Download Syndrome of fever

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MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Uniform tutorial
Theme: Fever syndrome
(Lesson 11)
Tashkent - 2011
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APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator
senior professor Rustamova M.T.
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Manual on uniform methodical system on the topic:
Fever syndrome
PRACTICAL SESSION № 11
Syndrome of fever in surgical infection
Topic: Characteristics of fever, skin changes and other clinical manifestations in general,
local, specific and nonspecific, aerobic and anaerobic infections. Differential diagnosis and
treatment. Tactics GP ..
1. Venue activities and equipment: clinic, hospital records of patients, test results, handouts,
quizzes, case studies.
2. Duration of training: 327 minutes
Chronological map of classes.
stages of training
form class
№
Duration
of activity
(327min)
1
Introductory speech teacher, study subjects
5
2
Discussion of homework. Interactive game "lottery"
The survey, discussion
(Annex № 1)
30
3
Admission of patients in the clinic, dispensary
work. Study dispensary cards.
Reception questioning,
examination of patients.
Primary surgical treatment
of wounds.
60
4
Improvement of practical skills, interpretation of
laboratory data, radiographs.
The algorithm of
60
break
30
5
Discussion of the practical lessons with the teacher.
A poll debate
35
6
Hearing the abstract of the report the student,
followed by discussion as a group
Abstract messages,
discussion threads
32
7
Group discussion as interactive games. The solution
of case problems on the wound, securing the
students' knowledge
Working in small groups,
interactive game
65
8
Conclusion lecturer on the topic. Evaluation of each
student on a 100 ballnoy system and announces it.
(Annex № 2,3)
10
4
Distributes tasks for self-training.
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Independent work in the library
Magazine, the work
program, questions for
self-training.
3. Session Purpose:
Surgical infection accompanied with fever - the most important cause of patients to a surgeon
clinics. Often these kinds of local surgical infection as a furuncle, carbuncle, hydradenitis,
lymphadenitis are due to lower immunity, and often the first manifestation of diabetes.
5. Interdisciplinary communication and vnutripredmetnye.
Biochemistry, pathological anatomy, patfiziologiya, therapy, endocrinology, infectious
diseases, anesthesiology and resuscitation, clinical pharmacology.
Lihorodka - a symptom of many diseases, most often it is observed in infections. Lihorodka
plays an important role in protecting the body against infection. An increase in temperature
increases the phagocytic activity of macrophages, increases production of interferon and
antibodies, and reduces the replication of some viruses.
Normal temperature:
- When measured in the oral cavity - 36,0-37,30 C (average 36.80 C)
- When measured in the armpit - 36.40 C
- When measured in the rectum - 37.30 C.
If the temperature in the oral cavity above 37.30 C, and in the rectum - 37.70 C above, we
speak of a fever. The temperature should be measured with a thermometer in the rectum in a
special envelope, or by catheter to the pulmonary artery. The temperature in the mouth also
can be very informative, but is a less reliable indicator. The temperature in the armpit, usually
does not provide the necessary information, so you do not measure. Normal body temperature
in many patients does not exceed 98,60 F (37,00 C). Fever above 990F (37,20 C) has a
definite clinical significance and should attract the attention of a doctor. Fever may be
accompanied by any inflammatory process in the body, but is a relatively late symptom. In
patients with gangrenous appendicitis before the development of perforation may have only a
moderate increase in temperature. Fever is not always indicative of the accession of bacterial
infection. Chill in combination with fever and bacteremia is usually observed is an indication
for the implementation of bacterial blood culture and find the source of the bacteremia.
Degree increase in temperature can have a value in the differential diagnosis. For example, to
start a high fever of acute appendicitis is not typical. The body temperature above 1020F
(38,90 C) indicated in bacterial peritonitis, salpingitis, pyelonephritis and pneumonia. The
high peaks of temperature, as defined in the same time (as a typical fence), there are abscess
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formation in the abdominal cavity. In general it can be assumed that patients with abdominal
pain, fever higher than the harder condition. It should be recalled that the fever and
abdominal pain are not always occur and require surgical intervention (eg, familial
Mediterranean fever). However, the variability of the temperature of the reaction in various
diseases of the abdominal cavity is so large that a diagnosis or, alternatively, to exclude any
disease solely on the basis of the temperature curve can not. In dehydrated patients or elderly
patients, the temperature reaction in suppurative-inflammatory diseases may be small or
absent. In young children, on the contrary, a high fever often occurs in mild disease.
Hypothermia also has to attract the attention of physicians because of septic phenomena may
be more important predictor than the fever. Antibiotics should be avoided until the cause is
still unclear fever, unless antibiotic treatment is not a necessary measure to reduce body
temperature.
Normally, the temperature can vary during the day at 10C. In the morning she is usually
lower than in the evening. The maximum temperature observed in the afternoon.
The temperature during infection does not exceed 40,5-41,00 C (as opposed to hyperthermia,
in which it is above 41.00). Hyperthermia - a pathological condition in which the heat
production exceeds heat dissipation. Hyperthermia is defined as I have said a significant rise
in temperature, usually above 410C. It is observed in heat stroke, as well as tumors,
infections, and hemorrhagic stroke with a lesion of the hypothalamus.
Classification of Fever
During fever
Fever is considered "severe" if does not last more than 2 weeks and the fever called "chronic"
when it is longer than 2 weeks.
In addition, during fever distinguish between temperature rise (stadium incrementi), during
the height of fever (fastigium, or acme) and a period of low temperature (stadium
decrementi).
Lowering the temperature is (and is detected by the temperature curve) is different. The
gradual, step-like decrease in temperature for 2-4 days with little evening rises are called
lysis. A sudden, rapid completion of fever with temperature drop to normal within a day
called the crisis. As a rule, accompanied by a rapid drop in temperature, profuse sweat. This
phenomenon before the antibiotic era attached special importance because it symbolized the
beginning of the period of recovery.
Increased body temperature (level)
Increased body temperature from 37 to 380 C is subfebrile fever (from Lat. Sub under, below
+ febris fever).
Moderately elevated body temperature from 38 to 390 C is called a febrile fever.
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High body temperature from 39 to 410 C was named pireticheskoy (from the Greek. Pyretos
fever) fever.
Excessively high body temperature (over 410 C) - is giperpireticheskaya fever. This
temperature itself can be life threatening.
Temperature curves
At elevated temperatures is important for the clinician not only once the measured
temperature of the body, and its dynamics over time. Typically, temperature measurement is
carried out 2 times a day (7-9 am and 17-19 pm). Daily fluctuations in temperature
(temperature curves) are helping to establish the type and form of fever.
Distinguish six main types of fever and 2 forms of fever.
It should be noted that our predecessors gave great importance to the temperature curves in
the diagnosis of disease, but nowadays all these classical types of fever are of little help in the
work as antibiotics, antipyretics, and steroids alter not only the nature of the temperature
curve, but the entire clinical picture disease.
Type of fever
1. Permanent or persistent fever (febris continua). There is a constantly raised body
temperature and during the day difference between morning and evening temperatures do not
exceed a 10 C. It is believed that this increase in body temperature characteristic of lobar
pneumonia, typhoid fever, viral infections (eg influenza).
2. Remittent fever (febris remittens, remitting). There is a constantly raised body temperature,
but diurnal fluctuations in temperature above 10 C. Such a temperature rise occurs in
tuberculosis, purulent diseases (eg, pelvic abscess, empyema of the gall bladder, wound
infections), and malignancy.
By the way, fever, with sharp fluctuations in body temperature (range between morning and
evening body temperature is greater than 1 degree), accompanied in most cases and even a
fever, commonly called a septic (see also intermittent fever, hectic fever).
3. Intermittent fever (febris intermittens, intermittent). Daily fluctuations, as in remitting to
exceed 10 C, but this morning is at least within limits. Moreover, increased body temperature
appears periodically, approximately equal intervals (usually around noon or night) for several
hours. Intermittent fever is particularly characteristic of malaria, as well as observed for
cytomegalovirus infection, infectious mononucleosis and a purulent infection (eg,
cholangitis).
4. The debilitating fever (febris hectica, hectic). In the mornings, as in intermittent, there is
normal or even low body temperature, but that daily fluctuations in temperature reaches 3-50
C, and are often accompanied by debilitating sweats. A similar increase in body temperature
characteristic of active pulmonary tuberculosis and septic diseases.
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5. Reversed, distorted or fever (febris inversus) is different in that morning body temperature
is greater than the evening, although occasionally it is still usual small evening rise in
temperature. Feedback fever occurs with tuberculosis (often), sepsis, brucellosis.
6. Improper or irregular fever (febris irregularis) manifests the alternation of different types
of fever and is accompanied by a varied and irregular daily fluctuations. Incorrect fever
occurs in rheumatoid arthritis, endocarditis, sepsis, tuberculosis.
The main causes of fever - infections, malignancy, crush syndrome, prolonged, myocardial
infarction, cerebral hemorrhage, drug allergy, systemic lupus erythematosus, gout, acute
hemolysis.
I have returned from trips to suspect endemic infection. For their diagnosis often requires
special techniques.
Fever main symptom of acute HIV infection (observed in 50% of patients).
And also can not forget about the so-called simulation. Simulation is usually found in
hospitalized patients. You can simulate a fever, plunging the thermometer into the warm
water, applying it to a heat source, heating the friction on the bed sheets and even on the oral
mucosa.
Simulation is suspected in the following cases:
- Touch the skin has a normal temperature,
- No symptoms such as tachycardia, facial flushing, sweating,
- Atypical nature of the temperature curve
- Temperature too high (41.00 and up).
You can use a different classification:
1. Intermittent fever - occurs with a regular increase and decrease to normal. For example: 3,4
day malaria - every 48 or 72 hours, the temperature rises. The minimum temperature below
the day 370S.
2. Remittent fever. The temperature change above 1.00 as well. The minimum temperature of
day more than 370S.
3. Undulating fever. The constant or remittent temperature for several days followed by a
normal temperature. Lowering the temperature gradually.
4. Fever constant. At the same time throughout the day temperature will be high, change it
does not exceed 1.00 C. This temperature is observed in viral infections, such as the flu.
5. Fever of unknown origin. About unclear fever say when:
- Fever persists for more than 3 weeks;
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- Temperature above 380S;
- After a week of examination the cause of temperature remains unclear.
With fever of unknown etiology in the first place should be suspected of having tuberculosis,
infective endocarditis, diseases of the liver and biliary tract, lung cancer, which is atypical.
But apart from the above there is fever and various surgical diseases, such as purulent
diseases of soft tissues - with paronychia, felon, boils, boils, abscesses, phlegmon,
paraproctitis, bedsores, vascular disease - limfangoitah, lymphadenitis, thrombophlebitis
(superficial and deep) , acute abdominal disease - appendicitis, cholecystitis, peritonitis,
abscesses in the liver and lungs, pylephlebitis, with surgical sepsis, with osteomyelitis, with
thyrotoxicosis, gynecological diseases - with adnexitis, salpingitis, oophoritis.
When sepsis is accompanied by fever, with pale skin. In the IV century BC, Aristotle
introduced the term "sepsis", which refers to the poisoning of the body's own tissue decay
products. Allocate the following form of the disease:
1. Pyo-resorptive fever is seen in 24-25% of patients. It is characterized by clearly defined
purulent foci undulating course of the process, the type of intermittent fever. It occurs at least
7 days after the opening of a purulent focus of the continued severity of parallelism and
functional disorders. Blood cultures in these patients, mostly sterile.
2. Septicemia diagnosed in 25-26% of patients with acute purulent diseases. It is
characterized by severe general condition of the patient, high fever, disturbance of the various
functional systems, which progress, in spite of an active influence on the hearth.
3. Pyosepticemia. She characterized metasticheskie ulcers against a background of clinical
signs of septicemia. Occurs in 32-35% of patients.
4. Chronic sepsis. Characterized by a history of purulent foci in various organs and tissues
that do not manifest themselves acutely, but are able to maintain long-term time the
inflammatory reaction in the body. Blood cultures in these patients is not sterile. Clinically
observed deterioration of the periodic temperature response.
These clinical-anatomical forms are not the phases of generalized surgical infection, although
they may move into one another.
Differentiation of sepsis in the rate of deployment of symptoms is as follows:
1) fulminant sepsis - clinical picture develops over 1-2 days (2% of patients).
2) Acute sepsis occurs within 5-7 days (39-40% of patients).
3) Subacute sepsis lasts 7-14 days (50-60%);
4) Finally, chronic sepsis.
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Experience has shown that chronic sepsis caused by lesions of internal organs and systems,
rather than a primary source. The concept of hronosepsise, at the junction of many branches
of medical science, has no relation to surgical sepsis.
For the development of clinical disease since the introduction of infection should be made
available as early sepsis, occurring in up to 3 weeks after injury, when the role of the primary
focus is beyond doubt, and the latter develops in a month or more, under similar conditions
when the primary site loses its clinical significance , which often leads to unnecessary
presentation of acute cryptogenic sepsis.
Regardless of the form are three-phase flow of sepsis: 1) phase voltage, and 2) phase of
catabolic disorders, and 3) an anabolic, its duration is determined by the individual
characteristics of the organism and conditionally includes the period prior to discharge
patients from hospital.
Phase voltage is a response to the host's response to the introduction of the pathogen and its
aggressive actions, when a lack of local specific response in the form of inflammation include
the functionality of the system to ensure the mobilization of defense forces. Stimulation of
the hypothalamic-pituitary axis, and through it the sympathetic-adrenal systems leads to the
stress of life-support systems. Discrepancy gradually diminishing energy reserves and the
growing burden lead to depletion of the body and the strength of metabolic processes.
The clinical picture is dominated by hemodynamic disturbances and toxic manifestations in
the form of encephalopathy or focal CNS disorders that are accompanied by a deterioration of
functioning detoxification system (liver-kidney, respiratory), changes in the peripheral blood
and bone marrow hematopoiesis.
Catabolic phase - the brightest in their clinical manifestations - is characterized by
progressive consumption of enzyme and structural factors, followed by the onset of
decompensation of functional systems. Increased catabolism of protein, carbohydrates and
fats, water and electrolyte decompensation and acid-base balance are accompanied by a
process involving the local surrounding tissue, increasing the zone of destruction. All this
leads to a number of systemic disorders (cardiovascular failure, destruction of lung tissue
syndrome, a syndrome of hepatic and renal failure, etc.).
Anabolic phase characteristic of recovery of lost backup materials, and structural proteins in
the body. Go to the anabolic catabolic phase is generally carried out smoothly, but can pass
quickly and be accompanied by a general excitement, the fall in blood pressure, autonomic
disturbances, etc.
Thus, in formulating the diagnosis should reflect the primary source of sepsis, its course, a
form of manifestation, the causal microflora, the phase of the process. Examples:
1) carbuncle face. Early staphylococcal sepsis, septikopiemicheskaya form catabolic phase;
2) acute purulent lactation mastitis intramammary. Acute early staphylococcal sepsis,
septikopiemicheskaya form, the phase voltage.
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The cause of sepsis are: purulent diseases of soft tissues (108), peritonitis (61), anaerobic
infection (37); ginekolgicheskie pathology (25); therapeutic disease (9).
The most permanent manifestation of the organism's response to the development of general
purulent infection include fever and change in emotional status of patients. Daily fluctuations
in body temperature depends on many factors (the reactivity of the organism, the virulence of
microorganisms, the massiveness of infection, sepsis, and forms, etc.). Usually maesimalny
rise in body temperature observed during the evening hours, reaching 39-40,20 S. In the
morning it can be reduced to S. 37-38,50 However, not only the heat on a large scale is
characteristic of sepsis. In most patients the repeated changes in temperature during the day.
In this case it is accompanied by a sudden increase, as a rule, tachycardia, tachypnea, and
sometimes vomiting and sudden chill. The latter is usually a sign of a massive invasion of the
decay products of pyogenic bacteria or tissues. Therefore, this period shows the most blood
collection ha blood culture. Lowering the temperature can be accompanied by profuse sticky
sweat, marked weakness. Such dynamics of the temperature characteristic of staphylococcal
sepsis and occurs most frequently.
Depending on the type of agent may occur and certain variations of temperature changes.
Thus, for Pseudomonas sepsis is characterized by high temperature with small fluctuations.
But ultimately, we must assume that the temperature response depends not only on the type
of pathogen, but on the reactivity of the microorganism.
Hyperthermia syndrome is not always accompanied by sepsis. Elderly patients and in
areactivity conditions the temperature can be subfebrile not be accompanied by chills and
sweats. But this should not undermine confidence in the diagnosis, because in the end the last
pose of assessing the full range of clinical manifestations, laboratory data and
microbiological studies. However, the dynamics of temperature changes in the first days of
generalization of infection is fairly objective diagnostic criterion in determining the condition
of patients. Its importance further increases at a constant observation of patients, detection of
complications, especially metasticheskogo nature, and to assess the effectiveness of the
therapy.
In 30-50% of patients in the phase voltage and catabolic phase can install various degrees of
psychological disorders which are caused by progressive intoxication (headache, insomnia,
sweating, irritability, fatigue, painful, unpleasant sensations without specific localization and
without a precise description ), as well as tachycardia, decrease in blood pressure, shortness
of breath, pain in the heart, pale skin and mucous membranes.
Fever should be distinguished from hyperthermia - fever, body temperature regulation when
the process is not disrupted, and increased body temperature due to a change in external
conditions. The body temperature during fever infection usually does not exceed 410 C, in
contrast to hyperthermia, in which it is above 410 C
Mechanisms of thermoregulation
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Human body temperature - it's a balance between the formation of heat in the body (as a
product of all metabolic processes in the body) and the impact of heat through the surface of
the body, especially the skin (90-95%), as well as through the lungs, faeces and urine.
These processors are regulated by the hypothalamus, which acts as a thermostat. In the states,
causing fever, the hypothalamus tells the sympathetic nervous system in vasodilation of
blood vessels of the skin, excessive sweating, which increases the heat transfer. At lower
temperatures delay the hypothalamus tells the heat by narrowing the blood vessels of the
skin, muscle tremors.
An increase in temperature - is the result of the impact of various external and internal
stimuli, which are restructuring, "hypothalamic thermostat" (Heat center) to maintain the
temperature at a higher level than normal. For example, was "programmed" to level 35-37,
and began working at 37-39.
Most often trigger element is the so-called exogenous pyrogens. These include first of all
infectious agents (bacteria, viruses, fungi, parasites) and their toxins, degradation products of
proteins (eg, fever rezorbtsionnaya necrosis, infarctions, hematomas, hemolysis, burns),
allergens and immune complexes (collagen, serum sickness) ; other pyrogenic substances.
Exogenous pyrogens affect the thermal center of the hypothalamus is not directly but
indirectly through the endogenous pyrogen.
Endogenous pyrogen - low molecular weight protein produced by monocytes and
macrophages, blood tissues of the liver, spleen, lung, peritoneum. In certain tumor diseases lymphoma, leukemia monocytic, renal cell carcinoma (hypernephroma) - is an autonomous
production of endogenous pyrogen and, therefore, the clinical picture of fever is present.
Endogenous pyrogen after his release from the cells acts on thermosensitive neurons in the
preoptic area of the hypothalamus, where with the participation of serotonin induced
prostaglandin synthesis E1, E2 and cAMP. These biologically active compounds, on the one
hand, cause the intensification of heat production by the restructuring of the hypothalamus to
maintain body temperature at a higher level, and with another - affecting the vasomotor
center, causing peripheral vasoconstriction and decrease heat loss, which generally leads to
fever. Increase heat production is due to the increase in the intensity of metabolism mainly in
muscle tissue.
In some cases, stimulation of the hypothalamus might be due to pyrogenic, and disorders of
the endocrine (hyperthyroidism, pheochromocytoma) or autonomic nervous system
(cardiopsychoneurosis, neuroses), the effect of some medications (drug fever).
The most common cause of drug fever are the penicillins and cephalosporins, sulfonamides,
nitrofurans, isoniazid, salicylates, metiluratsil novokainamid, antihistamines, allopurinol,
barbiturates, intravenous infusion of calcium chloride or glucose, etc.
Fever of central origin is due to direct stimulation of the thermal center of the hypothalamus
as a result of an acute cerebrovascular accident, tumor, traumatic brain injury.
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Thus, increased body temperature may be due to activation of the system and ekzopirogenov
endopirogenov (infection, inflammation, pyrogenic substances tumors) or other reasons
without any involvement of pyrogens.
Since the degree of increase in body temperature is controlled by "hypothalamic thermostat,"
that even in children (with their immature nervous system), fever rarely exceed 410 C. In
addition, the degree of temperature rise depends largely on the condition of the patient: for
the same disease in different individuals, it can be different. For example, in pneumonia in
young people's temperature reaches 400 C and above, and in old age and in those depleted of
such a significant temperature rise does not happen, and sometimes it does not even exceed
the standards.
The symptoms accompanying the fever
Fever is characterized by the rise in body temperature. Fever is accompanied by increased
heart rate and breathing lowers blood pressure often, patients complain of a sensation of heat,
thirst, headache, decreased amount of urine. Fever enhances the metabolism, as well as
together with the appetite is reduced, the long-term febrile patients often lose weight. High
fever may be accompanied by delirium, which occurs most often in the elderly and
alcoholics.
Tachycardia
The relationship between body temperature and pulse, deserves great attention, because
ceteris paribus it is fairly constant. Usually, with an increase in body temperature by 1 degree
heart rate increases of at least 8-12 strokes in a minute. If the temperature of the body 360
with a pulse is, for example, 70 beats per minute, the body temperature of 380 C will be
accompanied by a quickening of the pulse 90 beats per minute.
The discrepancy between high body temperature and heart rate in one direction or another is
always subject to review, as in certain diseases it is important raspoznavatelnym feature (eg,
fever with typhoid fever, by contrast, is characterized by relative bradycardia).
Sweats
Sweating - one of the mechanisms of heat transfer. Sweating occurs when the temperature
drops, the temperature rises, on the contrary, the skin is usually hot and dry. Sweating is not
observed in all cases of fever, it is typical of purulent infection, infective endocarditis, and
some other diseases.
Chills
The term "chill» (frigor) is used to represent a state in which the patient feels the inner
trembling and cold. Chills accompanied by constriction of peripheral arterioles and the
appearance of "goose skin". Muscle tremors are sometimes so pronounced that it makes it
difficult and accompanied by a "thud" teeth (tremor chewing muscles), and cold, which feels
the patient does not disappear even after putting on warm clothes. Despite the fact that the
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skin and extremities cold, the body temperature is raised.
Shivering occurs at the time of rapid restructuring of the hypothalamic thermostat to maintain
a high body temperature. When body temperature rises sharply at 2-40 C. A gradual increase
in body temperature may be only a slight chilling.
Chill about an hour there after receipt of an infectious agent (viral or parasitic) diseases, or of
any foreign protein in the blood and rarely lasts more than 30 minutes.
Frequency of occurrence of fever has a certain diagnostic value. Schematically, you can
identify the disease, which is characterized by fever arising singly (eg, lobar pneumonia, the
response to transfusion of contaminated blood or incompatible in / infusion), and diseases
that occur with a series of such attacks.
Repeated chills commonly found in sepsis, septic lung disease, urinary tract, gall bladder and
bile ducts, erysipelas, cancer (lung cancer, hypernephroma, leukemia, Hodgkin's disease).
Regular alternation of febrile seizures (chills, fever, drop in temperature from sweating) and
afebrile periods characteristic of malaria. Attacks of this disease may be repeated on a daily
basis (daily fever), every other day (tertian) or two afebrile day (four-day fever).
In the old books written that chills any nature can be quickly terminated with intravenous
vasodilator drugs (eg papaverine).
Herpes
Fever is often accompanied by the appearance of herpetic eruption, it is not surprising: the
herpes virus is infected 80-90% of the population, although disease manifestations are
observed in 1% of the population, activation of the herpes virus occurs at low immunity.
Moreover, speaking of the fever, the townsfolk often meant by the word herpes. For example,
the word "fever" in the Dictionary of Russian language, SI Ozhegova and NJ Shvedova,
among others, and is denoted as "arising from a cold sore swelling on the lips. Ran a fever on
the lips, fever obmetala lips. "
With some types of fever herpes rash occurs so frequently that its appearance is considered
one of the diagnostic symptoms of the disease, for example, lobar pneumococcal pneumonia,
meningococcal meningitis.
Febrile seizures
Seizures with fever are found in 5% of children aged 6 months to 5 years. The probability of
developing seizures during fever depends not only on the absolute level of increase in body
temperature as the speed of its recovery.
Typically, the duration of febrile seizures do not exceed 15 minutes (on average 2-5 minutes).
In many cases, seizures are observed in the early days of fever and usually disappear on their
own.
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Bind convulsions with fever may be, if:
• the child's age does not exceed 5 years;
• There are no diseases that could be the cause of seizures (eg, meningitis);
• convulsions were not observed in the absence of fever.
In the first place the child with febrile seizures should consider meningitis (lumbar puncture
is indicated for the corresponding clinical picture). To exclude spazmofilii infants estimate
the level of calcium. If convulsions lasted for more than 15 minutes, the appropriateness of
the EEG to exclude epilepsy.
Urinalysis
In general, urine often appears proteinuria (functional), which disappears soon after the fall of
body temperature to normal levels. In the urine of febrile states may appear cylinders,
ketones, and renal cell.
Simulation fever
False rise in temperature may depend on the thermometer itself, when it does not meet the
standard, which is rare. More common simulated fever.
Simulation is possible both to image the feverish state (for example, by rubbing the tank
mercury thermometer or a pre-heating) and to cover up the temperature (when the patient
holds a thermometer so that it is not heated).
In various publications the percentage of simulations and fever negligible amounts of 2 to 6
percent of the total number of patients with elevated body temperature.
Simulation of fever is suspected in the following cases:
• skin feels has a normal temperature and no symptoms accompanying fever, as tachycardia,
reddening of the skin;
• there is too high a temperature (from 410 C and above) or daily fluctuations in temperature
are atypical in nature.
If you plan to simulate a fever, we recommend the following:
• Compare the findings with the determination of body temperature by feel and with other
manifestations of fever, in particular, with a pulse rate.
• In the presence of a medical worker and the different thermometers measure the
temperature in both armpits and make sure the rectum.
• Measure the temperature of svezhevypuschennoy urine.
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The patient should explain all the events need to clarify the nature of the temperature, without
hurting his suspicion of the simulation, the more so that it can not be confirmed. 1. Fever:
basic information
Fever (febris) - this is a protective-adaptive reaction of the organism, which occurs in
response to pathogenic stimuli and is expressed in the restructuring of thermoregulation to
maintain a higher than normal level of body temperature.
Thermoregulation: the mechanism of fever.
• Classification of fever: the degree of fever, temperature curves, periods of current fever
• The symptoms that accompany a fever: sweating, chills, cold sores, changes in the overall
analysis of urine.
• Simulation of fever.
Approach to the Patient with acute fever
Disease with acute fever occurred widely in practice and as a medical problem arose long
before the thermometer. Meanwhile, the lack of a clear algorithm of these patients leads to an
erroneous diagnosis, to excessive and unnecessary treatment. The purpose of this file: To
familiarize the curious people to the algorithm of patients with acute fever and the
appointment of competent antipyretics.
Long subfebrilitet
Increased body temperature in the range 37-380 C is considered to be subfebrilitet first and
foremost a doctor should answer the question of whether long subfebrilitet manifestation of
any organic disease. If that is not observed, the increase in body temperature associated with
the autonomic nervous system.
Prolonged fever of unknown origin
Fever of unknown origin causing considerable anxiety as the patient and doctor. In these
cases, the patient knows that he has a potentially dangerous symptom that doctors can not
immediately be explained, the patient is subjected to numerous studies, the results of many of
these studies a negative or, even worse, "suspicious" ...
According to many clinicians, the ability to understand the causes of prolonged fever of
unknown origin, is the touchstone of diagnostic abilities of a doctor.
Travel fever
Supervision at the patient with fever (especially unexplained) should focus on the elucidation
of epidemiological factors, contact with animals and birds that visit regions endemic for
various diseases. Well assembled history often gives clues to the diagnosis ...
Hospital fever
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Hospital (nosocomial, or nosocomial), fever (occurring within 48 hours after admission),
there is an estimated 30% of hospitalized patients, and every third of them die. Hospital for
fever exacerbates the underlying disease and 4 times increased mortality compared with
patients who suffer from the same, but not complicated by fever and disease.
For acute fever are times when fever lasts for more than 14 days.
Acute fever is common in clinical practice and as a medical problem arose long before the
thermometer. However, knowing the algorithm of these patients leads to an erroneous
diagnosis (percentage of divergence of diagnoses in patients with fever in the prehospital and
hospital phases of up to 40%) or inappropriate treatment.
Diagnostic tactics
In the case of acute fever, it is desirable, on the one hand, to avoid unnecessary diagnostic
tests and unnecessary treatment for diseases that can result in spontaneous recovery. On the
other hand, it must be remembered that under the guise of banal respiratory infection may be
hiding a serious pathology (eg, diphtheria, endemic disease, zoonoses, and others) to be
recognized as early as possible.
If the temperature rise is accompanied by characteristic complaints and / or objective
symptoms, it can immediately navigate in the diagnosis of the patient. But often, especially
on the first day of the disease, the cause of fever is not possible. Then a basis for decisionmaking becomes the patient's health status before the fever and the dynamics of the disease.
Acute fever against the background of overall health
If you have a fever against the background of overall health, especially in man young or
middle age, in most cases you can assume an acute respiratory viral infection (ARI) with
spontaneous recovery within 5-10 days.
When the diagnosis of SARS should be aware that when an infectious fever, catarrhal
symptoms are always observed varying degrees of severity. After collecting the history and
physical examination will be required re-examination after 2-3 days and in most cases, no
tests (except for daily measurement of temperature) is not required.
The re-examination after 2-3 days you may:
• Improving health, reducing the temperature.
• New features, such as skin rash, attacks in the throat, wheezing lungs, jaundice, etc., which
will lead to a definite diagnosis and treatment.
• Deterioration / no change. In some patients the temperature remains high or deteriorating
general condition. In these situations require a second, more in-depth questions and conduct
further research to find disease with exogenous or endogenous pyrogenic: infection
(including focal), inflammatory or neoplastic processes.
17
Acute fever in an altered background
In the case of temperature increase on the background of an existing disease or serious
condition of the patient self-healing ability is low. Immediately appointed examination
(diagnostic includes a minimum of common blood and urine tests, chest X-ray). Such patients
are also subject to more regular, often daily monitoring, and define the indications for
hospitalization. The main options are:
• Patients with chronic illness. Fever may be associated primarily with a simple exacerbation
of the disease if it is infectious and inflammatory nature, such as bronchitis, cholecystitis,
pyelonephritis, rheumatism, etc. In these cases shows targeted doobsledovanie.
• Patients with reduced immune resistance. For example, suffering from hematologic
malignancies, HIV infection or receiving steroids (prednisone 20 mg / day) or
immunosuppressive drugs for any reason. The appearance of fever may be due to the
development of opportunistic infections.
• Patients who have recently been subjected to invasive diagnostic tests or therapeutic
manipulations. Fever may reflect the development of infectious complications after the study
/ treatment (abscess, thrombophlebitis, bacterial endocarditis). Increased risk of infection,
there is also a drug by intravenous administration of drugs.
Acute fever in patients older than 60 years
Acute fever in elderly and senile age is always a serious situation, because of the decrease in
functional reserve in these patients under the influence of fever can rapidly develop acute
disorders such as delirium, cardiac and respiratory failure, dehydration. Therefore, these
patients require immediate laboratory and instrumental examination and determine the
indications for hospitalization. It should be another important fact: at this age can be atypical
oligosymptomatic and clinical implications.
In most cases, fever in the elderly has an infectious etiology. The main causes of infectious
and inflammatory processes in the elderly:
• Acute pneumonia - the most common cause of fever in the elderly (50-70% of cases). Fever
even with extensive pneumonia may be small, auscultatory signs of pneumonia may not be
expressed, and in the foreground are the general symptoms (fatigue, shortness of breath).
Therefore, for any unknown fever shows radiography of lungs - it's the law (pneumonia - one
elderly). If you take into account the presence of a diagnosis of intoxication syndrome (fever,
weakness, sweating, tsefalgiya), violations of bronchial drainage function, auscultatory and
radiographic changes. In terms of differential diagnosis include the possibility of pulmonary
tuberculosis, which often occurs in geriatric practice.
• Pyelonephritis is usually manifested by fever, dysuria and back pain, in the general analysis
of urine revealed bacteriuria and Pyuria, ultrasonography reveals changes pyelocaliceal
system. The diagnosis is confirmed by bacteriological examination of urine. The emergence
18
of pyelonephritis is most likely in the presence of risk factors: female gender, bladder
catheterization, urinary tract obstruction (kidney stones, prostate adenoma).
• Acute cholecystitis can be suspected when combined with fever, chills, pain in right
hypochondrium, jaundice, especially in patients with already well-known chronic disease of
the gallbladder.
Other, less frequent causes of fever in elderly and senile age, include herpes zoster,
erysipelas, meningoencephalitis, gout, polymyalgia rheumatica, and, of course, SARS,
especially in the epidemic period.
Thus, the main directions of the diagnostic tactics depend on the flow of fever and a
background in which it originated.
Short-term fever (less than 4 days) with mild to uncomplicated background in young and
middle age: ambulatory monitoring with mandatory supervision after 2-3 days. The main
reason for the fever - SARS. No additional surveys are not required except for daily
measurement of temperature.
If the fever lasts more than a week, or there is deterioration or develop new symptoms, the
survey is assigned (mandatory minimum: a general analysis of blood and urine tests, CT),
control is carried out every day and raises the question of admission.
Additional tests shall be appointed immediately in all severe cases, especially in middle and
old age, as well as the presence of chronic diseases and other risk factors. Required daily
monitoring, the issue of hospitalization.
Therapeutic tactics in acute fever
Therapeutic tactics in acute fever, is presented in the table below.
Treatment is not required
In acute fever in young patients without complicating factors, and subject to satisfactory
general state of the routine use of antipyretics and antimicrobial agents are usually not shown
because it does not affect the prognosis and duration of disease. Such patients should be
given comfort mode, adequate and varied diet, avoid loading duties. From a physician is
required only observation of the development of the disease, perhaps the appointment of
antiviral agents.
Keep in mind that:
• First, the fever itself is rarely life-threatening. Usually, infectious diseases, if the
temperature does not decrease, it does not exceed 410 C. For example, when the temperature
is higher ARD 40.50 is observed only at 0.1-0.3% of patients.
19
• Second, we must remember that fever is a protective reaction of the body, so aim to
normalize body temperature is not always appropriate. When infection on a background of
high temperature inhibited the reproduction of viruses and bacteria, and at a temperature
above 380 C is 2-3 times more active than low-grade or normal body temperature.
• Third, antipyretics may give negative side effects (eg, gastroduodenal bleeding,
agranulocytosis, Reye's syndrome).
• Finally, the fever may be the only symptom, and antipyretic therapy "blurs" the picture and
contributes to a later appointment etiotrop treatment.
Appointment of antipyretics
It is important to remember the following points:
• Do not assigned to receive antipyretics course!
• If prescribed antibiotics, an additional antipyretics do not apply!
• Physical methods of cooling (fan spray, rubbing alcohol or warm water) is generally
ineffective, and without (30 minutes before the procedure) receiving antipyretics are
contraindicated because they lead to a further increase in temperature.
Appointment of antipyretics justified in the following cases:
• Fever above 410 C (possible damage to the nervous system).
• Fever above 380 C in patients with decompensated cardiovascular and bronchopulmonary
systems, within which may worsen as a result of increased oxygen demand.
• Fever above 380 C in the postoperative period, with psychoses (including alcoholic) and
senile dementia in children under 5 years (risk of febrile seizures).
• Poor tolerance of fever at any level.
As the fever-reducing medicine more often as a fever-reducing drugs use aspirin, ibuprofen
and acetaminophen.
Aspirin (acetylsalicylic acid) is an effective antipyretic. In 1999, the Pharmacological
Committee of Russia made a counter-part instructions for use of aspirin acute viral infections
in children younger than 15 years, due to the risk of Reye's syndrome - a deadly toxic
encephalopathy. Using the instant form of aspirin does not eliminate the systemic effects of
the drug on the synthesis of "protective" prostaglandins in the gastric mucosa and reduces the
risk of gastrointestinal bleeding, but only reduces the local irritant effect of the drug on the
gastric mucosa. Aspirin is not indicated at high risk of bleeding, in conjunction with
anticoagulants and pregnancy.
Paracetamol - this is the only antipyretic, which is approved for use in children as young as 3
months of age. This is the drug of choice for treatment of fever. The action of paracetamol
20
begins after 30-60 minutes and lasts for 4 hours. In contrast to ibuprofen and other
nonsteroidal anti-inflammatory drugs, paracetamol has mainly a central action, does not
inhibit prostaglandin synthesis outside the CNS, and therefore does not cause adverse effects
such as erosion of the stomach, gastroduodenal bleeding, aspirin asthma. Paracetamol is part
of the complex preparations (Coldrex, Lorain, Panadol, Solpadein, cold remedy, Ferveks).
Notorious hepatotoxicity of paracetamol occurs only for the occasional admission of huge
doses (140 mg / kg) drug.
Ibuprofen. Antipyretic effect of ibuprofen is comparable with that of paracetamol, but it lasts
longer. Unlike paracetamol may cause skin reactions and disorders of the gastrointestinal
tract, worsen asthma. Therefore, ibuprofen believe antipyretics 2nd row, it is used in case of
intolerance or the limited effectiveness of paracetamol. Without medical supervision can be
assigned to ibuprofen for children older than 1 year.
Metamizole (analgin) more than 30 countries banned for use and removed from the
pharmaceutical market, since promotes agranulocytosis (in studies this complication
developed in average in 1 of 1700 patients). In Russia, not prohibited, but in 2000,
Pharmacological Committee of Russia introduced restrictions: use in children under the age
of 12 only on prescription, and the duration of treatment without medical supervision should
not exceed 3 days. If fever is often used parenterally in the lytic mixture with
diphenhydramine (the latter acts as a synergist antipyretics).
Antimicrobial therapy
If the fever is associated with bacterial infection, it requires the appointment of appropriate
antimicrobial therapy (for short-term fever is usually not granted). The issue of antimicrobial
therapy must be put in patients with high certainty the presence of infection or lack of
immunity in patients with severe general condition, patients elderly.
Preference should be given broad-spectrum antibiotic:
• Protected aminopenicillins amoxycillin with clavulanic acid (amoksiklav, Augmentin)
• Fluoroquinolones (ofloxacin, ciprofloxacin, pefloxacin, sparfloxacin)
• II generation macrolides (roxithromycin, clarithromycin, azithromycin).
Conclusion "fever of unknown origin" is authorized in cases where the increase in body
temperature above 38 0C lasts longer than 2 weeks, and the cause of fever remains
unexplained after routine investigations.
In the International Classification of Diseases 10th revision fever of unknown origin has its
own code section R50 Symptoms and signs, which is quite reasonable, since hardly expedient
to erect a symptom of a nosological form.
According to many clinicians, the ability to understand the causes of prolonged fever of
unknown origin is the touchstone of diagnostic abilities of a doctor. Nevertheless, it is
difficult to identify the disease diagnosed in some cases impossible. Among febrile patients,
21
which was originally spotted the diagnosis "fever of unknown origin" on the share has not
been fully deciphered cases occur, according to different authors, from 5 to 21% of such
patients.
Diagnostic approach
Diagnosis of fever of unknown origin must begin with an assessment of social,
epidemiological and clinical characteristics of the patient. To avoid errors you must obtain
answers to two questions:
• What kind of person is sick (or social status, occupation, psychological portrait)?
• Why does the disease manifest right now (or why it took such a form)?
1. Carefully collected history is of paramount importance. You must collect all available
information about the patient: information about previous diseases (particularly tuberculosis
and valvular heart disease), surgical interventions, taking any medications, working and
living conditions (travel, personal hobbies, contact with animals).
2. Conduct a careful physical examination, and perform routine investigations (blood count,
urinalysis, blood chemistry, Wasserman, ECG, chest radiography), including blood cultures
and urine samples.
3. Think about the possible causes of fever of unknown origin in a particular patient and
examine the list of diseases that manifest prolonged fever
According to different authors, based on prolonged fever of unknown origin in 70% turns out
to be the "big three":
1. infection - 35%
2. Malignant tumors - 20%
3. systemic connective tissue disease - 15%
Another 15-20% are in other diseases and about 10-15% of cases the cause of fever of
unknown origin and remains unknown.
4. To generate a diagnostic hypothesis. Based on these data to try to find a "leading thread,"
and in accordance with the hypothesis designate certain additional studies.
It must be remembered that in any diagnostic problem (including a fever of unknown origin)
in the first place to look for common and frequent, and not some rare and exotic diseases.
5. If you mess up, go back to the beginning. If the hypothesis is formed diagnostic insolvent
or there are new assumptions about the causes of fever of unknown origin, it is important to
re-examine the patient and ask him to re-examine medical records. Conduct additional
laboratory tests (routine discharge of) and create new diagnostic hypothesis.
The list of possible causes of fever of unknown origin
22
Tactics at the local GP surgery infection?
The answers to these questions:
Lihorodka - a symptom of many diseases, most often it is observed in infections. Lihorodka
plays an important role in protecting the body against infection. An increase in temperature
increases the phagocytic activity of macrophages, increases production of interferon and
antibodies, and reduces the replication of some viruses.
Normal temperature:
- When measured in the oral cavity - 36,0-37,30 C (average 36.80 C)
- When measured in the armpit - 36.40 C
- When measured in the rectum - 37.30 C.
If the temperature in the oral cavity above 37.30 C, and in the rectum - 37.70 C above, we
speak of a fever. The temperature should be measured with a thermometer in the rectum in a
special envelope, or by catheter to the pulmonary artery. The temperature in the mouth also
can be very informative, but is a less reliable indicator. The temperature in the armpit, usually
does not provide the necessary information, so you do not measure. Normal body temperature
in many patients does not exceed 98,60 F (37,00 C). Fever above 990F (37,20 C) has a
definite clinical significance and should attract the attention of a doctor. Fever may be
accompanied by any inflammatory process in the body, but is a relatively late symptom. In
patients with gangrenous appendicitis before the development of perforation may have only a
moderate increase in temperature. Fever is not always indicative of the accession of bacterial
infection. Chill in combination with fever and bacteremia is usually observed is an indication
for the implementation of bacterial blood culture and find the source of the bacteremia.
Degree increase in temperature can have a value in the differential diagnosis. For example, to
start a high fever of acute appendicitis is not typical. The body temperature above 1020F
(38,90 C) indicated in bacterial peritonitis, salpingitis, pyelonephritis and pneumonia. The
high peaks of temperature, as defined in the same time (as a typical fence), there are abscess
formation in the abdominal cavity. In general it can be assumed that patients with abdominal
pain, fever higher than the harder condition. It should be recalled that the fever and
abdominal pain are not always occur and require surgical intervention (eg, familial
Mediterranean fever). However, the variability of the temperature of the reaction in various
diseases of the abdominal cavity is so large that a diagnosis or, alternatively, to exclude any
disease solely on the basis of the temperature curve can not. In dehydrated patients or elderly
patients, the temperature reaction in suppurative-inflammatory diseases may be small or
absent. In young children, on the contrary, a high fever often occurs in mild disease.
Hypothermia also has to attract the attention of physicians because of septic phenomena may
be more important predictor than the fever. Antibiotics should be avoided until the cause is
still unclear fever, unless antibiotic treatment is not a necessary measure to reduce body
temperature.
23
Normally, the temperature can vary during the day at 10C. In the morning she is usually
lower than in the evening. The maximum temperature observed in the afternoon.
The temperature during infection does not exceed 40,5-41,00 C (as opposed to hyperthermia,
in which it is above 41.00). Hyperthermia - a pathological condition in which the heat
production exceeds heat dissipation. Hyperthermia is defined as I have said a significant rise
in temperature, usually above 410C. It is observed in heat stroke, as well as tumors,
infections, and hemorrhagic stroke with a lesion of the hypothalamus.
1. Permanent or persistent fever (febris continua). There is a constantly raised body
temperature and during the day difference between morning and evening temperatures do not
exceed a 10 C. It is believed that this increase in body temperature characteristic of lobar
pneumonia, typhoid fever, viral infections (eg influenza).
2. Remittent fever (febris remittens, remitting). There is a constantly raised body temperature,
but diurnal fluctuations in temperature above 10 C. Such a temperature rise occurs in
tuberculosis, purulent diseases (eg, pelvic abscess, empyema of the gall bladder, wound
infections), and malignancy.
By the way, fever, with sharp fluctuations in body temperature (range between morning and
evening body temperature is greater than 1 degree), accompanied in most cases and even a
fever, commonly called a septic (see also intermittent fever, hectic fever).
3. Intermittent fever (febris intermittens, intermittent). Daily fluctuations, as in remitting to
exceed 10 C, but this morning is at least within limits. Moreover, increased body temperature
appears periodically, approximately equal intervals (usually around noon or night) for several
hours. Intermittent fever is particularly characteristic of malaria, as well as observed for
cytomegalovirus infection, infectious mononucleosis and a purulent infection (eg,
cholangitis).
4. The debilitating fever (febris hectica, hectic). In the mornings, as in intermittent, there is
normal or even low body temperature, but that daily fluctuations in temperature reaches 3-50
C, and are often accompanied by debilitating sweats. A similar increase in body temperature
characteristic of active pulmonary tuberculosis and septic diseases.
5. Reversed, distorted or fever (febris inversus) is different in that morning body temperature
is greater than the evening, although occasionally it is still usual small evening rise in
temperature. Feedback fever occurs with tuberculosis (often), sepsis, brucellosis.
6. Improper or irregular fever (febris irregularis) manifests the alternation of different types
of fever and is accompanied by a varied and irregular daily fluctuations. Incorrect fever
occurs in rheumatoid arthritis, endocarditis, sepsis, tuberculosis.
When diabetes occurs:
24
A) microangiopathy - a defeat just fine vascular network. Major changes occur in the basal
membrane of capillaries. It is characterized by the accumulation of mucopolysaccharides in
it, glycoproteins, lipids. In this case the membrane of the capillaries thickens repeatedly (800
times). Celebrated its splitting into layers, between which the collagen fibers. These changes
of the membrane and the endothelium of the capillaries is likely to disrupt the selective
filtration of biological fluids and exchange diffusion, which prevents the removal of
metabolic products, providing tissues with nutrients and oxygen. Hypoxia causes destructive
changes in the tissues until the development of necrotic gangrenous process.
B) polyneuropathy - due to impaired glucose metabolism in nervous tissue, glikozirovaniya
membranes of nerve cells and damage to the vasa nervorum. Somatic and autonomic
neuropathy may be treated as independent factors in development of trophic ulcers. Sensory
diabetic neuropathy is manifested decreased pain, tactile, temperature, vibration,
proprioceptive sensitivity. The skin, deprived of protection mechanisms (lack of response to
mechanical, thermal, chemical injury), has a high risk gnoynonekroticheskih lesions.
B) general and local immune deficiency - pronounced energy deficit observed in diabetes,
reduces the adaptive capacity of the body and leads to an imbalance of cellular and humoral
immunity, as well as the lack of factors of nonspecific defense. One of the major defects of
immunity in diabetes mellitus is considered a violation of the phagocytic function of
polymorphonuclear leukocytes. Underlying pathology is the reduction of neutrophils to
fagotsiotzu microorganisms, which leads to incomplete destruction of the antigen.
All these above factors lead to the occurrence and severity of boils and carbuncles in patients
with diabetes.
1. Diagnosis of local surgical infection is largely not present any difficulty. Complaints of the
patient, careful history taking and professional examination of patients can make an accurate
diagnosis. Local treatment of surgical infection in the stage of infiltration is antibiotic
therapy, physical therapy, immobilization (if affected limb), detoxification therapy. In the
stage of suppuration comes into force "the golden law of Surgery" - where there is pus, it
should be released. Also, we need to continue antibiotic therapy, taking into account the
sensitivity of microorganisms to antibiotics.
6. The tactic is to GPs early diagnosis of local surgical infection. With signs of sepsis patients
hospitalization is shown in purulent surgical ward. Here we must bear in mind that the
presence of boil or other purulent foci in the front part is a direct indication for hospitalization
of such category of patients in specialized departments of oral and maxillofacial surgery. In
the absence of the latter patients should be hospitalized in surgical units or purulent surgery
department of general practitioners. Since a considerable development of venous and
lymphatic network in the face contributes to the rapid spread of infection. Progressive
thrombosis in the face boils can spread to the anastomoses on the venous sinuses of the solid
shell of the brain that leads to thrombosis them, posing a threat of severe complications purulent basal meningitis.
6.2. The analytical part.
25
Appendix № 2
Teacher offers to disassemble diagnose a patient with erysipelas inflammation of the lower
limb was accompanied by a fever.
The teacher divides the group into 3 subgroups with the expectation 1,2,3,1,2,3, etc. All up I
1nomera subgroup all 2 rooms - II, all 3 rooms - III subgroup. These subgroups have different
places in the audience.
Draw by lot a job. "Diagnosing a patient with erythematous form of erysipelas of the lower
extremity." 2. "Diagnosing the patient with abscess form of erysipelas of the lower
extremity." 3. "Diagnosing a patient with necrotizing bullosa form of erysipelas of the lower
extremity."
Then given time to prepare for writing answers in workbooks. Then one of the members of
each group read out the answer. At this time, the rival group, together with the teacher is the
expert. Briefing - 3 min., Division of - 2 min., Preparation time - 10 minutes. Speech groups 10 minutes (30 min.). Properly respond to a group is encouraged and is declared the winner.
8. Criteria for evaluating the current control:
№
%
evaluation
Criteria
1
96-100
Excellent "5"
The full presentation is on the edematous limb
pain syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions gives a correct and comprehensive
answer. To think independently and draw
conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets
the data of clinical and instrumental studies.
Independently, with knowledge of the facts
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational problems applies
unconventional approaches grounded in the
responses.
2
91-95
Excellent "5"
In full view of a syndrome of limb ischemia,
classification, diagnosis, and treatment methods
dif.diagnostike. The questions gives a correct
and comprehensive answer. To think
independently and draw conclusions. Selfsupervised patients and skillfully applies the
practical skills. Interprets the data of clinical
and instrumental studies. Independently, with
26
knowledge of the facts involved in the choice of
treatment. Actively involved in conducting
intraktivnyh games. In solving the situational
problems applies unconventional approaches
grounded in the responses. When interpreting
the data biochemistry made one mistake
3
86-94
Excellent "5"
The full presentation is on the edematous limb
pain syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions gives a correct and comprehensive
answer. To think independently and draw
conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets
the data of clinical and instrumental studies.
Independently, with knowledge of the facts
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational tasks made some errors
4
81-85%
"Good"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. Selfsupervised patients and skillfully applies the
practical skills. Interprets the data of clinical
and instrumental studies, but not fully aware of
the value of individual data. Knowingly
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational tasks made some errors
5
76-80%
"Good"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. To think
independently. Self-supervised patients and
skillfully applies the practical skills. Interprets
the data of clinical and instrumental studies, but
not fully aware of the value of individual data.
Knowingly involved in the choice of treatment.
Actively involved in conducting intraktivnyh
games. In solving the situational tasks and skills
made a few inaccuracies
27
6
7
8
9
Good "4"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. To think
independently and draw conclusions. Selfsupervised patients and skillfully applies the
practical skills. Independently, with knowledge
of the facts involved in the choice of treatment
tactics, but admits mistakes. In carrying out the
practical skills makes a grave error. Situational
problems decides not to complete.
Satisfactory "3"
The student is aware of the edematous limb pain
syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions do not give a complete answer. Make
mistakes in presenting the classification and
dif.diagnostike. The answers are not confident.
Practical skills and case studies serves correctly.
71-75%
66-70%
Satisfactory "3"
At half the questions gives the correct answer.
Answers are not confident. Poor knowledge of
the classification of ischemia. To individual
questions knows the answers, but to present
their idea can not.
Satisfactory "3"
Half the questions asked gave the correct
answer. In presenting the essence of the
syndrome, diagnosis, diff. Diagnostic algorithm
for the interpretation of medical mistakes.
Uncertain poses a problem. Practical skills are
difficult to perform. Situational tasks executes
correctly.
Unsatisfactory "2"
The student has no idea about the syndrome,
classification, diagnosis of the disease, does not
know diff.diagnostike treatment policy and is
not able to perform practical skills.
61-65%
55-60%
10
under
54%
Quiz 9:
• Features of fever in furuncles, carbuncles, hydradenitis, subcutaneous and corn abscess,
phlegmon, and lymphadenitis?
66-70%
28
• Skin changes at the local surgical infection?
• The differential diagnosis of cellulitis lymphangites and erysipelas?
• The role of diabetes in the development of furunculosis and carbuncle?
• Methods of diagnosis and treatment of local surgical infection?
• Tactics GPs at a local surgical infection?
10. References:
• Summary:
2. Athalia AE GST and other GP surgery with the standards of response. T.2000g. P.74.
3. Gostishev VK General Surgery M. 1993.
4. John Murtha. Directory of GP. M.1998g Trans. from English. Yaz. 1230 sec.
5. Denisov IN, Shevchenko, Y., Nazirov FG Clinical guidelines and formulary. M.2005g.
S.1147.
6. Karimov SH.I. Hirurgik kasalliklar. T. 2005y.
7. Karimov SH.I. Surgical diseases. T. 2005.
8. Conde, R. and L. Nayhus Clinical Surgery M. 1998. Trans. from English. 716s.
9. Lopukhin M., Saveliev VS Surgery. M.1998g Trans. from English.
10. Nazirov FG, Gadoev AG Guide for general practitioners. Tashkent 2005
11. Gostishev VK Operational purulent surgery. M. 1996.
12. Clinical guidelines for practitioners based on evidence-based medicine. M. 2002
13. Kurbangaliev SM Sketches of purulent infection in surgery, the M.1985
14. Makarenko TP, Kharitonov LG, Bogdanov AV General surgical patient management
profile in the postoperative period. M. 1989
15. Family Medicine. Guide in 2 volumes under the leadership of acad. Krasnov AI Samara.
1995 S. 384 768.
16. Stoyan Popkirov. Purulent-septic surgery. Sofia. 1986 S.483.
17. Electronic versions of lectures on surgery GPs. 2006 TMA.
18. Information obtained from the Internet: http://www.doktor.ru/medinfo
http://medinfo.home.ml.org