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Sumy state university medical institute




НазваSumy state university medical institute
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Дата06.06.2013
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Task 1


In a hospital by an ambulance the patient Н. 22 years was delivered. Common condition is severe, patient is adynamic. Overhead eyelids are tomentous, a patient can not unassisted hands open eyes. Skin pale, with a cyanochroic tint, tone of skeletal muscles is decreased, sounds hearts are muffled, extrasystolie, HR 130 in min, RR 40 in min, breathing superficial. The day before used the canned cucumbers in food. Other family members have clinic of the food poisoning, disorders of sight.

1 Formulate a preliminary diagnosis.

2 Plan of inspection.

3 Treatment.

Task 2


The patient К., 38 years, is hospitalized in a hospital with complaints about a headache, dizziness, general weakness, "net", "fog", doubling of objects in eyes, loop of vision. The laboured swallowing, dryness in mouth appeared in future. On the eve patient used the canned fungi in food. Objectively: Ptimalum, mydriasis, anisocoria, nasal voice, hoarse, speech inexpressive. At an auscultation in lungs - hard breathing, RR 28 in min Hearts Sounds are muffled, expansion of borders of relative dullness of heart to the left, HR 95 in min, arterial TENSION is 140/95 mm Hg

1 Formulate preliminary diagnosis.

2 Plan of inspection.

3 Treatment.


Task 3

In an infectious hospital a patient is delivered in grave condition. Became ill suddenly: pain in an epigastric area, appeared weight in stomach, muscular weakness. Temperature is normal. Moderate Ptimalum of eyelids, mydriasis, nystagmus, strobismus, getting of voice hoarse, joined in 5-6 hours. Internal organs: expansion of borders of heart, deafness of cardiac tones, bradycardia. It is set from epidemiological anamnesis, that 18 hours back ate the smoked sausage, caviar, pickled fungi. Two men, which ate the same foods, are in hospital in grave condition with similar symptoms.

1 Formulate diagnosis.

2 Name a causative agent.

3 With what diseases is it necessary to differentiate this pathology?


Task 4

In an infectious department patient 32 years is delivered in a day after the use of the pickled fungi. Became ill suddenly: vomiting, nausea, diarrhoea. Later on background of disappearance of nausea and vomiting complaints appeared about swelling of stomach, constipation, dryness in to the mouth, "fog" in eyes, doubling of objects, violation of swallowing. Objectively: consciousness is stored, temperature normal, arterial TENSION 160\100 mm Hg. Muffled cardiac tones, moderate tachycardia are determined. In lungs changes are not present. RR 22 in min. Take place Ptimalum, anisocoria, mydriasis, nystagmus, getting of voice hoarse. Stomach is swollen, a liver and spleen is not enlarged. Excrement without the pathological admixtures. In blood moderate leukocytosis with the change of formula to the left, speed-up ESR.

1 Formulate diagnosis.

2 What factors of transmission possible?

3 What duration of latent period?

4 What materials must be collected for specific diagnostics?

5 Prescribe specific diagnostics of disease.

6 Plan of treatment.


^ Standards of answers to the tasks

Task 1

1 Botulism, ophthalmoplegic, myasthenic syndromes, severe course.

2 General hemanalysis, urines. Authentication of botulotoxine in blood of patient (bioassay on white mise).

3 Lavage of stomach and intestines by solution of soda. Antibotulinic serum A, Е 10000 ME and B 5000 ME interval at 12 o'clock. Detoxication therapy, chloramphenicol 0,5 4 times per day during 5 days, oxygen therapy (hyperbaric oxygenation), symptomatic treatment.


Task 2

1 Food botulism, ophthalmoplegic, phonolaryngoplegic and phagoplegic syndromes, severe course.

2 Blood on the reaction of neutralization on white mise (bioassay).

3 Lavage of stomach, intestines by solution of soda. Antibotulinic serum A, Е 10000 ME and B 5000 ME interval at 12 o'clock. Detoxication therapy. Chloramphenicol 0,5 g 4 times per day in course 5 days. Symptomatic treatment. Oxygen therapy.


Task 3

1 Botulism, ophthalmoplegic, myasthenic syndromes, severe course.

2 Clostridium botulinum.

3 Food toxicoinfection, poliomyelitis, viral encephalitis, Guillain-Barre syndrome, poisoning of POS.


Task 4

1 Food botulism, ophthalmoplegic, phonolaryngoplegic syndromes, severe course. Myocarditis.

2 Food, infected by the spores of causative agent of botulism and anaerobic terms.

3 6-24 hours, an extension is possible to 10 days.

4 Hemanalysis, vomitive masses, scourages of stomach, defecating, bits and pieces of food with the purpose of exposure of ботулинического toxin.

5 Blood on the reaction of neutralization on white mise (bioassay).

6 Lavage of stomach, intestines by solution of soda. Antibotulinic serum A, Е 10000 ME and B 5000 ME interval at 12 o'clock. Detoxication therapy. Chloramphenicol 0,5 g 4 times per day in course 5 days. Symptomatic treatment. Oxygen therapy.


4 Materials for audience independent work

4.1 List of educational practical tasks which must be executed on practical class

  • To capture the methods of inspection of patient botulism.

  • To provide curation of patient botulism.

  • To provide differential diagnostics of botulism.

  • To work out a plan of laboratory inspection.

  • To interpret the results of specific inspection of patient botulism.

  • To recognize complications of botulism.

  • To work out a plan of treatment of patient botulism.

  • To define a medical tactic in the case of origin of the urgent conditions.

  • To draw medical documentation in fact of establishment of diagnosis "botulism".



4.2 Professional algorithm in relation to forming of skills and abilities of diagnostics of botulism


pores

Task

Sequence of implementation

Remarks, warnings in relation to self-control

1

2

3

4

1

To capture the methods of clinical inspection of patient by botulism

Complaints


Anamnesis of disease


Anamnesis of life

Epidemiological anamnesis


To distinguish complaints which characterize syndromes :

- - dyspepsia;

- - ophthalmoplegic;

- - phagoplegic;

- - phonolaryngoplegic


To pay attention on beginning, term, sequence of origin of symptoms, their dynamics:

- diplopia;

- odynophagia;

- diartria;

- violation of salivation;

- violation of breathing


To determine the carried diseasees


To determine given, about

realization of fecal-oral mechanism of transmission.

Use of the canned foods, sausage, smoked, salt fish by patient



1

2

3

4













2

To provide curation of patient

To provide an objective inspection


General examination


Digestive system


Nervous system



Expressed, dynamics of symptoms conditioned by duration and severity of course of disease


To pay attention on:

- cross-eye;

- Ptimalum of eyelids;

- - anisocoria;

- nystagmus;

- - hoarse voice, diartria. Speech not expressive


To pay attention on:

- - mucous membrane of cavity of mouth;

- flatulence;

- constipation;

- absence of peristaltic murmurs


To pay attention on:

- doubling in eyes;

- - "net", "fog" in eyes;

- mydriasis;

- - strobismus;

- violation of swallowing;

- allolalia;

- - miastenia;

- violation of breathing



1

2

3

4







Cardiovascular system


Respiratory system

To pay attention on:

- muffled tones;

- - tachycardia;

- expansion of borders of relative dullness of heart;

- systole murmur on apex


To pay attention on:

- oppressing of tussive reflex;

- limitation of function of intercostal muscles;

- violation of breathing (apnoea) rhythm;

- frequenting of breathing

3

To prescribe laboratory and additional researches

General analysis of blood


Hemanalysis, the vomitive masses, scourages of stomach, defecating

To pay attention on:

- neutrophilic leukocytosis with the change of leukocytar formula to the left;

- increase of ESR.


Presence of botulotoxine


^ Materials of post-audience independent work

Subjects of Research work :

Features of course of botulism in modern terms.

Modern methods of specific diagnostics of botulism.

Problems of etiotropic treatment of botulism today.

Modern looks to pathogenesis.


X URGENT CONDITIONS For PATIENTS WITH INFECTIOUS DISEASES WITH FECAL-ORAL MECHANISM of TRANSMISSION. DEHYDRATION SHOCK. ENTERORRHAGIA AND OTHER SURGICAL COMPLICATIONS. PRINCIPLES OF DIAGNOSTICS AND HELP.

^ CONCLUDING SESSION of RICH in content MODULE 1


Duration - 2 hours.


1 Actuality of theme. The urgent CONDITIONS for infectious patients develop often, especially at the severe course of disease. Wrong diagnostic decisions result not only in ineffective and uneffective medical measures, but present a threat for life of patient. What a presence or threat of development is before diagnosed at a sick critical condition and realization of reanimation measures is before begun, the greater probability of success is in treatment.

Knowledge of the urgent conditions for infectious patients is necessary for doctors of all specialities, especially those, who works in multi-field and rural medical establishments. They often remain in private with problems which arise up for a patient suddenly. From speed of decision-making, the rightness of actions of doctor life of man depends.


2 Educational aims of class (with pointing of mastering level which is planned)

2.1 A student must know:

а- 2

  • determination of dehydration shock;

  • pathogenesis of dehydration shock;

  • clinical and laboratory diagnostics of aquatic-electrolyte violations at the different degrees of dehydration;

  • differential diagnostics of dehydration shock with the shock conditions of other genesis;

  • principles of treatment, first aid to patient on the before-hospital stage;

  • pathogenesis of enterorrhagias;

  • clinic and laboratory diagnostics of enterorrhagias;

  • differential diagnosis of enterorrhagias;

  • principles of treatment, first aid a patient on the before-hospital stage.


2.3 A student must be able:

а- 3

  • to observe the basic rules of work at a sick-bed with the urgent conditions;

  • to take the case history;

  • to inspect a patient, ground a diagnosis for timely direction of patient in an in-patient department;

  • to provide differential diagnostics of the urgent conditions;

  • to work out a plan of laboratory and additional inspection of patient;

  • to interpret the results of laboratory inspection;

  • to work out an individual plan of treatment taking into account epidemiology data, stage of disease, to render the first aid on the before-hospital stage;

  • to give recommendations in relation to the regimen, diet, inspection, supervision in the period of reconvalescence.



3 Materials of before class of independent work

^ 3.1 Base knowledge, abilities, skills, necessary for the study of theme (intersubject integration)

Discipline

To know

Able

1

2

3

Previous disciplines

Microbiology

Properties of S. typhimurium, S. typhi, Vibrio cholerae. Methods of specific diagnostics

To interpret the results of specific methods of diagnostics of salmonellosis, cholera, typhoid

Physiology

Parameters of physiological norm of organs and systems of man; indexes of laboratory inspection are in a norm (general analysis of blood, urines, parameters of AAC, electrolytes et cetera)

To estimate data of laboratory inspection

Physiopathology

Mechanism of violation of functions of organs and systems at the pathological conditions of different genesis

To interpret pathological changes on results a clinical and laboratory inspection

Immunology and allergology

Basic concepts of object, role of the system of immunity, are in an infectious process, influence on the term of elimination of causative agent from the organism of man


To estimate data of immunological researches



1

2

3

Epidemiology

Epidemic process (source, mechanism of infection, ways of transmission) at salmonellosis, cholera, typhoid; prevalence of pathology in Ukraine and in the world

To take the epidemiology history, provide antiepidemic and prophylactic measures in the hearth of infection

Propaedeutics of internal diseasees

Basic stages and methods of clinical inspection of patient

To take the history, provide the clinical inspection of patient, define pathological symptoms and syndromes. To analyse finding

Clinical pharmacology

Pharmakokinetics and pharmacodynamics, side effects of facilities of specific nosotropic therapy

To prescribe treatment depending on the degree of severity of course, individual features of patient. To write recipes

^ Subsequent disciplines

Domestic medicine


Pathogenesis, epidemiology, dynamics of clinical displays, possible complications of infectious diseases. Principles of prophylaxis and treatment

To provide differential diagnostics of diseasees of different genesis. To recognize infectious disease, its complication; to interpret data



1

2

3







laboratory inspection. In good time to hospitalize a patient in an infectious in-patient department. To render the first aid in the case of necessity

^ Intrasubject integration

Infectious diseases

Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogenesis, epidemiology, dynamics of clinical displays, laboratory diagnostics, possible complications of infectious diseases.

To provide differential diagnostics of diseasees of different genesis. To recognize an infectious disease, its complication; to interpret data of laboratory inspection. To prescribe treatment. To render the first aid on the before-hospital stage

    1. Structure-logical chart of maintenance of theme

    2. List of the recommended literature

Basic:

1. Voizianova ZH.I. Infectious and parasitogenic diseases: in 3 b –K.: Health, 2002. - B. 3. - P. 354-389

2. Guidance on infectious diseases / edited Yu. V. Lobzin.- SPb.: Folio, 2003. - 1040 p.

3. E.P. Shuvalova Infectious diseases. - Rostov: Phoenix, 2001 - 953 p.


Additional:

4. N.A. Gavrisheva, Antonova Т. В. the Infectious process. Clinical and physiopathology aspects. - СП.B.: Special literature, 1999. - 255 p.

5. Clinical-laboratory diagnostics of infectious diseases : guidance for doctors. - SPb.: FOLIO, 2001. - 384 p.


^ 3.4 Materials for self-control

3.4.1 Questions for self-control

1 What diseases are accompanied by the syndrome of dehydration?

2 Stages of pathogenesis of syndrome of dehydration.

3 Basic clinical symptoms at the syndrome of dehydration.

4 Name the degrees of dehydration depending on the loss of liquid.

5 Basic cause of lethality at the syndrome of dehydration.

6 Plan of inspection of patient with the syndrome of dehydration.

7 Hemography of patient with the syndrome of dehydration.

8 Differential diagnosis of dehydration shock.

9 Determination of dehydration shock.

10 Clinic of dehydration shock.

11 Estimation of degree of dehydration on the before-hospital stage for a patient with diarrhoeaй.

12 Stages of provide of patient with dehydration.

13 Complex of medical measures at syndrome of dehydration.

14 What solutions need to be used for rehydration.

15 Perforation of bowel and enterorrhagia. Determination, etiology.

16 Pathogenesis, clinical displays of perforation of small intestine, term of origin .

17 Pathogenesis, clinical displays of enterorrhagia, term of origin.

18 First aid in the case of perforation of small intestine.

19. First aid in the case of enterorrhagia.

20 Plan of treatment of patient with an enterorrhagia and perforation of small intestine.


^ 3.4.2 Tests for self-control

To choose right answers

Variant 1

1 pathological condition which develops because of the catastrophic diminishing of volume of circulatory liquid and loss of electrolytes:

  1. dehydration shock;

  2. anaphylactic shock;

  3. infectiously-toxic shock;

  4. hemorragic shock.


2 Hypovolemic shock:

  1. dehydration of ІV level;

  2. dehydration of І level;

  3. dehydration of ІІ level;

  4. dehydration of ІІІ level


3 Hypovolemic shock develops because of loss of liquid at:

  1. all answers are true;

  2. bleeding (hemorragic shock);

  3. vomiting and diarrhoea;

  4. the long fever.


4 Mostly dehydration shock develops at:

  1. acute intestinal diseases;

  2. respiratory diseases;

  3. blood infections;

  4. diseases of external covers.


5 Diarrhoea syndrome and vomiting are reason:

  1. dehydration shock;

  2. anaphylactic shock;

  3. infectiously-toxic shock.


6 Compensated dehydration shock develops:

  1. at lack of changes of hemodynamics at ward;

  2. there is decline of systole arterial TENSION;

  3. hypotermia;

  4. at hypohemoglobinaemia.


7 the Subcompensated dehydration shock develops at:

  1. decline of systole arterial TENSION;

  2. increase of systole arterial TENSION;

  3. decline of diastole arterial TENSION;

  4. increase of diastole arterial TENSION.


8 Normal index of imperceptible losses of liquid for the grown man with mass of body 70 kg:

  1. 1000 ml in days;

  2. 500 ml in days;

  3. 700 ml in days;

  4. 1500 ml in days;


9 What type of diarrhoea is characteristic for salmonellosis:

  1. secretory;

  2. exsudate;

  3. osmotic;

  4. mixed?


10 Normal concentration of sodium in plasma of blood :

  1. 135-150 mmole/l;

  2. 125 mmole/l;

  3. 170 mmole/l;

  4. 110 mmole/l.


11 Normal concentration of potassium in plasma of blood :

  1. 3,5-5,5 mmole/l;

  2. 2,5 mmole/l;

  3. 2,0 mmole/l;

  4. 4,5 mmole/l.


Variant 2

1 Collapse, severe intoxication at typhoid develops on:

A - on the 1-2th week of disease;

B - on the 3th week of disease;

C - on the 4th week of disease;

D - on the 4-5th week of disease.


2 Bleeding at typhoid arises up on:

A - on the 3-4th week of disease;

B -на to the 2nd week of disease;

C - on the 1st week of disease;

D - on the 1-2 week of disease.


3 Bleeding at typhoid is accompanied:

A - by the decline of temperature of body;

B - by fervescence;

C - temperature does not change.


4 Excrement at an enterorrhagia:

A melena;

B - fetid;

C - an excrement does not change.


5 For an enterorrhagia at typhoid characteristically:

A tachycardia;

B bradycardia;

C asystole;

D diapulse.


6 In a blood test at an enterorrhagia:

A violation of coagulability of blood;

B hyperhemoglobinemia;

C leukocytosis;

D - normocytosis.


7 Enterobrosia at typhoid can come:

A - on the 3th week of disease;

B - on the 1st week of disease;

C - on the 2nd week of disease;

D - on the 5th week of disease.


8 Peritonitis at typhoid is accompanied by appearance:

A - protective tension of muscles of stomach;

B - absence of respiratory excursion of abdominal wall;

C stomach-aches;

D disappearances of hepatic dullness at percussion;

E - all answers are true.


9 Peritonitis at typhoid is accompanied by appearance:

A - Blumberg's sign;

B - Mayo-Robson's symptom;

in - symptom of Voskresensky;

D - symptom of Krymov.


10 Can the symptoms of acute appendicitis appear as complications of typhoid?

A - yes;

B - no;

C - not always;

D - often.


Standards of right answers

Variant 1: 1. A; 2. A; 3. A; 4. A; 5. A; 6. A; 7. A; 8. A; 9. A; 10. A; 11. A.

Variant 2: 1. A; 2. A; 3. A; 4. A; 5. A; 6. A; 7. A; 8. E; 9. A; 10. A.


^ 3.4.3 Situational tasks
1   ...   8   9   10   11   12   13   14   15   16

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