Questioning the patient and collecting anamnesis

Questioning the patient. In psychiatry, interviewing the patient is considered the most important examination method. Most symptoms of mental disorders can be identified only from the patient’s words (phenomena of mental automatism, obsessive thoughts and fears, delusions, many deceptions of feelings, depersonalization and derealization disorders, etc.) Some mental disorders based on observation behind the patient’s behavior can only be “suspected” (auditory hallucinations when the patient listens to the glemma; delusions of persecution - due to a tense and frightened appearance, etc.). In case of sudden agitation, stupor, impaired consciousness, it is necessary to ask questions after these states have passed the GS; it is better to talk to patients in a “psychotic state”, having previously received information about it from relatives and friends, but in non-psychotic disorders, it is better to ask the patient himself first, which increases his confidence to the doctor.

The survey requires the psychiatrist to have certain skills that are acquired in the process of gaining professional experience. On the one hand, the patient should always be allowed to speak out, and on the other, the initiative should always be in the hands of the doctor. No single scheme is possible. You usually have to start with what was the reason for contacting a psychiatrist. The doctor is always required to have restraint, patience, unfailing goodwill and sympathy, even with obvious hostile attitude to him

sick. However, it is always necessary to maintain a distance and avoid familiarity. You should never hide the purpose of the question from the patient or introduce yourself as someone other than a psychiatrist. If you refuse to answer questions, the most important ones must still be asked and the patient’s reaction to them noted.

The purpose of the questioning is to find out how much the patient understands what is happening around him, is oriented in the place and in the world, and retains memory for the most important events in his life and for the events that preceded going to the doctor. The patient is asked to explain those actions or statements that others might suspect of a mental disorder. If the patient himself does not speak out about his painful experiences, then he is asked leading questions about hallucinations, delusions. other disorders that may be suspected based on his behavior or information received about him. It is always useful to ask about the presence of suicidal thoughts, not only in the present, but also at any time in the past. It is also important to find out the patient’s attitude towards all identified painful experiences and behavioral characteristics: lack of criticism, partial, unstable or sufficiently critical attitude towards them.

Questioning of the patient should be carried out in the absence of his family and friends.

Anamnesis in psychiatry is usually divided into subjective and objective, although these designations are very conventional.

Subjective history. Information from the patient himself is collected during the interview process. The history of the disease comes down to finding out when and what signs of it first appeared, what events preceded it, how these manifestations changed, when they disappeared, etc. The history of life includes memories: what family did you grow up in, who are the parents, how did you study, what kind of in childhood and adolescence there were behavioral disorders (running away from home, etc.). It is important to find out whether there was abuse of alcohol, drugs and other intoxicating drugs, at what age it began, how intense it was. Data on how the patient evaluates your social status - work and family: is he satisfied with it, what is he burdened by and what is missing? It is of interest to ask the patient about those events of his past life that he himself considers the most difficult, how he experienced them, whether there were suicidal thoughts and attempts.

Somatic history, in addition to past serious illnesses, should take into account information about traumatic brain injuries, even with instant loss of consciousness, neurointoxication and brain infections, and a tendency to allergic reactions.

Objective anamnesis - information obtained from relatives and friends and other persons who know the patient well. It is better to obtain this information from each person separately, in the absence of others. The name “objective” is conditional, since each interviewee brings a subjective attitude towards the patient into his story. The doctor must lead the conversation, finding out the facts and stopping attempts to impose someone else's opinion on himself. They also collect an anamnesis of the disease: they find out when and what manifestations of it arose and what could have contributed to this, as well as a life history: information about hereditary burden (mental illnesses, dementia, alcoholism and drug addiction, suicides among blood relatives, as well as the presence of persons among them with an unusually difficult character). From parents you can learn about developmental features in childhood. Next, they are asked the same questions as the patient himself. It is important to find out what the patient kept silent about and what he presented differently.

1. Collect and evaluate the genealogical history, life history and illness of the child.

When collecting a life history, find out:

Social history:

Family completeness: whether there is a father and immediate relatives of the mother.

Family educational level: specialized secondary education (technical school, vocational school).

Psychological climate of the family: attitude towards the child is even, affectionate; The relationship between the parents is friendly, are there any bad habits?

Housing conditions: does the family have a separate apartment with an area of ​​at least 6 m2 per person.

Financial security of the family: the financial security of the family is 60% of the minimum consumer budget of a family of four people.

The level of sanitary and hygienic conditions for caring for the child and the apartment: is sanitary and hygienic care for the child and the apartment provided?

Biological history:

Features of the antenatal period: absence of gestosis of pregnancy, extragenital diseases of the mother, occupational hazards in parents, surgical interventions, viral diseases during pregnancy, threat of miscarriage, etc.

Features of the intrapartum period: duration of labor, surgical intervention ( C-section), asphyxia at birth, birth injury, HDN, acute infectious and non-infectious diseases and other diseases.

Impacts that worsen health in the postnatal period: repeated acute diseases of any etiology, early transfer to formula feeding, complications after vaccination, etc.

Genealogical history:

Family pedigree, taking into account at least 3 generations (generations are designated in Roman numerals from oldest to youngest (from top to bottom), all family members of one generation are assigned a serial number, and symbols are used);

Absence or presence of hereditary diseases;

General history: index hereditary history complications = the total number of diseases for all known relatives: the total number of relatives of the proband (the patient from whom the study begins); an index of more than 0.7 indicates a burdened medical history;

Direction of burden: burden index for some disease(disease group) = total number of diseases in all known relatives (for example, disease diabetes mellitus): for the total number of relatives of the proband; an index of more than 0.4 indicates a burdened history of the disease (group of diseases).

When collecting anamnesis of the disease, find out:

Complaints at the onset of the disease and during the observation period (based on the story of the patient or his parents).

Time, circumstances of development and course of the disease from the first day of occurrence until the moment of examination.

The dynamics of general symptoms of the disease (temperature, sleep, appetite, mood, lethargy, thirst, etc.).

Manifestations of the disease in all systems and organs (respiratory, cardiovascular, digestive, urinary, musculoskeletal, endocrine, nervous systems and sensory organs).

Previous treatment, its results, reactions to medications.

Conduct a clinical examination (examination, palpation, percussion, auscultation) of a sick child.

During a clinical examination, evaluate:

The patient's condition: satisfactory, moderate, severe, very severe.

Position of the child: active, passive, forced.

Consciousness: clear, darkened, absent.

Nervous system, behavioral parameters: leading lines of NPR, behavior, pathological signs.

Condition of the skin and visible mucous membranes: color, cleanliness, moisture, skin elasticity, hairline and nails.

Subcutaneous fat layer: uniformity of distribution, fold thickness, presence of compactions and edema, their localization and prevalence; tissue turgor.

Condition of the muscular system: muscle tone and strength.

Condition of the skeletal system: size and shape of the head, large fontanelle (size, condition of the bone edges and soft tissues, bulging, recession), condition of the sutures of the skull, presence of craniotabes, shape chest, the presence of rachitic rosaries, Harrison's groove, bracelets and strings of pearls, curvature of the spine (kyphosis, lordosis, scoliosis) and limbs, flat feet; shape, size, mobility of joints (shoulder, elbow, wrist, hip, knee, ankle, small joints of the hands and feet).

Lymphatic system: size, quantity, consistency, mobility, sensitivity of lymph nodes (submandibular, chin, cervical anterior and posterior, occipital, parotid supra- and subclavian, axillary, thoracic inguinal, popliteal).

Anthropometry: body weight and length, head and chest circumference, other indicators.

Respiratory organs: voice, cry, presence of cough, sputum; breathing through the nose or mouth; type of breathing, number of breaths per minute, ratio of pulse to respiration, depth of breathing, rhythm; presence and type of shortness of breath (inspiratory, expiratory, mixed); symmetry of the chest; percussion and auscultation of the lungs.

Cardiovascular system: external examination; pulsation of the carotid arteries, swelling and pulsation of the neck veins, pulsation of the heart and epigastrium; apical impulse, its location, strength, prevalence; pulse, its characteristics (synchrony, frequency per minute, filling, tension, rhythm); borders of cardiac dullness; auscultation of the heart; determination of blood pressure.

Gastrointestinal tract: condition of the mucous membrane of the oral cavity, oropharynx, tongue (coloring, moisture, plaque, follicles, cracks, condition of the papillae); condition of teeth (deciduous, permanent, number, timing and sequence of eruption, presence of caries); the shape and size of the abdomen, the presence of dilation of the veins of the anterior abdominal wall, visible peristalsis, divergence of the rectus abdominis muscles, the condition of the navel; determination of ascites, liver size; palpation of the abdomen; condition of the anus (cracks, gaping), rectal prolapse; stool and its character (color, smell, consistency, pathological impurities).

Urinary system: examination of the lumbar region, palpation of the kidneys and Bladder; frequency of urination, pain, urinary incontinence; diuresis, ratio of daytime and nighttime diuresis; examination data of the external genitalia.

Endocrine system: disturbance of growth (gigantism, dwarfism) and body weight (obesity, wasting), distribution of the subcutaneous fat layer, condition of the thyroid gland (size of lobules, isthmus, presence of nodes), genitals.

Conduct anthropometry and assess the physical development of young children using the centile method, calculate the Chulitskaya (fatness, axial), Erisman, and Tour indices.

Determine the child's age group.

Carry out measurement and weighing according to generally accepted methods.

All anthropometric measurements are carried out on naked children, after sleep, before meals or 2-3 hours after meals, preferably in the morning or early afternoon.

Body length measured in a lying position using a horizontal stadiometer (you can use any horizontal surface with a centimeter tape attached to it). The child is placed in the stadiometer on his back so that the top of his head tightly touches the stationary transverse bar of the stadiometer. An assistant fixes the child's head in a position in which the lower edge of the orbit and the upper edge of the external auditory canal are in the same vertical plane. The child's legs are straightened by lightly pressing on the knees. The movable bar of the stadiometer is pressed tightly against the heels. The distance between the movable and fixed bars corresponds to the length of the child’s body.

Body weight measured on special horizontal scales with a maximum permissible load of up to 25 kg. If the child can sit, he can be placed on the wide part of the scale, placing his feet on the narrow part. The scales should be carefully adjusted before weighing.

Chest circumference measured by placing a measuring tape in front at the level of the nipples, in the back under the lower angles of the shoulder blades. In this case, the child’s arms should be lowered. Breathing is calm.

Head circumference determined by applying a centimeter tape, passing it from behind along the occipital point, and from the front along the superciliary arches.

Body length represents the distance between the upper sternal and pubic points.

Leg length – the distance between the trochanteric and heel points.

The shoulder circumference is determined by placing a measuring tape at the site of greatest thickening of the biceps muscle.

Thigh circumference measured by placing a measuring tape under the gluteal fold.

Shin circumference determined at the site of maximum volume of the gastrocnemius muscle.

Assess the child's physical development.

The basis for assessing physical development is the child’s body length. Next, body weight and chest circumference are assessed. Anthropometric indicators are assessed using standard centile tables.

Table 33

Centile assessment of indicators

4.Define based on the results of comparison of centile estimates of length, body weight and chest circumference harmony of physical development.

Physical development is considered:

harmonious, If the difference in corridor numbers between any two of the three indicators (length, body weight and chest circumference) does not exceed 1;

disharmonious, if this difference is 2;

sharply disharmonious, if the difference is 3 or more.

Table 34

Basic anthropometric indices in children of the first year of life

In psychiatric practice, interviewing the patient is the most important examination method. The main part of the symptoms of mental illness can be detected only from the patient’s words. Such disorders include phenomena of mental automatism, delusions, obsessive thoughts and fears, deceptions of feelings, depersonalization and derealization. Other mental disorders can only be suspected based on observation of the patient’s behavior. These disorders include auditory hallucinations (the patient listens to something), delusions of persecution (the patient looks tense and frightened). In the case of sudden agitation, stupor, or impaired consciousness, the patient should be questioned only after these conditions have passed. It is better to talk with a patient in a psychotic state after first receiving information about him from family and friends. For non-psychotic disorders, it is first of all better to ask the patient himself, which increases his confidence in the doctor.

Interviewing a patient requires special skills from a psychiatrist. A unified survey scheme is simply impossible, since, on the one hand, the patient must be allowed to speak out, and on the other hand, the initiative must always be in the hands of the doctor. You need to start a conversation with the patient with what served as the basis for contacting a psychiatrist. The doctor is always required to have patience, restraint, goodwill, and also sympathy for the patient, even with his clearly hostile attitude towards the psychiatrist. At the same time, it is necessary to avoid familiarity and maintain distance. In no case should you hide the purpose of the questioning from the patient or introduce yourself as someone other than a psychiatrist. In case of refusal to answer the questions posed, the most important of them should still be asked to the patient. In this case, the doctor must note the patient’s reaction to these questions.

The purpose of the questioning is to find out how much the patient understands what is happening around him, how he is oriented in place and time, whether his memory is preserved for the most important events in his life, as well as for events that occurred before going to the doctor. The psychiatrist must ask the patient to provide an explanation for his actions or statements that those around him could suggest a mental disorder. If the patient himself does not speak out about his painful experiences, then the doctor should ask leading questions about hallucinations, delusions and other disorders. It is useful to ask the question about the presence of suicidal thoughts in the patient’s mind, not only in the present time, but also at any time in the past. In addition, it is necessary to find out the patient’s attitude towards all detected painful experiences and behavioral characteristics, such as a complete lack of criticism, partial, unstable or sufficiently critical attitude towards them.

Questioning of the patient is carried out only in the absence of his relatives and friends.

Psychiatric history is divided into subjective and objective.

Subjective history. In this case, information is collected from the patient himself during the interview process. Anamnesis of the disease consists of finding out the time of the first appearance and characteristics of the signs of the disease, what events preceded it, how the manifestations changed when they disappeared. The life history includes the patient’s memories of the family he grew up in, who his parents were, how he was educated, and what behavioral disorders he had in childhood and adolescence (for example, running away from home). It is necessary to find out whether there was abuse of alcohol, drugs or other intoxicating drugs, at what age it began, and how severe it was. Equally important are data on the patient’s assessment of his social status– work and family. The psychiatrist must find out whether the patient is satisfied with his status, what he is burdened with and what he lacks. Also important is information about those events of the past life that the patient himself considers the most difficult, how he experienced them, whether there were suicidal thoughts and attempts at such moments. The somatic anamnesis takes into account previous diseases, information about traumatic brain injuries, even with a short loss of consciousness, brain infections, neurointoxications, and a tendency to allergic reactions.

Objective anamnesis reflects information received from relatives and friends of a mental patient. It is recommended to obtain this information from each person individually. The psychiatrist should guide the conversation by asking only the facts. At the same time, you need to stop any attempts to impose someone else’s opinion on yourself. In addition, an anamnesis of the disease itself is collected. In the process of collecting this anamnesis, they find out when and what manifestations of the disease arose, and what reason could have contributed to this. They also collect an anamnesis of the patient’s life, focusing on information about hereditary burden. From the patient's parents you can learn about the developmental features of childhood. After this, they are asked the same questions as the patient himself. It is important to find out those facts that the patient kept silent about.

Passport part.

FULL NAME:
Gender: male
Date of birth and age: September 15, 1958 (45 years old).
Address: registered in TOKPB
Address cousin:
marital status: Not maried
Education: secondary vocational (surveyor)
Place of work: not working, disabled group II.
Date of admission to hospital: 10/6/2002
Diagnosis of direction according to the ICD: Paranoid schizophrenia F20.0
Final diagnosis: Paranoid schizophrenia, paroxysmal type of course, with an increasing personality defect. ICD-10 code F20.024

Reason for admission.

The patient was admitted to the Tomsk Regional Clinical Hospital on October 6, 2002 by ambulance. The patient’s cousin asked for help due to his inappropriate behavior, which consisted in the fact that during the week before admission he was aggressive, drank a lot, had conflicts with relatives, suspected them of wanting to evict him and deprive him of his apartment. The patient’s sister invited him to visit, diverted his attention, interested him in children’s photographs, and called an ambulance.

Complaints:
1) for poor sleep: falls asleep well after taking aminazine, but constantly wakes up in the middle of the night and cannot fall asleep again, does not remember the time of onset of this disorder;
2) for headache, fatigue, weakness, which is associated both with taking medicines, and with an increase in blood pressure (maximum figures - 210/140 mm Hg);
3) forgets first and last names.
4) cannot watch TV for a long time - “the eyes get tired”;
5) it’s hard to work “tilt”, you feel dizzy;
6) “cannot do the same thing”;

History of present disorder.
According to relatives, we managed to find out (by phone) that the patient’s condition changed 1 month before hospitalization: he became irritable, actively engaged in “ entrepreneurial activity" He got a job as a janitor in a cooperative and collected 30 rubles from residents. per month, worked as a loader in a store, and repeatedly took food home. He didn’t sleep at night, when his relatives asked him to see a doctor, he became irritated and left home. Ambulance was called by the patient’s cousin, because during the week before admission he became fussy, drank a lot, began to conflict with relatives, accusing them of wanting to evict him from the apartment. Upon admission to the TOKPB, he expressed certain ideas about his attitude, could not explain the reason for his hospitalization, stated that he agreed to stay in the hospital for several days, and was interested in the duration of the hospitalization, since he wanted to continue working (he did not collect money from everyone). Attention is extremely unstable, speech pressure, speech is accelerated in tempo.

Psychiatric history.
In 1978, while working as the head of a geodetic party, he experienced a pronounced feeling of guilt, reaching the point of suicidal thoughts due to the fact that his wage was higher than that of his colleagues, while the responsibilities were less burdensome (in his opinion). However, it didn’t come to the point of suicide attempts - love and affection for her grandmother stopped her.

The patient considers himself sick since 1984, when he was first admitted to a psychiatric hospital. This happened in the city of Novokuznetsk, where the patient came “to work.” He ran out of money and wanted to sell his black leather bag to buy a ticket home, but no one bought it at the market. Walking down the street, he had the feeling that he was being followed; he “saw” three men who were “following him and wanted to take his bag.” Frightened, the patient ran to the police station and pressed the button to call a policeman. The police sergeant who appeared did not notice the surveillance, told the patient to calm down and returned to the department. After the fourth call to the police, the patient was taken to the police station and “began to be beaten.” This was the impetus for the onset of an affective attack - the patient began to fight and scream.

A psychiatric team was called and the patient was taken to the hospital. On the way, he also fought with the orderlies. He spent six months in a psychiatric hospital in Novokuznetsk, after which he “on his own” (according to the patient) went to Tomsk. At the station the patient was met by an ambulance team, who took him to the regional hospital mental asylum, where he stayed for another year. Of the drugs used for treatment, the patient remembers only chlorpromazine.

According to the patient, after the death of his grandmother in 1985, he left for the city of Biryusinsk Irkutsk region to the woman who lived there my own sister. However, during one of the quarrels with his sister, something happened (the patient refused to specify), which led to the sister’s miscarriage and the patient’s hospitalization in a psychiatric hospital in Biryusinsk, where he stayed for 1.5 years. It is difficult to indicate the treatment being carried out.

It should be noted that, according to the patient, he “drank a lot, sometimes it was too much.”
The next hospitalizations were in 1993. According to the patient, during one of the conflicts with his uncle, in a fit of anger he told him: “Or you can hit him in the head with an ax!” My uncle was very scared and therefore “deprived me of my registration.” Afterwards, the patient very much regretted the words he had spoken and repented. The patient believes that it was the conflict with his uncle that was the reason for his hospitalization. In October 2002 - real hospitalization.

Somatic anamnesis.
He doesn’t remember any childhood illnesses. Notes a decrease in visual acuity from class 8 to (–) 2.5 diopters, which persists to the present day. At the age of 21, he suffered from an open form of pulmonary tuberculosis, was treated at a tuberculosis dispensary, and does not remember the medications. For the last five to six years, he has been experiencing periodic rises in blood pressure to a maximum of 210/140 mm. rt. Art., accompanied by headache, tinnitus, flashing of flies. He considers blood pressure figures to be 150/80 mm as normal. rt. Art.
In November 2002, while in the Tomsk Regional Clinical Hospital, he suffered from acute right-sided pneumonia and was treated with antibiotics.

Family history.
Mother.
The patient does not remember the mother well, since she spent most of her time as an inpatient in a regional psychiatric hospital (according to the patient, she suffered from schizophrenia). She died in 1969, when the patient was 10 years old; the mother does not know the cause of death. His mother loved him, but could not significantly influence his upbringing - the patient was raised by his maternal grandmother.
Father.
The parents divorced when the patient was three years old. After this, my father went to Abkhazia, where he started new family. The patient met his father only once in 1971 at the age of 13, after the meeting he was left with painful, unpleasant experiences.
Siblings.
The family has three children: elder sister and two brothers.
The older sister is a primary school teacher, lives and works in the city of Biryusinsk, Irkutsk region. He does not suffer from mental illness. The relationship between them was good and friendly; the patient says that he recently received a postcard from his sister and showed it to him.
The patient’s middle brother has been suffering from schizophrenia since the age of 12, is a group II disabled person, is constantly being treated in a psychiatric hospital, and currently the patient knows nothing about his brother. Before the onset of the disease, my relationship with my brother was friendly.

The patient's cousin is also currently being admitted to the TCU for schizophrenia.
Other relatives.

The patient was raised by his grandparents and older sister. He has the most tender feelings for them, and speaks with regret about the death of his grandfather and grandmother (his grandfather died in 1969, his grandmother in 1985). However, the choice of profession was influenced by the patient’s uncle, who worked as a surveyor and topographer.

Personal history.
The patient was a wanted child in the family; there is no information about the perinatal period and early childhood. Before entering the technical school, he lived in the village of Chegara, Parabelsky district, Tomsk region. Among his friends he remembers “Kolka”, with whom he still tries to maintain a relationship. Preferred games in company, smoked from the age of 5. I went to school on time, loved mathematics, physics, geometry, chemistry, and received “C” and “D” in other subjects. After school, I “went to drink vodka” with friends, and the next morning I was “sick with a hangover.” He showed a desire for leadership in the company and was the “ringleader.” During fights, I experienced physical fear of pain. The grandmother did not raise her grandson very strictly; she did not use physical punishment. The role model was the patient's uncle, a surveyor-topographer, who subsequently influenced the choice of profession. After finishing 10th grade (1975), he entered the geodesy technical school. I studied well at the technical school and loved my future profession.

He strove to be part of a team, tried to maintain good relationships with people, but had difficulty controlling his feelings of anger. I tried to trust people. “I trust a person up to three times: once he deceives me, I will forgive, the second time he deceives me, I will forgive, the third time he deceives me, I will already think what kind of person he is.” The patient was absorbed in work, the prevailing mood was good and optimistic. There were difficulties in communicating with girls, but the patient does not talk about the reasons for these difficulties.

I started working at the age of 20 in my specialty, I liked the work, there were good relationships with the work team, and I held small management positions. He did not serve in the army due to pulmonary tuberculosis. After his first hospitalization in a psychiatric hospital in 1984, he changed his job many times: he worked as a salesman in a bread store, as a janitor, and washed entrances.

Personal life.
He was not married, at first (until the age of 26) he thought “it was too early,” and after 1984 he did not marry for the reason (according to the patient) “what’s the point of producing fools?” Permanent sexual partner did not have a wary attitude towards the topic of sex, refuses to discuss it.
Attitude to religion.
He showed no interest in religion. However, recently I began to recognize the presence of a “higher power”, God. Considers himself a Christian.

Social life.
He has not committed any criminal acts and has not been brought to trial. Didn't use drugs. He has been smoking since he was 5 years old, then - 1 pack a day, recently - less. Before hospitalization, he actively consumed alcohol. He lived in a two-room apartment with his niece, her husband and child. He loved to play with the child, look after him, and maintained a good relationship with his niece. He had conflicts with his sisters. The last stress was a quarrel with my cousin and uncle before hospitalization about the apartment, which I am still experiencing. No one visits the patient in the hospital; relatives ask doctors not to give him the opportunity to call home.

Objective history.
It is impossible to confirm the information received from the patient due to the lack of an outpatient card of the patient, an archival medical history, or contact with relatives.

Somatic status.
The condition is satisfactory.
The physique is normosthenic. Height 162 cm, weight 52 kg.
The skin is of normal color, moderately moist, turgor is preserved.
Visible mucous membranes are of normal color, the pharynx and tonsils are not hyperemic. The tongue is moist, with a whitish coating on the back. The sclera is subicteric, the conjunctiva is hyperemic.
Lymph nodes: submandibular, cervical, axillary lymph nodes 0.5 - 1 cm in size, elastic, painless, not fused with surrounding tissues.

The chest is normosthenic in shape and symmetrical. The supraclavicular and subclavian fossae are retracted. The intercostal spaces are of normal width. The sternum is unchanged, the abdominal angle is 90.
The muscles are developed symmetrically, to a moderate extent, normotonic, the strength of the symmetrical muscle groups of the limbs is preserved and the same. There is no pain with active or passive movements.

Respiratory system:

Lower borders of the lungs
Right left
Parasternal line V intercostal space -
Midclavicular line VI rib -
Anterior axillary line VII rib VII rib
Mid axillary line VIII rib VIII rib
Posterior axillary line IX rib IX rib
Scapular line X edge X edge
Paravertebral line Th11 Th11
Auscultation of the lungs With forced exhalation and quiet breathing during auscultation of the lungs in the clino- and orthostatic position, breathing over the peripheral parts of the lungs is hard vesicular. Dry “crackling” wheezing is heard, equally pronounced on the right and left sides.

The cardiovascular system.

Heart percussion
Boundaries of Relative Dullness and Absolute Dullness
Left Along the midclavicular line in the 5th intercostal space Internally 1 cm from the midclavicular line in the 5th intercostal space
Upper III rib Upper edge of IV rib
Right IV intercostal space 1 cm outward from the right edge of the sternum In the IV intercostal space along the left edge of the sternum
Auscultation of the heart: the sounds are muffled, rhythmic, no side sounds were detected. The emphasis of the second tone is on the aorta.
Arterial pressure: 130/85 mm. rt. Art.
Pulse 79 beats/min, satisfactory filling and tension, rhythmic.

Digestive system.

The abdomen is soft and painless on palpation. There are no hernial protrusions or scars. The muscle tone of the anterior abdominal wall is reduced.
Liver along the edge of the costal arch. The edge of the liver is sharpened, smooth, the surface is smooth, painless. Dimensions according to Kurlov 9:8:7.5
Symptoms of Ker, Murphy, Courvoisier, Pekarsky, phrenicus symptom are negative.
The stool is regular and painless.

Genitourinary system.

Pasternatsky's symptom is negative on both sides. Urination is regular and painless.

Neurological status.

There were no injuries to the skull or spine. The sense of smell is preserved. The palpebral fissures are symmetrical, the width is within normal limits. Movements of the eyeballs are in full range, horizontal nystagmus is small-scaled.
Sensitivity of facial skin is within normal limits. There is no facial asymmetry; the nasolabial folds and corners of the mouth are symmetrical.
Tongue in the midline, taste preserved. No hearing disorders were detected. The gait with eyes open and closed is smooth. In the Romberg pose, the position is stable. Finger test: no misses. There are no paresis, paralysis, or muscle atrophies.
Sensitive area: Pain and tactile sensitivity in the hands and body is preserved. Articular-muscular sensation and a sense of pressure in the upper and lower extremities are preserved. Stereognosis and two-dimensional spatial sense are preserved.

Reflex sphere: reflexes from the biceps and triceps brachii, knee and Achilles muscles are preserved, uniform, and slightly animated. Abdominal and plantar reflexes were not examined.
Sweaty palms. Dermographism is red, unstable.
No pronounced extrapyramidal disorders were identified.

Mental status.

Below average height, asthenic build, dark skin, black hair with slight grey, appearance appropriate for age. Takes care of himself: looks neat, neatly dressed, hair combed, nails clean, clean shaven. The patient easily makes contact, is talkative, and smiling. Consciousness is clear. Oriented to place, time and self. During a conversation, he looks at the interlocutor, showing interest in the conversation, gesticulates a little, his movements are fast, somewhat fussy. He is distant with the doctor, friendly in communication, willingly talks on various topics concerning his many relatives, speaks positively about them, except for his uncle, whom he took as an example in childhood and whom he admired, but later began to suspect of a bad attitude towards himself, an attempt to deprive his living space. He talks about himself selectively, almost does not reveal the reasons for his hospitalization in a psychiatric hospital. During the day he reads, writes poetry, maintains good relationships with other patients, and helps the staff in working with them.

Perception. No perceptual disorders have been identified at this time.
The mood is even, during the conversation he smiles and says that he feels good.
Speech is accelerated, verbose, articulated correctly, and phrases are grammatically constructed correctly. Spontaneously continues the conversation, slipping into extraneous topics, developing them in detail, but not answering the question asked.
Thinking is characterized by thoroughness (a lot of insignificant details, details not directly related to the question asked, the answers are lengthy), slippages, and the actualization of secondary features. For example, to the question “Why did your uncle want to deprive you of your registration?” - answers: “Yes, he wanted to remove my stamp in my passport. You know, the registration stamp is rectangular. What is yours? I had my first registration in ... year at ... address.” The associative process is characterized by paralogicality (for example, the task “excluding the fourth odd one” from the list “boat, motorcycle, bicycle, car” excludes a boat based on the principle of “lack of wheels”). He understands the figurative meaning of proverbs correctly and uses them in his speech as intended. Content-based thinking disorders are not detected. He manages to concentrate, but is easily distracted and cannot return to the topic of conversation. Short-term memory is somewhat reduced: cannot remember the name of the curator, the “10 words” test does not reproduce completely, from the third presentation 7 words, after 30 minutes. – 6 words.

The intellectual level corresponds to the education received, a lifestyle that is filled with reading books, writing poems about nature, about mother, the death of relatives, about one’s life. The poems are sad in tone.
Self-esteem is reduced, he considers himself inferior: when asked why he didn’t get married, he answers, “What’s the point of producing fools?”; The criticism regarding his illness is incomplete, he is convinced that at present he no longer needs treatment, he wants to go home, work, and receive a salary. He dreams of going to his father in Abkhazia, whom he has not seen since 1971, to give him honey, pine nuts, and so on. Objectively, the patient has nowhere to return, since his relatives deprived him of his registration and sold the apartment in which he lived.

Mental status qualification.
The patient’s mental status is dominated by specific thinking disorders: slippages, paralogicality, updating of secondary signs, thoroughness, attention disorders (pathological distractibility). Criticism of one's condition is reduced. Makes unrealistic plans for the future.

Laboratory data and consultations.

Ultrasound examination of the abdominal organs (12/18/2002).
Conclusion: Diffuse changes in the liver and kidneys. Hepatoptosis. Suspicion of doubling of the left kidney.
General blood test (07/15/2002)
Hemoglobin 141 g/l, leukocytes 3.2x109/l, ESR 38 mm/h.
The reason for the increase in ESR is possibly the premorbid period of pneumonia diagnosed at this time.
General urine test (07/15/2003)
Urine is clear, light yellow. Microscopy of the sediment: 1-2 leukocytes in the field of view, single erythrocytes, crystalluria.

Rationale for diagnosis.

Diagnosis: “paranoid schizophrenia, episodic course with increasing defect, incomplete remission”, ICD-10 code F20.024
Based on:

History of the disease: the disease began acutely at the age of 26, with delusions of persecution, which led to hospitalization in a psychiatric hospital and required treatment for a year and a half. The plot of the delirium: “three young men in black jackets are watching me and want to take away the black bag that I want to sell.” Subsequently, the patient was hospitalized several times in a psychiatric hospital due to the appearance of productive symptoms (1985, 1993, 2002). During the periods of remission between hospitalizations, he did not express delusional ideas, there were no hallucinations, but the disturbances in thinking, attention and memory characteristic of schizophrenia persisted and progressed. During hospitalization at the Tomsk Regional Clinical Hospital, the patient was in a state of psychomotor agitation, expressed some delusional ideas about relationships, and stated that “his relatives want to evict him from the apartment.”

Family history: heredity is burdened with schizophrenia on the part of the mother, brother, cousin (being treated at the Tomsk Regional Clinical Hospital).
Current mental status: the patient exhibits persistent disturbances in thinking, which are obligate symptoms of schizophrenia: thoroughness, paralogism, slippage, actualization of secondary signs, uncriticality of one’s condition.

Differential diagnosis.

Among the range of possible diagnoses when analyzing the mental status of this patient, one can assume: bipolar affective disorder (F31), mental disorders due to organic brain damage (F06), among acute conditions are delirium delirium (F10.4) and organic delirium (F05).

Acute conditions - alcoholic and organic delirium - could be suspected in the first time after the patient's hospitalization, when fragmentary delusional ideas of attitude and reform were expressed to him, and this was accompanied by activity adequate to the expressed ideas, as well as psychomotor agitation. However, after the relief of acute psychotic manifestations, the patient, while productive symptoms disappeared, remained obligate symptoms characteristic of schizophrenia: disturbances in thinking (paralogism, unproductiveness, slipping), memory (fixation amnesia), attention (pathological distractibility), and sleep disturbances persisted. There was no evidence for the alcoholic genesis of this disorder - withdrawal symptoms, against the background of which delirious stupefaction usually occurs, data on the patient's massive alcoholism, characteristic of undulating delirium and perception disorders (true hallucinations). Also, the absence of data on any organic pathology - previous trauma, intoxication, neuroinfection - in a place with a satisfactory somatic condition of the patient allows us to exclude organic delirium during hospitalization.

Differential diagnosis with organic mental disorders, in which disorders of thinking, attention and memory also occur: there is no evidence for traumatic, infectious, toxic damage to the central nervous system. The patient does not have any psycho-organic syndrome, which forms the basis for the long-term consequences of organic brain lesions: there is no increased fatigue, no pronounced autonomic disorders, and there are no neurological symptoms. All this, coupled with the presence of disturbances in thinking and attention characteristic of schizophrenia, makes it possible to exclude the organic nature of the observed disorder.

To differentiate paranoid schizophrenia in this patient from a manic episode within the framework of bipolar affective disorder, it is necessary to remember that the patient was diagnosed with a hypomanic episode within the framework of schizophrenia during hospitalization (there were three criteria for hypomania - increased activity, increased talkativeness, distractibility and difficulty concentrating) . However, the presence of delusions of attitude, disturbances in thinking and attention, uncharacteristic of a manic episode in affective disorder, casts doubt on such a diagnosis. Paralogism, slippage, and unproductive thinking that remain after the relief of psychotic manifestations are more likely to testify in favor of a schizophrenic defect and hypomanic disorder than in favor of an affective disorder. The presence of a follow-up history of schizophrenia also allows us to exclude such a diagnosis.

Rationale for the treatment.
The prescription of antipsychotic drugs for schizophrenia is a mandatory component of drug therapy. Given the history of delusional ideas, the patient was prescribed a long-acting form of a selective antipsychotic (haloperidol-decanoate). Given the tendency to psychomotor agitation, the patient was prescribed the sedative antipsychotic drug chlorpromazine. The central M-anticholinergic blocker cyclodol is used to prevent the development and reduce the severity of side effects neuroleptics, mainly extrapyramidal disorders.

Supervision diary.

10 September
t˚ 36.7 pulse 82, blood pressure 120/80, respiratory rate 19 per minute Getting to know the patient. The patient's condition is satisfactory, he complains of insomnia - he woke up three times in the middle of the night and walked around the department. Depressed mood due to the weather, unproductive thinking, paralogical with frequent slippages, detailed. In the area of ​​attention - pathological distractibility Haloperidol decanoate - 100 mg IM (injection dated September 4, 2003)
Aminazine – per os
300 mg-300 mg-400 mg
Lithium carbonate per os
0.6 – 0.3 – 0.3g
Cyclodol 2 mg – 2 mg – 2 mg

11 September
t˚ 36.8 pulse 74, blood pressure 135/75, respiratory rate 19 per minute The patient’s condition is satisfactory, complaints about poor sleep. The mood is even, there are no changes in mental status. The patient sincerely rejoices at the notebook given to him and reads the poems he has written aloud with pleasure. Continuation of treatment prescribed on September 10

September 15th
t˚ 36.6 pulse 72, blood pressure 130/80, respiratory rate 19 per minute The patient’s condition is satisfactory, no complaints. The mood is even, there are no changes in mental status. The patient is glad to meet you and reads poetry. Tachyphrenia, speech pressure, slipping up to the point of fragmented thinking. Unable to eliminate the fourth extra item from the presented sets. Continuation of treatment prescribed on September 10

Expertise.
Labor examination The patient is recognized as a group II disabled person; re-examination is not required in this case, given the duration and severity of the observed disorder.
Forensic examination. Hypothetically, in the event of committing socially dangerous acts, the patient will be declared insane. The court will decide to conduct a simple forensic psychiatric examination; Taking into account the severity of existing disorders, the commission may recommend compulsory inpatient treatment in the TokPub. The final decision on this issue will be made by the court.
Military expertise. The patient is not subject to conscription into the armed forces of the Russian Federation due to the underlying disease and age.

Forecast.
In the clinical aspect, it was possible to achieve partial remission, reduction of productive symptoms and affective disorders. The patient has factors that correlate with good prognosis: acute onset, the presence of provoking moments at the onset of the disease (dismissal from work), the presence of affective disorders (hypomanic episodes), late age of onset (26 years). However, the prognosis in terms of social adaptation is unfavorable: the patient has no housing, connections with relatives have been disrupted, persistent disturbances in thinking and attention persist, which will interfere with work activity in the specialty. At the same time, the patient’s basic work skills are intact, and he enjoys participating in intra-hospital work activities.

Recommendations.
The patient needs continuous long-term treatment with selected drugs in adequate dosages, with which the patient has been treated for a year. The patient is recommended to stay in a hospital due to the fact that social connections he is impaired, the patient does not have his own place of residence. The patient is indicated for creative self-expression therapy according to M.E. Stormy, occupational therapy, since he is very active, active, wants to work. Recommended work activity is any, except intellectual. Recommendations to the doctor – work with the patient’s relatives to improve the patient’s family ties.

Used Books.

1. Avrutsky G.Ya., Neduva A.A. Treatment of the mentally ill (Guide for doctors).-M.: Medicine, 1981.-496 p.
2. Bleikher V.M., Kruk I.V. Dictionary psychiatric terms. Voronezh: Publishing house NPO "MODEK", 1995.-640 p.
3. Vengerovsky A.I. Lectures on pharmacology for doctors and pharmacists. – Tomsk: STT, 2001.-576 p.
4. Gindikin V.Ya., Guryeva V.A. Personal pathology. M.: “Triad-X”, 1999.-266 p.
5. Zhmurov V.A. Psychopathology. Part 1, part 2. Irkutsk: Irkut Publishing House. Univ., 1994
6. Korkina M.V., Lakosina N.D., Lichko A.E. Psychiatry. Moscow - “Medicine”, 1995.- 608 p.
7. Lecture course on psychiatry for students Faculty of Medicine(lecturer – candidate of medical sciences, associate professor S.A. Rozhkov)
8. Workshop on psychiatry. (Training manual) / compiled by: Eliseev A.V., Raizman E.M., Rozhkov S.A., Dremov S.V., Serikov A.L. under the general editorship of prof. Semina I.R. Tomsk, 2000.- 428 p.
9. Psychiatry\Ed. R. Shader. Per. from English M., “Practice”, 1998.-485 p.
10. Psychiatry. Uch. village for students honey. university Ed. V.P. Samokhvalova.- Rostov n\D.: Phoenix, 2002.-576 p.
11. Guide to Psychiatry\Edited by A.V. Snezhnevsky. – T.1. M.: Medicine, 1983.-480 p.
12. Churkin A.A., Martyushov A.N. A brief guide to the use of ICD-10 in psychiatry and addiction medicine. Moscow: “Triad-X”, 1999.-232 p.
13. Schizophrenia: a multidisciplinary study\ edited by Snezhnevsky A.V. M.: Medicine, 1972.-400 p.

Passport part(it is taken out on title page; it needs to be clarified at the end of the conversation).

1. I. Complaints: 1, 2, 3, etc. in order of importance to the patient. After each, write down its clarifications (“clarifications”). If he complains “about a neighbor,” then write it down (this is good for assessing his mental status).

Life history and illness “provide food” for all components of mental status and for personality assessment.

1. II. Anamnesis of life(psychobiographical study):
2. Date and place of birth, number and number of children in the family (brothers, sisters). Personal characteristics, occupation and fate of father, mother, brothers and sisters. Financial situation of the family in childhood and later. General characteristics of the family: friendly - disunited; organized - unorganized, etc.
3. Heredity: mental disorders, seizures, binge drinking, “difficult” characters.
4. Pregnancy, childbirth; harm and development in early childhood. Enuresis. Sleepwalking, etc.
5. Studies: Kindergarten(including as far as I remember), what (and when) I graduated from, how I studied, what difficulties there were and how my relationships with teachers, classmates, and parents developed. Teenage hobbies. Features of puberty.
6. Professional route: who and when (years) worked, professional growth and decline, relationships with superiors, with juniors. Difficulties - successes. Reasons for dismissals.

Military service: how did you cope with adaptation to it and its “hardships”, in what rank did you leave? Disability: group, since when, reason.

1. Sexual development: Orientation; hair growth, wet dreams, attraction, whether you fell in love, sex life; sex life married; divorces - marriage - cohabitation (if not shown in paragraph 1).
2. Diseases and injuries suffered, their nature (sometimes the circumstances of injury), immediate and long-term consequences.

Allergological history.

1. Personal characteristics: self-assessment of memory, intelligence, character (volitional and emotional properties, sociability, etc.), hobbies (hobbies), predominant interests (“how one lives”). What it was and what it is now.
2. Drug history: substance abuse + alcohol + drug addiction. Tolerance, craving, loss of quantitative and situational control, vomiting or other “protective signs” in case of overdose, the nature of withdrawal. Atypical intoxication and troubles due to behavior during intoxication. Self-assessment of consumption: little - excessively consuming - painfully dependent.

III. History of the disease. Since when has he considered himself sick? What preceded this disease. How did the disease manifest itself over time? Features of the flow. Where and when was he treated? Treatment results. Mental state after discharge(s). Disability. Circumstances of the latest exacerbation of the disease. Reasons for current hospitalization. The dynamics of disorders and the nature of treatment in the present admission before supervision: it became better (slightly, noticeably, significantly) - no changes occurred - it became worse (slightly, noticeably, significantly).

1. IV. Mental status– is described “for the day” of supervision (however, in epicrises, the status is described in dynamics “for the period” of treatment). The notes about the “items” of the anamnesis are in principle also valid for the status items. Status descriptions reflect both the healthy part of the psyche (personal characteristics, situational state) and disorders of artificially isolated components (functions) of the psyche. Ideas about status are partly formed when working on complaints and anamnesis, but in many “points” of status these ideas should be enriched by special questioning to identify purely subjective phenomena (depersonalization, senestopathy, etc.) or phenomena that the person being studied is silent about. Mildly expressed disorders that are therefore only noticeable to the patient themselves, for example, mild memory loss, usually require special questioning. In such cases, questioning and the self-reports (self-assessment, self-observation) of patients obtained during questioning in the aspects of “was - became” and clarifying pathopsychological studies become important.

Psychological phenomena reflecting the characteristics of the person under study (memory, thinking, feelings, emotional reactions... etc.), especially if they were previously reflected in anamnesis and complaints, can be recorded in the status partly in an evaluative manner, for example: “high-level memory, good saved for events near and far, personal and public.” Psychopathological deviations and symptoms identified during questioning or observation are subject to description (“display”) in the most detailed, evidence-based, multi-parameter manner. For example: “Discovers a slight decrease in memory. I noticed this by the fact that...” (or “... this is expressed by the fact that...”; or “... this is manifested by the fact that...”; or simply “I began to remember worse what I read, phone numbers, names of new acquaintances, more often forgets those left somewhere- or things"). If this kind of information was recorded earlier during the presentation of the anamnesis, then the function (in this case memory) should be assessed and indicated “look in the anamnesis...”. Non-rigid STATUS SCHEME could be as follows:

1. General impression, demeanor, appearance, condition of clothing and hairstyle.
2. Consciousness. Orientation (in place, in time, in one’s own personality); its clarity - vagueness, characteristics of disorientation (for judgments about turning off or clouding of consciousness).
3. Availability— contact, its degree and impact on the productivity of communication. Characteristics of speech. Psychological mechanisms of low accessibility: melancholy, indifference, burden with painful experiences, protest, misunderstanding, hearing loss, etc.
4. Perception. Preservation of the senses. Description of senestopathy, paresthesia, illusions, hallucinations, psychosensory disorders.
5. Memory in aspects the near - the ancient, the personal - the public. Manifestations of hypo/hypermnesia, amnesia, pseudoreminiscences and confabulations. Pathopsychological study: memorizing 10 words (Luria square), memorizing numbers.
6. Thinking: Acceleration-deceleration; logic, consistency, purposefulness of thinking. Clarity and level of judgment and inference.

A. Disorders currents of associations: vagueness (looseness) of judgments - reasoning - fragmentation - incoherence; torpidity - thoroughness - perseveration; ideational automatisms, breaks and influxes of thoughts.

B. Disorders judgments: “productive”: (morbid ideas): obsessive, overvalued, delusional. Description of them in aspects: systematized - unsystematized; abstractness (interpretation-imagery (sensuality); emotional intensity - neutrality. Tests for basic operations of thinking: blank card, elimination of the 4th extra person, pictogram, etc.

1. Attention: adequacy (selectivity) - inadequacy of its focus. Concentration - vagueness (absent-mindedness, lack of concentration) or exhaustibility. Sustainability, stiffness- increased distractibility. Pathopsychological studies: Kraepelin counting, Schulte test, proofreading test. Symptoms: distractibility, exhaustion, stiffness, chainedness (to highly significant ideas).
2. Intelligence. Cumulative level of memory, thinking and attention (see earlier). A stock of information and skills (general cultural, professional, school, everyday and everyday). In particular, ideas about the past, natural phenomena, political and cultural events (erudition). Wealth is poverty of imagination and analogies. Cleverness (heuristic thinking). Criticality: towards one’s own strengths and weaknesses, to what is happening. The ability to use “knowledge” taking into account situational contexts, in particular when interpreting unfamiliar proverbs. Syndromes: dementia (indicating the severity of intellectual impairment), dementia (and its qualitative variants). The tests are the same as for studying memory, thinking, and attention.
3. Emotional sphere.

A.) Mood(emotional background) is described on the basis of observations and special questioning about emotional radicals. Usually the patient has to name them: joy, melancholy (sadness), anxiety, apathy, malice (anger), fear (fear). Symptoms: euphoria, depression, mania, apathy, anxiety, fear, tension, confusion (affect, bewilderment) and syndromes corresponding to the radical. Additional non-affective symptoms: a) secondary (= congruent, = homonomic), resulting from emotional radicals and b) primary (not congruent with affect).

B) Emotional reactions(emotional component of mental reactions): their radical (radicals), vegetative and motor components. Liveliness and richness (exaltation) or monotony (fading, monotony). Degree of expression. Situational semantic adequacy (clarity) - inadequacy of the direction of reactions.

Symptoms: weakness, lability, torpidity of affect, inadequacy, ambivalence, etc.

IN). Emotional relationships (feelings): to loved ones, to events in personal and social life, to hospitalization, doctors, medical staff, to illness, to one’s future, etc. They are usually visible externally in the form of emotional reactions during the examination of anamnesis, as well as during special questioning. Symptoms: strengthening↔weakening of feelings (flattening = emotional dullness), emotional impoverishment, inadequacy of relationships (relationships). Ambivalence of feelings.

1. Will. Thirst for activity - lack of desires. The ability to make decisions, take risks, mobilize for social adaptation and significance. What you do in the department: reading, handicrafts, board games, helping other patients, helping staff, taking care of yourself. Symptoms: hyperbulia - hypobulia - abulia, parabulia.
2. Attractions As a rule, they are usually hidden by the sick. Since alcoholic pathological attraction has been studied previously, it is necessary to ask - “is there a similar unusual craving for something else?” (to food, persons of the same sex, children, vagrancy, etc.). Whether or not suicidal thoughts, intentions or actions have occurred. Ask about conditions and motives. Are they not there now?
3. Movements(motor skills): deceleration - acceleration. Inadequacies in the form of mannerisms, angularity, torpidity (viscosity), etc. Motor stereotypies and echopraxia. Distribution of tone in parts of the arms and neck muscles. Stupor (substupor): catatonic, depressive, hysterical.
4. Three basic wishes, insist on formulation. Plans for the future, near and far.
5. VKB(internal picture of the disease). Does he consider his condition to be painful and in what way does he see (find) his illness. Manifestations of suffering, the patient’s understanding of the causes of the disease, attitude towards it; considers hospitalization justified - unjustified, inappropriate - unfair. Fear of stigmatization from neighbors and work colleagues.
6. Rehabilitation attitudes: three “basic desires.” Plans for the near and distant future.
7. V. Clinical assessment is the process and result of research, “the pinnacle of clinical medicine.” All more or less significant information should be included in it in such a way that “ends meet” or contradictions that should be resolved are indicated. It may be structured in different ways, but its natural course is a story about

1) what happened → 2) what happened → 3) what happened → 4) what needs to be done.

The clinical content of these stages is functional, not strictly fixed, determined by the general, for example, rehabilitation context and the hypothesis being developed. The content is expressed by the following, artificially isolated from the whole, clinical preliminary aspects (components, storylines):

1. Heredity and personality traits in dynamics.
2. Description and designation of symptoms, isolated and purified from numerous background circumstances; their integration into the syndrome(s), which can be complete (expanded) or rudimentary in the form of only a certain “coloring”: depressive, paraphrenic, oneiric, etc. Syndromes can be combined.
3. Identification of dynamic aspects: a) initial period - debut - manifestation - outcome (remission, etc.); b) type of flow: continuous - fur-shaped - periodic (recurrent, phase).
4. Assessment of data from available paraclinical, neurological and somatic studies.
5. Assessment of the role of identified factors (genetic, personal and psychogenic, organic, residual-organic and exogenous) in qualities (values): cause, effect, inhibitory or facilitating condition (also influencing the characteristics of symptoms and course).
6. Assessing the experience of previous treatment with psychotropic and other drugs and methods, taking into account the intensity and duration of exposure.

The formation of ideas about these aspects, their “elaboration” begins from the very beginning of the study. And then they “play around in your head,” prompting you to clarify. For a novice doctor, these 6 aspects should be presented in writing and separately (“for training”), and as these skills become automated, more and more integrative.

Only after figuratively specific ideas, “feeling” and a holistic understanding of the aspects should clinical assessment itself (its core), i.e. presentation of integrative aspects according to the stages of the clinical plot in evaluative terms.

At the same time, the shares of descriptive-figurative and abstract-evaluative elements in each aspect are not the same. The actual evaluative parts can either be taken in brackets, or written in a parallel column, or separately after the figurative part.

Clinical assessment is crowned with comparisons with standard “clinical” descriptions of diseases, selection of the most appropriate standard and, in accordance with this, preliminary diagnosis. The diagnosis notes the most essential, practically significant circumstances, including individual ones. Usually this is nosology (name of the disease), syndrome(s), type of course, degree of progression, personality characteristics and personality changes. Sometimes the influencing conditions are also indicated (background, “soil”): “on organically inferior soil”, “in the climacteric period”. But most often the background diagnosis(es) are recorded on a separate line. Concomitant diseases, neurological and others, are recorded next to the background ones.

Along with the preliminary diagnosis, concomitant diseases are also recorded: neurological, etc. In this case, the diagnosis of the disorder for which the patient is being treated is considered the main one. The diagnosis also indicates complications arising, for example, from taking psychopharmacological drugs.

1. VI. Differentiated diagnosis, essentially, also begins from the very beginning of the study. At first, this is a comparison of the properties of symptoms and their qualification, later - a comparison of holistic and complete clinical entities (diseases). Differential diagnosis is carried out, first of all, with diseases whose clinical picture is similar to that of the “case” being studied. However, given the educational nature of the medical history, a differential diagnosis “for training” should be carried out with all groups of diseases indicated in Snezhnevsky’s table (circles).

Differential diagnostic formulas reflect the “left” and “right” view of the problem and can be of two types.

1) “This is not an excluded disease (specify), since the patient’s symptoms (1, 2... – specify) not typical for the excluded disease”;

2) “This is not an excluded disease (which one - indicate), since his available to him characteristic features (1, 2 5, 6, 7… – specify) are absent in the studied patient.”

Most often, one formula is enough. Bilateral differences in mild cases create the impression of redundancy of evidence; they are useful in difficult cases and for training differentiation skills. In any case, it is advisable to say (write) something like the following before one of the selected formulas:

“Despite the existing general nonspecific symptoms (1, 2 3, 4,… – indicate)", the patient (or "in the case under consideration") does not have an excluded disease (specify which one), because…". Next, use formula 1) or 2).

Having strengthened, canceled or improved the preliminary diagnosis with a differential diagnosis procedure, they form final diagnosis: main, background, accompanying and complications. In the accompanying paper, the first place is given to clinical entities that influenced clinical picture(background factors).

VII. Treatment and rehabilitation plan:

A. Regime, strategy and purpose of therapy.

B. Social help: employment, disability group, normalization of family situation, etc.

B. Psychohygienic work with relatives.

VIII. Forecast. Rehabilitation potential of the patient (taking into account the social environment, somatic and neurological health, personal characteristics). Prognosis: for recovery, for life, for performance.