Diagnostic algorithm and types of diagnoses
In surgical practice, the diagnostic process is divided into several stages. First, the physician formulates a provisional diagnosis based solely on initial clinical examination data. The main goal of this stage is to outline a plan for specialized diagnostic methods.
Once the results of laboratory, functional, and instrumental tests are obtained, the definitive clinical diagnosis is established, forming the basis of the treatment plan. Any diagnosis must have a strict structure:
- Primary disease.
- Complications of the primary disease.
- Concomitant diseases.
The examination plan is always structured on the principle "from simple to complex" and "from non-invasive to invasive." Special methods include X-ray, ultrasound, endoscopic, and radioisotope studies, as well as biopsy.
Invasive procedures (diagnostic puncture, laparoscopy, thoracoscopy) that compromise tissue integrity are associated with a high risk of bleeding, internal organ damage, and infectious complications. Therefore, the physician must consider contraindications and prioritize safe methods. As soon as the cause of the patient's condition becomes clear, the diagnostic search is immediately terminated.
Glasgow Coma Scale
To assess the functional state of the central nervous system, the Glasgow Coma Scale (Glasgow Coma Scale) is used. It is most commonly applied in traumatic brain injuries, acute cerebrovascular accidents, severe poisonings, and endogenous intoxications. The patient's condition is evaluated across three responses:
- Eye Opening (Eye Opening): from 1 (no response) to 4 points (spontaneous opening).
- Verbal Response (Verbal Response): from 1 (absent) to 5 points (clear and oriented speech).
- Motor Response (Motor Response): from 1 (absent) to 6 points (obeys commands).
The total score ranges from 3 points (deep coma or brain death) to 15 points (clear consciousness). The prognostic value of the scale is high: patients scoring a total of more than 9 points have a significantly higher chance of successful recovery. The Glasgow Scale is also included as a component in more complex comprehensive severity assessment systems.
SAPS system and mortality prediction
For a comprehensive determination of general severity and outcome prediction, the SAPS (Simplified Acute Physiology Score) system is used. Its essence lies in assessing how much physiological parameters deviate from the norm (both upwards and downwards). If a parameter is normal, it is awarded 0 points.
The system takes into account 14 parameters:
- Patient age (over 45 years is scored).
- Vital functions: pulse, systolic blood pressure (SBP), body temperature, respiratory rate (RR).
- Fact of mechanical ventilation.
- Laboratory data: urea, hematocrit, leukocyte count, blood glucose, potassium, sodium, bicarbonate level ($HCO_3$).
- Neurological status according to the Glasgow Coma Scale.
The more a parameter deviates from the norm, the more points are awarded (up to 4 for each criterion). The final score directly correlates with predicted mortality. For example, a score of 5–6 points corresponds to a mortality probability of about 10.7%, a sum of 13–14 points to 30.0%, and at 20 points the risk increases to 81.1%. In clinical practice, similar prognostic systems—APACHE II and APACHE III—are also widely used.
Briefly: answers to topical questions
How is each score of the motor response (from 1 to 6) broken down in detail on the Glasgow Coma Scale?
The motor response according to the Glasgow Coma Scale is evaluated from 1 to 6 points depending on the response to commands or painful stimuli.
- 6 points — performing movements on command.
- 5 points — pain localization: the patient can point to the painful site or performs a purposeful movement toward the source of pain.
- 4 points — withdrawal of limbs in response to painful stimulation.
- 3 points — abnormal flexion in response to pain.
- 2 points — abnormal extension in response to pain.
- 1 point — absence of movements or response.
What comprehensive scales for assessing severity and multiple organ failure exist, apart from SAPS and APACHE?
In addition to the SAPS and APACHE systems, specialized prognostic indices are used to assess the severity of a condition and organ dysfunction.
- SOFA score (Sequential Organ Failure Assessment) — used for dynamic assessment of the severity of organ-system dysfunctions in patients with sepsis.
- Mannheim Peritonitis Index — a scoring system based on clinical risk factors for assessing severity and prognosis in peritonitis.
- Glasgow-Blatchford score (The Glasgow-Blatchford Bleeding Score) — used for predicting risks, mortality, and management tactics in gastrointestinal bleeding.
- Glasgow Coma Scale (Glasgow Coma Scale) — evaluates the functional state of the central nervous system and the degree of impaired consciousness.
For quick memorization of the Glasgow Scale criteria, use the English acronym EVM: Eyes — up to 4 points, Verbal — up to 5 points, Motor — up to 6 points (4+5+6 = 15).
Class and exam questions
What is the difference between a provisional diagnosis and a clinical diagnosis?
A provisional diagnosis is made based on the initial examination and is necessary to formulate a plan for special examinations. The clinical diagnosis relies on all collected data and determines treatment tactics.
When should the diagnostic algorithm be stopped?
The examination algorithm is stopped at any stage as soon as the clinical diagnosis of the disease is fully clarified.
What Glasgow Coma Scale score is considered favorable?
A condition is considered prognostically more favorable when the patient scores more than 9 points — this significantly increases the chances of recovery.
What does a score of 0 on the SAPS scale mean?
In the SAPS scoring system, zero points mean that the measured clinical or laboratory parameter is within normal physiological ranges.
What else to study on this topic
- Critical values of 14 laboratory and clinical parameters of the SAPS system
- Specific contraindications to invasive examination methods (laparoscopy, thoracoscopy)
- Comparison of prognostic systems SAPS, APACHE II, and APACHE III
- Assessment of abnormal flexion and extension during motor response testing on the Glasgow Coma Scale
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