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CHRONOLOGICAL DIAGNOSIS in RHEUMATIC DISEASES
Khanov A.G., Stazharov M.Yu.
Key words: diagnosis in therapy, types of diagnoses, chronological diagnosis, definition of the chronological diagnosis, uniform terminology of the diagnosis, nosological entity, disease complication, disease outcomes, consequences (results), syndrome, clinical situation, physiological process, organ function, subclinical organ damage, condition, clinical event, approximate chronological diagnosis of rheumatoid arthritis, application of the chronological diagnosis in medical practice.
Diagnosis is lies at the root of every action. The encyclopedic dictionary of medical terms of the Russian academy of medical sciences (2009) offers 21 types of the diagnosis. And this is only the beginning. With development of the diagnostic and treatment process new types of diagnosis can appear in the process of development of medical demands. At present we observe “the shift” to statistics in processing of diagnosis. Standardization is definitely useful and progressive. But at a certain period the patient as a human being and an organism drops out. Besides, requirements and comments to processing of clinical and pathologicoanatomic diagnoses as well as their coding take up large volumes. We offer introduction of the working notion – “the chronological diagnosis”.
The chronological diagnosis is a disease diagnosis of a certain person represented in the form of pathogenetic and chronological chains from the first cause moment and ending with recovery or a primary cause of death.
It doesn’t replace official records in medical documentation. It is included into interim annual epicrises of dispensary patients and into the section “Disease state” of an in-patient discharge summary. Disease progress through years or months can be described with three groups of notional terms:
The clinical event,
The condition,
The element of the morphological basis of the disease and arising functional disturbances, detected with laboratory, X-ray, morphological and other research methods.
Terminology for processing of the chronological diagnosis can be amended and changed in practice during “the trial period”.
The only obligatory condition is comparison of the morphological substrate with a new condition or a clinical event. Thus, the patient’s complains have relative value. It is important what organic and functional changes caused morphological disturbances in organs and tissues. It is also possible to track in real time the period of duration of the morphological “attack”, what organs and systems were involved, and the end of a specific episode of the disease. Filling in of the chronological diagnosis is a creative process depending on the tasks of a doctor – clinician. It is possible to track not the whole disease progress but only the part of it, but more thoroughly, for example the joint syndrome. Processing of the chronological diagnosis with the apparent lack of definition of its criteria can have a significant applied nature. The most important thing is assessment of personal “qualification” and results of treatment by certain conditions and clinical events.
Use of the chronological diagnosis in organization of medical assistance.
Coding of medical records using specific symbols in health care establishments with a large flow of patients as well as in private clinics.
Optimization of criteria of selectingpatients for admission to hospital, determination of indications for admission to specialized divisions for the effective use of the final fund of various in-patient departments at different stages.
Broaden options for use of the register data of patients with rheumatologic diseases from the standard list to selection of various patient groups in order to carry out differentiated therapeutic activities in different clinical groups.
Planning of medical treatment expenses depending upon the category of complexity of patients in specialized departments.
Specification of the criteria for assessment of quality of work of rheumatologic departments during expert examinations.
Brief and succinct description of the disease progress of a certain patient with real division based on tempo of the disease progress.
Improving consistency of operations between the inpatient and outpatientdepartments.
Application of the chronological diagnosis in treatment of a specific patient.
Assessment of efficiency of the conducted complex therapy and, primarily, baseline therapy.
Comparison of the clinical picture with the morphological (X-ray) stage of the disease.
Marking of medical cards with special symbols with specification of the X-ray stage of the disease, specific conditions and clinical events over the years.
Strict division of clinical presentations of the rheumatologic disease, its complications and comorbidity.
Individual treatment of a specific patient in conditions of medical aid standards.
Planning of admission to hospital to solve clinical tasks with subsequent expert assessment of medical procedures and their efficiency.
Assessment of economic expenses on treatment of rheumatologic diseases and medical treatment expenses depending upon the category of complexity of patients with regard to comorbidity of a specific patient.
Formation of the individual clinical “picture” of the rheumatologic patient.
Use of the chronological diagnosis by practicing doctors.
Formation of the own clinical archives, prediction of the patient’s disease progress, choice of drugs and therapeutic approaches in different clinical situations.
Besides, it is possible to compile the chronological diagnosis not only of the whole patient’s life, but also description of the disease progress with injury of a specific organ, a system or a certain anatomic area.
- The Ministry of Health Care of Russia established the list of terms and definitions of the uniform terminology used for regulatory documentsfor the system of standardization in medicine:
- nosological entity,
- complication;
- outcomes of diseases, consequences (results),
- syndrome,
- clinical situation,
- physiological process,
- organ function.
- Thus, the patient is defined as a consumer of a medical service turning to a medical establishment or a medical worker for assistance. Standardization and coordination of notions is an important progressive step in health care organization. But, in fact, it leads to determination of the patient’s state at the moment of ambulation, and one-time rendering of medical assistance in a certain disease. The health care system “loses” the motivation to “cure” the patient, and obtains the motivation to provide more services. We shall “combine” the language of statistics and the language of clinical medicine, taking into account that any disease is not a static but dynamic construction with its stages of development. Finally we need the patient’s diagnosis, not his/ her diseases. The clinical nosological diagnosis can be expressed in this case with a number of syndromes. “Intensity” of the syndrome will be determined with a number of symptoms in the syndrome. It is always interesting for a clinician to follow the disease progress and manifestations of the disease not only at the first visit but also during the long period to assess the nature of the disease progress, efficiency of the used treatment and development of a clinician’s own methods in selection of the therapeutic approach.
- Modern medical documentation is overloaded with different, not always necessary, or routine information. Description of a number of certain symptoms takes up a lot of space, but actually can be reduced to one or two phrases clear to specialists. Actually descriptions of rheumatic diseases progress are typical, only the number of their complications is unique.
- In this sphere the most progressive specialists are cardiologists who introduced the terms obvious to everybody: cardiovascular continuum, metabolic and ACS (acute coronary syndrome). They also widely apply succinct and generally accepted abbreviationsin diagnoses: LVH (left ventricular hypertrophy), DLP (dyslipidemia), AH (arterial hypertension), etc.Analogous examples can be found also in foreign medical literaturein rheumatology. So, the WHO and the International League of Associations for Rheumatology (1994) introduced the terms: symptom-modifying antirheumatic drugs — SM-ARD and disease-controlling antirheumatic treatment– DC-ART for classification of the RA therapy.
- We are interested in notions used in cardiology for description of various clinical conditions and their stages, such as: the subclinical organ damage, the condition, the clinical event. We haven’t found definitions of these terms in the available literature.
- In rheumatology such final points of observation as heart attacks, insults and deaths in cardiology do not reflect problems of our patients. It is desirable to distinguish levels of target lesions syndromes both on the morphological level and on the level of the whole body. Having described the disease progress of a certain patient using a set of terms characterizing organs damage, conditions and clinical events we obtain the medical history of the rheumatologic disease over several years. It is possible to summarize the case in any time interval. Simultaneously it is possible to assess the bijection of the disease – the target organ syndrome shall correspond to the organismic level syndrome.
- We offer description of the RAas an example.
| Subclinical organ damage (morphological substrate of target lesions or functional disturbances) | Condition | Clinical event |
| Synovitis – intraarticular exudate of free liquid. Erosive arthritis Fibrous and bony ankylosis Circumarticular osteoporosis Joint space narrowing Subchondral sclerosis | Joint deformity Joint subluxation Contracture Ulnar hand deviation, Hand deformity (Boutonniere deformity, Swan neck deformity, opera glass hand) DVR (digitus V rheumaticus) of the foot Valgus of the leg | Joint“attack” |
| Osteonecrosis | Simple necrosis of the femoral head, the semilunar and the ankle bones and that of other skeleton bones | Depressed fracture and secondary arthrosis |
| Osteophyte | Secondary arthrosis(as a complication, often of“radicular” joints) | Joint“attack” |
| Inflammation of synovial bursa | Bursitis (often in the region of the elbow joint) | Bursal abscess Baker’s cyst with possible breakage |
| Atlantoaxial joint arthritis | Subluxation (luxation) of the atlantoaxial joint with compression of the spinal cord or vertebral arteries | Tetraparesis (tetraplegia) |
| Arthritis of the cricoarytenoid joint | Dysphonic, respiratory and dysphagic disorders (rough voice, dyspnoea, dysphagia, recurrent bronchitis) | aphonia |
| Damage of the ligamentous apparatus (tendovaginitis, ligamentitis) | Tendinoussynovitis Tunnelneuropathy | Carpal tunnel syndrome, nerve compression syndrome (the ulnaland tibial nerves) |
| Rheumatic granulomas | Granulomatous valvular defects (often that of aortic valve) Rheumatoid nodules in skin and lungs | Development of the aortal valvular disease Rheumatoid nodules in lungs (Caplan syndrome) |
| Cutaneous vasculitis, ulcerative necrotizing vasculitis, nail bed infarction, digital arthritis, angiitislivedo | Livedo reticularis | Digital arteritis with sphacelation of fingers |
| Eye lesion | Scleritis, episcleritis, dry keratoconjunctivitis, peripheral ulcerative keratitis | Vision loss associated with scleromalacia |
| Heart damage | Pericarditis | Dry pericarditis, pericarditis with effusion, carditis |
| Lungs damage | Pleurisy, Damage of breathing passages Interstitial lungs damage |
Dry pleurisy, pleurisy with effusion. Pleural fibrosis. Bronchiectasia, bronchiolitis, panbronchiolitis. Interstitial pneumonia, acute eosinophilic pneumonia, Apicalfibrobullous disease,Caplan syndrome(RA +pneumoconiosis) |
| Lungs vascular injury (vasculitis) | Pulmonary hypertension, diffuse alveolar haemorrhage with capillaritis | alveolitis |
| Nervous system disturbance | Symmetrical motor and sensory neuropathy, mononeuritis multiplex, cervical myelitis | Paresis, plegia |
| Renal irritation | Nephritis, pyelitis | Urologic infection, chronic kidney disease, acute renal failure |
| Marrow failure | Anaemia, thrombocytosis, neutropenia | Anaemia Lymphadenopathy |
| Amyloidosis | amyloidosis of kidney, lungs, bowels, lien, heart | Nephropathy with proteinuria and CKD enterobrosia, irritable bowel syndrome CHF |
| Focal and diffuse myositis | Muscleatrophy | Cachexia |
| Systemic osteoporosis | Reduction of bone mineral density | Pathologic fractures |
| Atherosclerosis | Arterial sclerotic disease | complications of cardiovascular diseases (MI, apoplectic attack, CHF) |
| Temporary or constant immunosuppression | Site of infection | Infectional arthritis |
| Temporary or constant immunosuppression | Frigorism, defatigation, stress | Subinfection |
| Temporary or constant immunosuppression | Opportunistic infections | Pulmonary tuberculosis, atypical mycobacterial infection, nocardiasis, aspergillus infection, cytomegalovirus pneumonitis |
| Inherited or acquired nonspecific drug hypersensitivity | Baselinetherapy Toxic lungs damage as a result of treatment NSAID gastropathy | Complications after the drug therapy with Methotrexate, gold salts, penicillamine, sulfasalazine, GIT ulcers, ruptures |
