesens localis), you cannot limit yourself to examining only the area to which the complaint relates, but it is necessary to examine the entire part of the body.

Then they examine head, face, neck, then chest and thoracic organs, special attention should be paid to examination mammary glands, especially in women over 35 years of age If you suspect surgical disease abdominal organs and retroperitoneal space Using superficial palpation, all floors of the abdominal cavity are examined. Next they carry out deep palpation, and subsequently percussion and auscultation of the abdominal cavity.

Every woman should clearly know what stages of a complete preventive examination should be followed during a 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 examined in a district consultation, it 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’s sad to realize that in the minds of many, quality services are associated with a paid consultation with a gynecologist. So, a good gynecologist will conduct an examination according to the following algorithm.

1. Conversation with a gynecologist

If nothing worries you, you can consult a gynecologist for a simple preventive gynecological examination. By the way, this needs to be done 2 times a year so that the doctor can rule out the asymptomatic course of various diseases in you. If you have any complaints, then this is a serious reason to seek help and advice from a gynecologist. First (unless, of course, it is Emergency) the gynecologist asks you a series of questions to fill out medical card. A standard set of questions, usually including finding out your individual characteristics body, clarifying complaints and problems, the presence of diseases (including chronic or hereditary), sometimes questions may be related to sexual life. You need to answer all these questions in detail and do not be shy, since we are talking 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 you have in advance).

2. External gynecological examination:

• pressure measurement,
• weight determination,
• breast examination,
• 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

Used to examine the cervix various techniques. Most often, a classic examination of the vagina is performed using disposable speculums. The gynecologist examines the organ for the presence of discharge and other pathological processes. Next, a manual (manual) vaginal examination is performed through the anterior abdominal wall. In this way, the doctor notes the shape, size, position, mobility, pain of the uterus and appendages. The presence of painful sensations is a signal for the doctor, as this may be a sign gynecological disease.

The most modern and informative way to examine the cervix and vagina is video colposcopy. A 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 video camera allows you to display images in digital format on the monitor screen. The data can be saved 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 exclude suspicion of cervical cancer. The cervix is ​​treated with a 3% solution acetic acid and the state of the epithelium is recorded using a video colposcope; after about 4 minutes, a Schiller test is performed (lubrication with 3% Lugol’s solution). In the cells of healthy, unchanged squamous epithelium of the cervix, iodine stains glycogen dark brown. If there are atrophic age-related changes, as well as dysplasia of the cervical epithelium (precancerous condition), then the cells stain poorly. In this simple and absolutely safe way, the gynecologist detects areas of pathologically altered epithelium. A cervical biopsy is prescribed only if necessary.

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

A smear examination of gynecological discharge is a bacteriological study. During laboratory analysis, the number of leukocytes is counted (more than 10 in the field of view may indicate the presence of infection). According to the results bacteriological research can be found:

• infectious agents,
• mushrooms (candidiasis),
• "clue cells" (bacterial vaginosis),
• change in normal flora in the discharge.

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

Cytological examination (cytology) is a mandatory stage early diagnosis oncological pathology of the cervix. An annual scraping of the cervix during a preventive examination is a guarantee of early diagnosis of cancer if it is asymptomatic.

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

An ultrasound can be the culmination of an examination by a gynecologist, since only after this the initial examination can be considered comprehensive and as complete as possible. This safe technique allows the gynecologist to obtain comprehensive information about all pelvic organs, including the uterus and ovaries, and makes it possible to determine the causes of uterine bleeding and disorders menstrual cycle, 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 examination, he may suggest doing an ultrasound. Gynecology and ultrasound research methods are closely related.

At the follow-up appointment, the gynecologist informs the woman about the results of tests taken during the first gynecological examination. Further development events develop according to an individual algorithm. The full treatment program (if any gynecological disease is detected) is signed by a gynecologist after diagnosis.

Initial examination of the patient

1.1. Patient's appearance

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

Just by the appearance of the patient, his facial expressions, posture, and preliminary anamnestic information, it is often possible to guess at a first approximation the syndrome, and sometimes the 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, degree of complexity).

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

To classify features of appearance as psychopathological phenomena and distinguish them from everyday, social, cultural non-psychotic analogues, it is necessary to take into account the suddenness, unexpectedness of their appearance, caricature, catchiness, psychological lack of motivation, aimlessness. It must be taken into account to what extent 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 patient contact (communication with others and the doctor)

It is necessary not only to describe the features of contact (easy, selective, formal), but also to try to find out the reasons for its difficulty. The reasons for the disruption of the patient’s contact with others may be darkness, 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 certain psychotropic drugs, alcohol, and drugs. Of course, in a number of cases it is difficult to immediately establish the reason for the absence, difficulty or limitation of contact, then only assumptions can be made.

To obtain benign information in a conversation with a manic patient, it is advisable to carefully listen and record his statements without interrupting with questions. It is almost impossible to remember them, and a manic patient is not able to repeat his statements. In cases of severe manic speech confusion, it is advisable to use a tape recording. It is important to pay attention to changes in the patient’s mood depending on the topic of conversation, and to the patient’s interest in certain topics. It is necessary to find out whether the external situation influences the structure of speech production or whether the latter is predominantly reproductive in nature. As the conversation progresses, attempts should be made to at least limitedly control the patient’s behavior and speech production, the direction of his attention, skillfully correct the manic patient’s attempts to completely suppress the activity of the interlocutor and take the initiative of the conversation into his 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, and remarks from manic patients, skillfully distracting and switching the conversation to other topics. The doctor should refrain from making humorous remarks and 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 convict them of mistakes, lies, deception, since this can cause a violent emotional outburst with aggression directed at the “offender” during angry mania. "

In all patients, including patients in a manic state, it is necessary to describe the features of maintaining distance, which are unique depending on the structure of the syndrome. Keeping a distance is determined by a complex, highly differentiated ethical feeling, the violation of which is of great diagnostic significance. The peculiarities of its manifestation reveal the state of the emotional sphere, intelligence, the level of critical assessment of the situation, the state of one’s health (partial criticism, anosognosia), and premorbid personality characteristics. Manic patients are characterized by an ironically mocking, ironically patronizing, mocking, familiar, familiar attitude towards the interlocutor, often combined with sexual ambiguity in statements, pantomimic swagger and obscenity. Quite typical is the addiction to flat (banal) inappropriate jokes in patients with chronic alcoholism and in patients with mori-like disorders. Depressed patients are characterized by a timid, dependent, melancholy and humiliated attitude towards the doctor and other medical staff. There are peculiarities of contact in patients with epilepsy (viscosity, sweetness or malice, hypocrisy, mentoring), schizophrenia (indifferent passivity, isolation), paranoia (thoroughness, pressure, expectation of understanding, obsequiousness alternating with arrogance), cerebral atherosclerosis (incontinence of affects, attempt to disguise memory defects), progressive paralysis and syphilis of the brain (gross absurdity, impudence, swagger), in patients with the consequences of traumatic brain injury (manifestation of “frontal” hyperesthesia, irritability, tearfulness) and so on.

In a conversation with an anxious patient, it is necessary to verbally probe the “sore point” - the source of anxiety, determining which questions increase anxiety. For delusional and anxiously delusional patients, these are most often questions concerning the wife, husband, children, apartment, pension, the immediate sad fate of loved ones and the patient himself; in patients with reactive depression - issues related to a traumatic situation; in patients with involutional depression - issues of marital and apartment-property relations. In a gentle aspect, it is advisable to move from an alarming topic that worries patients to an indifferent everyday one, and then return to the first 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 their complaints often come to the fore not of melancholy, but of somatic malaise (insomnia, general weakness, lethargy, decreased performance, lack of appetite, constipation, etc.). The doctor should begin to clarify the issue of intention to commit suicide last and only in a tactful, careful, gentle manner, taking into account the psychotraumatic 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 conversation, pauses, laconic answers in a quiet voice, silences, and the exhaustion of patients. It is necessary to pay attention not only to the content of answers, 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 modulation of speech).

Autism, negativism, mutism, and the patient’s stupor should not stop the doctor from trying to contact the patient, since it is often possible to determine the patient’s reaction to the doctor’s words based on the characteristics of the posture, its changes, facial expression, gestures, and vegetative reactions. In some such cases, the use of barbamyl-caffeine disinhibition is indicated. A fairly characteristic feature of autistic contact is that it is not eliminated by barbamyl-caffeine disinhibition. Sometimes you can get the patient's answers to questions asked to him in a quiet voice and succinctly. 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, forcedness, duration and variability during the day, increase or decrease in muscle tone, whether the patient resists attempts by staff to change his position, whether this resistance is expressed through passive or active actions, whether the patient changes the uncomfortable position, how pantomimically reacts to external stimuli, pain, food offer). You should pay attention to the facial expression of the substuporous and stuporous and the patient, the presence of vegetative and somatic disorders, whether the patient is tidy in natural functions.

When describing the characteristics of the patient’s contact, one should indicate the presence of selective interest in certain issues and the nature of the reaction to them, hyperactivity in contact (seizes the initiative of the conversation), an indifferent attitude, lack of interest, negative attitude, anger, exhaustion during the conversation. Patients with lethargy and negativism should not point out or 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 conversations with delusional patients prone to dissimulation, it is not recommended to ask questions directly “head-on” about the painful experiences that concern the patient but are hidden by him. Patients with relatively intact intellect and core personality often sensitively perceive the doctor’s attitude towards their delusional experiences and therefore prefer not to talk about them. During a conversation on neutral, abstract topics, the vigilance and self-control of the subject decreases and individual experiences and peculiarities of 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 middle and junior medical staff, patients, relatives and other persons. Delusional products with their thoroughness, detail, paralogical, symbolic judgments and other thinking disorders can be reflected in the patient’s written products and drawings. It is advisable to identify delusional ideas not by a continuous (non-sampling) survey in terms of trial and error, but after receiving preliminary information about probable, suspicious, possible delusional plots, focusing attention primarily on them in the conversation. When trying to identify delusions in a dissimulating patient in a conversation on supposed “delusional topics” in cases where the patient does not respond to them verbally, one should observe expressive (nonverbal) manifestations (facial expressions, pantomimes, timbre of voice, shine of eyes, and others). Sometimes dissimulating patients give a particularly intense refusal reaction precisely to the inclusion of a “delusional topic” in the conversation. Such delusional patients are characterized by unevenness and selectivity of contact: they talk much better about events that are not related to delirium, and become secretive, evasive, and formal when the conversation turns to events related to delusional experiences. Once the patient has been identified as being uncritical of delusional judgments, one should not try to dissuade him of their fallacy. 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 is confident that the doctor recognizes the truth of his explanations, messages, concerns and fears. Only a careful check of the possibility of correcting delusional constructs and their persistence for the purpose of differential diagnosis with delusions, overvalued and delusional-like ideas is allowed. In this case, the doctor must 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 conversations with other people, talking on the phone, taking notes, or keeping the medical history on the table, as this can increase alertness and fear in anxious and some delusional patients. In some cases, a skillful psychotherapeutic relationship regime (Constorum 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, ability to work, well-being and even life. As a rule, they express emotional tension, the elimination of which is the first and necessary task of the doctor. Subjective complaints are signs of the disease, symptoms in which one finds oneself pathological process, sometimes still 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. Underestimating the significance of subjective complaints is unjustified and, in addition, represents 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 of their presentation and description can help in choosing the heuristic direction of the conversation when obtaining anamnestic information and examining the patient’s mental state.

A conversation with a patient usually begins with identifying complaints. This is a familiar relationship between doctor and patient, and therefore identifying complaints helps to establish natural contact between them. It should be borne in mind that the verbal presentation of complaints is often poorer than the existing sensations and behind complaints, for example, insomnia, headaches, dizziness, a whole complex can be hidden various disorders. Thus, patients often call dizziness a feeling of instability, lightheadedness, darkening of the eyes, general weakness, nausea, slight intoxication, double vision. But even when the patient adequately uses terms such as headache, dizziness, weakness and others, it is necessary to strive for their careful detail, allowing the maximum use of the clinical features of each symptom for topical and nosological diagnosis. For example, when clarifying complaints about headaches, it is necessary to find out the nature of the pain (sharp, dull, pressing, aching, etc.), 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 its muscular, vascular, hypertension, psychogenic, mixed or other nature.

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

Apparently, it is more reasonable and expedient to move from identifying patient complaints to a medical history, and not to a life history, as is usually customary in medical history charts. Questioning about the patient’s life after complaints and medical history will make him more focused and productive, will allow him to pay attention to many necessary details and facts, because the doctor’s questioning about the patient’s life will take 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, and the doctor’s thinking must be flexible to such an extent that, under the pressure of accumulating facts that contradict the primary diagnostic hypothesis, he can 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 thoughts; it should be a working tool, help obtain facts, facilitate their organization and comprehension, and be steps towards a final, well-founded clinical diagnosis. Diagnostic hypotheses should not be gloves that are easily thrown away, just as they should not be rags that for some reason they hold on to despite their uselessness.

1.4. Anamnesis

Repeated attempts have been made to assess the practical significance of each of the diagnostic methods. Thus, the anamnesis, according to Laud (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 through examination and history, and these methods also contribute to the correct further direction of the diagnostic search.

Obtaining reliable anamnestic information from the patient and his environment is not a one-time short-term procedure. Often this is a long, labor-intensive process of identifying, clarifying and supplementing the necessary information, repeatedly returning to it to create, sift, polish and substantiate diagnostic hypotheses. By establishing trusting contact with the patient and those around him, obstacles associated with existing prejudices, fears, fears, mistrust of psychiatrists are eliminated, inadequate ideas about mental illnesses, the fatal role of heredity in them are corrected, and often only after this the patient’s relatives and other people from his surroundings provide more detailed and reliable amnestic information.

In some cases it turns out to be advisable to use special moves to revive in memory the most significant associative connections, because they are not in a chaotic form, but have a certain orderliness (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 their anamnestic information, while avoiding suggestions and leading questions. The danger of the latter increases significantly in the presence of memory gaps, with certain individual characteristics of the patient (childhood, phenomena of psychophysical infantilism, hysterical personality, increased suggestibility). The questions asked during the examination should only activate and stimulate the patient to openly, frankly present his medical history, family history and life history. An example of this type of question: “What memories from childhood do you remember about your father? Mothers? About past illnesses? Other question options are possible, in particular, alternative questions (offering a choice). Example: “Were you the first or last student at 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 predetermined. For example: “Did you hear male or female voices when you entered the department?” Actively paradoxical suggestive questions are used (apparent denial of a fact, the existence of which the patient assumes). For example: “Have you ever had conflicts with your parents? Brother? Wife? When using the last two options, positive responses must be carefully detailed and rechecked.

It is also necessary, as far as possible, to follow the sequence of the study, starting with a free survey. The significance of the first conversation, which often has a unique, inimitable character, is especially great. 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 - listens carefully. This part of the conversation can be indicative, preliminary, and can help establish contact with the patient. In the second half of the conversation, the doctor uses all variants of questions to fill in gaps, gaps in information, and clarify ambiguities. When obtaining anamnestic information from relatives about the present disease, the patient’s life must rely primarily on their involuntary memorization. Previously it was believed that it was not always complete and accurate, but this is not entirely true. Involuntary memorization can be more accurate and reliable than voluntary, but unlike the latter, it requires the doctor’s active work 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 the statements made by the patient and relatives with specific facts and examples. Subsequently, when observing relatives of a patient during visits, medical leave, or in remission, the doctor can include deliberate (voluntary) remembering 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 not possible to obtain anamnestic information at all due to the peculiarities of their mental state (syndromes of stupor, confusion and narrowing of consciousness, catatonic and apathetic substupor and stupor, different kinds agitation, severe depressive syndromes). In other patients, anamnestic information may be obtained in an inaccurate or deformed form (patients with Korsakoff, psychoorganic, dementia syndrome, oligophrenia, gerontological mentally ill patients, children). In such cases, the role of objective anamnesis increases immeasurably, which sometimes has to be limited.

When obtaining anamnestic information in a conversation with a patient or his relatives, the degree of detail in certain sections of the anamnesis depends on the intended diagnosis (on the preliminary diagnostic hypothesis). Thus, in patients with certain forms of neuroses and psychopathy, a detailed study of the characteristics of family upbringing, sexual development is necessary; in persons with endogenous diseases, it is important to pay special attention to the genealogical history; in persons with oligophrenia, epilepsy, organic diseases Early childhood (including prenatal and antenatal) history should be carefully examined. Each nosological form has its own priorities for the sections of the anamnestic study.

The specific weight and value of subjective and objective anamnestic information compared to the data of mental, neurological and other studies in 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 structure of personality, its social adaptation, because when talking with a doctor and in a hospital, patients often hide and dissimulate many personal characteristics and characteristics of their behavior in order to show their best side. It is advisable to obtain an objective history from many people (relatives, friends, acquaintances, employees and others). They characterize the patient from different sides, from different points of view, at different age periods, in different situations, circumstances. This creates the possibility of verifying anamnestic information.

1.4.1. History of the present disease.

Possible pathogenic factors that preceded the onset of the disease or its relapse are identified and described: acute and chronic infectious and somatic diseases, intoxication, pathology during childbirth, nutritional disorders, external and internal conflicts in everyday life, family, at work, loss of loved ones, fear, job change , places of residence and others. It should be borne in mind that random factors that preceded the onset of psychosis or its relapse are often confused with the causes of the disease. And this leads to the cessation of the search for true causal factors. For example, the formation of a pre-neurotic radical from the first years of a child’s life is overlooked, the importance of such unconscious factors as the course of intrapsychic personal 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 determine the time of 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 a thorough identification and detailed description of the first signs of the disease, the order of development and change of symptoms, and clarification of the patient’s attitude to the symptoms.

When re-hospitalized, the medical history should briefly reflect (using archive stories illness and outpatient card of a psychiatric dispensary) the clinical picture of the disease on all admissions, the dynamics of the disease, the nature of clear intervals and remissions, the formation of the defect, data from paraclinical studies (EEG, CT and others), the number of relapses, inpatient and outpatient therapy. It is advisable to pay attention to the entire arsenal of previously used means biological therapy and its other types, on drug doses, on treatment results, adverse reactions and complications, on their nature, severity, duration and outcome. When studying remissions and clear intervals, it is necessary to reflect in the medical history their quality, depth and clinical features, difficulties of work and family adaptation, finding out their causes, as well as the characteristics of characterological changes that interfere with family and work adaptation. The condition of the patient’s home is of interest, especially in patients with senile, vascular psychoses, progressive paralysis and other progressive diseases.

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

In cases where obtaining detailed anamnestic information upon admission of a patient to a hospital is impossible due to mental disorders (depression, amentia, mutism and others), the anamnesis should be collected during the examination in the hospital. Despite the importance of carefully collecting anamnestic information, it is necessary to strive to ensure that the conversation with the patient is not excessively lengthy, and that the record contains the maximum of necessary information with the utmost brevity of presentation. For example, if 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 characteristics, and the like.

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

It usually begins with genealogical research, which involves clarifying the following questions. Presence among the patient’s relatives (in the direct line - great-grandfather, grandfather, father; great-grandmother, grandmother, mother; siblings, children, grandchildren; in the lateral line - great-uncles, grandmothers, uncles, aunts, cousins, nieces, nephews; by maternal or paternal line) cases of deformities, left-handedness, delays and defects in intellectual development, speech development, mental retardation, outstanding abilities for anything, epilepsy, psychosis, suicide, degenerative diseases of the 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 relationship between parents is revealed; age of the parents at the patient’s birth; in case of twinning - qualification of monozygosity or dizygosity, study of diseases in the second twin. It's important to get details 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 compile family pedigrees 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 varying degrees of severity (expressivity of the pathological gene) and manifestation (penetrance of the pathological gene) of inherited signs of the disease, 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 diseases in adulthood and late age (Alzheimer's disease, Pick's disease, Huntington's chorea, epilepsy and others). Usually inherited varying degrees pronounced predisposition to mental illness, and mental illness manifests itself when exposed to certain external factors(mental trauma, infection, alcoholism and others) mainly at a certain age (usually in critical age periods: puberty, maturation, involution). The disease can be clearly detected in only one family member (with incomplete penetrance), transmitted through generations, or manifested only in individuals of a certain gender. When compiling pedigrees, it is important to obtain anamnestic data on an extremely large number of people 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 some relatives to identify the syndrome of multiple anomalies (malformation).

Table 1.1

Conventional genealogical designations of characteristics

A legend should be compiled for the pedigree (explanation of abbreviations and conclusions about the type and nature of inheritance of the pathology).

Pedigree example:

Legend: The proband's maternal grandmother suffered from seizures, the proband's maternal aunt suffered from epilepsy, and the proband's mother suffered from migraines. Data from a clinical and genealogical study indicate a dominant pattern of inheritance of epilepsy in the proband.

The following important diagnostic data 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 its course. The presence of somatic pathology (kidney diseases, diabetes, congenital defects and other heart diseases, arterial hypertension or hypotension, endocrine diseases, toxoplasmosis), alcohol abuse, drug use, smoking, chemical intoxication, use of hormonal and psychotropic drugs, antibiotics and others medicines, exposure to radiation (including x-ray exposure), vibration, the influence of heavy physical labor, and so on. The mother has a burdened obstetric history (infertility, narrow pelvis, repeated miscarriages, multiple births, stillbirth, prematurity, neonatal death). Features of the patient’s conception and the course of the mother’s pregnancy: conception while intoxicated, 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, prematurity (less than 37 weeks) or postmaturity (more than 42 weeks) of the fetus. Nature of labor: prolonged, rapid, with forceps, Werbow's bandage, birth of premature twins, intrauterine hypoxia, umbilical cord prolapse, premature placental abruption, cesarean section and others surgical interventions. Pathology of the child during childbirth: asphyxia, cerebral hemorrhage, hyperbilirubinemia, need for resuscitation. It is necessary to pay attention to the following features of the newborn period: deviation from the norm of 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 developmental defects. An indirect indicator of damage to the nervous system in a newborn may be a delayed attachment of the child to the breast (on the 3-5th day), discharge from the maternity hospital later than 9 days (not due to the mother’s illness). The age and state of health of the father at the time of conception is also determined: alcohol abuse, the presence of radioactive and x-ray exposure, somatic and nervous diseases. You should pay attention to instructions about pathological abnormalities during paraclinical examination of the mother, fetus and newborn (according to medical documentation).

1.4.3. Anamnesis of life(biography of the patient).

The study of anamnestic information is at the same time a study of the personal profile of a given individual before illness, since the personality structure is reflected in the characteristics of the biography, professional path and activity, in the characteristics of relationships in microsocial groups (family, school, production, military service), in the characteristics of the acquisition and manifestations of bad habits, as well as in the features of adaptation to stressful and traumatic circumstances. It should be borne in mind that insignificant, seemingly secondary facts from the anamnesis may turn out to be significant in 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 influence of certain harmful effects on the occurrence of a given disease - “trace reactions”, according to Frumkin Ya. P. and Livshits S. M., 1966; “ the principle of the second strike”, according to A. A. Speransky, 1915). This especially applies to the occurrence of reactive psychoses, epilepsy, late traumatic psychoses, psychoses due to previously suffered encephalitis, some forms alcoholic psychoses.

An important etiological factor in the development of a number of mental illnesses may be psychotraumatic, depressing complexes formed in childhood as a result of the following factors: sudden separation of the child from his mother with his transfer to a nursery school, hospitalization without a mother, acute experiences of fear (including fear of death), loss of loved ones (care, death) and beloved animals, blockade of motor activity, conflict situations between parents, lack of love and attention on the part of parents, the presence of a stepfather, stepmother, psychophysical defects, discrimination from peers, difficulties in adapting to a public school, in a team, features of teenage self-affirmation, etc. Information is needed about the personality characteristics of the parents, their education , profession, interests. The character of the family in which the patient was raised should be assessed: harmonious, inharmonious, destructive, disintegrating, disintegrated, rigid, pseudo-solidary family (according to Eidemiller E.G., 1976). Peculiarities of upbringing in the family are noted: according to the “rejection” type (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 pre-neurotic radicals: “aggression and ambition”, “pedantry”, “egocentricity”, “anxious syntony”, “infantility and psychomotor instability”, “conformity and dependence”, “anxious suspiciousness” and “isolation”, “contrast ”, with tendencies towards auto- and heteroaggressiveness, towards “overprotection” (according to Garbuzev V.I., Zakharov A.I., Isaev D.N., 1977).

You should pay attention to the features of a child’s development in the first years of life: deviation from the norm in 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 relatives had such manifestations, to find out the dynamics of these disorders (progressive or regressive course, intensification during puberty). One should also take into account the characteristics of crying, the development of the orienting reflex, attention, attitude towards the mother and other relatives. It is necessary to pay attention to the features of interest in toys, their choice, dynamics play activity, the presence of excessive, aimless activity or its insufficiency, decrease, deviations in the development of self-care skills. The following indicators are also taken into account: compliance of the child’s mental development with 4 stages - motor (up to 1 year), sensorimotor (from 1 year to 3 years), affective (4-12 years), ideational (13-14 years); sleep characteristics: depth, duration, restlessness, sleepwalking, sleep-talking, night terrors; the presence of child diseases and their complications, vaccinations and reactions to them. When raising a child outside the family (nursery, kindergarten, with relatives), you should find out the age at which he was separated from his mother and the duration of his stay outside the family, the characteristics of his behavior in the children's group.

It is important to pay attention to children's deviant behavioral reactions: refusal, opposition, imitation, compensation, overcompensation and others. The following are taken into account: age at admission to school; interest in school, academic performance, favorite subjects, repeating a year, how many classes you completed; features 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 emerging sexual attraction (Lichko A. E., 1973); forms of behavior disorders: deviant and delinquent, running away from home (emancipatory, impunitive, demonstrative, dromomaniacal), vagrancy, early alcoholism, deviations of sexual behavior (masturbation, petting, early sex life, teenage promiscuity, transient homosexuality and others), suicidal behavior (demonstrative, affective, true). Identifying the characteristics of child development is especially important when diagnosing neuroses, mental infantilism, minimal brain dysfunction, psychosomatic disorders, pathocharacterological development, personality accentuations, and 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 of the position with education and profession, promotion, frequency and reasons for changing jobs, attitude of the team, administration, work environment before illness; features of living conditions; past illnesses, infections, intoxications, mental and physical injuries; when started smoking, smoking intensity; alcohol consumption (in detail): when you started drinking, how much and often you drank, drank alone or in company, 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, anticonvulsants, antibiotics and other drugs, allergic reactions to foods. 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 immediate relatives.

1.4.4. Sexual history.

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

The characteristics of sexual life (regularity, irregularity, etc.), the number of pregnancies, the nature of their course, the presence of medical and criminal abortions, stillbirths, miscarriages are clarified; age and duration of menopause, its impact on general health, subjective experiences during this period.

When found pathological abnormalities 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 certain psychopathy, pathological personality development, neuroses, personality accentuations, endocrinopathies, and endogenous psychoses. Sexual history in cases of identifying signs of paraphilia should contain information about sexual characteristics and deviations in the patient’s relatives.

The following facts of sexual history are also of interest: the patient’s age at marriage; characteristics of maternal and paternal feelings; were there any divorces, the reasons for them; relationships in the family, who is the leader in the family. You should get an idea of ​​the type of family (“family diagnosis”, according to Howells J., 1968): harmonious family, inharmonious family (actually inharmonious family, destructive family, disintegrating family, broken family, rigid, pseudo-solidary family according to Eidemiller E.G., 1976). If the patient is lonely, then the cause of loneliness and the attitude towards it are clarified. 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 any disruptions in social adaptation, whether he had losses of loved ones and what his reaction was to them.

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

Anamnestic information should be collected in such a volume and so carefully that it becomes possible to determine personality traits and character before the onset of mental illness and changes in personality and character during the period of the disease, up to the time 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 the difficulties of distinguishing the manifestation of the disease from premorbid personality characteristics, especially during periods of age-related crises.

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

Forgotten history refers to events, incidents, harmful factors that took place in the past, thoroughly forgotten by the patient and his relatives, but the identification of which is possible with the persistent efforts of the doctor. For example, if there is clinical manifestations, characteristic of the consequences of traumatic brain injury and the absence of indications in the anamnesis of such injury, it is necessary to re-analyze in detail and purposefully the features of ontogenesis, including the intrauterine, prenatal, perinatal and postnatal periods. In this case, it is important to adhere to a special “sterile” interview technique so as not to evoke suggestively conditioned “memories” in the patient and his relatives. Lost anamnesis is events, facts, exposure to pathogenic factors in past life the patient, about which he himself does not know, but they can be identified by the doctor with sufficient skill and perseverance from relatives, acquaintances, from medical and other documentation, as well as information that is lost to the doctor forever. Lost information can make it much more difficult diagnostic work. Forgotten and lost anamnesis are of particular importance for the diagnosis of mental disorders in the long-term period after suffering traumatic brain injuries or encephalitis. Forgotten and lost anamnesis includes not only external privates and exquisites etiological factors, events, harmfulness, but also data about heredity, often missed in questioning, about erased, latent, atypical forms of pathology in relatives, especially in the ascending generations and in the patient’s children. Forgotten and lost anamnesis are rarely detected during a continuous, schematic, untargeted survey; usually it is revealed only if the doctor has a clear diagnostic hypothesis, formed during the examination of the patient, with good contact with the patient and his environment.

Taking an anamnesis is not a simple shorthand thoughtless recording of information, facts with a subsequent diagnostic assessment of them, but intense, dynamic, constantly creative thinking process. Its content is the emergence, struggle, and sifting out of diagnostic hypotheses, in which both rational (conscious, logical) and intuitive (unconscious) forms of the doctor’s mental activity participate in their inextricable unity. The intuitive aspect of the diagnostic process should not be underestimated, and one should constantly remember that it is based on previous experience and must undergo subsequent maximum logical refinement and extremely accurate 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 personality structure

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

For asthenic type characteristic: narrow rib cage 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 the seventh cervical vertebra, thin pale skin, coarse hair (“Don Quixote type”). This type of somatoconstitution correlates with schizothymia: unsociability, secrecy, emotional restraint, introversion, craving for loneliness, a formal approach to assessing events, a tendency to abstract thinking. In addition, there is restraint of manners and movements, a quiet voice, fear of causing noise, secrecy of feelings, control over emotions, a tendency towards intimacy and solitude in difficult times, difficulties in establishing social contacts (Kretschmer E., 1930; Sheldon V., 1949).

The picnic type is characterized by: relatively large anteroposterior dimensions of the body, a barrel-shaped chest with an obtuse epigastric angle, a short massive neck, short limbs, 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, a practical mindset, love of comfort, thirst for praise, extroversion, sociability, craving for people. Also typical are such signs as relaxation in posture and movements, socialization of food needs, pleasure from digestion, friendliness with others, thirst for love, a tendency to gallant treatment, tolerance for the shortcomings of others, spinelessness, serene contentment, the need to communicate with people in difficult times ( Kretschmer E., 1915; Sheldon W., 1949).

The athletic type is characterized by: good development of bone and muscle tissue with moderate development of the fat component, cylindrical chest with a right epigastric angle, wide shoulder girdle, relatively narrow pelvis, large distal limbs, powerful neck, face with pronounced brow ridges, dark skin, thick curly hair (“Hercules type”). The athletic type correlates with such personal characteristics as confidence in posture and movements, the need for movements and actions and pleasure from them, decisive manners, risk-taking, energy, desire for leadership, perseverance, emotional callousness, aggressiveness, love of adventure, etc. 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 patients with schizophrenia, and among patients with affective pathology, people with a pyknic physique are more common. There are indications that individuals with an athletic somatotype often suffer from epilepsy (Kretschmer E., 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 the type of higher nervous activity (the phenomena coincide to a certain extent). The type of higher nervous activity is the innate characteristics of the basic nervous processes (their strength, balance and mobility - 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 - personality. Psychodiagnostics of personality is possible on the basis of family and personal history (biography), as well as an indicative study of the type of higher nervous activity using a personality questionnaire developed by B. Ya. Pervomaisky (1964), an abbreviated version of which is presented below.

Table 1.2

A shortened version of a personality questionnaire to determine the type of higher nervous activity.

1. Strength of the excitatory process:

1) performance;

2) endurance;

3) courage;

4) determination;

5) independence;

6) initiative;

7) self-confidence;

8) gambling.

2. Braking force:

1) exposure;

2) patience;

3) self-control;

4) secrecy;

5) restraint;

6) distrust;

7) tolerance;

8) the ability to refuse what you want.

3. Mobility of the excitatory process:

1) how quickly do you fall asleep after excitement?

2) how quickly do you calm down?

3) how easy is it for you to interrupt your 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 at any cost?

3) how slowly do you fall asleep after excitement?

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 quickly do you wake up?

4) the degree of inclination to move, excursions, and travel.

6. Inertia of the braking process:

1) how typical is slowness for you?

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

3) how slowly do you wake up?

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

7. State I signaling system:

1) 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 spontaneous do people consider you?

8. State of II signaling system:

1) how prudent are you?

2) the degree of inclination to carefully think through one’s 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 evaluates his own 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. Strength type VND: if (M1+M2): 2 > 3.5 - strong type (Sn); if (M1+M2):2< 3,5 - слабый тип (Сн).

2. Balance of the VNI type: if the difference between M1 and M2 is 0.2 or less - balanced type (Vr), 0.3 or more - unbalanced type (Hp) due to the nervous process that turned out to be greater: Hp(B> T) or Нр(Т>В).

3. Mobility of the excitatory process: if M4 > M3 - the excitatory process is inert (Vi), if M3 > M4 or M3 = M4 - the excitatory process is mobile (Vp).

4. Mobility of the braking process: if M6 > M5 - the braking process is inert (Ti), if M5 > M6 or M5 = M6 - the braking process is mobile (Bp).

5. Specially human type of GNI: if the difference between M7 and M8 is 0.2 or less - average type (1=2), 0.3 or more with M7 > M8 - artistic type (1>2), with M7< М8 - мыслительный тип (2>1).

VND type formula: example - 1>2 СНр(В>Т) ВпТп.

It is advisable to clarify the patient’s personal characteristics with relatives and other close people. At the same time, it is desirable that personal characteristic the patient was 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 personality structure is difficult to overestimate, since psychiatric pathology is a personality pathology (Korsakov S. S., 1901; Kraepelin E., 1912 and others). Endogenous psychoses are personality diseases per se. In the structure of the 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 pathos - Snezhnevsky A.V., 1969). In exogenous psychoses, the personality structure largely determines clinical form psychosis.

1.6. Mental state examination

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

(A. A. Ukhtomsky)

No matter how much experience a psychiatrist has, his examination of the patient’s mental state cannot be of a chaotic, unsystematic nature. It is advisable for each doctor to develop a specific scheme for studying the main mental spheres. We can recommend the following completely justifiable sequence of research into 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 certain 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, and the scientific processing of medical histories.

A qualified examination is possible only if there is sufficient knowledge of the phenomenological structure of the main psychopathological symptoms and syndromes. This allows the doctor to develop a standardized 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 (childhood, adolescence, adolescence, young, mature, elderly, senile), his sensorimotor, emotional, speech and ideational characteristics.

In the medical history, it is necessary to clearly separate 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, and an extensive amount of psychiatric information, but also a manner of communication with the patient that is adequate to the mental state of the patient, and the nature of the conversation with him. It is important to be able to “feel” into the patient’s experiences, while showing sincere interest and empathy (this is of particular importance for patients with neuroses, psychosomatic diseases, psychopathy 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 he said and how he said it, to capture the nonverbal (expressive) components of the message, to qualify the nature and severity of psychopathological and neurotic symptoms, syndromes and their dynamics. The questioning of the patient when examining his mental status should be delicate, “aseptic” (not be of a psychologically traumatic nature). Essential (clinically significant) questions should be hidden (alternate, 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 - using the same and different methods (Obraztsov V.P., 1915; Pervomaisky B.Ya., 1963; Vasilenko V.Kh., 1985). The essence of this rule in psychiatry is that the doctor, along with the utmost detail of the symptom, returns two or three times to identify and confirm it, using different formulations of questions. One should strive to confirm clinical signs by 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 medical history data, as well as the deforming effect on the symptoms of the psychotropic drugs he is taking.

The clinical picture of the disease can be significantly distorted by an incorrect assessment of the so-called psychological analogues of mental disorders. Many psychopathological phenomena correspond to psychological phenomena observed in healthy people. At the same time, painful signs - psychopathological symptoms - seem to grow out of psychological phenomena, not always acquiring an 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 insufficient knowledge of the differential differences between outwardly (phenomenologically) similar symptoms of the disease and syndromes (depression and apathy, illusion and hallucination, mild stunning and abortive amentia, and others). An even greater danger is posed by the so-called psychologization of psychopathological phenomena, in which there is a tendency to “explain”, “understand” psychopathological symptoms from everyday and psychological positions. For example, clarifying the fact of adultery during delusions of jealousy, explaining the symptom of family hatred by the characteristics of the puberty period, and so on. In order to avoid such mistakes, it is necessary, firstly, to remember their possibility, and secondly, to carefully study the medical history. Important in this regard is the study of 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 - “Humanology”).

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

It is extremely important to strive for a specific description of symptoms and syndromes, to reflect the objective manifestations of clinical signs, to accurately register statements (neologisms, slippage, reasoning, and others), and not limit ourselves to the abstract qualification of symptoms and syndromes - “pasting 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 subtle course of the disease.

Observation in a psychiatric clinic must be specially organized, thoughtful, and targeted. It should implicitly contain elements of theoretical thinking and should be aimed at finding the meaning of what is observed. Observation is not without subjectivity, because observed facts can be seen in the spirit of the observer’s expectations and depend on his conscious and unconscious attitudes. This requires a rejection of hasty, premature conclusions and generalizations, and control by other methods to increase the objectivity of observation.

A correctly conducted conversation between a doctor and a patient when identifying complaints, collecting anamnestic data and during a psychopathological study has a psychotherapeutic effect (such as a cathartic one), helps to get rid of or alleviate a number of patients’ fears, apprehensions, internal tension, gives real orientation and hope for recovery. The same applies to conversations 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 “Facial expressions, pantomimics and their pathology.”

From the point of view of psychological contact, the initial examination is like a first date... The first date is when the doctor meets the patient, and the patient meets the doctor. It is no coincidence that I compared the initial examination to a first date. Expectations from the first date are always very high... But it is precisely on the first acquaintance that the further communication between the doctor and the patient often depends, when a long-term and trusting contact can be established, and the patient can find HER OWN DOCTOR. A specialist and a person whom you trust and are not afraid of. A gynecologist whose visit you don’t put off, but on the contrary, you call for any reason and for no reason. A doctor to whom you are not embarrassed to ask a stupid question, and you will always be sure that you will receive a patient and calm explanation. From a medical point of view, the primary medical examination is the most extensive and lengthy (if carried out correctly) and takes from 30 minutes to an hour. The examination begins from the moment the woman enters the office, how she sits down and what she says. A woman is always nervous when she comes to a gynecologist... A woman is especially nervous when she comes to a new doctor, a new gynecologist... Everything unknown usually causes fear, so some anxiety before the first visit to a gynecologist is quite natural, especially considering the intimate nature of this process , and especially if the gynecologist is a man. However, many experienced women specifically choose a man as a gynecologist, considering him a more attentive and professional specialist. A woman almost always experiences a feeling of uncertainty, awkwardness or even fear, and for her this is stress, since we are talking about a very delicate issue and concerns intimate organs and aspects of life. Some women, due to shyness, are embarrassed to even talk about their problems, and then they have to reveal “all their secrets” to the doctor and undergo examination in the most hidden places of the body. But remember that you do not owe anyone anything, and are not obliged to make excuses to anyone for the circumstances of your life, or special sexual hobbies, but you will have to talk about many things (even very intimate ones) - the accuracy of the information helps the correct diagnosis... But embarrassment can be overcome by understanding that you don’t need to undress right away... The patient and I have time to make our first assessment of each other... It’s more difficult for a doctor, he always sees a patient for the first time, without knowing anything about her... The patient has more opportunities to understand what the doctor is like. She asks her friends and acquaintances, reads the doctor’s thoughts and answers on his personal website on the Internet and can assess the doctor’s personality already during the first conversation! The patient can refuse to be examined by this doctor and choose another if during the conversation the doctor seems unpleasant to her... This is your right and I will not condemn you for this action... So, our acquaintance begins with a conversation. 1. CONVERSATION (STUDYING COMPLAINTS AND LIFE HISTORY). First I talk with you, listen to your complaints. At the same time, I am always interested exactly your complaints, Your vision and feeling of the disease (and not the opinions and diagnoses of doctors). Therefore, when preparing for the initial appointment, try to analyze - what is bothering you? You, and only you. Try to remember where (with what symptoms, after what event your problems STARTED)! Try to formulate your complaints in advance. It is very important to remember when they appeared and how they proceed Your periods when was last menstruation. Remember time of onset of sexual activity, number of sexual partners, characteristics of sexual activity and methods of preventing unwanted pregnancy. Need to be clearly stated all your pregnancies ending in childbirth, abortion or miscarriage. And please, do not start your visit to the doctor by “dumping” all the accumulated tests and conclusions onto the table. I will ask you questions that may seem irrelevant, sometimes even outrageous, but these insignificant little things (or intimate details, and these are not “little things” at all) often help in making a diagnosis, since many diseases are associated with conditions life, work, sexual activity, stress, etc. There are no shameful topics at an appointment with a gynecologist! Everything you tell me will remain within the walls of this office, I will keep all your secrets. Therefore, it is necessary to answer all questions frankly, because the key to success is mutual cooperation. And very often, many women’s problems (for example, long-term unmotivated nagging pain in the lower abdomen, irritability) are associated with problems in sexual life... After a conversation, studying complaints and finding out your history, a medical examination begins. To examine you, the doctor will need you to undress. My advice is, do not come to the gynecologist wearing clothes that cannot be removed in parts (for example, overalls). Otherwise, it may happen that you have to be completely naked for some time (this won’t bother me, but will you?) 2. DOCTOR EXAMINATION. The inspection begins with a study your body type, the nature of fat deposits, the distribution and amount of hair on the body, skin condition and appearance features, examination thyroid gland and large lymph nodes, inspection and palpation (feeling) your mammary glands. They form part of the female reproductive system. Body type, skin and distribution of body fat, hair condition and growth, thyroid gland and mammary glands can tell the doctor a lot about the woman patient (hormonal changes, chronic diseases). 3. DOCTOR GYNECOLOGICAL EXAMINATION. During this and subsequent stages, you will have to undress and sit in a special gynecological chair. Its design may be different, but the essence is ultimately the same: the woman sits in it, reclining or lying down, with her pelvis closer to the front edge and with her legs wide apart, raised up and bent at the knees, the ankles of which rest on special stands. Having taken the required position, try to relax as much as possible - this will make it more comfortable and easier for both you and the doctor. I took care of you and bought a comfortable, beautiful and quite expensive gynecological device (made in Poland, and Poles love and respect women). EXAMINATION OF THE EXTERNAL GENITAL ORGANS. The examination on the gynecological chair begins with a careful examination of the condition of the external genitalia (perineum, clitoris, labia minora and majora). Sometimes I examine tissue under magnification (through a colposcope). INTRAVAGINAL INSPECTION. Next, I conduct an examination using gynecological mirrors, which allow us to examine the walls of the vagina and cervix, the color, quantity and nature of the discharge. The dimensions of the mirrors are small and the instrument fits freely into your vagina. If the patient is still a virgin, a mirror examination is not performed. The only obstacle and cause of pain during examination may be your fear, which causes tension in the muscles of the perineum. If you take the examination calmly and relax the muscles of the perineum, then the examination will not cause you any trouble... During the examination in the mirrors, material is taken for laboratory research - smear for flora and smear for the presence of pathological cells (oncocytology). 4. COLPOSCOPY WITH DIGITAL PHOTOGRAPHY AND DOCUMENTATION OF IMAGES. During the initial examination (and necessarily once a year), I perform colposcopy on all my patients - examination of the cervix under high magnification, with the ability to photograph changed areas. Using this method, it is possible to determine cervical erosion, leukoplakia, papillomatosis and other inflammatory or oncological changes. If necessary, under colposcopy control, I take biopsy(a small piece of tissue with special forceps) of the changed area and send the material for histological examination (the tissue is stained in a special way and studied under a microscope with high magnification) and an accurate diagnosis is made. 5. ULTRASOUND STUDY WITH A VAGINAL SENSOR. During a transvaginal examination, a sensor is inserted into the vagina. This method is one of the leading and most reliable research methods in gynecology. The sensor is in almost direct contact with the organ being examined, so there is no need to fill the bladder, the study is not hampered by obesity, adhesions, or the presence of scars on the anterior abdominal wall. The accuracy and quality of examination with a vaginal ultrasound probe is 10 times higher than conventional ultrasound, which examines the pelvic organs through the abdominal wall, painfully filling the woman’s bladder. 6. VAGINAL GYNECOLOGICAL EXAMINATION. After examining the speculum and ultrasound of the pelvic organs, I perform bimanual vaginal examination. At the same time, fingers right hand wearing a sterile glove, they are inserted into your vagina, and with your left hand the internal genital organs (uterus, ovaries, bladder) are palpated through the abdominal wall. If the patient relaxes the muscles of the perineum and abdominal wall sufficiently, the procedure is painless. RECTAL EXAMINATION. Women after 30 years of age, and if indicated, even earlier, undergo a digital rectal examination of the rectum (examination through the anus - anus), which allows a more accurate assessment of the condition of the genital organs and timely identification of rectal pathology (hemorrhoids, fissures, cancer). Virgins it is also necessary to examine on a chair (in the presence of a mother or a nurse), examining the condition of the external genitalia and the hymen, located at the entrance to the vagina. Internal organs examined by digital examination through the rectum, which allows the doctor to assess the size and condition of the uterus and appendages. The girl retains her virginity during this study. For an ultrasound examination of a virgin, it is necessary to FILL THE BLADDER, since it is impossible to perform a vaginal ultrasound on a girl who is not sexually active. The female body is complex and completely hormone dependent- is subject to fluctuations in hormone levels, so it is often necessary to additional methods research, some of which we do ourselves in our center, some of which we direct in other medical institutions. A competent gynecologist will help you maintain your health and beauty, delay old age and improve your quality of life only with your help! And carefully analyze what list of services they offer you for 50 - 70 hryvnia in other medical centers or examinations “at a dirty window sill “through connections.” Do not skimp on the most valuable thing - the health of your intimate organs... If you go to a regular antenatal clinic, you will have to undress four times and in each office pay for various services of different specialists and, As a result, no one is responsible for you as a whole (for your body)!

Candidate of Medical Sciences, obstetrician-gynecologist of the highest category
gynecologist-endocrinologist and ultrasound diagnostics doctor
SEMENYUTA Alexander Nikolaevich