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Sumy state university medical institute




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3.2 Structure-logical chart of maintenance of theme of class

^ Chart of diagnostics and treatment of cholera (Cholera)

Epidemiology anamnesis:




no

yes. Clinical displays:








yes, cholera Verification of diagnosis not







yes. A diagnosis is confirmed:

no



Treatment



Recovery: discharge



Observation:


Chart of diagnostics and treatment of dehydration shock



^ 3.3 List of the recommended literature

Basic:

1. Voizianova ZH.I. Infectious and parasitogenic diseases: in 3 b. - K.:Health, 2001. - p. 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, Antonova Т. В. the Infectious process. Clinical and physiopathology 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 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 Degrees of dehydration depending on the loss of fluid.

5 Basic reason of lethality at syndrome of dehydration.

6 Plan of inspection of patient with syndrome of dehydration.

7 Hemography of patient with 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 diarrhoea.

12 Stages of treatment of patient with dehydration.

13 Complex of medical measures at the syndrome of dehydration.

14 What solutions do need to be used for rehydration?

15 Features of causative agent of cholera.

16 Description of toxins.

17 Source of infection and factors of transmission.

18 Pathogenesis of cholera.

19 Classification of cholera.

20 Basic clinical syndromes of cholera.

21 Clinical displays depending on severity of course.

22 Complications of cholera.

23 Differential diagnosis.

24 Plan of inspection of patient with cholera.

25 Methods of specific diagnostics of cholera. Interpretation of results of laboratory research.

26 First aid to the patient with cholera.

27 Rules of discharge of reconvalescents from in-patient department.

28 Prophylaxis and measures in hearth.


^ 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 fluid and loss of electrolytes is:

  1. dehydration shock;

  2. anaphylactic shock;

  3. infectious-toxic shock;

  4. hemorragic shock.


2 Hypovolemic shock - is:

  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 fluid at:

  1. all answers are true;

  2. bleeding;

  3. vomiting and diarrhoea;

  4. 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 of:

  1. dehydration shock;

  2. anaphylactic shock;

  3. infectiously-toxic shock.


6 Compensated dehydration shock develops:

  1. because of lack of changes of hemodynamics at ward;

  2. there is arterial TENSION at the decline of systole;

  3. at hypothermia;

  4. at hypohemoglobinemia.


7 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 fluid for adult with weight 70 kg is:

  1. 1000 ml in day;

  2. 500 ml in day;

  3. 700 ml in day;

  4. 1500 ml in day.


9 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.


10 Mostly dehydration shock develops at:

  1. acute intestinal diseases;

  2. respiratory diseases;

  3. blood infections;

  4. diseases of skin covers.


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;

D - 4,5 mmole/l.


Variant 2

1 Cholera belongs to:

  1. food toxicoinfection;

  2. blood infections;

  3. enteroideas;

  4. viral diarrhoea;

  5. food intoxications.


2 causative Agent of cholera :

  1. pale treponema;

  2. fusiform stick;

  3. Vibrio comma;

  4. Vibrio cholera;

  5. Clostridium botulinum.


3 What toxins are distinguished by the causative agent of cholera :

  1. endotoxin;

  2. choleragen;

  3. all mentioned;

  4. exotoxin?


4 Source of infection at cholera:

  1. food;

  2. sick man and transmitter;

  3. water;

  4. grazing animal;

  5. canned foods.


5 Factors of transmission at cholera:

  1. food;

  2. unwashed vegetables;

  3. water;

  4. all mentioned;

  5. milk products.


6 Starting mechanism in pathogenesis of cholera :

  1. toxin, able to oppress the tissue breathing;

  2. defeat by the toxin of enterocytes of small intestines;

  3. defeat by the toxin of the digestive system;

  4. penetration of vegetative forms of causative agent from bowels in organs and tissues;

  5. defeat by the toxin of adrenic departments of the nervous system.



7 Duration of latent period at cholera:

  1. 2 weeks;

  2. 1 month;

  3. All are right;

  4. 2-3 hours - 5 days;

  5. 6-24 hours, continuation is possible to 10 days.


8 What research is basic for diagnostics of cholera :

  1. hemanalysis for the exposure of toxin;

  2. research of urine for the exposure of toxin;

  3. hemanalysis, the vomitive masses, scourages of stomach, defecating, bits and pieces of food with the purpose of exposure of toxin;

  4. research of foods for the exposure of vibrio;

  5. bacteriologic examination of the vomitive masses, scourages of stomach, defecating.


9 What preparation is used for etiotropic therapy at cholera:

  1. Bicillini - 5 intramuscular for 1500000 ME 1 time/day;

  2. Sol. gentamуcini sulfatis 4 % intramuscular 1 ml 3 times/day;

  3. Tab. Tetracyclini 0.3-0.5 D 4 times/day;

  4. Laevomycetini succinatis solubil.1,0 intramuscular 4 times/day;

  5. Tab. Rovamicini for 3000 МЕ 3 times/day?


10 For peroral rehydration they use:

  1. glucosolan;

  2. quartasol;

  3. threesol;

  4. acesol.



Variant 3

1 Way of transmission at cholera:

  1. respiratory;

  2. aquatic;

  3. transmissible;

  4. parenterally.


2 What research is basic for confirmation of diagnosis of cholera :

  1. general analysis of blood;

  2. bacteriological;

  3. serum;

  4. virologic?


3 Quarantine measures are conducted during:

  1. 5 weeks;

  2. 14 days;

  3. 5 days;

  4. not conducted.


4 Cholera belongs to:

  1. food toxicoinfection;

  2. blood infections;

  3. viral diarrhoea;

  4. enteroideas;

  5. food intoxications.


5 On what does severity of course of cholera depend?

  1. degree of dehydration;

  2. dose of toxin;

  3. product, that contains a toxin;

  4. condition of the nervous system;

  5. all mentioned?



6 Whether immunity is Produced after the carried cholera:

  1. not produced;

  2. compound-specific antitoxic is produced;

  3. compound-specific antibacterial is produced;

  4. is species-specific produced antibacterial?


7 What type of causative agent causes disease:

  1. viruses;

  2. helmints;

  3. vibrios;

  4. fungi?


8 Basic method of therapy :

  1. serum-therapy;

  2. antibiotics therapy;

  3. antiviral therapy;

  4. rehydration.


9 What complication is typical:

  1. enterobrosia;

  2. enterorrhagia;

  3. hemiparesis;

  4. typhoid?


10 Research of what material is most informing:

  1. blood;

  2. urines;

  3. faeces;

  4. saliva?


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 of 2: 1 A; 2 D; 3 C;4 B; 5 C; 6 B; 7 D; 8 E; 9 C; 10 A.

Variant of 3: 1 B; 2 B; 3 C; 4 D; 5 A; 6 A; 7 C; 8 D; 9 D; 10 C


3.4.3 Tasks for self-control

Task 1


The patient С., 18 years, complains about frequent stool. Diarrhoea began acutely, unexpectedly. Stool to 20-25 times per day, watery, "rice-water" reminds. Then the frequent vomiting joined without preliminary nausea. Vomitive masses remind "rice-water" also. Weakness, dryness, is marked in the mouth, thirst. Temperature of body 36,5 0С. It is known from epidemiological anamnesis, that patient 2 days back had a rest in a village for a grandmother, where used water from an open reservoir. At examination: skin of cyanotic tint, cold to the feel, turgor is decreased. A abdomen is pulled in, painless. Tachypnea, tachycardia, decline of arteriotony, oliguria, cramps of muscle of shin.

1 Formulate diagnosis.

2 Work out plan of inspection of patient.

3 Work out plan of treatment.


Task 2

Patient К., 20 years, complains about diarrhoea without a stomach-ache, which began acutely a day ago. Stool more than 20 times per day, watery, a "rice-water" reminds. Frequent vomiting without previous nausea. A weakness, dryness, in to the mouth, thirst are marked. Temperature of body 36,0 0С. It is known from epidemiological anamnesis, that 2 days prior to disease socialized with a patient which had alike clinical presentation. At examination: skin pale, with a cyanotic tint, a turgor is decreased, "hands of laundress", lines of face are sharp, voice hoarse, myotonias of shin. Arterial TENSION is 70/50 mm Hg, pulse of the weak filling 130 per min, tachypnea.

1 Formulate diagnosis.

2 Work out plan of inspection of patient.

3 Work out plan of treatment.


Task 3

There is a patient in the induction centre of infectious hospital. He has sharp lines of face, round eyes black circles, on face expression of suffering, a body is covered by cold then. Skin easily going to the fold which is not smoothed out. Abdomen falling back. Myotonias of extremities. An arteriotony is decreased. Heart sounds are deaf. Pulse threadlike. Temperature of body 35 0С. According to the relatives of house he had the frequent vomiting and diarrhoea. A patient 2 days back returned from India.

1 Formulate diagnosis.

2 Work out plan of inspection of patient.

3 Work out plan of treatment.

Task 4

Patient А., 66 years, became ill at 5 o'clock of morning, disease began with diarrhoea. Stool 5-6 times, in great numbers, at first excrement, then watery, turbid, with white flakes, odourless; vomiting 5 times; thirst, myotonias of shins. It is known from anamnesis, that 3 days back a patient was in locality, where the cases of acute intestinal infection are registered. Hospitalized in an infectious hospital in 6 hours after the beginning of disease. In an induction centre there was vomiting by a "fountain". Objectively: consciousness is stored, skin is dry, cold to the feel, turgor is decreased, tongue dry, cyanosys of lips, tag of nose, acrocyanosis, hoarse voice, falling back eyes, oliguria. The lines of face are sharp, mucous membranes of cavity of mouth and conjunctiva dry, hyperemic. Sounds of heart are muffled. In lungs is vesicular breathing, RR 26 in min, pulse 120 in min, rhythmic, weak filling, arterial TENSION is 80/50 mm Hg; abdomen is pulled in, painless. In blood: Нb - 160 D/l, er. 5,0х1012/l, leuc 10х109/l ( change of formula to the left), ESR-15 mm/hour, Нt 0,55/l, K+ 3,5 mmole/l, Na 130 mmole/l, Cl 90 mmole/l. Uranalysis: specific gravity - 1030, albumen is tracks, er. - 1-2 in eyeshot, cylinders grainy.

1 Formulate a diagnosis.

2 Define the degree of dehydration.

3 Provide specific diagnostics of disease.

4 Hearth of infection at this disease.

5 Name mechanisms and factors of transmission of infection.

6 To what factors is pathogenicity of causative agent related?

7 Work out plan of treatment.

8 Define time of quarantine measures.

9 Plan an urgent prophylaxis at contact persons.


Task 5

The common condition of patient is very severe. On questions answers hardly. Voice getting hoarse. Skin covers pale, dry, the lines of face are sharp, eyes falling back. Nail phalanxes are cyanotic. Tongue dry. The folds of skin do not fall out. Pulse threadlike. Arterial TENSION is not determined. Heart Sounds are acutely weak. Abdomen is pulled in. Frequent cramps of lower limbs, vomiting, diarrhoea, temperature of body 350С. From epidemiological anamnesis: 2 days back returned from a journey on Crimea.

1 Formulate diagnosis.

2 Name a disease causative agent.

3 Hearth of infection?

4 Name the mechanism of infection at this disease.

5 What immunity is formed at this disease?

6 Work out a plan of inspection of this patient.

7 With what diseases is it necessary to provide differential diagnostics?

8 Work out a plan of treatment.


^ Standards of answers to the tasks

Task 1

1 Cholera, typical form, gastroenteritis, severe course. Dehydration of III degree.

2 Bacteriologic examination of excrement, the vomitive masses. RA, RIHA, IEA.

3 In/salt solutions (threesol, acesol, quartasol and other) to stopping of vomiting, diarrhoea, renewal of hemodynamics, diuresis. In flow of time Tetracyclinum 1,2 D in day or doxycyclin 0,2 D in day during 5 days.
Task 2

1 Cholera, typical form, gastroenteritis, severe course. Dehydration of ІІІ degree.

2 Bacteriologic examination of excrement, vomitive masses. RA, RIHA, IEA. Speed-up methods: immobilization and microagglutination of 01-vibrios by anticholreric serum, REEF.

3 Rehydration infusional therapy by salt solutions (threesol, bisol, quartasol etc.) to stopping of diarrhoea and vomiting, antibacterial therapy (Tetracyclinum 0,3 g of х 4 in day or doxycyclin 0,1 g x 2) is whereupon possible during 5 days.


Task 3

1 Cholera, typical form, algide. Dehydration shock of ІІІ level

2 Clinical hemanalysiss, urine, coprogramm, hematocritis, relative closeness of plasma. Bacteriologic examination of excrement, vomitive masses (classic and speed-up).

3 Rehydration therapy by crystalloid solutions (threesol, bisol, chlosol et cetera), rehydron, heparin 150 ME/kg, prednisolon 5 mg/kg, aminocaproic acid.


Task 4

1 Cholera, algide. Dehydration shock of ІV level

2 Biotypes of Vibrio cholerae: Vibrio cholerae asiaticae, Vibrio cholerae El - Tor.

3 Patient and bacillicarrier.

4 Fecal-oral.

5 Proof, species-specific.

6 Bacteriologic examination of excrement, vomitive masses, sowing on 1% peptone water. Serum reactions of RIHA, RN, IEA. General analysis of blood and urine. Determination of hematocritis, specific gravity of plasma, electrolytes (K, Na, Cl), AAC of blood.

7 With salmonellosis gastroenteritis, shigellosis, escherichiosis, rotavirus gastroenteritis, poisoning fly-agaric, arsenic, methyl alcohol, antifreeze.

8 Rehydration therapy (bi/threesol, quartasol, solution of Ringer, glucose, with the subsequent passing to peroral rehydration). Etiotropic therapy (Tetracyclinum, doxycyclin). Symptomatic therapy.


Task 5

1 Cholera, typical form, severe course. Dehydration of 3th degree.

2 2 th degree by WHO, 3th degree by Pokrovskiy.

3 Material for research are defecating and the vomitive masses of patient. 1 Reaction of immobilization and microaglutination of vibrios by anticholeric О-serum and immunofluorescent method. 2 Sowing on 1% peptone water for the selection of clean culture and her authentication. The results of bacteriologic examination can be got in 24-36 hours. 3 With the purpose of retrospective diagnostics determine the titrus of vibriocide and agglutinating АB in RA (pair serums), diagnostic titrus of aglutinating antibodies 1:80 - 1:320, and vibriocide - 1: 1000.

4 Patients and bacillicarriers, reconvalescents.

5 Mechanism of infection is fecal-oral, ways of transmission aquatic, alimentary, contact-domestic. Factors of transmission: infected water, foods (milk, rice, fish, crabs, shrimps), dirty hands, flies.

6 Termal stabile endotoxin, termal labile exotoxin (choleragen) with strong entertoxic action, and also fibrinolysin, hyaluronidase, collagenase, neuraminidase and other

7 I/v rehydration are crystalloid solutions (threesol, bisol, acesol, lactosol), solutions are infused at speed 100-120 ml/min to 4 l, then 60 ml/min. After normalization of pulse, arterial TENSION is a transition on drop infusion of solutions. For a fight against acidosis - 4% solution of sodium (drop infusion 5 ml/kg) bicarbonate; droperidol 0,25% 0,5 mg/kg, Tetracyclinum 0,3 g 4 times a day no less than 5 days.

8 5 days.

9 Hospitalization in an observation hospital; Tetracyclinum 0,3 g 4 times per day on the extent of 4 days.


4 Materials for audience free work

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

  • to capture the methods of inspection of patients with cholera and dehydration shock;

  • to provide curation of cholera patient;

  • to provide differential diagnostics of dehydration shock, cholera;

  • to work out plan of laboratory inspection;

  • to interpret the results of specific inspection of patient with dehydration shock;

  • to recognize complications;

  • to define a medical tactic in the case of origin of the urgent conditions;

  • to draw medical documentation.


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

pores.

Task


Sequence of implementation

Notes, warnings in relation to self-control

1

2


3

4

1

To capture the methods of clinical inspection of patient with dehydration shock, cholera



^ I Find out the complaints of patient


II to Find out anamnesis:

1 Anamnesis of disease


2 Anamnesis of life


3 Epidemiological anamnesis


To separate complaints, which characterize syndrome of dehydration


To pay attention on: sequence of origin, dynamics of symptoms, peculiar to dehydration shock


To define suffered diseases


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

2


To provide curation of patient



II Provide objective inspection


1 General examination:

--general condition of patient;

--skin, mucous membrane of oropharynx


^ 2 Digestive system:

- a glossoscopy;


--percussion of abdomen;

--palpation of abdomen;


description of defecating


3 the Cardiovascular system:

- pulse;

- arteriotony;


- cardiophony


To remember: presence, expressed, dynamics of symptoms conditioned by term and severity of course of disease, depend on age of patient, concomitant pathology


To pay attention on:

- - languor, adynamy, dormancy of patient;

- - temperature of body;

- cyanosys of skin, acutely decreased turgor


To pay attention on:


- - tongue is incrustated by a white raid;

- dryness of tongue;

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


- amount, character, propensity to constipations


To pay attention on:

- - tachycardia;

- - mildly decreased arterial TENSION (a considerable decline testifies to complications);

- - moderate deafness of tones of heart

1

2

3

4

3

To prescribe laboratory and addtional researches

General analysis of blood


General analysis of urine


Bacteriologic research of defecating, vomitive masses, scourages of stomach.

Acid-alcalie condition

To pay attention on:

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

- increase of ESR

- albumen;

- specific gravity;

- amount

Presence of choleric vibrios


K+, Cl-, Na+, pH












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