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Sumy state university medical institute




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Materials of after-class free work

Subjects of Research work :

  • Features of course of infectious diseases in modern terms.


  • Modern methods of specific diagnostics of infectious diseases.

  • Problems of etiotropic treatment of infectious diseases today.



ІІ GENERAL DESCRIPTION OF GROUP OF INFECTIOUS DISEASES WITH FECAL-ORAL MECHANISM OF TRANSMISSION. TYPHOID. PARATYPHOIDS A AND B


Duration - 2 hours.


^ 1 Actuality of theme: typhoid meets in all regions, but most widespread in the countries of Africa, South America, Asia. Annually in the world about 33 million people are ill on typhoid, lethality in regions is 0,3-2,3 %. Spreading disease is promoted by absence of effective methods of sanitation of transmitters of S. typhi - basic source of infection (chronic transmitter of causative agent is formed at 2-4 % reconvalescents); firmness of causative agent is in an environment; fecal-oral mechanism of transmission; propensity of disease to epidemic distribution in regions with a low social and sanitary-hygenic level, in the conditions of ecological calamities; high enough receptivity of man to disease.

Distribution of typhoid in Ukraine is assisted by the low social and sanitary-hygenic level of population, natural calamities (floods in western areas and others like that), defects of utilits, development of international contacts, immigration processes ( from the countries of the Asian region), absence of the proper watchfulness, and often and corresponding knowledge for doctors.


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

2.1 A student must know:

а- 2

  • etiology of typhoid, factors of pathogenicity of causative agent;

  • epidemiology of typhoid;

  • pathogenesis;

  • clinical displays of typhoid at a typical course;

  • clinical-epidemiological features of paratyphoid A and paratyphoid B;

  • pathogenesis, terms of origin and clinical displays of complications of typhoid;

  • laboratory diagnostics of typhoid;

  • principles of treatment;

  • principles of prophylaxis;

  • tactic in case of origin of the urgent conditions;

  • prognosis of typhoid, paratyphoids A and B;

  • rules of discharge of reconvalescents from an in-patient department;

  • rules of the observation of reconvalescents.


2.2 A student must be able:

а- 3

  • to observe the basic rules of work at sick-bed with typhoid, paratyphoids A and B;

  • to take the case history with the estimation of epidemiology data;

  • to inspect patient, distinguish basic symptoms and syndromes of typhoid, ground a clinical diagnosis for timely direction of patient in an in-patient department;

  • to provide differential diagnostics of typhoid;

  • on the basis of clinical inspection in good time to recognize possible complications of typhoid, urgent conditions;

  • to draw medical documentation in fact of establishment of diagnosis "typhoid" (urgent notification);

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

  • to interpret the results of laboratory inspection;

  • to analyse the results of specific methods of diagnostics depending on material and period of disease;

  • to work out an individual plan of treatment taking into account epidemiology data, stage of disease, presence of complications, severity of the condition, allergist anamnesis, concomitant pathology; to render the first aid on the before-hospital stage;

  • to work out a plan of antiepidemic and prophylactic measures in the hearth of infection;

  • to give recommendations in relation to the regimen, diet, inspection, supervision in a 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. typhi, S. paratyphi A, S. paratyphi B; methods of specific diagnostics of typhoid


To interpret the results of specific methods of diagnostics of typhoid, paratyphoids A and B


Physiology


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

To estimate data of laboratory inspection

Physiopathology


Mechanism of violation of functions of organs and systems at the disorders of different genesis


To interpret pathological changes on results of laboratory inspection at the parafunctions of organs and systems of different genesis

Immunology and allergology


Basic concepts of object, role of the system of immunity, in an infectious process, influence on the term of elimination of causative agent from the organism of man. Immunological aspects of chronic bacterial transmitter

To estimate data of immunological researches


Epidemiology


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

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

Neurology



Pathogenesis, clinical signs intoxication encephalopathy

To provide a clinical inspection

patient with the defeat of the nervous system

Dermatology


Pathogenesis, clinical description of exanthemas

To recognize a rash for a patient with typhoid

Surgery


Clinical-laboratory signs of perforation of ulcer of small intestine, enterorrhagia, tactic of the first aid


In good time to diagnose these complications, prescribe a corresponding inspection, render the first aid

Propaedeutics of internal diseasees


Basic stages and methods of clinical inspection of patient


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

Clinical pharmacology


Pharmakokinetics and pharmacodynamics, side effects of chloramphenicol, cyprofloxacin, facilities of nosotropic therapy


To prescribe treatment depending on age, individual features of patient, to choose the optimal regimen of reception and dose of preparation, write recipes

Reanimation and intensive therapy



Urgent conditions:

  • ITS;

  • enterorrhagia;

  • perforation of intestines,




In good time to diagnose and give help at the urgent conditions





infectious-toxic encephalopathy




^ 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 an infectious disease, his complication; to interpret data of laboratory inspection. In good time to hospitalize 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



^ The scheme of diagnostic and treatment of typhoid fever (Typhus abdominalis)

The epidemiological anamnesis:


- during last 3 weeks there are no consumption of water from exit reservoirs, wellss, technical water; the consumption of unboiled milk, washed fruits and vegetables; the contact with persons had the fever state









yes. The clinical characteristic: no


- 1 week (the gradual start): graded rise of temperature, pale face, faint, adenamia; the typhoid tongue (large, dry, with white and grey covering, with prints of teeth on the limbs); the ulcer’s tonsillitis Duge; the characteristics of vagotonia: the concerning bradycardia with dicrotia of pulse; diffusion bronchitis, the symptom of Filipoveech (yellow colour of palms and phleghms); the symptom of Kotlarenko 1 (the phenomenon of crepitation in right a region under armpits); the symptom of Padalka (the dulling of percussion sound in ileocaecum region); ”the cross” symptom of Shtenberg (ache during the palpation on the pace of bruga from right region under armpits to left region under ribs).

^ 2 week (the period of heat): fever (the temperature lines as a type of Vunderlih, Botkin, Kildushevskii); status typhosus – the turbidity of consciousness, ”quiet” speaking; swarm: roseolosis with appearance on the 7 – 10 days of illness; and localization predominate on stomach and by sides; the quantity of roseoles is less – 5 – 15; monomorphia, roseola elevata; is added; conserved more then fever and disappear with out pigmentation; the fuligulosis tongue; the symptom of Kotlarenko 2 (the smell of amiak near the bed); the increase of liver, spleen, meteorism, constipatiti.

3 week (the period of complications): the intestinal bleeding, perforation of intestine with evolution of peritonitis the infectious and toxic shock.












yes yes, the typhoid fever. The verification of diagnosis: no


- the bacteriological examination (haemoculture, copro-, urino-, bili-, roseolo-, mieloculture, vomit, pus, liquor);

- the serological examination: RА of Vidal (the diagnosticlevel with О- and Н-Аg is 1:200; with Vi-Ag is 1:40); RIHA the method of paired serum (the increase of level of antititre in 4 and more times)



no

y
-the formation with definition of forms, severity, complications

The differential diagnosis with flu, swarm typhoid fever, paratyph no uses, Brucellosis, miliar tuberculosis, sepsis, pneumonia, leptospirosis, infectional mononucleosis, malaria
es
. The diagnosis is true no





Treatment:


- the hospitalization is necessary; the bed regime (to 10 day of normalization of body’s temperature); the diet № 4, 4B; the antibiotic therapy till 10 day of normal temperature (levomycetine, Ampicilline, Bactrime, Ryfampicine); the pathogenetic therapy: dysintoxicative (in veins: the solution of Ringer, 5 % solution of glucose, reopoliglucine, polialment solutions); the rise of resistance of organism (immunomodulative therapy, vitamins); treatment of complications






Recovery: discharge
- the clinical recovery on 21 day of normal temperature; the negative results of third times bacteriological examination of stool, urine and ones bile; for positive bacteriological analysis – treatment in stationary; with permission of epidemiological doctor there is the writing out of bacteriocarrier






Dispansarisation:
For the patients without decree: during 3 months in RID (thermometria, at the end – the bacteriologic examination of evacuation, urine, gall); on the inspection of SES – for 2 years. For patients with decree: during 2 years in RID (thermometria, bacteriological examination of evacuation, urine, gall); on the inspection of SES – during all life


3.3 List of the recommended literature

Basic:

1. Voizianova ZH.I. Infectious and parasitogenic diseases: in 3 b. - K.:Health, 2001. - С. 433-457.

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

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


Additional:

4. N.A. Gavrisheva, T.V. Antonova Infectious process. Clinical и pathophysiological aspects. - SPb.: 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 Way of transmission of typhoid, paratyphoids A and В.

2 Factors of pathogenicity of S. typhi.

3 Stages of pathogenesis of typhoid.

4 Morphological changes in the wall of small intestines depending on the period of disease.

5 Stages of cyclic clinical course of typhoid.

6 Basic symptoms of typhoid in the initial period of disease.

  1. Supporting symptoms of typhoid in height of disease.

  2. Description of rash for a patient with typhoid.

  3. Types of fever at typhoid.

  4. Features of paratyphoid A and paratyphoid В.

  5. Specific complications of typhoid.

  6. Pathogenesis, clinical displays of perforation of small intestine at typhoid, time of origin.

  7. Pathogenesis, clinical displays of enterorrhagia at typhoid, time of origin.

  8. Hemography of patient with typhoid in height of disease.

  9. Plan of inspection of patient with typhoid.

  10. Methods of specific diagnostics of typhoid. Interpretation of results depending on the period of disease and material for research.

  11. Etiotropic therapy of typhoid : doses, ways of introduction, duration of treatment.

18 Principles of nosotropic therapy of typhoid.

19 Treatment of complications of typhoid.

20 Rules of discharge of reconvalescents from an in-patient department.


^ 3.4.2 Tests for self-control

To choose right answers

  1. The causative agent of typhoid is:

A - Salmonella enteritidis;

B - Salmonella typhi;

C - Salmonella paratyphi A;

D - Salmonella paratyphi B;

E - Salmonella typhimurium.


2 Source of infection at paratyphoid A:

A is a patient with paratyphoid A;

B is a healthy transmitter of causative agent;

C is a cattle;

D is poultry;

E are rodents.


3 Latent period at typhoid mostly makes:

A - 1-3 days;

B - 3-7 days;

C - 9-14 days;

D - 14-25 days;

E - no less 21 day.


  1. Typical clinical displays of typhoid in height of disease:

A is diarrhoea with substantial aquatic-electrolyte violations;

B is an enteroplegia;

C is a fever;

D is insomnia;

E is a hepatolienal syndrome with an icterus.


  1. Status typhosus appropriately nosotropic predefined:

A - by the action of exotoxin;

B - by the action of endotoxin;

C - bleeding;

D – thrombovasculitis of vessels of cerebrum;

E - by inflammation of brain-tunics.


  1. Bile culture is prescribed to research:

A - on the first week of disease;

B - on the second week of disease;

C - on the third week of disease;

D - on the fourth week of disease;

E - on the fifth week of disease.


  1. For an exanthema at typhoid characteristically:

A - appears simultaneously with the increase of temperature;

B are single elements on a stomach;

C - appears at once, without rash in addition;

D - has roseola character;

E - appears not early than the 8th day of disease.


  1. Types of fever at typhoid:

A - Wunderlich;

B - Kildushvsky;

C - Botkin;

D - Padalka;

E - subfebrile.


  1. Typical changes in hemography in height of typhoid:

A is leukocytosis;

B is leukopenia;

C is a change of formula to the left;

D is a change of formula to the right;

E is an eosinophilia.


  1. Antibacterial therapy of typhoid is completed:

A - right after normalization of temperature;

B - on the third day after normalization of temperature;

C - on the 21st day of disease;

D - on a 10 days after normalization of temperature;

E - antibacterial therapy is not obligatory.


Standards of right answers

1. 2. A, 6. C; 7. B, C, D; 8. B; 9. B; 10. B


Dynamics of clinical symptoms of typhoid

Symptom

Week of disease

1

2

3

4

5

Increase of temperature

+

+

+

+

-

Headache

+

+

+

-

-

Insomnia

-

+

+

-

-

Typhus status

-

+

+

-

-

General weakness

+

+

+

+

+

Flatulence

+

+

+

-

-

stomach-ache

-

-

-

-

-

Rash

-

+

+

+

-

Symptom of Padalka

+

+

+

-

-

Symptom of Filippovich

-

-

+

+

+

Hepatolienal syndrome

-

+

+

+

+

Relative bradycardia

-

+

+

-

-


^ 3.4.3 Tasks for self-control

Task 1

For a patient during a week temperature rose gradually, appeared headache, general weakness, appetite decreased. Appealed to the doctor on the 8th day of disease. Objectively: temperature 39,5 0С, on questions answers languidly, answers clearly, skin pale, tongue is fuliginous, arterial TENSION is 100/60 mm Hg, pulse 74 in min. Flatulence, there are few roseolas on the skin of abdomen. Hepatolienal syndrome is determined. Constipations.

1 Formulate a diagnosis.

2 Plan of inspection.

3 Treatment.


Task 2

The patient of 32 years appealed to the district internist on the 5th day of disease with complaints about great headache, general weakness, absence of appetite, insomnia, increase of temperature from 37,5 0С in the first day of disease with her gradual increase to 39,0 0С in the day of appeal for medical help. Objectively: pallor of skin. A tongue is incrrustated by a greyish-white raid, imprints of teeth on sides, free of raid. Pulse 78 in min, arterial TENSION is 110/60 mm of Hg. A abdomen is mildly swollen, painless. A liver on a 1,5-2 cm comes under the edge of costal arc. Symptom of Padalka is positive. There is no stool during 2 days.

1 Formulate a diagnosis.

2 Plan of inspection.

3 Treatment.


Task 3

A patient 36 years ill about 3 weeks: gradual increase of temperature, which from the 2th week of disease purchased undulating character, decline of capacity, headache, insomnia. Treated oneself ambulatory with the diagnosis of "ARI". Because of absence of effect directed in an in-patient department. At examination: pale, adynamic, on questions answers languidly. Temperature 40 0С, fuliginous tongue, flatulence, positive symptom of Padalka. Liver comes on 2-3 cm from under the edge of costal arc. The bottom pole of spleen is palpated. In 2 days dizziness, sonitus, , death-damp on face, melena appeared after hospitalization. Arterial TENSION is 70/40 mm Hg, pulse 120 in min, temperature decreased to norm.

1 Diagnosis.

2 Plan of inspection.

3 Treatment.


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 with typhoid, paratyphoids A and В.

  • To provide curation of patient with typhoid.

  • To provide differential diagnostics of typhoid.

  • To work out a plan of laboratory inspection.

  • To interpret results of specific inspection of patient with typhoid.

  • To recognize complication of typhoid.

  • To work out plan of treatment of patient with typhoid.

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

  • To draw medical documentation at making of diagnosis "typhoid".



4.2 Professional algorithm in relation to forming of skills and abilities of diagnostics of typhoid, paratyphoids A and B




Task


Sequence of implementation


Remarks, warnings in relation to self-control

1

2

3

4

1


2



To capture the methods of clinical inspection of patient with typhoid, paratyphoids A and B


To provide curation of patient



I to Find out the complaints of patient


1 Anamnesis of disease

II to Find out anamnesis:


2 Anamnesis of life


3 Epidemiological anamnesis

II to Provide an objective inspection


1 General examination:

- it is the common condition of patient;


- it is a skin, mucous gutturs


2 Digestive system:

- glossoscopy;

- percussion of abdomen;

- palpation of abdomen;


- description of defecating



To distinguish complaints which characterize syndromes :

- - general intoxication;

- - organ defeats;

- - additional defeats


To pay attention on gradual beginning; term, sequence of origin, dynamics

- fever;

- - headache;

- - parahypnosiss;

- delays of stool;

- rash;

- - other symptoms


To find out the carried diseases


To find out data in relation to realization of fecal-oral mechanism of transmission, to pay attention on stay of patient in regions with

increased risk of infection of typhoid and paratyphoids A and B


To remember: presence, expressed, dynamics of symptoms predefined by a term and severity of course of disease, depend on age sick, to concomitant pathology


To pay attention on:


- languor, adynamy, dormancy of patient;

- - temperature of body;

- pallor of skin;

- presence, localization, character of rash;

- presence of quinsy of Duge (2 -5 % patients)


To pay attention on:

- "fuliginous tongue";

- hepatolienal syndrome;

- flatulence;

- positive symptom of Padalka;

- symptoms of peritonitis (presence testifies to the perforation of small intestine);

- propensity to constipations (appearance of melena testifies to the enterorrhagia)








3 Cardiovascular system:


- pulse;

- arteriotony;


- cardiophony


4 Respiratory system:

- it is an auscultation of lungs

5 Nervous system

To pay attention on:

- relative bradycardia (tachycardia testifies on complication!);

- - dicrotism of pulse;

- - mildly decreased arterial TENSION (considerable decline testifies on complication!);

- moderate deafness of tones of heart


To pay attention on:

- presence of signs of bronchitis at part of patients.

At severe course the typhus condition, delirium, hallucinations are possible

3



To prescribe laboratory and additional researches, to interpret their results


1 General analysis of blood



To pay attention on typical changes: leukopenia, lymphomonocytosis, aneosinephyllia, thrombopenia (leukocytosis, anaemia, acceleration of ESR arise up in the case of development of complications)








2 General analysis of urine

3 US of OAC

4 Hemoculture


5 Coprourine culture

6 Serum methods:

- RA, (Widal reaction) RIHA;

- - IEA


Absence of considerable changes at typical course

Hepatolienal syndrome

Prescribeed regardless of period of disease during all period of fever, desirably as possible before

From the end of the first week of disease

Prescribeed in the pair serums of blood with interval 10 days; diagnostic titrus - 1:200;

diagnostic titrus 1: 100


5 Materials of after-class of independent work
1   2   3   4   5   6   7   8   9   ...   16

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