Working as a doctor in a district hospital, very often there is not enough time for a more complete primary examination of the doctor and its documentation. Therefore, I tried to create a template that makes it almost impossible to miss a particular body system, plus takes less time to fill.

Primary examination by a doctor ________________________

COMPLAINTS:________________________________________________________________________________

____________________________________________________________________________________
ANAMNESIS MORBI.

Acutely fell ill, gradually. The onset of the disease from _______________________________________

For medical assistance (not) applied to the PIU, VA ____________ to the doctor _________________. Outpatient treatment: no, yes: ____________________________________________________________________________
Effect of treatment: yes, no, moderate. Appeal to the SMP: no, yes ___ times (a). Delivered to rest by
emergency indications (yes, no) from the scene of an accident, street, home, work, public place through ____
min, hour, day. SMP done:______________________________________________________________
He is hospitalized in the _________________________ department of the Central District Hospital.

ANAMNESIS VITAE.
VZR / CHILD: from ___ ber, ___ childbirth (natural, opera). The course of pregnancy: b / patol., complicated by _______________________________________________________________ in the period of _______ weeks.
Born (was) full-term (oh) (yes, no), in the period of ____ weeks, weighing ______ g,
height____ cm. Breastfeeding (yes, no, mixed) up to ___ year(s). Vaccinations on time, medical
rejection due to _________________________ Examination of the pediatrician is regular (yes, no). General development corresponds to age (yes, no), sex (yes, no), male/female development.
Consists of "D" (yes, no) doctor ____________________ with DZ: ___________________________________
Regularity of treatment (yes, no, amb, stats). Last hospital. ____________ where __________________
Transferred zab: TBS no, yes ______ Vir. Hepatitis no, yes _______ d. Brucellosis no, yes __________ d
Operations: no, yes _________________________________ complications _________________________________
Blood transfusions: no, yes _________ d, complications __________________________________________
Allergy anamnesis: calm, burdened _________________________________________________________
Living conditions: (not) satisfactory. Food is (not) sufficient.
Heredity is (not) weighed down _____________________________________________________________
Epidemiological history: contact with an infectious patient with symptoms: _____________________________ (yes, no),
where when____________________________________________
Bad habits: no smoking, yes ____ years, no alcohol, yes ____ years, no drugs, yes ____ years.

STATUS PRAESENS OBJECTIVUS
General condition (moderate, severe, extremely severe, terminal) severity, (not) stable
noe, due to _________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Consciousness (clear, retarded, somnolent, stuporous, soporous, coma___st)
Glasgow _____ points. Behavior: (mis)oriented, excited, calm. Reaction
on examination: calm, negative, tearful. Position of the patient: active, passive, forced
____________________________________________________________________________________
Constitution: asthenic, normosthenic, hypersthenic. Proportional yes, no __________
______________________________ Symmetric yes, no ___________________________________
Skin: clear, rash
Normal color, pale, (sub)icteric, earthy, hyperemic
Cyanosis: no, yes, diffuse, local ___________________________________________________
Humidity: dry, normal, increased, hyperhidrosis. Visible mucous membranes: pale, pink, hyperemic
Adipose tissue: weakly, moderately, excessively expressed, (not) uniform ___________________
Peripheral edema: no, yes, generalized, local ______________________________________
Peripheral l / nodes are enlarged: no, yes _____________________________________________ Т _________ * С_
Muscles: hypo, normal, hyper tone. Developed: weak, moderate, pronounced. Height _____ cm, weight _____ kg.
Seizures: no, yes. Tonic, clonic, mixed. _____________________________________
Respiratory organs: breathing through the mouth and nose is free yes, no __________________________________
Gr.cell: symmetrical yes, no ________________ no deformation, yes _____________________________
When breathing, the mobility of both halves is symmetrical yes, no ______________________________
Pathological retraction of the compliant areas of the chest: no, yes _____________
Participation of an additional muscle group in the act of breathing: no, yes _____________________________________
Palpation: soreness: no, yes on the right along the ______ line, on the ur _____________ ribs,
on the left along ________________________________ lines, on ur __________________ ribs.
Voice trembling is carried out evenly yes, no ___________________________________________
Percussion: normal pulmonary sound yes, no ____________________________________________
The lower borders of the lungs are displaced no, yes, up, down, right, left.____________________________
Auscultatory breathing: vesicular, puerile, hard, bronchial, laryngotracheal,
saccaded, amphoric, attenuated, Kussmaul, Biot, Cheyne-Stokes, Grokk Nad
all lungs, right, left, upper, middle, lower sections ____________________________ Wheezing:
no, yes; dry (high, low, medium tone), wet (finely, medium, coarsely blistered, crepitus),
over all the lungs, on the right, on the left, upper, middle, lower sections.
Pleural friction noise: no, yes, on both sides, right, left ___________________________________
Shortness of breath: no, yes, inspiratory, expiratory, mixed. NPV_______ per minute.
Cardiovascular s-ma.
On examination: Jugular veins swollen yes, no. S-m * dancing carotid * neg, half. S-m Musset neg, floor.
The apex beat is determined no, yes in ______ m / r. There is no cardiac impulse, yes, spilled.
Epigastric pulsation no, yes
Palpation: S-m * Cat's purr * negative, floor, above the aorta, at the apex, ___________________
Percussion: The borders of the heart are normal, shifted to the right, top, left ___________________________
Auscultatory: Tones are clear, muffled, weakened, sonorous due to an artificial valve,
features of tones _________________________________________________________________________
Heart murmurs - functional, organic. Features: ______________________________
_
____________________________________________________________________________________
Rhythm sin-yes, no. Tachycardia, bradycardia, tachyarrhythmia, bradyarrhythmia. Heart rate _____ per minute.
Pulse filling and tension: small, weak, full, intense, satisfactory, empty, thread-
visible, missing. Frequency Ps____ in min. Pulse deficit: no, yes ____________ per minute
BP____________________________________mm.Hg. CVP______ cm H2O.
Organs of the gastrointestinal tract.
Tongue: moist, dryish, dry. Clean, lined with ______________________ plaque ________________
Swallowing impaired no, yes ______________________________________________________________
We pass the esophagus: yes, it is difficult, no _________________________________________________
Abdomen: correct form yes, no ____________________________________________________________

Hernial protrusions: no, yes __________________________________________________________
_____________________________________________________________________________________
Size: sunken, normal, increased due to obesity, ascites, pneumatosis to-ka, tumors, obstruction.
Palpation: soft, muscular defense, tense. Painful no, yes in _____________________
_____________________________________________________________________________________
_________________________________________________________________________________ region
S-m Kocher floor, neg. S-m of the Resurrection floor, neg. S-m Rovsing floor, neg. S-m Sitkovsky floor, neg.
S-m Krymov floor, neg. S-m Volkovich 1-2 sex, neg. S-m Ortner gender, neg. S-m Zakharyin sex, neg.
S-m Mussi-Georgievsky floor, neg. S-m Kerte floor, neg. S-m Mayo-Robson sex, neg.
Fluctuation of free fluid in the cavity: no, yes ______________________________________
Auscultatory: intestinal peristalsis: active, sluggish, absent. Liver: enlarged no, yes
____ cm below the costal arch, wrinkled, reduced, painful yes, no
Consistency: pl-elast, soft, hard. Edge: sharp, rounded. Sensitive: no, yes ___________
Gallbladder: palpable - no, yes ___________________________________, painful: no, yes.
Spleen: palpable no, yes. Increased: no, yes, dense, soft. Percussion length ______ cm.
Stool: regular, constipation, frequent. Consistency: watery, mucoid, liquid, mushy,
well-formed, firm. Color: regular,yellow,green,aholic,black.
Impurities: no, mucus, pus, blood. Smell: normal, offensive. Helminths no, yes ___________________
Urinary system.
The area of ​​the kidneys is visually changed: no, yes, on the right, on the left ____________________________________
_____________________________________________________________________________________
S-m Pasternatsky neg, floor, right, left. Palpable: no, yes, right, left ___________________
Diuresis: preserved, regular, reduced, frequent, in small portions, ischuria (acute, hron, parodoxal,
complete, incomplete), nocturia, oliguria _______ ml / day, anuria ______ ml / day.
Soreness: no, yes, at the beginning, at the end, during the entire urination.
Discharge from the urethra: no, mucous, purulent, sanious, bloody, etc. ___________________
Sexual system.
The external genital organs are developed according to male, female, mixed type. Correct: yes, no ___________
_____________________________________________________________________________________
Husband: visually enlarged scrotum no, yes, left, right. There are no varicose veins, yes, on the left ____ degrees.
Painful on palpation no, yes, on the right, on the left. There is no hernia, yes, on the right, on the left. Character__
_____________________________________________________________________________________
_____________________________________________________________________________________
Female: Vaginal discharge scanty, moderate, copious. Character: slimy, cheesy,
bloody, blood. Color: transparent, yellow, greenish. Fetid no, yes _________________
Visible damage: no, yes, character __________________________________________________
STATUS NERVOSUS.
The face is symmetrical: yes, no. Smoothness of the nasolabial triangle: left, right.
Eye fissures D S. Eyeballs: centered, converged, diverged, left sync, right sync.
Pupils D S. Photoreaction: lively, sluggish, absent. Pupil diameter: OD constricted, medium, dilated.
OS narrowed, medium, extended. Movements of the main apples: saved, limited ______________________
_____________________________________________________________________________________

Nystagmus no, yes: horizontal, vertical, rotation; large-, medium-, small-sweeping; constant,
in marginal leads. Paresis: no, yes. Hemiparesis: left, right. Paraparesis: lower, upper.
Tetraparesis. Tongue deviation: no right, left. Swallowing impaired: no, yes ____________________
_____________________________________________________________________________________
Palpation of the nerve trunks and exit points is painful: no, yes_________________________________
_____________________________________________________________________________________
Muscle tone D S. Hypo-, a-, normo-, tone (left, right). Tendon reflexes: brisk on the right,
reduced, absent, on the left animated, reduced, absent. ______________________
Meningeal signs: Stiffness of the occipital muscles on _____ fingers. S-m Kernig negative, floor ___________
C-m Brudzinsky neg., floor. Root marks: S-m Lasegue negative, gender _______Additional data:
STATUS LOCALIS:___________________________________________________________________________
_______________________________________________________________________________________

_______________________________________________________________________________________

________________________________________________________________________________________

PRELIMINARY DIAGNOSIS:
________________________________________________________________________________________

__________________________________________________________________________________

SURVEY PLAN:
1 UAC (deployed), OAM. 5 ultrasounds.
2 BHC, COAGULOGRAM, Blood Gr. and Rh. 6 ECG.
3 M/R,RW. 7 FL.ORG.GR.CELLS.
4 Feces for I/g, scatology, tank culture of feces. 8 FGDS

9 R-graphy in two projections ____________________________________________________________
10 Doctor's consultation-________________________________________________________________

MANAGEMENT PLAN:

MODE____ DESK #____
1
2
3
4
5

Ibraimov N.Zh.
Anesthesiologist-resuscitator
Zhambyl Central District Hospital.

Initial examination of the patient

1.1. Appearance of the patient

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

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

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

To classify appearance features as psychopathological phenomena and distinguish them from everyday, social, cultural non-psychotic counterparts, it is necessary to take into account the suddenness, unexpectedness of their appearance, caricature, catchiness, psychological lack of motivation, aimlessness. It should 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 the patient's 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 violation of the patient's contact with others can be clouding, confusion, narrowing of consciousness, mutism, negativism phenomena, an influx of hallucinations and illusions, delusional mood, apathy, autism, deep depression, fear, agitation, drowsiness, aphasia, as well as taking certain psychotropic drugs, alcohol, 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 listen carefully, without interrupting questions, and record his statements. It is almost impossible to remember them, and the manic patient is not able to repeat his statements. With severe manic speech confusion, it is advisable to use a tape recording. It is important to pay attention to the change in the patient's mood depending on the topic of the conversation, to the patient's interest in certain topics. It is necessary to find out whether the external situation affects the structure of speech production or whether the latter is predominantly reproductive in nature. As the conversation progresses, attempts should be made at least to a limited extent to control the behavior and speech production of the patient, the focus of his attention, to skillfully correct the attempts of the manic patient to completely suppress the interlocutor's activity 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, comments of manic patients, skillfully distracting and switching the conversation to other topics. The doctor should refrain from joking remarks, avoid sexual topics, as there is a risk of being included in overvalued, delusional and delusional ideas of erotic content.

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

In all patients, including patients in a manic state, it is necessary to describe the features of keeping a distance, which have an originality depending on the structure of the syndrome. Keeping a distance is determined by a complex, highly differentiated ethical sense, the violation of which is of great diagnostic value. In the features of its manifestation, the state of the emotional sphere, intellect, the level of critical assessment of the situation, the state of one's health (partial criticism, anosognosia), premorbid personality traits reveal themselves. Manic patients are characterized by an ironically mocking, ironically patronizing, mocking, familiar, familiar attitude towards the interlocutor, often combined with sexual ambiguity in statements, pantomimic swagger and obscenity. Predilection for flat (banal) inappropriate jokes is quite typical in patients with chronic alcoholism and in patients with Morio-like disorders. Depressed patients are characterized by a timid, dependent, sadly humiliated attitude towards the doctor and other medical staff. There are features of contact in patients with epilepsy (viscosity, sweetness or malice, hypocrisy, mentoring), schizophrenia (indifferent passivity, isolation), paranoia (substantiveness, pressure, expectation of understanding, obsequiousness replaced by arrogance), atherosclerosis of cerebral vessels (incontinence of affects, an attempt to disguise memory defects), progressive paralysis and syphilis of the brain (gross absurdity, arrogance, swagger), in patients with the consequences of a traumatic brain injury (manifestation of "ceremonial" hyperesthesia, irritability, tearfulness), and so on.

In a conversation with an anxious patient, it is necessary to verbally probe the "sore point" - the source of anxiety, determining which questions increase anxiety. In delusional and anxiety-delusional patients, these are most often questions relating to the wife, husband, children, apartments, pensions, 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 sparing aspect, it is advisable to move from an alarming, exciting patient topic to an indifferent everyday one, and then return to the first one to clarify the details of interest and its emotional significance.

In a conversation with depressed patients, one should not lose sight of the fact that they often complain not of melancholy, but of somatic ailments (insomnia, general weakness, lethargy, decreased performance, lack of appetite, constipation, etc.). To clarify the question of the intention to commit suicide, the doctor should proceed last and only in a tactful, cautious, sparing form, given the psycho-traumatic nature of the very clarification of this topic. Conversation can increase sadness and anxiety in such patients, but sometimes their verbal response reduces the severity of depression and suicidal tendencies. It is advisable to adapt to the slow pace of the conversation, pauses, laconic answers in a quiet voice, 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, hand-wringing, a special modulation of speech).

Autism, negativism, mutism, stupor of the patient 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 by the features of the posture, its change, facial expression, gestures, autonomic reactions. In some such cases, the use of barbamyl-caffeine disinhibition is indicated. A rather 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 low voice and succinctly. It is advisable to alternate questions addressed to painful experiences with neutral (indifferent) questions. It is important to carefully study the features of the patient's posture (its naturalness, compulsion, duration and variability during the day, increase or decrease in muscle tone, whether the patient resists attempts by the staff to change his posture, passive or active actions express this resistance, whether the patient changes an uncomfortable posture, how pantomimically reacts to external stimuli, pain, the offer of food). Attention should be paid to the facial expression of the substuporous and stuporous and patient, to the presence of vegetative and somatic disorders, whether the patient is neat in natural functions.

When describing the features of the patient's contact, one should indicate the presence of selective interest in certain questions and the nature of the reaction to them, hyperactivity in contact (intercepts the initiative of the conversation), indifference, lack of interest, negative attitude, anger, exhaustion during the conversation. Patients with lethargy and negativism should not be pointed out, made comments in a loud, categorical, imperative form - this usually not only does not improve contact, but can completely destroy it. The best contact is achieved if you communicate with them quietly, calmly, in the form of a request. In a conversation with delusional patients prone to dissimulation, it is not recommended to directly raise questions about the patient's worrisome, but painful experiences hidden by him. Patients with a relatively intact intellect and personality core are often sensitive to the doctor's attitude to their delusional experiences and therefore prefer not to talk about them. In the process of talking on neutral, abstract topics, vigilance, self-control of the subject decreases and individual experiences, features of judgments related to the hidden delusional or other psychopathological complex may appear. It should be borne in mind that by hiding delusional products from the doctor, the patient can report it to the middle and junior medical staff, patients, relatives and other persons. Delusional products with their thoroughness, detail, paralogical, symbolic judgments and other mental disorders can be reflected in the patient's written products and drawings. It is advisable to identify crazy ideas not by the method of a continuous (non-selective) survey in terms of trial and error, but after receiving preliminary information about probable, suspicious, possible crazy plots with an emphasis in the conversation in the first place on them. When trying to identify delusions in a dissimulating patient in a conversation on alleged "delusional topics" in cases where the patient does not respond verbally to them, one should observe expressive (non-verbal) manifestations (facial expressions, pantomime, voice timbre, eye gleam and others). Sometimes dissimulating patients give a particularly intensive refusal reaction precisely to the inclusion of a “delusional topic” in the conversation. Such delusional patients are characterized by uneven, elective contact: they talk much better about events that are not related to delirium, and become secretive, evasive, formal when the conversation switches to events associated with delusional experiences. After identifying the patient's non-criticality to 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 sure that the doctor recognizes the truth of his explanations, messages, fears and fears. Only a careful check of the possibility of correcting delusional constructions and their stability is allowed for the purpose of differential diagnosis with delusions, overvalued and delusional ideas. At the same time, the doctor should direct the edge of his arguments to the logically weak links of erroneous judgments, forcing the patient to justify them again. When talking with patients, it is not recommended to be distracted by conversations with other people, talking on the phone, taking notes, keeping the medical history on the table, as this can increase alertness, fears in anxious and some delusional patients. In some cases, a skillful psychotherapeutic regimen of relationships (Constorum IS) 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, vitality, fears of loss of health, disability, 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 a disease, symptoms in which a pathological process reveals itself, 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. The underestimation of the significance of subjective complaints is unjustified and, moreover, is ignoring the specifics of a person with his articulate speech, ability for reflection, introspection, and interpersonal contact. Taking into account the nature of the patient's complaints, the manner in which they are presented and described can help to choose the heuristic direction of the conversation when obtaining anamnestic information and examining the patient's mental state.

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

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

Apparently, it is more reasonable and expedient to move from identifying complaints of patients to an anamnesis of the disease, and not to an anamnesis of life, as is usually accepted in the schemes of the case history. Questioning about the patient's life after complaints and anamnesis of the disease will make it more focused and productive, will allow you to pay attention to many necessary details, facts, because the doctor's questioning about the patient's life will take place taking into account the primary diagnostic hypothesis. It is important, however, that the hypothesis be provisional, one of the possible, and not biased, final, unshakable. This will avoid the danger of suggesting facts and symptoms to the patient and drawing them into a diagnostic hypothesis. In many cases, it is useful to play several hypotheses, while 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. The diagnostic hypothesis should not bind the doctor's thought, it should be a working tool, help to obtain facts, contribute to their organization and comprehension, be steps to the final substantiated clinical diagnosis. Diagnostic hypotheses should not be gloves that are easily thrown away, just as they should not be rags that for some reason are held on to, despite their uselessness.

1.4. Anamnesis

Repeated attempts have been made to evaluate the practical significance of each of the diagnostic methods. So, the anamnesis, according to Laud (1952), in 70% of cases, and according to R. Hegglin (1965), in 50% of cases, leads to a justified assumption about the diagnosis. According to Bauer (1950), in 55% of cases, diagnostic questions can be correctly resolved thanks to the examination and anamnesis, in addition, these methods 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 laborious process of identifying, clarifying and supplementing the necessary information, repeatedly returning to it to create, sift, polish and substantiate diagnostic hypotheses. When establishing a trusting contact with the patient and those around him, obstacles associated with existing prejudices, fears, fear, distrust of psychiatrists are eliminated, inadequate ideas about mental illnesses, about the fatal role of heredity in them are corrected, and often only after that the patient's relatives and other persons from his environment gives more detailed and reliable amnestic information.

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

At the beginning of the conversation, patients should be given the opportunity to freely present anamnestic information, while avoiding suggestion and leading questions. The danger of the latter increases significantly in the presence of memory gaps, with some individual characteristics of the patient (childhood, phenomena of psychophysical infantilism, hysterical personality, increased suggestibility). The questions asked during the examination should only activate, stimulate the patient to an open, frank presentation of the medical history, family history and life history. An example of this kind of question is: “What childhood memories do you have of your father? Mothers? About past illnesses? Other variants of questions 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 laid in advance. For example: “Did you hear male or female voices when you entered the department?”. Active paradoxical suggestive questions are used (apparent denial of the fact, the existence of which the patient is supposed to have). For example: “Have you ever had conflicts with your parents? Brother? Wife? When using the last two options, positive answers should be carefully detailed and re-checked.

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 is especially great, which often has a unique, unrepeatable character. The second and subsequent conversations usually proceed differently, but the prerequisites for their productivity are already laid in the first conversation.

At the beginning of the conversation, the psychiatrist takes a somewhat passive position - he listens attentively. 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 a real disease, the patient's life has to be based mainly on their involuntary memorization. Previously, it was believed that it is not always complete and accurate, but this is not entirely true. Involuntary memorization can be more accurate and reliable than voluntary memorization, but unlike the latter, it requires the doctor to actively work with the respondent. It is important to avoid leading, inspiring questions. However, it is necessary and permissible to use clarifying, supplementing, detailing, recalling, controlling questions. One should strive to obtain confirmation of the statements expressed by the patient and relatives with specific facts and examples. Subsequently, when observing relatives of the patient during visits, medical leave, in remission, the doctor can turn on the deliberate (arbitrary) memorization of relatives, giving them a certain observation scheme. Obtaining anamnestic information in a psychiatric clinic has its own specifics. In a significant number of patients, upon admission to the hospital and during their stay in it, it is generally not possible to obtain anamnestic information due to the peculiarities of their mental state (syndromes of stupefaction, confusion and narrowing of consciousness, catatonic and apathetic substupor and stupor, various types of excitation, severe depressive syndromes ). In other patients, anamnestic information can be obtained in an inaccurate or deformed form (patients with Korsakov's, psychoorganic, dementia syndrome, oligophrenia, gerontological mentally ill, children). In such cases, the role of an objective anamnesis immeasurably increases, which sometimes have to be limited.

When receiving anamnestic information in a conversation with the patient, his relatives, the degree of detail of certain sections of the anamnesis depends on the proposed diagnosis (on the preliminary diagnostic hypothesis). Thus, in patients with some forms of neurosis and psychopathy, a detailed study of the characteristics of family education, 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, and organic diseases, data from early childhood (including prenatal and antenatal) history. Each nosological form has its own priorities for sections of the anamnestic study.

The share, value of subjective and objective anamnestic information compared with the data of mental, neurological and other studies in various diseases differ significantly. The value of an objective history is especially high 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 on the structure of the personality, its social adaptation, because when talking with a doctor and in a hospital, patients often hide, dissimulate many personal characteristics, features of their behavior in order to show themselves from the best side. It is desirable 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 present illness.

Possible pathogenic factors that preceded the debut of the disease or its relapse are identified and described: acute and chronic infectious and somatic diseases, intoxication, pathology in childbirth, malnutrition, external and internal conflicts in everyday life, family, at work, loss of loved ones, fear, job change , place of residence and others. It should be borne in mind that it is often allowed to mix random factors that preceded the onset of psychosis or its relapse 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 preneurotic radical from the first years of a child's life is overlooked, the significance 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 such questions: “Until what time 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, ascertaining the patient's attitude to the symptoms.

When re-hospitalizing, the medical history should briefly reflect (using archival case histories and an outpatient psychiatric dispensary card) the clinical picture of the disease for all admissions, the dynamics of the disease, the nature of light intervals and remissions, the formation of a defect, data from paraclinical studies (EEG, CT, and others) , the number of relapses, conducted inpatient and outpatient therapy. It is advisable to pay attention to the entire arsenal of previously used biological therapy and its other types, to the doses of drugs, to the results of treatment, adverse reactions and complications, to their nature, severity, duration and outcome. When studying remissions and light intervals, it is necessary to reflect in the history of the disease their quality, depth and clinical features, difficulties in labor and family adaptation, clarification of their causes, as well as features of characterological changes that interfere with family and labor adaptation. Of interest is the state of the patient's home, 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 behavior of the patient on the way, in the emergency room, pay special attention to suicidal tendencies.

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

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

It usually begins with a genealogical study, which involves the clarification of the following questions. The presence among the relatives of the patient (in a straight line - great-grandfather, grandfather, father; great-grandmother, grandmother, mother; siblings, children, grandchildren; on the lateral line - great-uncles, grandmothers, uncles, aunts, cousins, sisters, nieces, nephews; along maternal or paternal line) cases of deformities, left-handedness, delays and defects in intellectual development, in the development of speech, oligophrenia, 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 of parents to each other is revealed; the age of the parents at birth of the patient; with twinning - the qualification of monozygosity or dizygosity, the study of diseases in the second twin. It is important to obtain detailed information about the personal characteristics of the father, mother, other close relatives, about the social, economic, professional, educational status of the father and mother.

It is advisable to 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 interpreting them, it is necessary to take into account the possibility of different degrees of severity (expressivity of the pathological gene) and manifestation (penetrance of the pathological gene) of inherited signs of the disease, the diversity (clinical and type of heritability) of the same disease in relatives, as well as the possibility of phenocopies of mental illness , the possibility of developing endogenous mental illness in adulthood and late age (Alzheimer's disease, Pick's disease, Huntington's chorea, epilepsy, and others). A pronounced predisposition to mental illness is usually inherited to varying degrees, and mental illness manifests itself under the influence of certain external factors (mental trauma, infection, alcoholism, and others) mainly at a certain age (usually in critical age periods: puberty, maturation, involution). The disease can be clearly detected only in one family member (with incomplete penetrance), be transmitted through generations, or appear only in persons of a certain sex. When compiling pedigrees, it is important to obtain anamnestic data on the maximum number of persons who are related to the patient. It is desirable to obtain the results of paraclinical studies of the patient's relatives (biochemical, cytogenetic studies, EEG, and others). In some cases, it is necessary to examine some relatives to identify the syndrome of multiple anomalies (malformation).

Table 1.1

Conditional genealogical designations of signs

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

Pedigree example:

Legend: the proband's maternal grandmother had convulsive seizures, the proband's maternal aunt suffers from epilepsy, the proband's mother suffers from migraine. The data of clinical and genealogical research testify to the dominant nature of the inheritance of epilepsy in the proband.

The following important diagnostic data about the patient's parents and the features of his natal period are clarified. At what age did the mother begin menstruation and the nature of their course. The presence of somatic pathology (renal diseases, diabetes, congenital heart disease 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 other drugs means, exposure to radiation (including X-ray exposure), vibration, the effects of heavy physical labor, and so on. The presence of a burdened obstetric history in the mother (infertility, narrow pelvis, repeated miscarriages, multiple pregnancy, stillbirth, prematurity, neonatal death). Features of the conception of the patient and the course of the mother's pregnancy: conception in a state of intoxication, undesirability of conception, stressful conditions during pregnancy, infectious diseases in the first third of pregnancy (toxoplasmosis, rubella, cytomegaly, etc.), severe toxicosis of the first and second half of pregnancy, pathology placenta and polyhydramnios, Rh incompatibility, prematurity (less than 37 weeks) or overmaturity (more than 42 weeks) of the fetus. The nature of childbirth: protracted, rapid, with the imposition of forceps, Verbov bandage, birth in premature twins, intrauterine hypoxia, prolapse of the umbilical cord, premature detachment of the placenta, caesarean section and other surgical interventions. Childbirth pathology: asphyxia, cerebral hemorrhage, hyperbilirubinemia, need for resuscitation. It is necessary to pay attention to the following features of the neonatal period: deviation from the norm of body weight at birth, skin color, presence of jaundice, sucking disorder, decreased muscle tone, “twitching”, convulsive manifestations, diseases (especially meningitis, encephalitis), trauma, congenital developmental defects. An indirect indicator of damage to the nervous system in a newborn may be a late attachment of the child to the breast (on the 3-5th day), an extract from the hospital after 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 ascertained: alcohol abuse, the presence of radioactive and X-ray exposure, somatic and nervous diseases. Attention should be paid to indications of pathological abnormalities in the paraclinical examination of the mother, fetus and newborn (according to medical records).

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

The study of anamnestic information is simultaneously the study of the personality profile of a given individual before the illness, since the personality structure is reflected in the features of the biography, professional path and activity, in the features of relations in microsocial groups (family, school, production, military service), in the features of acquisition and manifestations of bad habits, as well as in the features of adaptation to stressful and psychotraumatic 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 hazards for the occurrence of this disease - “trace reactions”, according to Frumkin Ya.P. and Livshits S.M., 1966; “ the principle of the second blow”, according to Speransky A. A., 1915). This is especially true for the occurrence of reactive psychoses, epilepsy, late traumatic psychoses, psychoses due to previously transferred encephalitis, and some forms of alcoholic psychoses.

An important etiological factor in the development of a number of mental illnesses can be psycho-traumatic, depressive complexes formed in childhood as a result of the following factors: a sharp separation of the child from the mother with sending him to a nursery, 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 from parents, the presence of a stepfather, stepmother, psychophysical defects, discrimination from peers, difficulties in adapting to a public school, in team, features of teenage self-affirmation, etc. Information is needed about the characteristics of the personality of the parents, their education, profession, and interests. The nature of the family in which the patient was brought up should be assessed: harmonious, inharmonious, destructive, decaying, broken, rigid, pseudo-solidarity family (according to Eidemiller E. G., 1976). Peculiarities of upbringing in the family are noted: according to the type of “rejection” (undesirability of the child by sex, 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 features of the formation of preneurotic radicals: "aggressiveness and ambition", "pedantry", "egocentricity", "anxious syntonicity", "infantility and psychomotor instability", "conformity and dependence", "anxious suspiciousness" and "isolation", "contrast ”, with tendencies to auto- and hetero-aggressiveness, to “overprotection” (according to V. I. Garbuzev, A. I. Zakharov, D. N. Isaev, 1977).

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

It is important to pay attention to children's deviant behavioral reactions: refusal, opposition, imitation, compensation, overcompensation and others. Taken into account: age at admission to school; interest in school, academic performance, favorite subjects, repetition, how many classes he 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 due to the emerging sexual attraction (Lichko A. E., 1973); forms of behavioral disorders: deviant and delinquent, running away from home (emancipatory, impunity, demonstrative, dromomanic), vagrancy, early alcoholism, deviations in sexual behavior (masturbation, petting, early sexual activity, teenage promiscuity, transient homosexuality and others), suicidal behavior ( demonstrative, affective, true). Identification of the features of child development is especially important in the diagnosis of 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: study after school; features of military service; reasons for exemption from military service; lifestyle (interests, hobbies, activities); labor activity: compliance of the position with education and profession, promotion, frequency and reasons for changing jobs, the attitude of the team, administration, the situation at work before the disease; features of living conditions; past illnesses, infections, intoxications, mental and physical injuries; when he started smoking, the intensity of smoking; alcohol consumption (in detail): when he started drinking, how much and often he drank, drank alone or in company, the presence of a 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 a drug history: intolerance to psychotropic, anticonvulsants, antibiotics and other drugs, allergic reactions to food. In this case, the forms of reactions should be indicated: urticaria, Quincke's edema, vasomotor rhinitis, other reactions. It is desirable to obtain anamnestic information on these issues and in relation to the next of kin.

1.4.4. Sexual history.

The features of sexual education in the family are taken into account, as well as the characteristics 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 - the age of menarche, the establishment of the menstrual cycle, regularity, duration of menstruation, well-being in the premenstrual period and during menstruation. Features of libido, potency, onset and frequency of onanistic acts, homosexual, masochistic, sadistic and other perverse inclinations are noted.

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

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

The following facts of the sexual history are also of interest: the age of the patient's marriage; features of maternal and paternal feelings; were there any divorces, 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): a harmonious family, a disharmonious family (actually a disharmonious family, a destructive family, a disintegrating family, a broken family, a rigid, pseudo-solidary family according to Eidemiller E. G., 1976). If the patient is lonely, then the cause of loneliness and attitude towards it is clarified. It is established whether there are children, what are the relationships with them, the reaction to their growing up and leaving home, the attitude towards grandchildren.

It should be clarified whether the patient had breakdowns in social adaptation, whether he had the loss of loved ones and what is the reaction to them.

It is advisable to obtain characteristics for patients from the place of study, work, which would reflect: attitude to study and job duties, career advancement, character traits, relationships with the team, bad habits, behavioral characteristics.

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

In some cases, the detection of the onset of the disease presents significant difficulties due to the subtle nature of the symptomatology, 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 traits, especially during periods of age-related crises.

1.4.5. Forgotten History and Lost History(Reinberg G.A., 1951).

The forgotten history is understood as events, incidents, harmful factors that took place in the past, thoroughly forgotten by the patient and his relatives, but which can be identified with the persistent efforts of the doctor. For example, in the presence of clinical manifestations characteristic of the consequences of a traumatic brain injury and the absence of indications of such an injury in the anamnesis, it is necessary to re-analyze the features of ontogeny in detail and purposefully, including intrauterine, prenatal, perinatal and postnatal periods. At the same time, it is important to adhere to a special “sterile” survey methodology so as not to cause suggestive “memories” in the patient and his relatives. A lost anamnesis is events, facts, the impact of pathogenic factors in the patient's past life, which he himself does not know about, but they can be identified by a doctor with sufficient skill and perseverance from relatives, acquaintances, from medical and other documentation, as well as information which is lost to the doctor forever. Lost information can greatly complicate diagnostic work. Forgotten and lost anamnesis are of particular importance for the diagnosis of mental disorders in the long-term period after traumatic brain injuries and encephalitis. The forgotten and lost anamnesis includes not only external ordinary and exclusive etiological factors, events, harmfulness, but also information about heredity, erased, latent, atypical forms of pathology in relatives, especially in ascending generations and in the children of the patient, often missed in the question. Forgotten and lost anamnesis are rarely detected during a continuous, schematic, non-targeted survey, usually it is detected only if the doctor has a clear diagnostic hypothesis that has developed during the examination of the patient, with good contact with the patient and his environment.

The collection of anamnesis is not a simple shorthand thoughtless recording of information, facts, followed by a diagnostic assessment of them, but an intense, dynamic, constantly creative thought process. Its content is the emergence, struggle, screening out of diagnostic hypotheses, in which both rational (conscious, logical) and intuitive (unconscious) forms of the doctor's mental activity participate in their inseparable unity. The intuitive aspect of the diagnostic process should not be underestimated, and one should always 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 hypotheses, one should not forget about the so-called "economy of hypotheses", choosing the simplest ones that explain the largest number of discovered facts (Occam's principle).

1.5. Features of the personality structure

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

The asthenic type is characterized by: a narrow chest with an acute epigastric angle, poor development of the musculoskeletal and fatty components, pronounced supraclavicular and subclavian fossae, long thin limbs with narrow hands and feet, a narrow face with a sloping chin, a long thin neck with a protruding thyroid gland. cartilage and the seventh cervical vertebra, thin pale skin, coarse hair ("Don Quixote type"). This type of somatoconstitution correlates with schizothymia: lack of communication, secrecy, emotional restraint, introversion, craving for loneliness, a formal approach to evaluating events, a tendency to abstract thinking. In addition, there are restraint of manners and movements, a quiet voice, fear of making noise, secrecy of feelings, control over emotions, a tendency to intimacy and solitude in a difficult moment, 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, a strong development of adipose tissue (obesity), soft hair with a tendency to baldness (“Sancho Panza type”). The picnic type correlates with cyclothymia: good nature, gentleness, practical mindset, love of comfort, thirst for praise, extraversion, 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, a thirst for love, a tendency to gallant treatment, tolerance for the shortcomings of others, spinelessness, serene satisfaction, the need to communicate with people in a difficult moment ( Kretschmer E., 1915; Sheldon W., 1949).

The athletic type is characterized by: good development of bone and muscle tissue with a moderate development of the fatty component, a cylindrical chest with a right epigastric angle, a wide shoulder girdle, a relatively narrow pelvis, large distal extremities, a powerful neck, a face with pronounced superciliary arches, 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, a tendency to take risks, energy, desire for leadership, perseverance, emotional callousness, aggressiveness, love of adventure, in heavy minute need for activity, activity (Sheldon V., 1949).

Even E. Kretschmer (1915) revealed the predominance of individuals with asthenic physique among patients with schizophrenia, and among patients with affective pathology, people with a picnic 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 the 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 features of the main nervous processes (their strength, balance and mobility are the 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 signal systems - specifically the human, social type). The type of higher nervous activity is a genetically determined frame of personality. On the basis of this frame, under the absolutely necessary influence of the social environment and, to a lesser extent, the biological environment, a unique psychophysiological phenomenon is formed - a personality. Psychodiagnostics of a personality is possible on the basis of a 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

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

1. Strength of the excitatory process:

1) performance;

2) endurance;

3) courage;

4) decisiveness;

5) independence;

6) initiative;

7) self-confidence;

8) gambling.

2. Strength of the braking process:

1) exposure;

2) patience;

3) self-control;

4) secrecy;

5) restraint;

6) incredulity;

7) tolerance;

8) the ability to refuse the desired.

3. Mobility of the excitatory process:

1) how quickly do you fall asleep after the excitement?

2) How quickly do you calm down?

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

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

4. Inertia of the excitatory process:

2) to what extent do you achieve what you want at all costs?

3) how slowly do you fall asleep after worries?

4) how slowly do you calm down?

5. Mobility of the inhibitory process:

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

2) How quickly do you get angry?

3) how fast do you wake up?

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

6. Inertia of the braking process:

1) How slow are you?

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

3) How slowly do you wake up?

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

7. Status I signaling system:

1) the degree of practicality in everyday life;

2) expressiveness of facial expressions and speech;

3) a penchant for artistic activity;

4) how vividly can you imagine something?

5) How direct do people think you are?

8. State II signaling system:

1) How far-sighted are you?

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

relationships with other people;

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

4) the degree of inclination to mental work;

5) how self-critical are you?

9. Instructions for the study and processing of its results:

A person himself evaluates 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 of the VND type: if (M1 + M2): 2\u003e 3.5 - strong type (Sn); if (M1+M2):2< 3,5 - слабый тип (Сн).

2. The balance of the GNI type: if the difference between M1 and M2 is 0.2 or less - a balanced type (Ur), 0.3 or more - an unbalanced type (Нр) due to the nervous process that turned out to be greater: Нр (В> T) or Hp(T>B).

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 inhibitory process: if M6 > M5 - the inhibitory process is inert (Ti), if M5 > M6 or M5 \u003d M6 - the inhibitory process is mobile (Vp).

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

GNI type formula: example - 1>2 Sn Hp (V> T) VpTp.

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

The diagnostic value of elucidating the structure of personality can hardly be overestimated, since psychiatric pathology is a pathology of personality (Korsakov S. S., 1901; 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 patos - Snezhnevsky A.V., 1969). In exogenous psychoses, the personality structure largely determines the clinical form of psychosis.

1.6. Mental State Research

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

(A. A. Ukhtomsky)

Whatever experience the psychiatrist has, his study of the mental state of the patient cannot be chaotic, unsystematic. It is expedient for each doctor to develop a certain scheme for studying the main mental spheres. We can recommend the following quite justified sequence of the study of mental spheres: orientation, perception, memory, thinking and intellect, feelings, will, attention, self-consciousness. At the same time, the study and description of the 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 case histories.

A qualified examination is possible only if there is sufficient knowledge of the phenomenological structure of the main psychopathological symptoms and syndromes. This enables the doctor to develop a typed 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 period of the patient (childhood, adolescent, youthful, young, mature, elderly, senile), his sensorimotor, emotional, speech and ideation features.

In the case 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, an extensive amount of psychiatric information, but also a manner of communicating with the patient adequate to the mental state of the patient, the nature of the conversation with him. It is important to be able to "feel into" the experiences of the patient, while revealing 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 fix) what and how he said, to capture the non-verbal (expressive) components of the message, to qualify the nature and severity of psychopathological and neurotic symptoms, syndromes and their dynamics. The questioning of the patient in the study of his mental status should be delicate, "aseptic" (not of a traumatic nature). Significant (clinically significant) issues 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 - by the same and different methods (Samples V.P., 1915; Pervomaisky B.Ya., 1963; Vasilenko V.X., 1985). The essence of this rule in psychiatry is that the doctor, along with the utmost detail of the symptom, returns two or three times to identify and confirm it, using different formulation of questions. One should strive to confirm clinical signs by objective observation, objective anamnestic information (obtained from the words of other persons). At the same time, it is necessary to take into account the nature of the correspondence between the mental status of the patient and the data of the anamnesis, as well as the deforming effect on the symptoms of the psychotropic drugs taken by him.

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

Table 1.3

Correlation of psychopathological phenomena and their psychological analogues

The study of the mental state is hindered by insufficient knowledge of the differential differences in outwardly (phenomenologically) similar symptoms of the disease and syndromes (depression and apathy, illusions and hallucinations, mild stunning and abortive amentia, and others). An even greater danger is 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, finding out the fact of adultery in the case of delusions of jealousy, explaining the symptom of family hatred by the peculiarities of the puberty period, and so on. In order to avoid such errors, it is necessary, firstly, to remember about their possibility, and secondly, to carefully study the history of the disease. 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 - "Humanity").

In psychopathological research, it is necessary to give a detailed description not only of pathological disorders, but also of the “healthy parts” of the personality. It should be borne in mind that the constant synchronous recording of the information received, the results of the patient's observation may violate the freedom and naturalness of the patient's messages. Therefore, during the conversation, it is advisable to record only individual characteristic phrases, formulations and brief expressions of the patient, since recording "from memory" usually leads to inaccuracies, loss of valuable information, to smoothing, combing, impoverishment, desensitization of documentation. In some cases (for example, to fix 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, slipping, reasoning, and others), and not be limited to an abstract qualification of symptoms and syndromes - “sticking psychiatric labels”. A thorough description of the mental state often makes it possible, using anamnestic data, to reconstruct a more or less complex, sometimes long-term sluggish or inconspicuous course of the disease.

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

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

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 significance are presented in the section "Facial expressions, pantomimics and their pathology."

13.1. Examination of trauma patients

All patients with traumatic injuries should be seen promptly. The Emergency Nurses Association (ENA) has developed courses that teach how to examine trauma patients. In order to quickly identify life-threatening injuries and correctly prioritize treatment, primary and secondary examinations have been developed.

Initial inspection

The initial inspection begins with an assessment of:

Respiratory tract (A);

Breathing (B);

Neurological status, or disability (D);

Environmental conditions (E).

Let's take a closer look at the primary inspection of ABCDE.

BUT– before examining the airways in patients with trauma, it is necessary:

Immobilize the cervical spine with a cervical splint (collar), since until proven otherwise, it is believed that a patient with extensive injuries may have damage to the cervical spine;

Check if the patient can speak. If yes, then the airway is patent;

Check for blockage (obstruction) in the airways caused by the tongue (most common obstruction), blood, loose teeth, or vomit;

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

If the blockage is caused by blood or vomit, cleaning should be done with an electric suction. If necessary, a nasopharyngeal or oropharyngeal airway should be inserted. Remember that the oropharyngeal airway can only be used on unconscious patients. The oropharyngeal duct induces a gag reflex in conscious and semi-conscious patients. If the nasopharyngeal or oropharyngeal airway does not provide adequate air supply, the patient may need to be intubated.

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

Does the patient use additional muscles when breathing?

Are the airways heard bilaterally?

Is there any tracheal deviation or jugular vein swelling?

Does the patient have an open chest wound?

All patients with extensive trauma require hyperoxygenation.

If the patient is not spontaneously breathing freely or is not breathing effectively, a mask for artificial respiration is used prior to intubation.

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

Check for peripheral pulsation;

Determine the patient's blood pressure;

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

Does your skin feel warm, cool, or damp?

Did the patient sweat?

Is there obvious bleeding?

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

All patients with major injuries need at least two IVs, so they may need large amounts of fluids and blood. If possible, use a heater for solutions.

If the patient has no pulse, perform cardiopulmonary resuscitation immediately.

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

It is necessary to maintain immobilization of the cervical region until an x-ray is taken. If the patient is conscious and his mental state allows, then you should proceed to a secondary examination.

E- To examine all injuries, it is necessary to remove all clothing from the patient. If the victim has been shot or stabbed, law enforcement clothing must be saved.

Hypothermia leads to numerous complications and problems. Therefore, the victim must be warmed and kept warm. To do this, it is necessary to cover the patient with a woolen blanket, warm solutions for intravenous administration.

Remember that the initial examination is a quick assessment of the condition of the victim, aimed at identifying violations and restoring vital functions, without which it is impossible to continue treatment.

Table 8 shows the algorithm of actions during the initial examination of patients with trauma.

Table 8

Initial examination of patients with trauma

Secondary inspection

After the initial inspection, a more detailed secondary inspection is carried out. During it, all injuries received by the victim are established, a treatment plan is developed and diagnostic tests are carried out. First, check breathing, pulse, blood pressure, temperature. If a chest injury is suspected, blood pressure is measured on both arms. Then:

- establish monitoring of cardiac activity;

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

- use a urinary catheter to monitor the amount of fluid absorbed and excreted (the catheter is not used for bleeding or urination);

- use a nasogastric tube to decompress the stomach;

- with the help of laboratory tests, the blood type, hematocrit and hemoglobin levels are determined, toxicological and alcohol screenings are carried out, if necessary, a pregnancy test is done, and the level of electrolytes in the serum is checked.

Assess the need for family presence. Relatives may need emotional support, the help of a clergyman or a psychologist. If any of the family members wish to be present during resuscitation procedures, explain all manipulations performed to the victim.

Try to calm the patient. The victim's fears may be ignored due to the haste. This may worsen the condition of the victim. Therefore, it is necessary to talk with the patient, explaining what examinations and manipulations he is undergoing. Encouraging words and kind intonations will help to calm the patient.

To improve the patient's condition, anesthesia is also done and sedatives are used.

Listen carefully to the patient. Gather as much information as possible about the victim. Then carefully inspect the victim from head to toe, turn the patient over to check for back injuries.

Memo "the sequence of collecting information from the patient"

Subjectively: what does the patient say? How did the incident happen? What does he remember? What complaints does he make?

Allergy history: does the patient suffer from allergies, if so, to what? Does he carry a memo for doctors (in the form of an engraved bracelet, an extract from the medical history or a medical card with contraindications to drugs, etc.) in case of emergency?

Medications: Does the patient take any medications regularly, and if so, which ones? What medication has he taken in the last 24 hours?

Anamnesis: what diseases did the victim have? Has he had surgery?

Time of last meal, last tetanus shot, last menstrual period (if the patient is of childbearing age, it is necessary to find out if she is pregnant)?

Events leading to injury: how did the incident happen? For example, a car accident could have occurred as a result of a myocardial infarction while driving, or a patient was injured as a result of a fall during fainting or dizziness.

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

Therapist's examination ​

Date of inspection: ______________________
FULL NAME. patient:_______________________________________________________________
Date of Birth:____________________________
Complaints for pain behind the sternum, in the region of the heart, shortness of breath, palpitations, interruptions in the work of the heart, swelling of the lower extremities, face, headache, dizziness, noise in the head, in the ears ________________________________________________________________________

_
_______________________________________________________________________________

Medical history:___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________

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

Allergic history: not weighed down, weighed down ________________________________
_______________________________________________________________________________

The general condition is satisfactory, relatively satisfactory, of moderate severity, severe. Body position active, passive, forced
Build: asthenic, normosthenic, hypersthenic _____________________
Height __________ cm, weight __________ kg, BMI ____________ (weight, kg / height, m²)
Body temperature: _______°C

Skin: color is pale, pale pink, marble, icteric, redness,
hyperemia, cyanosis, acrocyanosis, bronze, earthy, pigmentation _____________________
_______________________________________________________________________________
The skin is wet, dry _____________________________________________________________
Rash, scars, striae, scratches, abrasions, spider veins, hemorrhages, swelling _______________________________________________________________________________

Oral mucosa: pink, hyperemia ____________________________________

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

Subcutaneous adipose tissue expressed excessively, poorly, moderately.

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

The cardiovascular system. The tones are clear, loud, muffled, deaf, rhythmic, arrhythmic, extrasystole. Noises: none, systolic (functional, organic), localized at the apex, in Botkin's t., above the sternum, to the right of the sternum ________________
_______________________________________________________________________________
Blood pressure ________ and ________ mmHg Heart rate _______ in 1 minute.

Respiratory system. Shortness of breath is absent, inspiratory, expiratory, occurs when _____________________________________________________________. Respiratory rate: _______ in 1 minute. Percussion sound clear pulmonary, dull, shortened, tympanic, boxed, metallic _____________________
____________________________. Borders of the lungs: unilateral, bilateral descent, upward displacement of the lower borders ______________________________ In the lungs during auscultation, breathing is vesicular, hard, weakened on the left, right, in the upper, lower sections, along the anterior, posterior, lateral surface ____________________________. There are no rales, single, multiple, small-medium-large bubbling, dry, moist, whistling, crepitating, congestive on the left, on the right, on the anterior, posterior, lateral surface, in the upper, middle, lower sections _____________________
_________________________________. Sputum_____________________________________.

Digestive system. Smell from the mouth ____________________________________. Tongue wet, dry, clean, coated __________________________________________
The abdomen ____ is enlarged due to p / fatty tissue, edema, hernial protrusions ___________________________________________________________, palpation is soft, painless, painful _________________________________________________________
There is a symptom of peritoneal irritation, no ___________________________________________
The liver along the edge of the costal arch, enlarged ___________________________________________,
____ painful, dense, soft, surface smooth, bumpy _____________________
_______________________________________________________________________________
The spleen ____ is enlarged ______________________________________, ____ painful. Peristalsis ____ is disturbed _________________________________________________.
Defecation ______ times a day/week, painless, painful, stool formed, liquid, brown, free of mucus and blood ____________________________
____________________________________________________________________________

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

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

Survey plan(specialist consultations, ECG, ultrasound, FG, OAM, UAC, blood glucose, biochemical blood test): ______________________________________________
_______________________________________________________________________________

Treatment plan:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Signature _______________________ Full name

See the attachment to the message for the full version of the document.

The initial examination by a gynecologist is carried out after a preliminary consultation and, according to indications, includes various manipulations. The main ones are: visual examination of the external genital organs, instrumental (examination of the walls of the vagina and cervix in the mirrors), manual vaginal and rectal finger examination, examination of the thyroid and mammary glands.

If the doctor suspects a pathology of the cervix or vaginal mucosa, a colposcopy is performed - an examination of the vagina and cervix with special optics - "under a microscope".

An examination by a gynecologist is usually accompanied by taking the necessary tests - these can be smear tests, DNA-PCR for "hidden" infections, crops, etc. At the same time, we use only individual disposable instruments (mirrors, probes) and consumables (test tubes, gloves, etc.).

WHAT IS INCLUDED IN THE INITIAL GYNECOLOGICAL EXAMINATION

manipulation	Basic prices	Inspection simple	Inspection complex	Inspection selective
External, instrumental inspection	300	+	+	*
Vaginal examination	500	+	+	*
Rectal examination	500		+	*
Thyroid examination	200		+	*
Examination of the mammary glands	500		+	*
Colposcopy simple	1500		+	*
Taking tests	350		+	*
Disposable instruments and consumables	0	0	0	0
TOTAL:		800	3850
A DISCOUNT:		0	60%	0
TOTAL:		800	1 500	in fact

Please note that here are the prices for an examination by a gynecologist, without the cost of the doctor's appointment itself. During the initial treatment, the examination is possible only at the appointment with a specialist. Below are the basic prices for some services.

1. Gynecologist appointment + examination (simple) - 2,500 rubles.
2. Reception at the gynecologist + examination (complex) - 3,200 rubles.
3. Appointment with a pediatric gynecologist (examination included) - 2,500 rubles.

HOW IS THE EXAMINATION AT THE GYNECOLOGIST AT 14 - 15 - 16 - 17 years

What does a gynecologist do when examining adolescent girls at 14, 15, 16 and 17 years old? What to prepare for when you see this specialist? Despite many prejudices, the procedure for such an examination is not terrible. Often it passes even without penetration into the vagina. First of all, an examination by a gynecologist at school is necessary for the timely detection of diseases and hormonal disorders. And certainly not the state of the hymen, as it seems to so many teenage girls who have a visit to the doctor. What are the features of passing an examination by a gynecologist in adolescence? How do virgins and teenage girls who are already sexually active go through a gynecologist?

GYNECOLOGIST AT 12 - 13 YEARS.

At the age of girls under 14 years of age, a standard examination on a gynecological chair is usually not performed. The doctor only checks the growing mammary glands, in which seals (mastopathy) can form, as well as the genitals - they determine the vegetation on the pubis. In girls at 12-13 years old, gynecologists evaluate visible puberty and set the date for the next visit to the doctor. Inspection at school on a chair at an early age is carried out only for girls 12-13 years old who have already experienced menstruation. Examination by a gynecologist at 12-13 years of age involves a visual examination of the external genitalia, the development of the mammary glands, the order of hair growth according to the age norm. If there are complaints, it is possible to check the condition of the internal genital organs through the anus. These manipulations are agreed with the legal representative.

GYNECOLOGIST at 14 - 15 - 16 YEARS.

Until recently, the first examination was held at school by a gynecologist at the age of 14, but today girls get into a chair at the age of 10-12 years. Why? It's all about the early sexual development of children and the natural restructuring of the body. All the changes that occur in the body of a teenager are controlled by the onset of the production of female sex hormones, which leads to an increase in the mammary glands, the beginning of vegetation in the armpit and on the pubis, as well as the onset of menstruation. The lack of a timely gynecological examination at 14, 15 and even 16 years of age leads to the neglect of gynecological diseases. Often, girls with ovarian cysts, acute cystitis, anomalies in the structure of the external genital organs, in particular, with obstruction of the hymen, leading to the impossibility of the release of menstrual blood to the outside, often show up in the departments of pediatric gynecology "by ambulance". Early initiation of intimate relationships is also fraught with both genital injuries and unexpected pregnancy and STDs.

HOW THE RECEPTION AND EXAMINATION OF TEENAGERS AT THE GYNECOLOGIST IS GOING ON

If you are a virgin and undergo a routine gynecological examination at a school or district clinic, then the matter may be limited to a brief conversation and an external examination of the genitals. If there are complaints or abnormalities identified during a visual examination, it may be necessary to conduct a rectal examination - an examination through the rectum, to understand the state of the internal genital organs. If you are sexually active or have experienced intimate relationships with vaginal penetration, then even at 13, 14, 15 or 16 years old, the gynecologist examines you on the chair in the usual way, like an adult woman. It may be useful to conduct an ultrasound of the small pelvis, passing smears on the flora. But this is already possible only in a clinical setting.

In general, the course of a visit to a gynecologist for an examination at the age of 15-16 looks something like this.

A gynecological examination of adolescents, which is first performed at 14 years of age and older, usually begins, like any other visit to the doctor, with a conversation. During her doctor asks questions about the state of health and available complaints from the genitals. The next is a general inspection. It begins with an examination of the skin of the girl, an assessment of their color, the state of hair growth. Then they proceed to examination and palpation of the mammary glands, during which the presence of suspicious formations is excluded. Further examination takes place in the gynecological chair, which girls are most afraid of. Depending on its design, the patient is located lying down, or in a semi-lying position, bending her knees, resting her feet on special supports. In this position, the girl's external genitalia are examined, and a vaginal and / or rectal examination is also performed.

The main stage of the examination of a teenager by a gynecologist, like an ordinary woman, is precisely an intravaginal examination with a mirror and hands. When it is carried out, a special gynecological kit is used, all the instruments of which are sterile or disposable. The latter, for obvious reasons, is more preferable. Vaginal examination is performed with sterile, disposable gloves; while measuring the size of the cervix, the condition of the uterus and appendages, surrounding tissues. This kind of examination is carried out already at an older age, when the girl is sexually active, which often happens after 14-15 years. An examination by a gynecologist of adolescents with an intact hymen is performed through the rectum.

• Do not watch such videos on the Internet and do not study other "manuals" - this only increases the feeling of fear, because everything depicted is far from reality;
• When examined in a gynecological chair, relax as much as possible - discomfort is caused precisely by tension;
• Trust the doctor, you are not the first to be looked at by a gynecologist at 14-15 and 16 years old on the chair;
• Do not take a shower or wash your genitals at least 3-4 hours before the intended examination;
• Do not shave or epilate yourself - pubic hair indicates the course of her puberty and hormonal status in general.

Further, it all depends on the results of the survey. If everything is in order, then go on your way. If not, the doctor in the examination room or the school gynecologist will write a referral for a consultation with a specialist in pediatric and adolescent gynecology.

GYNECOLOGIST AT SCHOOL

Will you have to go through a school gynecologist at the age of 14-15 while studying at school or before it, upon admission and while studying at the institute? A health certificate from this specialist in educational institutions is sometimes a necessary requirement. So, for example, a gynecologist at school for girls in grades 8-9-11 happens during medical examinations. It is carried out for the timely detection of "feminine" diseases and hormonal disorders. If problems are found, doctors give a referral to a antenatal clinic or a specialized clinic for an in-depth examination by a specialized specialist.

All this is correct and reasonable, but not all girls are satisfied with the conditions of how such school events are held: gynecological examinations are often accompanied by rudeness, incorrectness, doubts about the sterility of instruments and confidentiality of information, loss of time, nerves ... All this makes us look for an alternative way solve the problem.

HELP FROM THE GYNECOLOGIST TO THE SCHOOL

Doctors will be able to see you today:

Bezyuk Laura Valentinovna Obstetrician-gynecologist, gynecologist endocrinologist, specialist in pediatric and adolescent gynecology. ultrasound. STD. Reproductive medicine and rehabilitation. Physiotherapy

Vakhrusheva Diana Andreevna Obstetrician-gynecologist, endocrinologist, ultrasound diagnostics. Inflammation, infections, STDs. Contraception. Physiotherapy. Anti-aging intimate medicine and aesthetic gynecology