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Ministry of public health of ukraine

Bukovinian state medical university


on the cathedral meeting of the

Department of patient care and higher nurse education


minute № ____

Head of department

Associate professor Plesh I.A.

Methodical guidelines

for 3rd – year students of the medical faculty

Module 2

The main duties and professional skills of nurse

at the surgical department

Semantic module 3

Surgical infection



Acute specific surgical infection

Subject: Nursing practice

3rd-year students of Medical faculty

Speciality: "General medicine" – 7.110101

7.110104 – "Pediatrics"

Duration - 4 hours

Methodical guidelines composed by:

Professor R.I. Sydorchuk

Assoc. professor O.Y. Khomko

Assistant R.P. Knut

Chernivtsi – 2008

AIM: To learn to distinguish and estimate value of syndromes in early diagnostics of a tetanus, to carry out complex prophylaxis and treatment. To acquaint students with clinical displays of anthrax, a diphtheria of wounds, to methods of prophylaxis and treatment.


The tetanus continues to remain one of 10 main reasons of mors of the population. Extremely long conservation of spores of the originator of anthrax in ground will cause of constant vigilance and knowledge of all aspects of this illness dangerous to the person. Important value gets also the professional factor. At cattlemen, shepherds, workers of the leather industry possible antrax, and at diggers, workers of an agriculture - a tetanus.


Spesific infection


It has been estimated that, every year, between 300 000 and 500 000 cases of tetanus occur worldwide with an overall mortality of 40 -15% In the UK, 200 cases occur annually, and the condition is also relatively uncommon elsewhere in Europe, in the USSR and in North America. The burden of this agonising infection falls on those in the other countries of the world, particularly on the children, the neonates, and on the eldery. Education programme to have universal active immunisation can and will lead to a reduction of the number of cases and, significantly, the mortality. Tetanus toxoid (now known as tetanus vaccine) practically eliminated tetanus in the armies during World War II. Today, if active immunity is properly initiated and maintained in an individual, death is unlikely even in the presence of clinical tetanus.

Closlridiumi tetanic the causal organism, is a Gram-positive anaerobic rod with terminal spores. Found in manure and soil (notably in market garden areas), it will invade any wound. It multiplies and produces a powerful toxin in any deep, contused wound in the presence of dead tissue, foreign bodies and other bacteria. Penetrating injury from the hoof of an animal can be associated'with this infeclion, while the prick of a rose thorn in a well-manured rose garden can be the sting of death of an elderly assiduous horticulturalist. The exotoxin produced in the inoculation site inhibits the cholinesterase at the motor endplates. resulting in an excess of acetylcholine locally and, therefore, a sustained state of ionic muscle spasm. The exotoxin also travels along the nerves to the central nervous system and causes extreme hyperexcitability of motor neurones in the anterior horn cells, thereby evoking explosive and widespread reflex spasms of muscle in response to sensory stimuli. Once fixed in the nerve tissue, the toxin can no longer be neutralised by antitoxin.

Period of onset. The shorter the interval between the first symptom and the first reflex spasm the poorer is the prognosis. If the interval is less than 48 hours, death is likely. It should be remembered that wounds containing tetanus organisms may have healed and been forgotten for months or years before some (unknown) change produces the right conditions for the organism to multiply and produce toxin (latent tetanus).

Symptoms and signs. Dysphagia, jaw stiffness and severe pains in the neck, back and abdomen precede the tonic muscle spasms. The sardonic smile (risus sardonicus) if tetanus is evidence of the onset of tonic muscle spasm. Respiration and swallowing become progressively more difficult, and reflex convulsions occur affecting all muscles and causing great pain, opisthotonus (spasm of the extensors of the neck, back and legs to form a backward curvature) and even muscle rupture. The spasms are spontaneous, but can be induced by trivial stimuli such as noise or movement and, when severe, will prevent respiration and produce cyanosis. Between the reflex convulsions, the tonic muscular spasm remains, thus distinguishing tetanus from strychnine poisoning. The temperature is elevated, the pulse is rapid, and respiratory failure and death during a cyanotic attack will usually follow if treatment is not initiated. At an early stage, the symptoms and signs of tetanus might be mistaken with tonsillitis, flu. backstrain, or an acute upper abdominal condition, therefore, careful examination of the patient for a wound is of paramount importance.

Treatment. Isolation, quietness and comfort, drainage of pus and wound toilet will be needed, tinman antitetanus globulin (e.g. Humotef) is given i.m. to limit the effects of free toxin and should be used in doses of 250-500 units to give cover throughout the period of establishing active immunity by giving toxoid (tetanus vaccine, adsorbed) i.m. Equine tetanus antiserum has been used but about 20 % of patients develop serum sickness and occasional anaphylactic reactions occur. Antibiotics, including penicillin and metronidazole, are indicated along with measures to protect the lungs.

Stage 1. A mild case, where there is tonic rigidity alone, will require initial sedation, relaxation by drugs such as promazine up to 200 mg i.m. and a barbiturate or diazepam (5 -50 mg i.v.). These drugs will be needed approximately 4 times during any 24-hour period.

Stage 2. A seriously ill patient, with dysphagia and reflex spasm, will need to have a nasogastric lube passed and sedation continued. The diet, the need for intravenous nutrition, (lie maintenance of balanced protein intake, and of renal function and cardiac function will be priorities. A tracheostomy should be considered if the patient find any difficulty in breathing. The meticulous care of the tracheostomy tube includes suction of mucus.

Stage 3. In dangerously ill patients, a major cyanotic convulsion will require curarisation, e.g. up to 40 mg tubocurarine i.v. initially and afterwards i.m. to maintain relaxation. It should be remembered that the curarised patient, though unresponsive, is conscious and sensitive and can hear everything that is being said. Intermittent positive-pressure respiration should be provided, and intensive nursing care with increas-ing sedation would be needed because it has been estimated that a patient at this stage will require at least 350 individual acts of nursing each day. The objective is to reduce the risk of death from spasms or pneumonia wherever possible, while realising that a lethal amount of toxin has already caused severe damage to the motor neurones and the brain with concomitant myocarditis and vascular failure. If recovery takes place, the patient can be weaned from the ventilator (after about 14 days so long as convulsions do not recur when the effects of the relaxants wear off).

Results. With the proper attention to nursing care, prophylactic antibiotic therapy, active and passive immunisation against tetanus and, where indicated, tracheostomy, curansalior, and assisted respiration, the death rate can be reduced to approximately 15 %. The results in the very veiling and very old nevertherless are still poor. The tetanospasmin produced by the infection is insufficient to generate immune response so a course of immunisation is recommended on recovery.

^ Gas gangrene

Wounds allowing the patient's own faecal flora clostridial spores in the soil, to enter the tissues give rise to anaerobic gas-producing infections. Surgery around the hip joint and leg amputations are at one risk from this postoperative complication, as are wounds of warfare. Clostridium perfringens is usually the cause in about 80 %, other

Clostridia, including CI. uede mat ions, CI. histolyticum, CI. septicum, may be causal. The Clostridia produce numerous toxins, including an a-toxin believed to be important in the pathogenesis of gas gangrene. Clostridial invasion of a traumatised muscle of the whole of that muscle from origin to the insertion produces a foul-smelling necrosis of the bun which losecontfactibility and become dull red. or black in appearance. If septicaemia occurs, gas produced in many organs, notably the liver (which necropsy drips with frothy blood - the foaming liver).

Subcutaneous tissues alone can be infected; the smelling necrosis, often spreading extensively, begin in the margin of an abdominal or thoracic wound.

Clinical features. The wound is under tension between the sutures and the pouting edges exudating brownish and foul-smelling fluid. The skin becomes coloured - a khaki colour - due to associated haemol. Crepitus can usually be detected. (Crepitus, to examining hand, feels like an old hair mattress, radiograph will show the gas in the muscles or in the skin. The patient, although toxic and pale, raised pulse, misleadingly appears mentally clear.

Treatment, to be effective, requires immediate actions:

1. Maximum doses of penicillin (up to 2 g 4-hourly) js traditionally the treatment of choice, although there is a better outcome with clindamycin metronidazole:

2. blood transfusion;

3. either exposure of all the affected muscle groups by long incisions or in the subcutaneous infection multiple subcutaneous drainage and slough extraction by incisions into the subcutaneous tissue;

4. hyperbaric oxygen where this is available is said to be helpful in the postoperative period.

The use of antigangrene serum: CI. Perfringens 10000UN, CI. Septicum 10000UN, CI. Oedematiens 10000UN. depleted and there has been little interest in resuming production.


Mycobacterium tuberculosis, discovered by Robert Koch in 1882, while he was working in the Imperial Health Office, Berlin, Germany. This acid-fast bacillus is spread bv airborn infection (or from infected cows fn the case of bovine tuberculosis). There are three types of primary infection:

a) direct spread to lungs

b) from tonsils to the lymph nodes where an abscess may form and track round the sternomastoid muscle, producing a collar abscess;

c) from lower ileal infection to the lymph node, the ileocaecal angle. The bacterium, which produces no pigment, grows well at 37°C and may be seen, if there are very many organisms, in the Ziehl-Neelsen stained smear. Growth of the bacteria takes 6 weeks; thus sensitivities to antituberculous drugs will be delayed.

Guidelines for treatment. Nutrition and hygienic living conditions are still crucially important in preventing the spread of this infection.

Treatment with triple therapy consisting of rifampicin 600 mg, isoniazid 300 mg and pyrazinamide 1500 mg per day given orally for at least 2-3 months is standard chemotherapy at present, followed by months of double therapy by rifampicin plus isonia. Sensitivity testing is usually available at the end of first period of triple therapy and if the source of infection is with an organism that is resistant to these drugs, appropriate changes can then be made. Ethambutol may be of use in resistant cases. In case of pulmonary tuberculosis, the sputum should be examined to assess progress every month until smears are negative, but should the number bacilli increases or the cultures remain positive, development of resistance or noncompliance of patient with treatment should be considered. Genitourinary and orthopaedic tuberculosis is effectively treated by the standard 9-month course. The use of pyrazinamide with rifampicin and isoniazid may be required. All these antituberculous drugs have side-effects which may require repeated careful assement and control; isoniazid causes a peripheral neuritis, ethambutol produces visual impairment, rifampicin is hepatotoxic. Pyrazinamide should be avoided in patients with gout.

It should be remembered that it is impossible to eradicate every tubercle bacillus from the body. Dormant and enveloped in fibrous tissue, any remaining bacilli are still able to cause a flare-up of disease, particularly after trauma, after gastrointestinal operations resulting in nutritional deficiency, in old age, immune deficiency or long-term use of steroids.

^ Tuberculous peritonitis

Acute tuberculous peritonitis. Tuberculous peritonitis sometimes has an onset that resembles so closely acute peritonitis that the abdomen is opened. Straw-coloured fluid escapes, and tubercles are seen scattered over the peritoneum and greater omentum. Early tubercles are greyish and translucent. They soon undergo caseation, and appear white or yellow, and are then less difficult to distinguish from carcinoma. Tubercles occasionally simulate fat necrosis or the nodules of peritoneal carcinomatosis. On opening the abdomen and finding tuberculous peritonitis, the fluid is evacuated, some being retained for bacteriological study. A portion of the diseased omentum is removed for histological confirmation of the diagnosis, and the wound closed without drainage.

At other times, although acute abdominal symptoms arise, the presence of ascites makes the diagnosis ofucule tuberculous peritonitis reasonably evident.

Chronic tuberculous peritonitis. Although the incidence of turberculous peritonitis has declined in Britain, in many parts of the world where measures for eradicating tuberculosis (especially the disease in cows) are enforced less strictly, the condition still occurs.

Presentation. Abdominal pain is present in 90 %, fever in 60%, loss of weight in 60 %, ascites in 60 %, night sweats in 37%, and abdominal mass in 26%.

Origin of the infection. Infection originates from:

a) tuberculous mesenteric lymph nodes;

b) tuberculosis of the ileocaecal region;

c) a tuberculous pyosalpinx;

d) blood-home infection from pulmonary tuberculosis, usually the "miliary" but occasionally the "cavitating" form.

There are four varieties of tuberculous peritonitis: ascitic, encysted, fibrous and purulent.

^ Leprosy (Hansen's disease)

Cicrhard Hansen first showed that leprosy was a bacterial infection caused by M. leprae. Because of the stigma attached to leprosy, Dr R.G. Cochrane and others recommended that it should be referred to as Hansen's disease. There are probably from 10 to 15 million leprosy sufferers in the world today.

Leprosy is an infectious disease widely spread throughout the tropical and subtropical areas of the world. It is caused by M. leprae, an acidfast bacillus morphologically like the tubercle bacillus. It is mainly, but not entirely, contracted in childhood and late adolescence. While the mode of transmission regarding the portal of entry of M. leprae is not known, the source of infection is mainly from the nasal secretions of patients with lepromatous leprosy and not from their skin. Leprosy is no longer endemic in northern Europe, as it was in the Middle Ages, and in Norway until the late 19th century; neither is it now spread by immigrants in Europe. These facts suggest that leprosy requires for its transmission some factors associated with poverty or lack of hygiene that are common in the areas where it is still endemic. A vast change in the outlook for this disease has occurred in the last 30 years. The condition was formerly regarded as hopeless, but in spite of the fact that it is now curable, only 25 % of the cases of this widely spread disease are under treatment. It is probably true to say that leprosy causes more paralysis, deformity, and misery than any other disease, but that, in many cases, these could now be prevented by modern therapy, given an adequate service for early diagnosis.

Although leprosy is a systemic infection, it presents predominantly as an infection of the skin, upper respiratory tract and dermal and peripheral nerves. L.eprosy must always be considered in a patient presenting with a combination of skin and neural disorder.

Medical treatment. Until 1980, dapsone (diaminodiphenyl sulphone, DOS) was the standard treatment for leprosy. For multibacillary cases the treatment duration is 2 years or until negativity is achieved, whereas for paucibacillary leprosy (which includes all tuberculoid cases) the treatment duration is a month or until the lesions become inactive. Rifampicin, the first bactericidal drug against M. leprae, is given in a dose of 600 mg a day for 2 days at the beginning of each month, while DOS is given in a dose of 100 mg daily. This two-drug regimen is adequate for paucibacillary cases. For multibacillary leprosy clofazimine at 50 mg daily is added as the third drug.

^ Fungi and Yeasts

Fungi and yeast organisms belong to the group of eucaryotes that have a true nucleus surrounded by a nuclear membrane. Fungi are unicellular organisms that multiply in slender filaments called hyphae, with each cell attached at its end to the next. No cellular differentiation for various functions exists as in higher organisms. Reproduction is by budding. Specialized branches of the hyphae produce comidia, which are the spores representing the infectious particles transmitted by air or by aerosol droplets. In general, fungal disease is not passed from person to person. Certain fungi that grow only as unicellular organisms but reproduce by budding are called yeasts. Many fungi that produce significant infections are «dimorphic», that is, they may grow either as mycelia or as yeasts depending on alterations of circumstances such as the lower ambient temperatures in soil or at 37° C in the body. One such fungus is Histoplasma capsulatum, the organism responsible for histoplasmosis. Another type of dimorphic fungus is Coccidioides immitis, which grows naturally as mycelia but in the tissue as spherules. Proliferation in the body is by rupture of spherules, which release endospores capable of reproducing to form other spherules.

Fungi can invade the mucosa of the respiratory tract following inhalation. In certain parts of the world, fungal pulmonary disease is endemic, especially rural farming regions. This is primarily because of the nature of the soil and the presence of bird and other droppings in which these molds propagate. Among the more important diseases are histoplasmosis (H. capsulatum), blastomycosis (Blastomyces dermatidis), and coccidioido-mycosis (C. immitis). Although the pulmonary disease may be mild or transient, the danger lies in dissemination; for example, H. capsulatum is rapidly phagocytosed. The lymph nodes are quickly involved, and cellular immunity, the principal defense, develops within 2 weeks. The disease ultimately resolves by fibrosis and calcification of the foci, both in the lung and elsewhere. Cavities or masses in the lung or mediastinum must be differentiated from cancer or tuberculosis. Diagnosis may require a thoracotomy for resection or biopsy of the mass. The diagnosis of distant lesions in the skin also is frequently made by histologic examination in tissue. Wide dissemination of the fungus usually occurs only in debilitated patients or in those with immuno-suppression.

Treatment of the disseminated form of this infection, other than by draining or resecting abscesses, is limited to the use of amphotericin B, a drug with severe toxicity. Pulmonary infections by B. dennatitidis or C. immitis have many of the same clinical characteristics, as do their complications. The disease they produce is mild except for dissemination in patients with depressed immunocompetence. Skin, bone, and the genitourinary tract become involved, as well as the brain in coccidioidomycosis.

Opportunistic infection by ubiquitous fungi is primarily in debilitated or diabetic patients, in cancer patients undergoing chemotherapy, or in those taking steroids. The genus Aspergillus infects the sinuses, ears, and lungs. In the lung, cavities with fungus balls may require resection. Other infections, including mucomycosis, may invade arteries, resulting in infarcts and necrosis. The nasal structures are attacked, requiring debridement. Such organisms may cause serious problems in severe burns.

Candida and other yeasts of this genus, which may be normal inhabitants of the skin and gastrointestinal tract, become invasive in the mouth, vagina, and other organs when overgrowth occurs because of alteration of the normal flora. Candidiasis becomes invasive with various factors, including malnutrition, steroid or broad-spectrum antibiotic therapy, indwelling catheters, and immunosuppression. Hematogenous infection may be transient or may be responsible for distant abscesses, especially in patients with leukemia or lymphoma. Candidal endocarditis is common in drug addicts and in patients with abnormal heart valves. Despite therapy, the mortality is high (30% to 50%) in all such debilitated patients.


Viruses are important in surgery because of their ability to induce diseases that require surgical correction, such as congenital malformations or the induction of lesions. For example, hepatitis viruses cause hepatitis and subsequent cirrhosis. The second important feature of viral infection for the surgeon is the ever-present danger of contracting hepatitis by pricking the finger with a contaminated needle or by ingesting material contaminated with faeces or other body secretions from patients with hepatitis. Many other viruses can play a major role in tissue destruction and reduction of immunocompetence. This is especially true for patients in whom immunosuppression has been induced following organ transplantation. In this group, cytomegalovirus is an important cause of damage to liver, kidney, lung, and other organs.

  1. ^

    Objectives for Students’ Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

  1. The etiology, a pathogeny, clinic, diagnostics and treatments of a tetanus.

  2. The reasons of occurrence of feature of clinic and treatment of a wound's diphtheria.

  3. The anthrax. An etiology, a pathogeny, clinic, diagnostics and treatments.

I.Tests and Assignments for Self – assessment

Multiple Choices.

Choose the correct answer/statement:

  1. Patient A., 22 years old, has addressed for medical aid with complaints to a pain of constant character in a site of the right palm which amplifies at movements by fingers, the general delicacy, subfebrile temperature. Objectively: at the basis of the third finger of the right hand on a palmar surface it is marked callosity skins around of which the edema and hyperemia of skin are observed. Through epidermis the purulent exudation is visible. A palpation of a place of defeat morbid, violation of function of fingers and brushes. It is possible to think of what pathology?

    1. A hypodermic panaritium of the basic phalanx IIIrd finger of the right hand.

    2. A dermal panaritium of the basic phalanx IIIrd finger of the right hand.

    3. A phlegmon of median checkered space of the right hand.

    4. Subcallosal abscess.

    5. Articular panaritium of the IIIrd finger of the right palm.

  2. Patient G., 28 years old, has addressed for medical aid with complaints to a pain of constant character in a region of IInd finger of the left hand, infringement of function of a finger. Objectively: on a dorsum of the basic phalanx of the IInd a finger of the left brush the inflammatory infiltrate 1,5Ч2 сm with a necrotic hinge in center is determined . What disease takes place in the patient?

    1. A skin panaritium.

    2. A subskin panaritium.

    3. A carbuncle.

    4. A furuncle.

    5. Erizipelid.

  3. Patient A., 26 years old has received a microtrauma (puncture) of a nail phalanx of the IInd finger of the left hand. 5 days later has addressed in a polyclinic where the diagnosis was exposed: a hypodermic panaritium of nail phalanx of the IInd finger of the left hand. Under what anesthesia it is expedient to execute disclosing of a panaritium?

    1. Local infiltrative anaesthesia.

    2. An intravenous narcosis.

    3. Intraosseous anaesthesia.

    4. A conduction anaesthesia by Oberst-Lukachevitch.

    5. Intubation narcosis.

  4. Patient M., 60 years old, admit in surgical department 10 days later from the beginning of disease with complaints to pains in a region of the IInd finger of the left hand, infringement of function of a finger, the general delicacy, a fervescence up to 38°С. Objectively: a condition of the patient satisfactory, pulse 90 per 1 minutes, arterial pressure - 120/80 mm Hg., a body temperature 38°С, IInd finger of the left hand dwarfed, deformed, a skin hydropic, cyanotic. In the field of an average phalanx on a palmar surface - is a fistula up to 0,3 sm with purulent discharges. Flexion contracture of finger. Active movements are absent. On a roentgenogram a destruction of a bone of middlephalanx is determined.

What disease at the patient?

    1. A bone panaritium.

    2. A pandactylitis.

    3. Tendovaginitis.

    4. A subskin panaritium as "cuff link".

    5. A thecal whitlow.

Real-life situations to be solved:

  1. Patient E., 35 years old, was treated during 3 days concerning a thecal whitlow of the fifth finger of the left hand. On given time of the complaint for a pain in a hand, infringements of a flexion of the Ist and Vth fingers. Objectively: expressed edema and morbidity in the field of the Ist and Vth fingers, rise in temperature up to 38°C. What complication was developed in the patient?

  2. Patient K., 18 years old, has addressed in surgical department with complaints to a throbbing pain in the field of the thumb of the right hand. From an anamnesis it is known, that 2 days later has received insignificant wound in time of nails paring. Objectively: nails platen is swollen in lateral side, hyperemia is observed. From under it is allocated insignificant quantity of white pus.

Diagnose. Your tactics.

II.Answers to the Self-Assessment:

    1. D;

    2. D;

    3. D;

    4. B;

    5. U-like phlegmon of the left hand.

    6. Diagnosis: paronychia of the thumb of the right hand. Tactics: to raise with the help of a scalpel the nail platen for pus discharge.


Essential reading:

  1. Gostishchev V.K. General surgery /The manual. – M.: GEOTAR-MED, 2003. – 220p.

  2. Lectures prof. B.I. Dmitriev from Odessa State Medical University.

  3. Surgery: Text-book for English medium medical students / S.I. Shevchenko, O.A. Tonkoglas, I.M. Lodyana, R.S. Shevchenko. – Kharkiv: KSMU, 2001. – 344p.

  4. Kushnir R. Ya. General surgery /Lectures.- Ternopil, Ukrmedknyha, 2005.- 308 p.

  5. Butyrsky A. General surgery /The manual.- Simpheropol: publishers CGMU, 2004.- 478 p.

Further reading:

  1. Oxford handbook of clinical surgery / Edited by G.R. Mc Latchie, D.J. Leaper, 2002.- 930 p.

IV.Students’ Practical Activities:

    • Work 1. To distinguish the basic clinical attributes of a tetanus, antrax and diphtheria of wounds;

    • Work 2. Methods of specific prophylaxis and treatment of an acute specific surgical infection;

    • Work 3. - to prove the plan of individual treatment (conservative and surgical) an acute specific surgical infection;

V.Seminar Discussion Of Theoretical Questions And Practical Work:

VI.The initial level of knowledge and skills is checked by the decision of situational problems (tasks) from each theme, answers to tests such as "Step", constructive questions etc.

Students must know:

    • Definition, classification of a panaritium, a phlegmon of hand;

    • A clinical picture of a panaritium, a phlegmon of a hand;

    • Diagnostics and treatment of a panaritium, a phlegmon of a hand.

    • An etiology, a pathogeny acute hematogenous osteomyelitis;

    • Diagnostics and medical tactics of purulent diseases of bones;

    • Kinds of operative treatment;-

    • Chronic forms of osteomyelitis, their treatments;

    • An etiology, a pathogenesis, methods of diagnostics, the basic clinical attributes of a tetanus, antrax, diphtherias of wounds;

    • Methods of specific prophylaxis and treatment of an acute specific surgical infection.

Students should be able to:

    • to collect an anamnesis;

    • to lead objective inspection of the patient;

    • to distinguish the basic clinical attributes of purulent diseases of fingers and hands;

    • to lead diagnostics of an acute purulent pathology of fingers and hands on their kind and localization;

    • to prove the plan of individual treatment (conservative and surgical);

    • to give the reference on an aftertreatment of patients.


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Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine Bukovinian state medical university

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