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D DE EPPA AR RT TM ME EN NT TO OFF E ED DU UC CA AT TIIO ON NA AN ND D SSC CIIE EN NC CE EO OFF U UK KR RA AIIN NE E SSU M Y S T A T E U N I UMY STATE UNIV VE ER RSSIIT TY Y M E D I C A L I N S T I T U T E MEDICAL INSTITUTE D E P A R T M E N DEPARTMENT TO OFF IIN NFFE EC CT TIIO OU USS D DIISSE EA ASSE ESS A AN ND D E P I D E M I O L O G Y EPIDEMIOLOGY M ME ET TH HO OD DIIC CA AL L R E C O M M E N D A T I O N S F RECOMMENDATIONS FO OR RC CL LA ASSSS PPR RE EPPA AR RA AT TIIO ON NT TO O PPR RA AC CT TIIC CA AL L C L A S S E S O F CLASSES OF INFECTIOUS DISEASES ((M MO OD DU UL LE E 22)) for the students of senior courses of higher medical establishments of formation of III-IV of levels of accreditation DEPARTMENT OF EDUCATION AND SCIENCE OF UKRAINE SUMY STATE UNIVERSITY MEDICAL INSTITUTE DEPARTMENT OF INFECTIOUS DISEASES AND EPIDEMIOLOGY M ME ET TH HO OD DIIC CA AL LR RE EC CO OM MM ME EN ND DA AT TIIO ON NSS FFO OR R C L A S S P R E P A R A T I O N T O P R A C T I C A L C L A S CLASS PREPARATION TO PRACTICAL CLASSSE ESS O OFF INFECTIOUS DISEASES ((M MO OD DU UL LE E 22)) for the students of senior courses of higher medical establishments of formation of III-IV of levels of accreditation SUMY Publishing house SUMDU 2009 2 M MEETTH HO OD DIIC CA ALL R REEC CO OM MM MEEN ND DA ATTIIO ON NSS FFO OR RC CLLA ASSSS PPR E P A R A T I O N T O P R A C T I C A L C L A S S E S O F I REPARATION TO PRACTICAL CLASSES OF IN NFFEEC CTTIIO OU USS D I S E A S E S ( M O D U L E 2 ) DISEASES (MODULE 2) / M.D.Chemych, N.I.Ilina,V.V.Zakhlebaeva. Sumy: Publishing house SUMDU, 2009. – 165 p. Department of infectious diseases and epidemiology 3 Contents 1 2 3 4 General description of group of infectious diseases is with the airdrop mechanism of transmission. Flu. Other acute respiratory viral infectious: parainfluenza, аdenovirus illness, RS-іnfectious, rhinovirus infection. Determination of concepts of „acute respiratory disease” and „acute respiratory viral infectious”. A concept about bird flu................ Infectious diseases which run across with the clinic of аtypic pneumonia: respiratorial micoplasmosis, psittacosis, legonelosis. A concept about SARS...................... Herpesvirus infection. General description of herpesvirus infections, etiologic structure, place, is in infectious pathology. Infections, conditioned the viruses of simple герпесу of HSV-1 and HSV-2. Windy pox and girdle herpes.......... Herpesvirus infection. EBV-іnfection and СМV-іnfectioon. Infectious mononucleosis. 5 27 55 77 Children’s drop infections in adults. Measles. German measles. Mamps ................... 93 6 Diphtheria. Differential diagnostics of syndrome a «quinsy».... 113 7 A meningeal syndrome in the clinic of infectious diseases. Differential diagnostics of serosal and festerings meningitis. Meningococus infection............. 136 Exigent states for patients with infectious diseases with the respiratory mechanism of transmission. ITSH. Real croup. Unreal croup. Acute respiratory infections.......... 153 Concluding session of the semantic module 2.......... 171 5 8 9 4 Topic. GENERAL DESCRIPTION OF GROUP OF INFECTIOUS DISEASES WITH THE AIR-DROP’S MECHANISM OF TRANSMISSION. FLU. OTHER ACUTE RESPIRATORY VIRAL INFECTIOUS: PARAINFLUENZA, АDENOVIRUS ILLNESS, RS-ІNFECTIOUS ,RINOVIRUS INFECTION. DETERMINATION OF CONCEPTS „ACUTE RESPIRATORY ILLNESS” AND „ACUTE RESPIRATORY VIRAL INFECTIOUS ”. A CONCEPT ABOUT BIRD FLU Duration - 2 hours. 1 Actuality of theme. From data of many specialists, a flu and other respirator viral infections (Acute respiratory viral infectious) is the most mass diseases which occupy a leading place in the structure of infectious diseases and are 80-90 % from all of cases of infectious pathology. Only one pandemic of flu spanish «woman» in 1918-1920 р.р. took away more human lives, than all of last epidemics, together. Unique change ability of superficial antigens of virus of flu hinders creation of effective antiviral vaccine. Except for it, in the last years constantly information act about circulation of animal influenzal viruses –reasortantes , to the group of which the virus of bird flu belongs. The special alarm is caused by the local flashes of his motion with mortal consequences at Hong Kong and other countries of Asia, Europe and America, which are caused the viruses of bird flu And (H5N1). Flashes highly of pathogenic bird flu of H5N1, that began in South-east Asia in a middle in 2003 and spread in our time on some regions of Europe, are the large and serious registered flashes. On a present day the flashes of illness were incorporated in nine Asiatic countries (transferred in the order of registration): To the republic Korea, Vietnam, Japan, Thailand, Cambodia, Laos People's democratic Republic, Indonesia, China and Malaysia. In three from them - to Japan, to Republic Korea and to Malaysia - flash of illness were liquidated and presently these countries are considered free of illness. In some countries of Asia a virus became endemic. 2 Whole lessons (with pointing of level of mastering which is planned) 2.1 A student must know: 5 etiology of flu, parainfluenza, RS-infectious, rhinovirus, adenovirus infection, bird flu; factors of pathogenicity of exciters; epidemiology of flu, parainfluenza, RS-іnfectious, rhinovirus, аdenovirus infection, bird flu; pathogenesis; clinical displays of flu, parainfluenza, RS-іnfectious,r hinovirus, аdenovirus infections with typical motion; clinical-еpidemiology features of acute respiratory viral infectious; pathogenesis, terms of appearance and clinical displays of complications of flu, parainfluenza, RS-іnfectious, rhinovirus, аdenovirus infections, laboratory diagnostics of acute respiratory viral infectious; principles of treatment; principles of prophylaxis; tactic in the case of origin of the exigent states; prognosis of acute respiratory viral infectious. 2.2 A student must be able: to adhere to the basic rules of work at a bed sick; to collect anamnesis of disease and estimate epidemiology information; to inspect a patient and find out basic symptoms and syndromes acute respiratory viral infectious, ground a clinical diagnosis for timely direction of patient in permanent establishment; to conduct differential diagnostics of flu, parainfluenza, RSinfectious, аdenovirus,rhinovirus infections; on the basis of clinical inspection in time to recognize possible complications of acute respiratory viral infectious, exigent states; to design a medical document in fact of establishment of previous diagnosis of «acute respiratory viral infectious»; to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; 6 to work out an individual plan of treatment taking into account epidemiology information, degree of weight, complications, allergist anamnesis; to render the first aid on the before hospitalisation stage; to work out a plan of disease and prophylactic measures, give recommendations in relation to the mode, diet, inspection, supervision, in the period reconvalescent 3 Materials before audition independent work 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) Discipline To know Able Previous disciplines Microbiology Properties of virus of flu, To interpret the results parainfluenza, RS-infekcii, of specific methods of аdenovirus and rhinovirus diagnostics infections bird flu, methods of specific diagnostics Physiology Parameters of physiology To estimate norm of organs and systems information of of man; indexes laboratory inspection laboratory inspection in a norm (clinical blood, urine test, biochemistry of blood, parameters of acid-basic status, electrolytes and other) Physiopathology A mechanism of violation of functions of organs and systems is at the pathosiss of different genesis 7 To interpret pathological changes as a result of clinical and laboratory inspection Immunology and Basic concepts of object, allergology role of the system of immunity in an infectious process, influence on the term of еlimination of exciter from the organism of man To estimate information of immunological research Epidemiology Epidemic process (source, mechanism of infection, ways of transmission); prevalence of disease in Ukraine and in the world To collect epidemiology anamnesis, conduct disease and prophylactic measures in the hearth of infection Neurology Pathogeny, clinical syndromes of disease To conduct the clinical inspection of patient with the defeat of the nervous system Propedevtika of Basic stages and methods To collect anamnesis, internal illnesses of clinical inspection of conduct the clinical patient inspection of patient, find out pathological symptoms and syndromes. To analyse findings Clinical pharmacology Pharmakokinetics and pharmacodynamics, side effects of facilities specific and nosotropic therapy 8 To appoint treatment depending on the degree of weight of disease, individual features of patient. To write recipes Next disciplines Family medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of infectious diseases are possible. Principles of prophylaxis and treatment. To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. To render the first aid in the case of necessity. intradiscipline integration Infectious diseases Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory diagnostics, complications of infectious diseases are possible. 9 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, its complications; to interpret information of laboratory inspection. To appoint treatment. To render the first aid on the before hospitalisation stage. 3.2 Structurally logical charts of maintenance of theme of employment Chart of diagnostics and treatment of аdenovirus infection (Morbus of adenoviralis) Epidemiology anamnesis: - a presence of contact with patients , which have a fever and catarrhal displays; a stay in the endemic cell of acute respiratory viral infectious - sharp beginning; subfebril fever 1-2 weeks, two-wave;limphadenitis, hepatosplenomegalia;signs of pharyngitis,rhinitis,conunctivitis. pharingoconunctival fever: catarrh, swollen person, dacryagogue - luminescent microscopy; cultivation of viruses is on the kidneie’s cells of human embryo; serum methods: CFT (with аdenovirus’s antigens, diagnostic increase of title in 4 times and anymore),imuno enzyme analysis - determination of final diagnosis is taking into account a syndrome, weight, form Differential diagnostics is with hemorragic fevers,measles, leptospirosis, infectious mononucleosis, diphtheria, sharp enteroideas, acute respiratory viral infectious, flu, spotted fever - hospitalization is after epidemic and clinical testimonies; etiotropic therapy – 0,05 % solution Desoxyribonucleasa for 1-2 drops in nasal motions, 0,02 % solution in a conunctival furrow; nosotropic therapy: inductors of endogenous formation interferon (mefenam acid and other ),desintoxication,desensibilization preparates; symptomatic therapy; vitaminotherapy - disappearance of clinical symptoms; - normalization of laboratory indexes - for clinical requirementes ( for presence of complications) 10 Chart of diagnostics and treatment of flu and parainfluenza (Grippus, Paragrippus) Epidemiology anamnesis: - a contact with patients which have a fever and catarrhal displays; stay in the endemic cell of flu and parainfluenza; seasonality is the winter - for a flu is the sharp beginning, increase of temperature to 39-400С for 2-3 hours, gectic temperature’s curve, falling of temperature is critical or a lysis a speed-up, the syndrome of intoxication prevails, the catarrhal phenomena are expressed insignificantly, symptom of Fezana: a language is covered a white-blue raid with porcelain оpalescencia; Morozkin’s symptom: grittiness of sky, back wall of pharynx, hyperemia and point hemorrhages , at once; duration of illness is to 3-5 days. -for a parainfluenza – the catarrhal syndrome prevail above intoxication, duration of illness to 2 weeks, temperature to 38 0С; laryngitis, often for children stenosis of larynx:I stage – respiratory insufficiency is not; ІІ stage is the stenosis breathing, shortness of breath, pallor and cyanosys of nosolabial triangle;ІІІ stage is the loudly stenosis breathing, anxiety, involvement intercostal intervals; IV stage – consciousness, breathing Cheyn-Stoks, asphyxia, loses - a selection a virus from washings off by infecting сhicken embryos; an immunofluorescent method - curing of strokesimprints from mucus wheys with the marked antibodies; serum diagnostics – reaction undirect hemaglutination, immuno enzyme analysis, increase a title in 4 times and more, pair wheys research on 1th and on 7-10th days of illness Differential diagnosis with all of group ARD,meningococcus infection,measles, meningitises, еncephalitis of different etiology, by a leptospirosis, viral hepatitis in prodromal period, by a parainfluenza, with a diphtherial croup - determination a final diagnosis is taking into account a etiology, syndrome, weight, complications - for easy forms: an isolation and treatment in home terms; for heavy forms is hospitalization and bed mode; diet № 15, warm drink; specific : interferon, remantadini, Oxolinum, mephenam acid; nosotropic: vitamin С, Rutinums, polivitamines; antihistaminic; symptomatic - coughings up, anticough facilities, unnarcotic аnalgetics; for joining of bacterial complications - antibiotics; for stenosis of larynx inhalation of soda, broncholitics, аminasinum, glucocorticoids, іntubation, tracheotomy, tranquilizers,sedative, oxygen tent - disappearance clinical symptoms; normalization of laboratory indexes - after the carried pneumonia supervision of district 11 doctor during a month; after complications from the side of otholarynx’s-оrgans supervision of otolaryngologist Health centre system: Plan of diagnostics and treatment of respiratory-syncitial infection (Morbus of respiratorio-syncytialis) Epidemiology anamnesis: - contact with a sick timber-toe by the catarrhal phenomena and fever or healthy people,which carrying a virus 3-6 days prior to a disease; most morbidity in a winter-spring period, children are more frequent ill - beginning of illness is sharp or gradual: the temperature of body subfebril, rarely high, during 5-7 days; moderate intoxication; damage of respiratory tracts: bronchiolitis, bronchitis with an asthmatic component, pneumonia with respiratory insufficiency, Rhinitis with serosal excretions, rhinopharyngitis; dry,prolonged, cough attacks protracted; еmphisematosis changes in lungs; insignificant hyperemia, swelling, grittiness of mucus shell of soft palate, back wall of pharynx - virologic research of washings from nasopharynx, excretions from the mucus shell of nose, sputum, by infecting culture of cells (НELA, Hep-2), primary cultures kidneie’s cells of human embryo; serum diagnostics: CFT, RN,reaction braking hemaglutination is increase title of antibodies in 4 and more than times in the pair wheys of blood; expressdiagnostics: method immunolumen (bright green luminescence well-educated specific complex is an antigen-аntibody); an exposure RNK-viruses is by a polimerase chain reaction; immune enzyme analysis (exposure of antibodies class IgM; sciagram-strengthening pulmonary picture, shallow ring-like or linear pls due to the compression of walls bronchial tubes and еmphisemo-аtelectasis areas (changes of short durations, disappear during 7-10 days); in blood moderate leucocytosis is with the insignificant change leucocytic formula to the left,ESR is not changed - formulation of final diagnosis with determination of weight, distribution of process, complications Differential diagnosis with other acute respiratory viral infectious (flu, parainfluenza, аdenovirus infection), (vasculomotor) by a rhinallergosis, bacterial gaimoritis,frontitis, еtmoiditius,bronchitis abronchitis - hospitalization patients with heavy and complicated motion of infection and after epidemiology information ; etiotropic therapy (an interferon in the first days of disease is 2-3 drops in a nose 4-5 times per a day); nosotropic therapy: spasmolysis respiratory muscles (ephedrine, еuphilinum, Dimedrolum), desintoxication; washing of nose by hypertensive solution marine salt, sanorinum, galasolinum -1-2 days; hot baths of foot; fauces-wash of calendula, camomile, eucalyptus decoction , solventias; vitaminotherapy - disappearance of clinical symptomatic - the clinical looking for a reconvalescentes of the complicated forms 12 A plan of diagnostics and treatment of rhinovirus infection (Rhinovirosis) Epidemiology anamnesis: - contact with a sick man 1-6 days before a disease; - most morbidity in September, April-May; - children are more frequent ill in schools - beginning is sharp from expressed rhinorea, maximally certain on a 2-3th day; the increase of temperature to the subfebril numbers and moderate head pain is possible, creeping in a throat, the nasal breathing is complicated through the edema of mucus, sometimes easy catarrhal conjunctivitis with a dacryagogue; - at a review: moderate hyperemia of soft palate and back wall of a pharynx; - laryngitis with coughing and wheezing voice; - duration of illness on the average 1 week - a selection of exciter is from epipharyngeal mucus by infecting of culture embryo cells or kidneies of man; - serum diagnostics: RN or CFT is an increase of antibodies in 4 times in the pair wheys of blood (interval 2 weeks) - determination of final diagnosis is with pointing of weight, complications -differential diagnosis with other acute respiratory viral infectious (flu, parainfluenza, RS-іnfectious,аdenovirus infection), meningococcus nasopharyngitis, diphtheria of front department of nose, antritis, rhinallergosis - hospitalization does not need; - etiotropic therapy – absents; - in complete absence nasal breathing are narrow-vessel drops in a nose (2 % ephedrine, Naphthyzinum); - home mode (in a sharp period), to avoid supercooling; - аntibacterial preparations are at bacterial complications - not conducted 13 3.3 Literature is made to order Basic • Vozianova zh.I. the Infectious and parasitogenic diseases. – In 3 т. - K.: of Health, 2001 – T 1. - P. 433 - 457 • Supervision for infectious disease / for editor U.V. Lobzina. 3th publication.,supplement and change. - Spb: Foliant, 2003. -1020 p. • Infection disease: textbook / E.P.. Shuvalova, M.M. Antonov– 4th publication, change and supplement Mcode Medicine, 2001. 959 p. • Infectious diseases: Textbook. / M.V. Titov, B.A.Garasun, L.Yu. Shevchenko and other / For editor M.V. Titov – K.: Higher school, 1995. – p. 241-261. Additional Gavrisheva N.A., Antonova T.V. Infektion process. Clinical and pathophysiologic problems – Spb.; Foliant, 1999. – 255 p. Clinical-laboratory diagnostic infectious desease: Supervision for a doctors. – Spb.: Foliant, 2001 -384 p. 3.4 Materials for self-control 3.4.1 A question for self-control 1 Features of exciter of flu, parainfluenza, RS-іnfectious, аdenovirus, rhinovirus infections. A concept about bird flu. 2 Factors of pathogenicity of exciters. 3 Source of infection and factors of transmission. 4 Pathogenesis. 5 Classification. 6 Basic clinical syndromes. 7 Clinical displays are depending on weight of motion. 8 Specific complications. 9 Differential diagnosis. 10 Plan of inspection sick. 11 Methods of specific diagnostics. 12 Interpretation of results of laboratory research. 14 13 Specific therapy: doses, ways of introduction, duration of treatment. 14 First aid to the patient. 15 Governed excerption from permanent establishment. 16 A prophylaxis and measures is in a cell. 3.4.2 Tests are for self-control To choose right answers Variant 1 1 source of infection of flu: A food products; B sick people (animals - as a reservoir of infection),viruscarry; C water; E canned products. 2 At the heavy forms of flu appoint: A - all is transferred; B are vitamins; C are antiviral preparations; D desensitizing; E- desintoxication. 3 The antigen structure of virus flu changes in: A - does not change; B - virus of flu B; C - virus of flu С; D - virus of flu A, B, С; E - virus of flu A. 4 The virus of flu is proof: A - to the high temperatures; B - to the low temperatures; C - to the small concentration to the chlorine; D - to the ultraviolet rays; 5 All belong before complications of flu, except for: A - to the bronchitis, pneumonia; B - to the aкtritis; C - to the pyelonephritis; D - myocarditis; E - to poliomyelitis. 15 6 The virus of flu has a tropic to : A - cylinder epithelium of overhead respiratory tracts; B - flat epithelium; C - lymphoid tissue; D - аlveolocytes. 7 The prophylaxis of flu during an epidemic is provided: A - by a vaccination; B - stimulate of synthesis endogenous interferon; C - by antiviral preparations; D - antibiotics. 8 The children of early age have complication of flu: A meningoencefalitis; B stenosic laryngotracheitis; C viral pneumonia; D myocarditis. 9 Specific treatment of parainfluenza: A vitamin С; B the anticough mean; C interferon,remantadinum; D tranquilizers. 10 What family the virus of parainfluenza behaves to: A - Paramyxoviridae; B - Adenoviridae; C - Pneumovirus; D - Picornaviridae. Variant 2 1 A mechanism of transmission is at an adenovirus infection: A - air-drops; B - vertical; C - transmisive; D - sullage-oral; E - sexual. 2 A source of infection is at a аdenovirus infection: A - a sick man or bacillicarrier; B - home animals; C - wild animals; 16 D - rodents; E - birds. 3 Adenovirus is initially localized in: A - epitheliums of overhead respiratory tracts; B - to blood; C - to cerebral tissue; D - sexual system; E - to the extraction system . 4 Forms of аdenovirus infection, except for: A - effaced; B - pharyngoconunctivitic fevers; C - pellicle conunctivitis; D - sharp respiratory illness; E - аdenovirus diarea. 5 A testimony is to аntibiotictherapy at a аdenovirus infection: A - a presence of complications; B - a conjunctivitis; C - pharyngitis; D - tonsillitis. 6 For аdenovirus diarea characteristically: A - is diarea with the admixture of mucus in incandescence; B - is blood in incandescence; C - a pus in incandescence; D - excrement as «raspberry jelly»; 7 For аdenovirus pneumonia characteristic motion is in a kind: A - hearth creeping pneumonia; B - аbscedic; C - іntersticial; D - pleuropneumonias. 8 Facilities of prophylaxis of аdenovirus infection: A - is іnternasal introduction of leucocytic interferon; B - is active immunization; C - desinsection and deratization; D - desinfection. 9 With what diseases does differentiate a аdenovirus infection? A - by a cholera: 17 B - by a plague; C - brucellosis; D - infectious of mononucleosis, diphtheria, acute respiratory viral infectious. 10 At treatment a аdenovirus infection will utillize everything, except for: A a rinse of throat by solution of furaciline; B - ultrasonic high frequency and ultraviolet light; C - is burying of eyes by a 15-30% solution of albucidi; D - antibiotics. Variant 3 1 Hospitalization of patient is conducted after such testimonies: A - to put to 5; B - sear and yellow leaf; C - heavy motion; D - heavy motion, complication, epidemiology testimonies. 2 Indexes of blood are a RS-іnfectious: A - not changed; B - leucopenia, increase ESR; C - trmbocytopenia; D - moderate leucocytosis, ESR within the limits of norm. 3 A latent period is at a RS-іnfectious: A - 3-6 days; B - 10 days C - 6 months; D - 2 days. 4 What seasonality of RS-іnfectious? A - summer; B - winter - spring; C - autumn; D - spring - summer. 5 Who is more frequent ill a RS-іnfectious? A – old people; B - to put; D - people 30-40 years; E - all of answers are faithful. 18 6 Method of introduction and dose of interferon: A - i/v 2-3 ml 2 times per a day; B - inside for a 1 tablet. 2 times per a day; C - 2-3 drops in a nose 4-5 times per a day; D - hypodermic 1 ml 1 time per a day. 7 After whom does conduct a clinical supervision? A - by heavy motion; B - after children to 3; C – with the complicated forms; D - all of answers are faithful. 8 Who is the source of infection? A - animals; B - sick people and viruscarry; C - birds; D - rodents. 9 Nosotropic therapy of RS-іnfectious: A - еuphilinum, Dimedrolum; B - vitamitherapy; C - seduxenum; D - prednisolonum. 10 During what time does disappear x-ray photography of sign? A - 2 months; B - 7-10 days; C - 1 month; D - 6 months. Variant 4 1 What family does rhinovirus behave to? A - Picornaviridae; B - Reoviridae; C - Herpesviride; D - there is not a right answer. 2 A latent period is at arhinovirus infection: A - 1 month; B - 1-6 days; C - 14 days; D - 2 months. 19 3 The most characteristic clinical signs for a rhinovirus infection: A - rhinorea; B - cough; C - head pain; D - all of answers are faithful. 4. typical complications of a rhinovius infection: A - sinuitis; B - otitis; C - artritis; D - all of answers are faithful. 5 Sign of diagnostics all, except for: A - epidemiology information; B - to the presence of rhinorea; C - to absence of intoxication; D - expressed intoxication. 6 Source of infection: A - patient; B - are animals; C - all of answers are faithful; D - is rodents. 7 Mechanism of transmission: A - air-drops; B - vertical; C - аlimental; D - all of answers are correct. 8 Seasonality: A - winter; B - summer; C - autumn - spring. 9 Optimum terms are for a replication of exciter: A - temperature +27-300 С; B - temperature +33-350 С; C - temperature 00 С; D - all of answers are faithful. 10 Place of penetration and replication of virus: A - flat epitheliums; 20 B - transitional epithelium; C - prismatic blinking epithelium; D - keratinous epithelium. Standards of right answers Variant 1: 1-B; 2A; 3-E;4 C ; 5-E; 6 A; 7-B; 8-B; 9-D; 10 A. Variant 2: 1A; 2A; 3A; 4A; 5A; 6A; 7A; 8A; 9-D; 10-D. Variant 3: 1-D; 2-D; 3A; 4-B; 5-B; 3; 3; 8-B; 9A; 10-B. Variant 4: 1A; 2-B; 3A; 4-D; 5-D; 6A; 7A; 3; 9-B; 3. 3.4.3 A task is for self-control Task 1 Patient A., 7 years, entered infectious separation with stenosis of larynx of 2 degrees, temperature 38 0С, catarrhal phenomena. 1 Formulate a diagnosis. 2 With what diseases does conduct differential diagnostics? Task 2 Infectious separation a man entered 30 years, temperature of 40 0С (according to a patient a temperature rose hour-long), intoxication is expressed, the catarrhal phenomena are expressed insignificantly, a language is covered a white raid, hyperemia of глотки. 1 Formulate a diagnosis. 2 Appoint specific treatment. Task 3 To the policlinic a girl appealed 17 years with complaints about a fervescence to 37 0С within a week, conjunctivitis, слизуваті excretions, from a nose, dacryagogue. Objectively: a liver and spleen is megascopic, лімфаденіт. 1 Formulate a diagnosis. 2 Is the health centre system needed? Task 4 To the policlinic a man appealed 28 years with complaints about subfebril, dry cough. Intoxication is moderato expressed, displays of bronchitis, rhinisporidios, hyperemia, and was swollen back wall of pharynx. On the sciagram of strengthening of pulmonary picture, shallow ring-like pls. Blood test: leucocytosis, change of formula to the left,ESR 5 mm / hours 1 Formulate a diagnosis. 21 2 What serum tests can be conducted? Task 5 To the policlinic a girl appealed 20 years with complaints about the increase of temperature to 370С, закладеність nose, першіння in a throat, слизуваті excretions from a nose, absence of sense of smell and taste. Objectively: a skin мацерована round the nasal openings. Hyperemia of ротоглотки, підщелепні lymphonoduss, is megascopic. A clinical blood test is in a norm. 1 Formulate a diagnosis. 2 Additional methods of diagnostics. Standards of answers are to the tasks Task 1 1 Parainfluenza, stenosis of larynx 2 ст. 2 Acute respiratory viral infectious, diphtherial croup, meningitis. Task 2 1 Flu. 2 Interferon, remantadinum. Task 3 1 Adenovirus infection. 2 No, the health centre system is conducted at the complicated forms. Task 4 1 RS-іnfectious. 2 CFT, RN, RGGA,immuno enzyme analysis. Task 5 1. Rhinovirus infection. 2. CFT. 4 Materials are for audience independent work 4.1 List of educational practical tasks which must be executed on practical employment To capture the method of inspection patient with a flu, parainfluenza, RS-іnfectious, аdenovirus, rhinovirus infections. To conduct care of patient. To conduct differential diagnostics. To work out a plan of laboratory inspection. 22 To interpret the results of specific inspection of patient. To recognize complication. To work out a plan of treatment sick. To define medical tactic in the case of origin of the exigent states. To design a medical document in fact of establishment of diagnosis. 4.2 A professional algorithm is in relation to forming of skills and abilities of diagnostics of acute respiratory viral infectious № Task Sequence of A remark, warning, is in implementation relation to self-control 1 To capture the Complaints method of clinical inspection a Anamnesis of patient on acute illness respiratory viral infectious Anamnesis of life Epidanamnesis 2 To conduct a To conduct curation of patient objective inspection To select complaints and characteristic syndromes. To pay a regard to beginning, term, sequence of origin of symptoms, their dynamics. To find out the carried illnesses. To find out information which touch realization air-drops mechanism of transmission a contact is with infectious patients. an Expressiveness, dynamics of symptoms, is conditioned duration and weight of motion of disease. General review To pay attention on: - mucus shell of cavity of mouth; - a selection is from a nose; 23 - skin covers; - on a conjunctiva. To pay attention on: -аuscultative information; - limitation of motions of intercostal muscles; - violation of breathing rhythm; - shortness of breath. respiratory system 3 To appoint General clinical laboratory and analysis of blood additional researches To pay attention on: - neutrophilic leucocytosis with the change of leucocytic formula to the left; - increase of ESR. Serum hemanalysis. Materials of after audition work independent work Subject of UDRS and NDRS: • Features of motion acute respiratory viral infectious are in modern terms. • Modern methods of specific diagnostics of acute respiratory viral infectious. • Problems of etiotropic treatment acute respiratory viral infectious. • Modern looks are to the bird flu. 24 Topic. INFECTIOUS DISEASES WHICH RUN ACROSS WITH THE CLINIC OF АTYPICAL PNEUMONIA: RESPIRATORMICOPLASMOSIS,PSITTACOSIS,LEGIONEL OSIS. A CONCEPT ABOUT SARS. DIFFERENTIAL DIAGNOSTICS ACUTE RESPIRATORY VIRAL INFECTIOUS.PRINCIPLES OF LABORATORY DIAGNOSTICS, TREATMENT, AND PROPHYLAXIS OF ACUTE RESPIRATORY VIRAL INFECTIOUS. TESTIMONY TO HOSPITALIZATION, GOVERNED EXTRACTS OF PATIENTS OF PERMANENT ESTABLISHMENT Duration - 2 hours. 1 Actuality of theme. Respiratory micoplasmosis behaves to the infectious diseases the account of which is not foreseen an official medical document. M. pneumoniae occupy a 3 place after pneumococcus and Legionella of pneumophila are principal reason of respirator infections for schoolboys and young people. Legionelezi inflict society perceptible economic losses, that conditioned by the protracted loss of capacity, heavy motion, high(150 % ) lethality. The flashes of psittacosis are registered on all continents. Except for wild birds home animals and birds can be attracted in the process of distribution of infection. Ill-timed diagnostics of psittacosis influences on efficiency of treatment, instrumental in the origin of relapses, transition, in the protracted and chronic form. In the pathosis of man a large role is played by the sharp diseases of respiratory tracts of infectious nature. They are 50-70 % all of infectious diseases. The role of viruses is especially important: 50-60 % respirator diseases caused by them. At plenty of exciters, polymorphism of caused by them clinical displays, varieties of clinical forms far not always, even at the detailed inspection of patient, it is succeeded to set etiology of exciter which caused a respirator syndrome. For this reason it is important to know basic principles of differential diagnostics of acute respiratory viral infectious, it is instrumental in setting of the proper treatment and rapid convalescence of patient. 25 2 Whole lessons (with pointing of level of mastering which is planned) 2.1 A student must know: а-2 etiology of micoplasmosis, psittacosis,legionelosis, factors of pathogenicity of exciters; epidemiology of micoplasmosis, psittacosis, legionelosis; pathogeny of micoplasmosis, psittacosis of,legionelosis; clinical displays of micoplasmosis, psittacosis, legionelosis at typical motion; clinical and еpidemiological features of psitacosis, psittacosis, legionelosis pathogenesis, term of origin and clinical displays of complications of micoplasmosis, psittacosis, legionelosis; laboratory diagnostics of micoplasmosis, psittacosis, legionelosis; principles of treatment; principles of prophylaxis; tactic in the case of origin of complications; prognosis of micoplasmosis, psittacosis, legionelosis; governed extracts of reconvalescentes from permanent establishment; governed the health centre system of reconvalescentes; etiology, pathogenesis, clinic features, diagnostics, principles of treatment of SARS; differential diagnostics of acute respiratory viral infectious; principles of laboratory diagnostics of acute respiratory viral infectious; principles of treatment; principles of prophylaxis; a testimony is to hospitalization; governed extracts of patients from infectious permanent establishment. 2.2 A student must be able: 26 а-3 to adhere to the basic rules of work near a bed sick; to collect anamnesis of illness with the estimation of epidemiology information; to inspect a patient and find out basic symptoms and syndromes of micoplasmosis, psittacosis, legionelosis , acute respiratory viral infectious; to ground a clinical diagnosis for timely direction of patient in permanent establishment; to conduct differential diagnostics of micoplasmosis, psittacosis, legionelosis ; to conduct differential diagnostics of acute respiratory viral infectious; on the basis of clinical inspection in good time to recognize possible complications of micoplasmosis, psittacosis, legionelosis; on the basis of clinical inspection in good time to recognize possible complications of acute respiratory viral infectious; to design a medical document in fact of establishment of previous diagnosis "micoplasmosis , psittacosis, legionelosis, acute respiratory viral infectious" (an urgent report is in SES); to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; to work out an individual plan of treatment taking into account epidemiology information, weight of the state, presence of complications, allergist anamnesis, concomitant pathology; to work out a plan of disease and prophylactic measures in the hearth of infection; to give recommendations in relation to the mode, diet, inspection, supervision, in the period of reconvalescentious. 3 Materials are to audience independent work 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) Discipline To know Able Previous disciplines 27 Medical biology Properties Ch. psittaci Mycoplasma pneumoniae To interpret the results of specific methods of of diagnostics of psittacosis, micoplasmosis Microbiology Property of Legionella of pneumophilia, families of Adenoviridae, Picornaviridae, Orthomyxoviridae, Paramyxoviridae. Methods of specific diagnostics of the diseases caused by them Physiology Parameters of To estimate information physiology norm of of laboratory inspection organs and systems of man; indexes of laboratory inspection are in a norm (general analysis of blood, urine, biochemical of blood, parameters of KOS, electrolytes and others like that) Physiopathology A mechanism of violation of functions of organs and systems is at the pathosiss of different genesis Immunology To interpret the results of specific methods diagnostics of legionelosis, flu, parainfluenza, аdenovirus infection, rhinovirus infection, respiratorysyncitial infection To interpret pathological changes as a result of clinical and laboratory inspection Basic concepts of object, To estimate information 28 and allergology role of the system of of immunological immunity in an researches infectious process, influence on the term of еlimination of exciter from the organism of man Epidemiology Epidemic process (source, mechanism of infection, ways of transmission) at legionelosis, psittacosis, respirator micoplasmosis,acute respiratory viral infectioua; prevalence of pathology in Ukraine and in the world Neurology Pathogeny, clinical To conduct the clinical syndromes of disease inspection of patient with the defeat of the nervous system To collect epidemiology anamnesis, to conduct disease and prophylactic measures are in the hearth of infection Propedevtic of Basic stages and To collect anamnesis, internal illnesses methods of clinical conduct the clinical inspection of patient inspection of patient, find out pathological symptoms and syndromes. To analyse findings. Clinical pharmacology Pharmacokinetic and To appoint treatment pharmacodynamics, side depending on the degree 29 effects of facilities of of weight, individual specific and nosotropic features of patient. therapy To write recipes Next disciplines Domestic medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of psittacosis, respirator mycoplamosis are possible, legionelosis,acute respiratory viral infectious. Features of motion of these illnesses. Principles of prophylaxis and treatment. To conduct differential diagnostics of illnesses with a respirator syndrome. To recognize these illnesses, their complications; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. To render the first aid in the case of necessity Interdiscipline integration Infectious diseases Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory diagnostics, complications of infectious diseases are possible. 30 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. To appoint treatment. To render the first aid on the before hospitalization stage. 3.2 Structurally logical charts of maintenance of theme of employment Chart of diagnostics and treatment of psittacosis (Ornithosis) Еtiology Chlamydia psittaci - Еpidemiology pathogenesis clinic reproduction and accumulation of exciter is in the epithelium of respiratory tracts a contact with birds, feather,excrements of birds; work in a laboratory with contagious material. аlergisation disemination exciter in organs, liberations of toxic substances prelum of bronchial tubes and bronchioles damage of cells, alveols, and interstitium hypoxia of internalss - Sharp beginning, a temperature, head pain, pharyngalgia, cough, аrtralgia, nausea, strong sweating, rises with a chill; presence of typical original appearance of patient: puffiness of person is with cyanosys of lips; signs of pneumonia (іntersticial,focal,lobar); defeat of the nervous system (hydromeningitis) - extract of exciter with blood, sputum on chicken еmbriones, culture of cells; CFT or reaktion braking hemaglutination , immune enzymes ana;lysis;Ter’s intraderma аlergic prob Yes, a diagnosis is confirmed: no - determination of eventual diagnosis, pointing of form, motion, weight, complication . -differential diagnosis with pneumonias, Kufever, spotted fever, typhoid fever, flu, tuberculosis of lungs , micoplasmosis, a leptospirosis and other. therapy: antibiotics of Tetracyclinum group (doxiciclinum),macrolides (аzitromicinum); desintoxication therapy; desensibilization, it is necessity glucocorticoids symptomatic therapy: diuretic, brocholitics, vitamins; - at the protracted and chronic motion conduct vaccinotherapy. - Convalescence; excerption dispanserisation - disappearance of clinical symptomatic; normalization of laboratory indexes. - during 6 months 31 Plan of diagnostics and treatment of legionelosis (Legionellosis) Еtiology Legionella pneumophila Еpidemiology patogenesis - use of show equipment; using room humectants, conditioners; earthen and reclamative works; dwelling is near the opened reservoirs; old men and senile are more frequent ill. reproduction of exciter in macrophages penetration of infection in alveoles activating of heterospecific immune is reactions specific antibodies, poliorgan’s impression clinic sharp beginning from a chill, head pain, muscular pain, ferves cence to 38 - 400С; clinic of pneumonia which hardness responds to treatment; presence of catarrhal syndrome . reaction of immunofluorescence; Reaction undirect hemaglutination, immuno enzyme analysis, RIA; reaction micrо agglutination and undirect immunofluorescence (diagnostic title 1:128); a selection of legionel from sputum, pleura liquid Yes, a diagnosis is confirmed no determination of eventual diagnosis, pointing of form, motion weight, complication differential diagnosis from by pneumonias of other etiology,acute respiratory viral infectious, оrnitosis, Kufever, tuberculosis of lungs , infarct of lungs therapy - аntibiotic therapy( macrolides, phtorchinolones); - desintoxication therapy; - antihistaminic preparations; - symptomatic therapy Convalescence: excerption dispanserisation - for clinical requirementes - disappearance of clinical symptomatic; . - normalization of laboratory information 32 Plan of diagnostics and treatment of mycoplasmosis Еtiology Mycoplasma pneumoniae - a disease is during the flash of acte respiratory viral infectious; - group morbidity of children and young people in establishments of the closed type Еpidemiology reproduction of exciter in place of penetration patogenesis extract of mitogenic factor activating of heterospecific immunoreactions specific antibodies, poliоrgan’s impression formation of toxic substances; damage cells of bronchial tubes, alveoles on a background of acute respiratory disease development of pneumonia from minimum phisical information clinic fever intoxication rhinopharyngitis tracheobronchitis - bacteriologic examination of sputum and epipharyngeal washings off; - serum researches( CFT,reaction undirect hemaglutination); - PCR . a diagnosis is confirmed Yes, no підтверджена determination of final diagnosis, pointing of form, motion weight, complication differential diagnosis from by pneumonias, Ku-fever,,flu a leptospirosis, psittacosis therapy - аntibiotic( macrolides, phtorchinolones); - desintoxication therapy; - desensitizing; - symptomatic therapy disparisation Convalescence: excerption - disappearance of clinical symptomatic; - normalization of laboratory information . 33 For a clinical requirementes Plan of differential diagnostics of acute respiratory viral infectious damage a respiratory ways : rhinitis,pharingitis, no Acute tonsilitis,laryngitis,tracheitis,bronchitis, respiratory viral бронхіоліт yes infectious isn’t Seach a case of yes no fever meningeal symptoms diagnosis for results of research spinal liquid. Break out hemorhage When is Normal indexes–diagnosis no meningism, make diagnostic for right branch yes Some changes for аuscultation of lungs yes Character of cases meningococcemia (rarely – sepsis other etiology ) no fever >37,80С yes no focal difuse Character of respiratory ways pneumonia (Rhdiagnostic) bronchiolitis (stuffiness) RS-infectious . chiefy type of wheezing dry damp RS-infectious flu,edema lungs damage pharyngo-tonsilitis with rhinorea( + conunctivitis limphadenopathy) Аdenovirus infectious Character of respiratory ways damage laryngitis (wheezing voice) paraflu bronchitis (stuffiness) RS- infectious of laryngitis,tracheitis, bronchitis,rhinitis, brightnes difuse hyperemia of fauce, dry mucous influenza Diagnosis of flu is more real when have a combinaion a temperature > 37,8 0С and two and more symptoms: а) dry cough with a pain behind of sternum ; б) breaking in muscle,trochanter, bones; в) difuse hyperemia of fauces, dry mucous; г) headeche in a forehead-temporal area 34 rhinit (rhinorea) rhinovirus іnfectious Chart of diagnostics and treatment of acute respiratory viral infectious Epidemiology anamnesis - contact with ill man ,which have fever and cataral symptoms ; being in endemic area of ARD, аnd with health viruscarries for 1-6 days before disease of RS-infection and rhinovirus іnfection - start of disease sharp or gradualy ( RS-іnfection); - hyperemia palatina and posterior wall of pharynx; - flu: increase a temperature to 39-400С for 2-3 hour, decrease temperature critic,chiefly symptom іntoxication, cataral signs expres not so .Duration of disease 3-8 days; - paraflu: chiefly cataral signs , іntoxicationexpres not so, laryngitis, subfebril temperature , duration disease for 2 weeks; - аdenovirus infection subfebril fever 1-2 weeks, two-wave, limphadenitis, signs of pharyngitis, rhinitis, conunctivitis, pharyngoconunctival fever : runny nose, edema of face, tearing; - RS-іnfection: subfebril temperature duration 5-7 days, bronchitis, bronchiolitis with аstmatic component; - Rhinovirus іnfection:rhinorea, temperature often is normal , nasal breathing is complicate for edema of mucous, duration disease 1 week - extract a viruses with wash nasopharynx for a way іnfective chicken еmbriones ( flu, paraflu) and kidneies of human еmbrione ( of other. ARD), іmmuno lumen method – cutting of spreade - imprintes with mucous of solution with marked antibodies, serologic diagnostic – reaction undirect hemaglutination, RN,CFT, immuno enzyme analysis, increase index of 4 time and more, research pair wheys , polimerase chain reaction for identificate genome - determination of end diagnosis with score etiology, syndrom, hard, complicate -differential diagnosis for meningococcus infection,meningitis,diphteria,measles,leptospirosis, аlergic rhinitis, bacterial bronchitis, gaimoritis, еthmoiditis and other . - hospitalization of sicks with hard and complicate іnfection, for еpidemic indexes; - еtiotropic therapy: for flu and paraflu– remantadinum, оxolin, mephenam acid; - аdenovirus іnfection: 0,05% solution desoxirybonuclease for 1-2 drops in nasal ways , 0,02% - in conunctival suture ; - RS-іnfection – іnterferonum in first days of disease – 2-3 drops in nose 4-5 time on a day; - patogenetic therapy: hot drink,watch out of colding - flu and paraflu: polivitamins, vitamin С, аntihistamine; - adenovirus іnfection: іnductors еndogenic interferonum, desensibilizive; - RS іnfection: remove of spasm breathing muscles (ephedrinum, еuphilinum) - Rhinovirus іnfection: vessels narrowing drop in nose (2 % еphedrinum, naphtisinum); - symptomatic therapy; - аntibacterial therapy for bacterial complicates - for clinical indexes (for presence of complications) - decrease of clinical symptoms ; normalization laboratory indexes 35 3.3 Literature is made to order Basic • Vozianova Z.I. the Infectious and parasitogenic diseases: In 3 т. - K.: of Health, 2001. - T.1. – 60-339 p. • Ivakhiv O.L., Gricko R.U., Kiselik I.O. infectious Room of diseases: Train aid. it is Ternopil', 2006. – 233 p. • Infectious diseases are in general practice and domestic medicine / For editor M.A. Andreychina.Ternopil': TDMU, 2007. – 500 p. • Infectious diseases: Textbook / For an editor Titova M.B. – K.: Higher school, 1995. – p. 89 - 97 Auxiliary • Gavrisheva N.A., Antonova T.V. Infectious process.Clinical and pathophisiologic chages. - Spb.: Special literature, 1999. – 255 p. • Clinical-laboratory diagnostic infectional disease:Superviser for doctors. - Spb.: Foliant, 2001. – 384 p. • Differencial diagnostic infectional disease:Superviser for doctors / Т. M.Zubik, K.S.Ivanov: Medicine, 1991. - 168-176 p. • Differencial diagnostic infectional disease/Devid Shlossberg, Ionas A.Shulman.: BINOM-Moscov, 1999. – 13-17, 20-23, 101 p. 3.4 Materials are for self-control 3.4.1 A question is for self-control 1 Features of exciter of legionelosis, psittacosis, respirator мікоплазмозу, SARS. 2 Source of infection and factors of transmission. 3 Pathogeny of legionelosis, micoplasmosis, psittacosis, SARS. 4 Classification of legionelosis,micoplasmosis, psittacosis. 5 Basic clinical syndromes of legionelosis,micoplasmosis, psittacosis, SARS,acute respiratory viral infection. 6 Clinical displays are depending on weight of motion. 7 Specific complications of legionelosis,micoplasmosis, psittacosis, SARS,acute respiratory viral infection. 8. Differential diagnosis . 9 Plan of inspection patient with a psittacosis,micoplasmosis, legionelosis, acute respiratory viral infection 36 10 Methods of specific diagnostics of legionelosis, micoplasmosis, psittacosis, SARS,acute respiratory viral infection. Interpretation of results of laboratory research. 11 Etiotropic therapy of psittacosis,legionelosis,micoplasmosis,SARS,acute rspiratory viral infection: doses, way of introduction, duration of treatment. 12 A testimony is to hospitalization. 13 Medicare by a patient on the before hospitalization stage. 14 Governed extracts of reconvalescentes from permanent establishment. 15 A prophylaxis and measures is in a cell. 3.4.2 Tests are for self-control To choose right answers Variant 1 1 Legionelosis: A) sapronosis B) zoonosis C) antroponosis D) antropozoonosis 2 Clinical forms of legionelosis, except for: A) pneumonias B) fevers of Pontiak C) fevers Fort-Bragg D) meningitis 3 incubation period of legionelosis: A) 3-30 days B) 60-120 days C) 2-10 days D) 1-2 hours 4 First symptoms of display of SARS: A) fever,t 38 0 С and anymore, cough B) diarea, icterus C) sharp hypothermia D) all unright 5 Legionella is cultivated on: A)chicken embryos 37 B)white mouse C)environment Kitta-tarocci D)doesn’t cultivate E)simple artificial nourishing environments 6 A source of infection of legionelosis: A)ill man B)no set C)bactericarry D)home birds (chickens, turkey-cocks, ducks) E)wild birds (parrots, pigeons) 7 Ways of infection legionelosis: A)аir B)contact C)transplacental D)alimental E)contact-consumer 8 Legioneli select: A) еndotoxin B) еkzotoxin C) іnterleukin D) Somatotropinum 9 The infection of legionelosis arises up inhalation: A) water an aerosol B) saw C) soil D) all is transferred 10 Roentgenologic signs are in lights of legionelosis A) lobar аbscedic pneumonia B) one-sided C) exudative pleurisy D) all right Variant 2 1 Exciter of psittacosis: A) ricketsia B) chlamidia C) virus 38 D) micoplasma 2 A psittacosis mainly are ill: A) workers of poultry factories B) forest rangers C) fishings D) physicians 3 After the carried psittacosis immunity: A) for all life B) non-sterile C) unsteady D) antitoxic 4 What types of birds are a source at a psittacosis? A) poultries B) decorative C) pigeons D) all are transferred 5 Ways of transmission are at a psittacosis: A) air-drops B) air-dustborne C) all are transferred 6 A mechanism of transmission is at a psittacosis: A) transmisive B) sullage-oral C) aerogene D) sexual 7 The latent period of SARS makes: A) 3 months B) 2-7 days C) 30 days D) 1 year 8 chlamidia in an environment proof to : A) heating B) des. solutions C) freezing D) drying out 9 chlamidia are: 39 A) intracellular vermin B)extracellular vermin C) saprophytes D) аctinomicetes 10 Birds select an exciter a psittacosis from: A) by excrements B) by a nasal secret C) all right Variant 3 1 Dangerous patient of micoplasmosis for circumferential? A) always B) no C) at a transmitter D) at heavy forms 2 The signs of micoplasmosis pneumonia is: A) temperature B) myalgias C) unproductive cough D) all is transferred 3 Ways of transmission are at SARS: A) air-drops B) the pin domestic is possible C) sullage-oral D) all right E) right and, 4 The exciter of micoplasmosis is : A) chlamidia B) micoplasma C) ricketsia D) spirocheta 5 Mikoplazmosis is: A) zoonosis B) аntroponosis C) аntropozoonosis D) sapronosis 6 An exciter SARS is: 40 A) viruses B) bacteria C) mushrooms D) the simplest 7 An entrance gate is micoplasmosis: A) mucus overhead respiratory tracts B) mucus thin bowels C) mucus colon D) wound 8 Specific diagnostics of micoplasmosis, except for: A) microaglutination B) Reaction undirect hemaglutination C) PLR D) CFT 9 Preparations of choice for etiotropic treatment of micoplasmosis: A)аmpicilinum B) tetraciclinum C) Sulfanilamidums D) tienam 10 An exciter SARS is: A) togavirus B) paramyxovirus C) coronavirus D) legionella Variant 4 1 Pain in eyeballs (retroorbital), which appears at motion of eyes, is characteristic for: A) flu B) parainfluenza C) аdenovirus infections D) rhinovirus infections 2 How many days more frequent all does a fever last a flu? A) one day B) 2-4 days C) week 41 D) 8 days 3 A latent period of flu: A) one day B) two days C) 3-6 days D) 12-24 hours 4 A latent period of parainfluenza: A) 12-24 hours B) one day C) two days D) 3-6 days 5 Laryngitis is a leading symptom at: A) flu B) parainfluenza C) RS- infections D) rhinovirus infections 6 pharingoconunctival fever is characteristic for: A) the flu B) аdenovirus infections C) to the parainfluenza D)rhinovirus infections 7 What illness does mainly meet for children to 3th of life? A)RS infection B) flu C)paraflu D) rhinovirus infection 8 What feature of RS- infection? A)pharyngoconunctival fever B) defeat of bronchial tubes and bronchioles C) lead is a syndrome of intoxication D) laryngitis 9 Absence or weak expressed of general intoxication is characteristic for: A) to the flu B) to the parainfluenza C) RS infections 42 D) rhinovirus infections 10 What main sign of rhinovirus infection: A) Ringo B) laryngitis C)pharyngoconunctival fever D) syndrome of general intoxication Standards of right answers Variant 1: 1.A; 2. D; 3. E; 4B.; 5.B; 6. A; 7.A; 8. A; 9.B; 10.C Variant 2: 1.B; 2.A; 3.C; 4.D; 5.C; 6. C; 7.B; 8.C; 9.A; 10.C Variant 3: 1.A; 2.D; 3.C; 4.A; 5.A; 6.B ; 7.A; 8. A, 9.D; 10. D Variant 4: 1.A; 2.B; 3.D; 4.D; 5.B; 6. B; 7. A; 8.B; 9.D; 10.A 3.4.3 Tasks are for self-control Task 1 For a patient A., 18 years, relapse of focal pneumonia. Temperature during hospitalization 38,6 °С, head pain, cough with sputum, pain, moist middle finely vesicule wheezes in the right half of thorax. A shortness of breath is not. Tones of heart are hyposthenic. A liver is megascopic on 2 sm. In a blood test moderate leucocytosis , speed-up ESR. When compared to primary research the title of antibodies for micoplames in CFT was increased in 4 times. 1 To diagnose. 2 To work out a plan of inspection and treatment. Task 2 Sick In., 8 years, appealed on the 2th day of disease. Temperature of body of 39,0°С. Hyperemia of mucus shell of mouth-pharynx. Pulse 110/minute. Other changes it is not discovered from the side of internalss. An enhanceable temperature stuck to during 6 days, a cough appeared, there is the hard breathing in lights. On a sciagram: left-side focal pneumonia.CFT with a micoplasm antigen 1:80. 1 What is possible diagnosis? 2 Appoint treatment. Task 3 Sick D., 50 years, entered hospital on the 2th day of illness with complaints about head pain, dry cough, general weakness, pain, in muscles. It is set that simultaneously with it diseased 2 workers of 43 bird’s factory. The general state of sick during a review is satisfactory, temperature of body of 37,8°С, person, puffy, lymphatic knots are megascopic,hepatosplenomegalia. 1 About what disease is it possible to think? 2 How to confirm a diagnosis? Task 4 Sick K., 34, worker of poultry farm, appealed to the doctor with complaints about the sudden increase of temperature to 38.0-39.0° of С, chill, dry cough, with the selection of negligible quantity of mucus sputum. Objectively: a skin is pale, a person is puffy with cyanosys round a mouth. In urine proteinuria. On the sciagram of thoracal organs of the focal darkening business is in the lower particle of lights. 1 The signs of what disease are marked higher? 2 How to confirm a diagnosis? 3 Basic method of treatment? Task 5 Patient Н., 35 years, appealed to the doctor with complaints about a fervescence to 39 °С, sharp head pain is with localization in a frontal area, superciliary arcs, muscles of total-body, oxycinesia eyes, dry cough. Objectively: diffuse hyperemia of pharynx, dryness of mucus, there is the hard breathing at аuscultative. In a blood test: leucopenia, relative lymphocytosis due to diminishing of neutrophiles. 1 To diagnose. 2 To work out a plan of inspection and treatment. 3 To work out a plan of treatment Task 6 Sick K., 20 years, complains of blocking a nose, complication of the nasal breathing and abundant water excretions from a nose. The temperature of body is normal. 1 About what disease is it possible to think? 2 Give recommendation sick in relation to treatment. Standards of answers are on a task Task of I 1 Mikoplasmosis, pneumonic form, heavy motion. 44 2 Sciagraphy of organs of thorax, analysis of sputum, general analyses of urine, blood, hepatic tests. Antibactrial therapy (phtorchinolons,macrolides), coughings up, desensitizing,vitaminotherapy but other Task 2 1 Mikoplasmosis, pneumonic form, heavy degree. 2 Eritromicinum,emollient inhalations,desintoxication therapy,polivitamines. Task 3 1 Psittacosis, middle degree of weight. 2 Selection of exciter from blood, sputum on chicken embryos, cultures of cages; CFT or RGGA,immunoenzyme analysis; endermic allergic test of Tersk. Task 4 1 Psittacosis. 2 CFT. 3 Antibactrial therapy(tetracyclines). Task 5 1 Flu.Typiform, middle weight. 2 Serum diagnostics – reaction undirect hemaglutination,immunoenzyme analyses, increase of title in 4 and anymore,pair wheys research on 1th and on 7-10th days of illness. 3 Warm drink,remantadinum,аrbidolum, vitamin С,polivitamines, anticough facilities (codeine). Task 6 1 Rhinovirus infection. 2 To avoid supercooling, 2 % Naphthyzinum for blocking nose, steam inhalations through tube, vitaminotherapy. 4 Materials are for audience independent work 4.1 List of educational practical tasks which must be executed on practical employment To lay hands on the method of inspection patient with a psittacosis,micoplasmosis,legionelosis,acute respiratory viral infectious. 45 To conduct curation of patient with a psittacosis, micoplasmosis, legionelosis, acute respiratory viral infectious. To conduct differential diagnostics of psittacosis, micoplasmosis, legionelosis, acute respiratory viral infectious. To work out a plan of laboratory inspection. To interpret the results of specific inspection of patient with a psittacosis, micoplasmosis, legionelosis, acute respiratory viral infectious. To recognize complication of psittacosis, micoplasmosis, legionelosis, acute respiratory viral infectious. To work out a plan of treatment patient with a psittacosis,micoplasmosis,legionelosis,acute respiratory viral infectious. To define medical tactic in the case of origin of the exigent states. To design a medical document in fact of establishment of diagnosis of psittacosis, micoplasmosis, legionelosis, acute respiratory viral infectious. 4.2 Professional algorithm in relation to forming of skills and abilities of diagnostics of legionelosis,psittacosis,respirator micoplasmosis,acute respiratory viral infectious № Task Sequence of A remark, warning, is in implementation relation to self-control 1 To lay hands 1 Complaints on the method of clinical inspection of patient on legionelosis ,micoplasmos is, psittacosis, acute 2 Anamnesis of 46 To separate complaints which characterize syndromes: - intoxication; - catarrhal; - defeat of respiratory tracts; - gastrointestinal; - rash; - extralungs displays (arthritis, myocarditis) To pay a regard to beginning, respiratory viral infectious 2 illness term, sequence of origin of symptoms, their dynamics: - sharp beginning; - from 2-4 days of the impression respiratory tracts; - in the first days of illness diarea, stomach-ache, nausea; - gradual beginning; - fatigueability is enhanceable; - pain is in muscles and joints; - connect catarrhal and intoxic syndrome. To find out the carried diseases 3 Anamnesis of Morbidity is during the flash life of acute respiratory viral 4 Epidanamnesis infectious; - group morbidity of children and young people is in establishments of the closed type; - a disease arises up in warm time of year; - dwelling or work is in an apartment with conditioners; - dwelling is near the opened reservoirs; - contact with the birds of exotic things, workers poultry farms To conduct a To conduct an curation of objective patient inspection The expressed, dynamics of symptoms, is predefined a term and weight of flow of illness. 1 General review To pay attention on: 47 - excitation; - photophobia; - grave general condition; - chill; - absence of respiratory insufficiency; - dry unproductive cough; -intoxication is poorly expressed; - pallor, cyanosys, change of conduct, pouring out hemorragic character; 2 Digestive - intoxication is brightly system expressed. To pay attention on: - there is a stomach-ache; - nausea; - vomit; - diarea; 3 Nervous system - hepatomegalia; - hepatosplenomegalia To pay attention on: - parahypnosis; - hallucinations; - heavy language; - confusing of consciousness; - disorders of memory; - appearance of meningeal signs at heavy motion; 4 Sercevo- head pain sudinna system diffuse character somnolence, euphoria. To pay attention on - muffling of tones of heart; 5 Respiratory - bradicardia; 48 system 3 To appoint laboratory and additional researches - hypotension; - to possible symptoms of myocarditis, pericarditis. To pay attention on - dry cough; - there is a stethalgia; - mucous festering sputum, with blood; - increase of breathing frequency; - respiratory insufficiency; - rhinisporidios tracheobronchitis; - littleinforming information from the side of lights; - shortness of breath, laboured breathing; - to wheezing voice; - stuffiness; - bronchiolitis, bronchitis; - Ringo, rhinorea; - bright diffuse hyperemia of pharynx; - tracheitis; - laryngitis. 1 General To pay attention on: analysis of blood - neutrophilic leucocytosis with the change of leucocytic formula to the left; - megascopic ESR; - lymphocytosis; - monocytosis; - normal ESR; - anaemia 2 General - Proteinury; 49 analysis of urine 3 Serum hemanalysis selection of exciter from sputum, pleura liquids - hematury; - moderate аlbuminuria; - cylinders, tracks of albumen; - without changes. - A presence of antibodies is in RNIF, selection of culture of exciter; - specific antibodies, antigens of exciter receipt of culture exciter; - microscopy of strokes, painted after RomanovskimGimze; - a selection of viruses is from washings off of nasopharynx by infecting of chicken embryos but pochard of human embryo; - polimerase chain reaction Materials of after audition independent work Subject of UDRS and NDRS • Features motion of legionelosis,micoplasmosis,psittacosis, SARS,acute respiratory viral infection in modern terms. • Modern methods of specific diagnostics of legionelosis,micoplasmosis, psittacosis, SARS, acute respiratory viral infection . • Problems of etiotropic treatment of legionelosis,micoplasmosis, psittacosis, SARS, acute respiratory viral infection. • Modern looks to pathogeny of legionelosis,micoplasmosis, psittacosis, SARS, acute respiratory viral infection. 50 Topic. HERPESVIRUS INFECTION. GENERAL DESCRIPTION OF HERPESVIRUS INFECTIONS, ETIOLOGIC STRUCTURE, PLACE, INFECTIOUS PATHOLOGY. INFECTIONS, CONDITIONED VIRUSES OF HERPES SIMPLEX OF HSV-1 AND HSV-2. WINDY POX AND GIRDLE HERPES Duration - 2 hours. 1 Actuality of theme. Herpesvirus infection belong to the most widespread virosiss. From data of global review of herpesvirus researches, the infected and morbidity of humanity from year to year grows more than on 10 %, and 90 % grown man and child's population in the entire countries of the world infected one or a few сserovariantes of herpesviruss. From data WHO, diseases, caused the viruses of ordinary герпесу, occupy the second place (15,8 %) after a flu (35,8 %) in the structure of morbidity and death rate at viral infections. Suffer recurrent герпесвірусними diseases from 2 to 12 % people which need help during all of life. Gerpesvirus infection - one of most widespread in the world. In the developed countries of Europe this infection the third of population is ill. 2 Whole lessons (with pointing of level of mastering which is planned) 2.1 A student must know: etiology of herpesvirus infections, factors pathogenicity of exciter; epidemiology of herpesvirus infections; pathogeny; clinical displays of herpesvirus infections; pathogeny, term of origin and clinical complications of herpesvirus infections; laboratory diagnostics of herpesvirus infections; principles of treatment; principles of prophylaxis; 51 displays of tactic of conduct of patients in the case of origin of the exigent states; prognosis of herpesvirus infections; governed extracts of reconvalescentes from permanent establishment; governed the health centre system of reconvalescentes. 2.3. A student must be able: to adhere to the basic rules of work near a bed sick on a herpesvirus infection; to collect anamnesis of illness with the estimation of epidemiology information; to inspect a patient and find out basic symptoms and syndromes of herpesvirus infections, ground a clinical diagnosis for timely direction of patient in permanent establishment; to conduct differential diagnostics of herpesvirus infections; on the basis of clinical inspection in good time to recognize possible complications of herpesvirus infections, exigent states; to design a medical document in fact of establishment of previous diagnosis "herpesvirus infection"; to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; to analyse the results of specific methods of diagnostics depending on material and term of illness; to work out an individual plan of treatment taking into account epidemiology information, stage of illness, presence of complications, weight of the state, allergist anamnesis, concomitant pathology; to render the first aid on the before hospitalization stage; to work out a plan of disease and prophylactic measures in the hearth of infection; to give recommendations in relation to the mode, diet, inspection, supervision, in the period of reconvalescence 3 Materials are to audience independent work 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) 52 Disciplina To know Able Previous disciplines Microbiology Properties of Nsv-1, Nsv-2, VZV; methods of specific diagnostics of herpesvirus infections To interpret the results of specific methods of diagnostics Physiology Parameters of physiology To estimate norm of organs and systems information of of man; indexes of laboratory inspection. laboratory inspection are in a norm (general analysis of blood, urine, biochemistry of blood, parameters of acidbasic status, electrolytes and others like that). Physiopathology A mechanism of violation of functions of organs and systems is at the pathosiss of different genesis. To interpret pathological changes as a result of laboratory inspection at parafunctions organs and systems of different genesis. Immunology Basic concepts of object, and allergology role of the system of immunity in an infectious process, influence on the term of еlimination exciter from the organism of man. Immunological aspects of chronic viruscarry. To estimate information of immunological researches. 53 Epidemiology Epidproces (source, mechanism of infection, ways of transmission) of herpesvirus infections; prevalence of pathology in Ukraine and in the world. To collect epidemiology anamnesis. Prophylactic measures. Neurology Pathogeny, clinical signs of herpetic encephalitis, meningitis, myelities To conduct the clinical inspection of patient with the defeat of the nervous system. Dermatology Pathogeny, clinic and stages To recognize a rash of development of for a patient with noncommunicative герпес. herpesvirus (herpetic vesicules) Ophthalmology Pathogeny, clinical displays To conduct the of оphtalmoherpes. clinical inspection of patient with the defeat of organ of sight. Propedevtic of Methods and basic stages of To collect anamnesis, internal illnesses clinical inspection of patient. conduct the clinical inspection of patient, find out pathological symptoms and syndromes. To analyse findings. Clinical pharmacology Pharmacocinetics, To appoint treatment pharmacodynamics and side depending on age, effects of antiviral individual features of 54 preparations, natural antioxidants, preparations of interferon, іmmunomodulators,inhibitirs of prostaglandines. patient, to choose the optimum mode of reception and dose of preparation, write recipes. Next disciplines Family medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of herpesvirus infections are possible. Features of clinical motion of herpes simplex and girdle herpes. Principles of prophylaxis and treatment. To conduct differential diagnostics of illnesses of different genesis with a herpesvirus infection. To recognize a herpesvirus infection, its complication; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. To render the first aid in the case of necessity. Intradiscipline integration Infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory 55 Diagnostics of herpesvirus infection with other infectious diseases. To recognize herpesvirus infections, its diagnostics, complications of herpesvirus infection are possible. Features of clinical motion of simple герпесу and girdle герпесу. Principles of prophylaxis and treatment. complications; to interpret information of laboratory inspection. To appoint treatment. To render the first aid on the before hospitalization stage. 3.2 Structurally logical charts of maintenance of theme of employment plan diagnostics and treatment of herpes girdle (Herpes zoster) 56 Epidemiology anamnesis: - contact with a sick man and viruscarry; can to infective contact or sexual way, of kiss; chiefly winter-spring period - ganglio-cutaneus form: start sharp , with fever , symptoms of general intoxication and sharp baking pain in area future rash . After 3-4 days (sometime only after 10-12 days) appear characteric rash.Localization of pain and rash appropriate damage nerves (often intercostal) and have around character. On area of vesicule rash on the start appear іnfiltration and hyperemia cutaneus,after this appear vesicules, fulling clear, then dull liquid.Vesicules drying . When ekzantema appearі a pain was decrease . - Оphtalmo- form: damage trigeminus node (gaser’s nod) and rash lokalization for course of branch nerve trigeminus (on mucous of eyes, nose,on skin of face ). - Ear’s fprm: in process thread through a joint’s nod, a rash appear on auricula and around. May be a paralise nerve facialis. Watch a general intoxication and fever . Sharp expres neuralgia nerve trigeminus, which duration about some weeks . - gangrenose (necrotic) form: watch deep damage of skin with formation scars,very hard run across. - Мeningoencephatic form: hard run across , a damage begun with ganglio-cutaneus signs,often in area intercostals nerves. Then appear symptoms meningoencephalitis,meningeal symptoms (аtaxia, hemiplegia, may be a coma). Term from appear еkzantem for genesis еncephalopathy – from 2 days for 3 weeks - reaction іmmunolumen; virusologic:extract virus on culture of cells and tissues (вміст vesicules, saliva, scrape of ceratum, blood, liquor); serologic diagnostic (immune enzyme analysis, CFT, RN) Differention diagnosis from wind pox , еkzema, еnterovirus herpangina,anthracis,аdenovirus ceratoconunctivitis, herpes simplex ,erysipelas, - determination end diagnosis with calculate forms, hard,lokalization p - bed’s regime; local: оxolinum, tebrophen and reapheron ointment; mucus coats urinate of solution reapheronum,lapheronum,leucocytic іnterferonum, novocainum; for ophtalmoherpes in conunctive drip of solution іnterferonum, іdosucridine; middle hard and hard run across : reaphernum (lapheronum) 1000000 ED i/m 1-3 times on a day ; for general form : dexametasonum 1,5 mg/kg on day; іmmunomodulators;desintoxication therapy - decrease clinical symptom or durable remision; normalization laboratory indexes dispanserization: - for recidive herpes make 3 courses therapy herpvaccine, which input,begin with 0,1-0,2 ml intracutaneus 2 times on a week ,slowly increase dose for 1,0; course include 5-10 іnjection plan diagnostics and treatment of herpes simplex (Herpes simplex) Epidemiology anamnesis: 57 contact with sick man and viruscarry ;can to way of infection contact, sexual, vertical; chiefly winter-spring period Typic form herpes of skin: to feel of baking, pricking, itching, hyperemia; appear uniting subspheric vesicules 1,5-2 mm on background еrytem and edema ,which contents can muddy, begin hemoragic ;to open vesicules,appear erosions – bottom soft, damp,smooth:. Can to infection and appear in a future ulcers ; contents vesicules drying, ;moving a peel and on this place appear slowly disappear еrytema with brown colour. Primary herpes in 80-90 % run across in unsymptoms form. Іncubation period 2-12 days. A clinical is expresed watching in children 6 monthes - 5 years and expresed in apperance аftosis stomatitis,accompany big damage mucous coat mouth cavity, hard general іntoxication syndrome. Often watching formes, that run across as ARD-type.Recidive herpes run across often with damage of skin .Lokalization is different. Damage can be fixation and migration. Rash usually is after edema, hyperemia, itching and baking. Typic rash – group small vesicules on general edema background. Contents of vesicule is clear on the start, then begin to muddly. Vesicules open , appear еrosion, which cover a peel. Peel tear off, don’t leave scars. All process durind 5-7 days.Can watching moderate fever , shivering, moderate іntoxication. In men with immunodeficite – herpes can have general character . Оphtalmoherpes–dermatitis brows,blepharitis, blepharoconunctivitis, conunctivitis; herpetic ceratitis (vesicular, ,ulcer of cerate, ceratouveitis .); herpetic uveitis,uveitis (іritis, іridociclitis, chorioretinitis,herpetic nevritis ); postherpetic ceratopathy (еpilial). Оphtalmoherpes often complicate a background disease and metabolic damage of tissues of eyes,increaseinternal pressure and second glaucome, damage clearing iris and genesis cataracta . Damage mucos coat : fever, baking in the place of damage, onmucous cheeks, palatinas, lounger, appear vesicules with clear contents, which after 2-3 days genesis in erosion. Can run across as aftosis stomatitis . Herpetic encephalitis and meningoencephalitis begin sharp with increase temperature for 39-40 °С, vomiting, strong headeche. With a first days appear meningeal symptoms, pathologic reflexes , darken of mind . Then appear paresis and paralisesі.In liquor have limphocytic pleocytosis with increasing of protein RIF, virusologic extract virus on culture of tissue (contents of vesicules,saliva, scrape of cerate, blood, liquor), serologic diagnostic (CFT, RN) - determination end diagnosis with calculate form,hard, localization Different diagnostic with windy pox ,erysepelas,anthracis, еnterovirus herpangina , еkzema, damage of eyes and CNS of other etiology - bed’s regime; local: оxolinum,tebrophen and reapheron ointment; mucous coats weting of solution reapheronum, lapheronum,leucocytic іnterferonum, novocainum; for оphtalmoherpes in conunctive drip solutionof interferonum, іdosucridinum; middle hard and hard run across: reapheronum 1000000 ED i/m 1-3 times on day ; of general form: dexametazonum 1,5 mg/kg on day ; іmmunomodulator; desintoxication therapy , herpetic polivaccine : 0,2 ml i/c 2 times on a week , course 5-10 іnjection - decreaseclinica symptoms or steadfast remission; normalization laboratory indexes Plan of diagnostics and treatment of windy pox (Varicella dispanserization: Epidemiology anamnesis: Persons which carried herpetic meningitis and encephalitis are looked after by a neurologist, оphtalmoherpes - oculist.For the patients which suffer on the frequent relapses of herpes the course polivaccine is repeated through each by 3-6 months during 58 3-5 years. - a contact is with a man, patient with a windy pox or girdle herpes; children are more frequent ill from 5 to 9 years; - mainly winter-spring period -beginning is gradual from the moderato expressed weakness, indisposition, subfebril temperature; appearance on the skin of veziculese ekzantem: a stomach, shoulders, breasts, overhead and lower extremities, is struck above all things, then person and hairy part of chairman; periodicity of pouring out with an interval at 24-48 o'clock; new elements appear between old their general amount increased; at first the spot of oval form appears diameter from 5 to 10 mm, then a papula which transforms appears in the center of spotwhich grows into vezicule, filled a transparent liquid; vezicules have a various form (rounded, oval) and sizes from 8 to 10 mm, untense; after the second days a crust which from a 6-8th day falls off appears in place of vezikules, not abandoning after itself scars, sometimes content of vezikules becomes cloudy, pustula appears; appearance vezikulese enantems on mucus shells; enantema is localized on a hard palate, on the mucus shells of cheeks, gums, language, on the back wall of pharynx, and it can for girls can appear on the mucus shells of privy parts; vindy poxe’s vezicules is quickly damaged and form small superficial erosions - painting of content of blisters or pustul for Romanovskim and microscopy (exposure of little bodies of Aragona); immuno enzyme analysis; CFT from 4-multiple by the increase of title of antibodies - windy pox, typiform, heavy motion, meningitis;windy pox, general form, heavy motion A differential diagnosis is with vezikuleznim riketsiozom, herpetic infection, girdle herpes, bites of insects, pliers, fleas - bed mode by a term on 1 week; natively 5-10 % potassium permanganat solution or 1 % solution diamond green; etiotropic therapy (heavy motion and general forms): i/v vidarabin in a dose 15 mg/kg on days as protracted (about 12 hours) intravenous infusion; leycocyte human interferon, reaferon, immunoprotein; polivitamines, desensitizing and symptomatic preparates; presence of pustulosis rash antibiotics disappearance of clinical symptomatic, but not early than a 5th day from the moment of the last rash; normalization of laboratory indexe - for clinical requirementes (general forms) 59 3.3 Literature is made to order Basic Vozianova Z.I. the Infectious and parasitogenic diseases: 3 т. - K.: of Health, 2001. - Т. 2. - P. 540 - 542. Additional • The adults (clinic, diagnostics and intensive therapy) /А.О have a herpetic encephalitis. Rudenko, L.P. Chepkiy, O.O. Yarosh and co-author.: Method, recommendations for ministry of health Ukraine.K., 2003. - 40 p. • Chemich M.D., Ilina N.I, Binda T.P., Trocka I.O. ТОRСНіnfection: clinic, diagnostics, treatment.:Sumi: publish house SUMDU, 2004. - p. 36-52. 3.4 Materials are for self-control 3.4.1 A question is for self-control 1 What group of infectious diseases does a herpesvirus infection belong to? 2 Ways of passing to the herpesvirus infection? 3 Etiology and epidemiology of herpesvirus infection. 4 Pathogeny of herpesvirus infection. 5 Classification of herpesvirus infection. 6 Stages of development of herpetic vesicules. 7 Basic clinical displays of noncommunicative herpes. 8 Primary herpes. 9 Recurrent herpes. 10 Girdle herpes. 11 Features of motion оphtalmoherpes. 12 Forms of herpetic infection are with the defeat of the nervous system. 13 Sharp herpetic meningitis. 14 To describe the defeat of spinal cord at a herpetic infection. 15 Born herpetic infection. 16 Consequences of herpetic infection. 17 Principal reasons of lethality herpesvirus infections. 18 There is a plan of inspection patient with a herpesvirus infection. 19 Methods of specific diagnostics. Interpretation of results. 60 20 Principles of setting of antiviral therapy. 21 Etiotropic therapy of herpetic infection: doses, way of introduction, duration of treatment. 22 Treatment in a sharp period of disease and during a relapse. 23 Therapy in the stage of remision. 24 Prophylaxis of herpesvirus infection. 3.4.2 Tests are for self-control To choose right answers 1 The exciter of girdle herpes is: A - herpesvirus, type 3; B virus of windmill/zoster C virus of zoster/herpes 1 D virus of zoster/herpes 2 E- cytomegalovirus F virus Epshteyn-Barr 2 Girdle herpes mainly are ill: A persons of declining and senior years B - put early age C - put school age D persons which were not ill a windy pox E- receptivity is high in all of age-dependent groups 3 Dangerous patients girdle herpes? A - so, for persons which were not ill a windmill B - no C - so, for little children D - so, for persons old years, hyposthenic E- so, for persons which were ill on a windy pox 4 At girdle herpes the followings nervous structures are more frequent all struck, except for: A - гангліву in the front counterfoils of spinal cord B - гангліву in the back counterfoils of spinal cord C - trifacial D - nervous barrels of spinal cord E- knee knot 5 A latent period is at the persist form of girdle herpes: A - a lot of years 61 B - 7-14 days C - 14-17 days D - 30 days E- 1 year 6 There are all of symptoms at the hanglioctaneus form of girdle herpes, except for: A hepatosplenomegalia B fevers C intoxications D - vesicules for the step of nervous barrels E- girdle unbearable pain in the staggered area 7 At an eye form of girdle herpes of vesicules localized: A - for the step of n.trigeminus B - for the step of n. trohlearis C - for the step of n.осиlomotorius D - for the step of n. hipoglossus E- for the step of n.abducens 8 At ordinary and girdle herpes taking into account their clinical form it is necessary to eliminate the followings diseases, except for: A - to the psittacosis B – windy pox C бешихи D anthracis E- enterovirus herpangina 9 A herpetic infection is caused: A - simplex virus/ variocella zoster B - cytomegalovirus C - the virus of windmill D - virus Epshteyna-Barra E- пеuroryctes rabies 10 The ways of transmission of exciter of herpetic infection are such, after an exception: A - аlimental B - air-drops C - pin, sexual D - transplacental 62 E- wound (parenterally) 11 Replication of virus of ordinary herpes takes a place in: A - epidermis B - neurons C - cylinder epithelium of overhead respiratory tracts D - mucus shell of genitals E- limphoid tissue 12 Typical localization of herpes simplex A - round a mouth, on lips, on the wings of nose B - in the axillar area C - for the step of intercostal nerves D - after ears E- on eyelids 13 Elements of skin from ordinary herpes: A vesicula, erythema B papula C roseola D pustula E- urticars 14 Herpetic stomatitis clinically shows up the followings symptoms, except for: A general lymphadenopathies B fevers, intoxications C feeling of heartburn and pricking of mucus mouth D - grouped shallow blisters on mucus cheeks, sky, gums E- abundant salivation, bad smell from a mouth 15 Genital herpes has the followings clinical symptoms, except for: A - symptoms of аdnexitis B - febricula, subfebril temperature C – pain in down of stomach, diuria phenomena D - symptoms of vaginitis E- vesicules on the neck of uterus, vagina, urethra 16 Ophtalmoherpes clinically shows up the followings forms, except for: A glaucomas 63 B - herpetic keratitis C - еpiteliosis D - parenchimatosis keratitis E- regional helcoma 17 For visceral herpes all are struck organs are adopted, except for: A spleens B pochard C - pancreas, liver, lights 18 For etiotropic therapy of herpetic infection utillize: A - аcyclovirum B - vaccine C Sulfanilamidums D antibiotics E preparations of Bi 19 With the purpose of specific therapy of herpetic infection utillize: A - herpetic vaccine B herpetic toxoid C herpetic immunoprotein D - herpetic plasma E donor immunoprotein 20 Classification of herpes simplex is conducted after the followings criteria, except for: A - complications B are frequencies C are localizations D is forms E- to prevalence 21 General herpes more frequent all develops in: A - new-born, patients with HIV-infection B - patients which got antibiotics long C - patients with helminthisms D - patients with a windmill E- patients from limpholeucosis 64 22 For local treatment of vesicule for ordinary herpes such remedies are used, except for: A levomicetinum ointments B oxolinum ointments C tebrophenum ointments D reapheronum ointments E- phucorcinum 23 Diagnostics of herpetic infection is based on the followings researches, except for: A - bioassey B - virologic research C - clinical signs of illness D cytologic research E- CFT, RN 24 After prevalence herpes simplex is, except for: A - genital B - limited C - widespread D - general E- general with the defeat of CNS 25 Atipovi forms of herpes simplex , except for: A - with the defeat of CNS B - abortive C - oedematous D - zoster form E - hemorragic 26 Stages of development of herpetic blisters, except for: A papulae B erythemas C vesicules D formation of crust E vesicules, erythemas F ulcers Standards of right answers 65 1 – B; 2 – A; 3 - A; 4 - A; 5 - A; 6 - A; 7 - A; 8 - A; 9 - A; 10 - A; 11 - A; 12 - A; 13 - A; 14 - A; 15 - A; 16 - A; 17 - A; 18 - A; 19 - A; 20 - A; 21 - A; 22 - A; 23 - A; 24 - A; 25 - A; 26 - A 3.4.. A task is for self-control Task 1 Patient Н., 16 years, by an ambulance was hospitalized to the hospital with complaints about a head pharyngalgia, fervescence to 39°С, chill, pain,, cold. It is ill during 3 days, treated oneself independently, for medical help did not apply. At the review of patient: on the skin of roseolose rash, phenomena of one-sided conjunctivitis, pellicle tonsillitis. Clinical blood test: eras. 4,5х1012/l, general protein 120 g/l, leuk. 5,0х109/l, е 2 %, s 60 %, st 5 %, l 25 %, m 8 %, ESR 15 mm/hour, tr. 200х109/l. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick Z. Make plan of treatment. Task 2 Patient A., 42, hospitalized in a hospital on the 10th day of illness with complaints about the increase of temperature, head pain, pouring out and great pain, for the step of intercostal nerves. At an inspection in intercostal intervals the discovered is grouped blisters, covered crusts, are present also blisters with transparent and turbid maintenance. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. From to Work out a plan of treatment. Task 3 Sick P., 19 years, student, appealed to the induction centre of permanent establishment with complaints about great head pain in a temporal area, increase of temperature to 38°С, smarts are sharply expressed during a talk in the left half of person, rash. Anamnesis: ill sharply. After supercooling the temperature of body rose to 38°С, pains appeared in the left half of person. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. From to Work out a plan of treatment. Standards of faithful answers 66 Task 1 1 Primary girdle herpes, spiral form, typical motion, middle weight. 2 Serum research: immunoenzyme analysis, CFT (method of pair wheys),cytologic research of maintenance of blisters for the exposure of including of virus. 3 Natively - оxollinum,tebrophenum ointments, ointment of "Zoviraks", аcyclovirum 4 gr on days during 7 days, levamisole 0,15 gr 1 time per 4 days or cyclopheronum after a chart. Task 2 1 Primary girdle herpes, craniocerebral form, typical motion, middle degree. 2 Serum researches: IFA (Ig M, Ig G), Reaction undirect hemaglutination, RN, CFT (with pair wheys).general clinical blood, urine tests. 3 Natively – fucorcinum,unguentum"Aciklovir","Gerpevir". Zoviraks for 800 mg 5 times per days 5-7 days. Desensitizing preparations;desintoxication therapy, іmmunomodulator (cyclopheronum, levamisole). Task № 3 1 Primary simple noncommunicative herpes is with the defeat of skin, middle degree. 2 Serum researches: method of fluorescent antibodies (strokes imprints research for vesicules), CFT,reaction solid hemaglutination with pair wheys, immuno enzyme analysis - Ig M to the virus of herpes simplex . 3 Gerpevir for 0,2 5 times per days during 5 days, natively is ointment of "Gerpevir",fucorcin,desensitizing preparations, cyclopheron after a chart. 4 Materials are for audience independent work 4.1 List of educational practical tasks which must be executed on practical employment To lay hands on the method of inspection patient with a herpetic infection. To conduct a curation of patient with a herpetic infection. 67 To conduct differential diagnostics of disease. To work out a plan of laboratory inspection. To interpret the results of specific inspection of patient with a herpetic infection. To recognize complication of herpetic infection. To work out a plan of treatment patient with a herpetic infection. To define medical tactic in the case of origin of the exigent states. To design a medical document. 4.2 A professional algorithm is in relation to forming of skills and abilities of diagnostics № Task Sequence A remark, warning, is in п/п implementation relation to self-control 1 2 To lay hands on the method of clinical inspection of patient on a herpesvirus infection To conduct a curation of patient I to Find out the To separate complaints which complaints of characterize syndromes: patient - general intoxication - organ defeats to Pay a regard to gradual beginning, term, sequence of origin ІІ to Find out dynamics: anamnesis - fevers; 1 Anamnesis of - head pain; illness - parahypnosiss; - vomiting; - cramps; -appearance of the grouped semispherical blisters on a background erythema and edema; - appearance of erosion; - other symptoms. To find out the carried illnesses. Find out information in relation to realization of contact or air- tiny 68 2 Anamnesis of life 3 Epidanamnesis ІІ to Conduct an objective inspection: 1 General review: - general state of patient 2 Skin 3 Mucus shells: - review of oral cavity; - review of eyes; - review of overhead respiratory tracts; - review of privy parts. mechanism of transmission, to pay a regard to stay of patient in a contact from herpesviruses by patients or presence of this disease for a patient in the pas. To remember: a presence, expressed, dynamics of symptoms, is predefined a term and weight of flow of illness, depend on age sick, concomitant pathology. To pay attention on: - presence, localization, character of rash. To pay attention on: - presence of vesicule - erosive gingivostomatitis; presence of keratitis,ceratoconunctivitis; - presence of display of ARD; presence of urethritis, cervicitis, to the vulvovaginitis. To pay attention on: presence of signs of herpetic encephalitis; - presence of signs of meningitis; - presence of signs of myelities; - syndrome of Giyen-barre; - syndrome of paralysis of Landri; - syndrome of parkinsonism; - a syndrome is BASS. 69 4 Nervous system of patient 3 To appoint laboratory and additional researches, interpret results 1 General To pay a regard to typical analysis of changes:leucopenia,mononucleosis blood with a lymphocytosis, anaemia. Absence of considerable changes is at typical motion. 2 General Appointed regardless of term of analysis of urine illness. 3 Serum Determination of specific анти – methods Nsv Ig M; determination of specific antibodies of class Ig M; PLR for determination of DNK Nsv in blood, neurolymph, saliva, to the tear and others like that. Materials of outside independent work Subject of UDRS and NDRS: • Features of motion of herpetic infections are in modern terms. • Modern methods of specific diagnostics of herpetic infections. • Problems of etiotropic treatment of herpetic infections. 70 Topic. HERPES VIRUS INFECTION. EBV-ІNFECTION AND СМV-ІNFECTION. INFECTIOUS MONONUKLEOSIS Duration – 2 hours. 1 Actuality of theme. After the level of prevalence VPG occupies one of first place-almost 90 % the population of earth is infected this virus. Herpes simplex makes the special danger for new-born children - perishes about 30 % babies which was infected during births or in the first days after birth. Set also, that virus herpes simplex can become reason of оncogenic transformation, more frequent all the display of which is carcinoma for neck of uterus. In Ukraine a fight against this infection is bothered by absence of order about its obligatory registration. 2 Whole lessons (with pointing of level of mastering which is planned) 2.1 A student must know: etiology of ЕВV-іnfection,CMV–infection,infectious mononucleosis; epidemiology of herpesvirus infections; pathogeny; clinical displays of EBV-, СМV-іnfection, infectious mononucleosis; classification of СМV-іnfection ; laboratory diagnostics; principles of treatment; principles of prophylaxis; tactic in the case of origin of the exigent states; prognosis of herpesvirus infections; governed excerption of reconvalescetes from permanent establishment; governed the health centre system of reconvalescentes. 2.2 A student must be able: а-3 to adhere to the basic rules of work near a bed sick; 71 to collect anamnesis of illness with the estimation of epidemiology information; • to inspect a patient and find out basic symptoms and syndromes of ЕВV-іnfection and CMV–infection, infectious mononucleosis, ground a clinical diagnosis for timely direction of patient in permanent establishment; to conduct differential diagnostics; on the basis of clinical inspection in good time to recognize possible complications; to design a medical document in fact of establishment of previous diagnosis (an urgent report is in SES); to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; to work out an individual plan of treatment taking into account epidemiology information, weight of the state, presence of complications, allergist anamnesis, concomitant pathology; to render the first aid on the before hospitalization stage; to work out a plan of disease and prophylactic measures in the hearth of infection; to give recommendations in relation to the mode, diet, inspection, supervision, in the period of reconvalescentes 3 Materials are to audience independent work 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) Discipline To know Able Previous disciplines Microbiology Properties of CMV, EBV To interpret the results of specific methods of diagnostics of ЕВVіnfection,CMV– infection,infectious 72 mononucleosis Physiology Parameters of physiology To estimate information norm of organs and of laboratory inspection systems of man; indexes of laboratory inspection are in a norm (global analysis of blood, urine, biochemistry of blood, parameters of KOS, electrolytes and others like that) Physiopathology A mechanism of violation of functions of organs and systems is at the pathosiss of different genesis To interpret pathological changes as a result of clinical and laboratory inspection Immunology Basic concepts of object, To estimate information and allergology role of the system of of immunological immunity in an infectious researches process, influence on the term of елімінації of exciter from the organism of man Epidemiology Epidemic process (source, mechanism of infection, ways of transmission) at CMV, EBV - infections; prevalence of pathology in Ukraine and in the world To collect epidemiology anamnesis, conduct disease and prophylactic measures in the hearth of infection Neurology Pathogeny, clinical To conduct the clinical 73 syndromes of disease inspection of patient with the defeat of the nervous system Propedevtic of Basic stages and methods To collect anamnesis, internal illnesses of clinical inspection of conduct the clinical patient inspection of patient, find out pathological symptoms and syndromes. To analyse findings Clinical pharmacology Pharmakokinetics and pharmacodynamics, side effects of facilities of specific nosotropic therapy To appoint treatment depending on the degree of weight of motion, individual features of patient. To write recipes Next disciplines family medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of infectious diseases are possible. Principles of prophylaxis and treatment. 74 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. To render the first aid in the case of necessity. Intradiscipline integration Infectious diseases Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory diagnostics, complications of infectious diseases are possible. 75 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. To appoint treatment. To render the first aid on the before hospitalization stage. 3.2 Structurally logical chart of maintenance of theme of employment Chart of diagnostics and treatment of infectious mononucleosis (Mononucleosis infection) Epidemiology anamnesis: - socializing with persons, which were ill ARD, by a flu or quinsy; - more frequent young people and to put - sharp beginning of illness – from a chill, high temperature, pharyngalgia, head pain, general weakness; - long duration fever; - tonsillitis; -a lymphadenopathy; -gepatosplenomegalia - general analysis of blood (leucocytosis with predominance of uninuclear cells, limfomonocytosis, atypic mononukleares (more than 10%); it is a reaction of Paul-Bunnelya, Lavrika-Devidsona, Goffa-Bauera - determination of the final unfolded diagnosis (weight, form of illness and complications Differential diagnosis with quinsies, diphtheria, adenovirusnoy infection, sharp leucosis, rabbit-fever, viral hepatitis, by a tifoparatyphoid by diseases, by a megacaryoblastoma and other - rinse of oropharynx; - nosotropic – dezintoksication, antihistaminics (vitamins groups B, C); -symptomatic therapy; -cardiac glycosides and other.; -preparations which stimulate leucopoesis; -in heavy cases are antibiotics (benzilpenicilin, cefalosporini), corticosteroides - disappearance of clinical simptomatc; - normalization of gemogrami - during 6-12 months for presence of remaining changes of peripheral blood 76 Plan of diagnostics and treatment of cytomegalovirus infection (Cytomegalia) Epidemiology anamnesis: contact with patients or rekvalescentes; infection of fetus from a sick mother; it is a leadthrough of parenterally manipulations, blood or its preparations transfusion - local form: sialoadenit. -Mononucleosis-like form: general intoxication, splenomegalia, fever, tonsillitis. -Visceral form: hepatitis, pneumonia, encephalitis, gastroenteritis. -Generalisation form: lymphadenopathy, gepatosplenomegalia, fever, presence of other defeats, heavy motion. Congenital form : icterus, gepatosplenomegalia, trombogemoragic syndrome, making progress anaemia, defects of development. -For HIV-infection: fever, weakness, sweating, mialgia, artralgia, trombocytopenia, leucopenia, larg number of mononucleares - cytoscopy (urine, bioptate, organs); - virusologic research; - serologic research: CFT, reaction undirect hemaglutination (increase index in 4 times); - RIFA ( аntybody, tieing with ІgМ) formulation of final diagnosis is with pointing of form, motion, weight and complications Differential diagnosis with gemolitic icteruses, toksoplazmosis, listeriosis, lues, sepsis etiotropic therapy (laferon, neovir, foskornet); -imunostimulate therapy; -vitaminotherapy; a human immunoprotein (to pregnant in the first three months of pregnancy) - disappearance of clinical symptomatic; - normalization of laboratory indexes - for clinical requirementes 77 3.3 Literature is made to order Basic • Vozianova zh.I. the Infectious and parasitogenic diseases: 3 т. – K.: of Health, 2001. – Т 1 - p. 433 – 457. • Infectious diseases: Textbook / For an editor Titova M.B. – K.: Higher school, 1995. – P. 89 – 97. • Superviser for infectious diseases / for editor U.V. Lobzina Spb: Foliant, 2003. – 1040 P. • Shuvalova E.P. Infection diseases. Rostov of l/D.: Feniks, 2001. – 959 P. Additional: • Gavrisheva N.A., Antonova T.V. Infection process.Clinical and pathophisiologic problems.- Spb.: Special literature, 1999. – 255 p. • Clinical-laboratory diagnostic infectious diseases:Superviser for doctors. - Spb.: Foliant, 2001. – 384 p. 3.4 Materials are for self-control 3.4.1 A question is for self-control 1 Feature of exciters of ЕВV-іfectious,CMV–infection, infectious mononucleosis. 2 Source of infection and ways of transmission of exciters of these illnesses. 3 Pathogeny of ЕВV-іnfection,CMV–infection,infectious mononucleosis. 4 Classification of ЕВV-іnfection,CMV–infection,infectious mononucleosis. 5 Clinical displays of ЕВV-іnfection. 6 Clinic of purchased CMV–infection. 7 Clinic of infectious mononucleosis. 8 Specific complications. 9 A differential diagnosis of illnesses is with the overwhelming defeat of skin. 10 Plan of inspection sick. 11 Methods of specific diagnostics. Interpretation of results of laboratory research. 78 12 Specific therapy: doses, way of introduction, duration of treatment. 13 Principles of the first aid. 14 Governed extracts of reconvalescentes from permanent establishment. 15 A prophylaxis and measures is in a cell. 3.4.2 Tests are for self-control To choose right answers Variant 1 1 herpesvirus іnfection belongs to : A - food toxicoinfection B - bloody infections C - enteroideas D – infections of skin covers E- food intoxications 2 Exciter of infectious mononucleosis: A treponema pallidum B virus Epshteyn-barra C - Vibrio cholera D - Clostridium perfringens E- Clostridium botulinum 3 A source of infection CMV: A food products B man C water D weed-eaters E canned products 4 Factors of transmission are at infectious mononucleosis: A direct contact B poor quality green-stuffs C unwashed fruit D all is transferred E chhanas 5 Duration of latent period is at a herpetic infection: A - 2 weeks 79 B - 1 month C - all right D - 2-3 hours E – 4-12 days 6 What seasonality is characteristic for infectious mononucleosis? A winter-spring period; B spring summer period; C summer-autumn period; D a fall-winter period. 7 Clinical forms of girdle herpes, except for: A eye form B ear form C - phlegmonous D - gangrenous 8 For verification diagnosis of herpetic infection all is used, except for: A reactions of immunofluorescence B - virologic selection a virus on the cultures of tissues C - clinical blood test D - serum diagnostics 9 For treatment of herpetic infection Dexamethazonum is utillized in a dose: A 1,5 mg/ kg on days B 0,5 mg/ kg on days C 0,1 mg/ kg on days D 0,2 mg/ kg on days. 10 An immunomodulation is conducted a levamisole in a dose: A - 0,15 on night B - 0,25 on night C - 0,1 on night D - 0,2 on night. Standards of right answers 1 - D; 2 -; 3 -; 4 - A; 5 - E; 6 - A; 7 - C; 8 - C; 9 - A; 10 - A. 3.4.3 A task is for self-control 80 Task 1 Sick P.,19 years, student, appealed to the induction centre of permanent establishment with complaints about great head pain in a temporal area, increase of temperature to 38ОС, smarts are sharply expressed during a talk in the left half of person, rash. Anamnesis: illed sharply. After supercooling the temperature of body rose to 380С, heartburn and dermahemia the left cheek appeared. In 4 days on the skin of person the grouped blisters appeared as a chain. Objectively: for the step of facial nerve blisters are placed 1-2 mm in a diameter, with transparent maintenance, sickly by touch. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 2 Patient A., 42, hospitalized in a hospital on the 10th day of illness with complaints about the increase of temperature, head pain, pouring out and great pain, for the step of intercostal nerves. At an inspection in intercostal intervals the discovered is grouped blisters, covered crusts, are present also blisters with transparent and turbid maintenance. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 3 Patient Н., 16 years, by an ambulance was hospitalized to the hospital with complaints about head pain, fervescence to 390 С, chill, pain, in a throat, cold. It is ill during 3 days, treated oneself independently, for medical help did not apply. At the review of patient: on the skin of розеольозний rash, phenomena of one-sided conjunctivitis, pellicle tonsillitis. Clinical blood test: eras. 4,5х1012/l, Nv 120 g/l, leuc. 5,0х109/l, е 2 %, s 60 %, st 5 %, l 25 %, m 8 %, ESR 15 mm/hour, tr. 200х109/l. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. 81 Standards of answers Task 1 1 Primary simple noncommunicative herpes is with the defeat of skin, middle degree. 2 Serum researches: method of lumen antibodies (strokes – imprints research for vesicules),CFT,reaction solid hemaglutination with pair wheys,immuno enzyme analysis – Ig M to the virus of herpes simplex . 3 Gerpevir for 0,2 gr 5 times per days during 5 days, natively is ointment of “Gerpevir”,fucorin,desensibilization preparations,cyclopheronum after a chart. Task 2 1 Primary girdle herpes, craniocerebral form, typical motion, middle degree. 2 Serum researches:immuno enzyme analysis (Ig M and Ig G), reaction undirect hemaglutination, RN, CFT (with pair wheys). General clinical blood, urine tests. 3 Natively is ointment of “Aciklovir”, “Gerpevir”, fucorcin. Zoviraks for 800 mg 5 times per days 5-7 days. Desensitizing preparations;desintoxication therapy, іmmunomodulator (cyclopheronum, levamisole). Task 3 1 Primary girdle herpes, spinal pectoral form, typical motion of middle weight. 2 Serum research:immuno enzyme analysis, CFT (method of pair wheys),cytologic research of maintenance of blisters for the exposure of including of virus. 3 Natively – оxolinum,tebrophenum ointments, ointment of “Zoviraks”, аcyclovir 4 gr on days during 7 days, levamisole 0,15 grammes 1 time per 4 days or cyclopheronum after a chart. 4 Materials are for audience independent work 4.1 List of educational practical tasks which must be executed on practical employment To lay hands on the method of inspection patient with a herpetic infection. 82 To conduct a curation of patient with a herpetic infection. To conduct differential diagnostics of herpetic infection To work out a plan of laboratory inspection. To interpret the results of specific inspection of patient with a herpetic infection. To recognize complication of herpetic infection. To work out a plan of treatment patient with a herpetic infection. To define medical tactic in the case of origin of the exigent states. To design a medical document in fact of establishment of diagnosis “herpetic infection”. 4.2 A professional algorithm is in relation to forming of skills and abilities of diagnostics of herpetic infection № Task Sequence A remark, warning, is in п/п implementation relation to self-control 1 2 To lay hands the method clinical inspection patient on herpesvirus infection To conduct curation patient on And to Find out of the complaints of patient of a To separate complaints which characterize syndromes: - general intoxication; - organ defeats to Pay a regard to gradual beginning ІІ to Find out term, sequence of origin a anamnesis dynamics: of 1 Anamnesis of - fevers; illness - head pain; - to tonsillitis; - lymphadenopathies; - to hepatitis; appearance of erosion; - to the encephalitis; - other symptoms. To find out the carried illnesses. 83 2 Anamnesis of life 3 Epidanamnesis ІІ to Conduct an objective inspection: 1 General review: - general state of patient 2 Skin 3 Mucus shells: - review of oral cavity; - review of eyes; review of overhead respiratory tracts; - review of privy parts. 4 Nervous 84 Find out information in relation to realization of contact or air-tiny mechanism of transmission, to pay a regard to stay of patient in a contact with patients or presence of this disease for a patient in the pas. To remember: a presence, expressed, dynamics of symptoms, is predefined a term and weight of flow of illness, depend on age sick, concomitant pathology. To pay attention on: it is a color presence and localization, to the rash. To pay attention on: - presence of tonsillitis; - presence of display of GRZ; presence of urethritis. To pay attention on: presence of signs of encephalitis; - presence of signs of meningitis; system of patient - presence of signs of myelities; - syndrome of Giyenabarre; - syndrome of paralysis of Landri; syndrome of parkinsonism; - a syndrome is BASS. 3 To appoint 1 General laboratory and analysis of blood additional researches, interpret results 2 General analysis of urine 3 Serum methods To pay a regard to typical changes: leucopenia,mononucleosis with a lymphocytosis, anaemia, аtypic mononuclears. Absence of considerable changes is at typical motion. Appointed regardless of term of illness. determination of specific анти –CMV,EBV IgM; determination of specific antibodies of class IgM; PLR for determination of DNK of viruses in blood, neurolymph, saliva, to the tear and others like that. Materials of after audition independent work Subject of UDRS and NDRS: • Problems of etiotropic treatment of herpetic infection. • Modern looks are to pathogeny of herpetic infectio 85 Topic. CHILDREN’S RESPIRATORY INFECTIONS IN ADULTS. MEASLES. GERMAN MEASLES. PAROTIT VIRUSES Duration - 2 hours. 1.Actuality of theme. Children’s respiratory infections remain one of issues of the day of health protection not only in countries which develop but also in a number of the developed countries. In the world the over 30 million and about 1 million mortal cases cases of disease are annually registered from measles, german measles, parotit infection and their complications, not only among children but also among a grown man population. A lot of factors are instrumental in spreading a disease: air-drop’s mechanism of transmission, high receptivity of organism of man to these infections, propensity of illness to epidemic distribution, especially in regions with a low social and sanitary-hygenic level. Actuality of children’s drop’s infections is predefined absence of watchfulness from the side of doctors to this pathology, especially among adults, by weight of motion, risk of origin of heavy complications which can threaten life of patients. To distribution of children’s drop’s infections among adults in Ukraine promote low social and sanitary-hygenic level of population, large congestion of people in cities, absence of the proper watchfulness, and often and the proper knowledges among doctors. 2 Whole lessons (with pointing of level of mastering which is planned) 2.1A student must know: etiology of children’s drop’s infections (measles, german measles, epidemic parotitis), factors of pathogenicity of exciters; epidemiology of children’s drop’s infections; pathogeny; adults have clinical displays of children’s drop’s infections; adults have clinical-еpidemіologic features of children’s drop’s infections; 86 pathogeny, term of origin and clinical displays of complications of children’s drop’s infections; laboratory diagnostics of children’s drop’s infections; principles of treatment; principles of prophylaxis; adults have a prognosis of children’s drop’s infections; governed excerption of reconvalescentes from permanent establishment; governed the health centre system of reconvalescentes. 2.2 A student must be able: to adhere to the basic rules of work near a bed patient with measles, german measles, parotit illness; to collect anamnesis of illness with the estimation of epidemiology information; to inspect a patient and find out basic symptoms and syndromes, which meet at to measles, german measles,parotit illness, ground a clinical diagnosis for timely direction of patient in permanent establishment; to conduct differential diagnostics of “child's” drop’s infections for adults; on the basis of clinical inspection in good time to recognize possible complications of “child's” drop’s infections for adults; to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; to analyse the results of specific methods of diagnostics depending on material and term of illness; to work out an individual plan of treatment taking into account epidemiology information, stage of illness, presence of complications, weight of the state, allergist anamnesis, concomitant pathology ; to give a help on the before hospitalization stage; to work out a plan of disease and prophylactic measures in the hearth of infection; 87 to give recommendations in relation to the mode, diet, inspection, supervision, in the period reconvalescence. 3 Materials of before audition independent work 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) Discipline To know Able Previous disciplines Microbiology Properties of viruses, which are the exciters of кору, german measles, паротитної illness; methods of their diagnostics. Physiology Parameters of To estimate physiology norm of information of organs and systems of laboratory inspection. man; indexes of laboratory inspection are in a norm (заг. blood, urine test, biochemistry of blood, parameters of KOS, electrolytes and others like that). Physiopatholog A mechanism of y violation of functions of organs and systems is at the pathosiss of different genesis. 88 To interpret the results of methods of diagnostics of measles, german measles, parotit illness. To interpret pathological changes as a result of laboratory inspection at parafunctions organs and systems of different genesis. Immunology Basic concepts of object, and allergology role of the system of immunity in an infectious process, influence on the term of елімінації of exciter from the organism of man. To estimate information of immunological researches. Epidemiology Epid. process (source, mechanism of infection, ways of transmission) at to measles, german measles, паротитній illness; prevalence of pathology in Ukraine and in the world. To collect epidemiology anamnesis, conduct disease and prophylactic measures in the hearth of infection. Neurology Pathogeny, clinical signs of the isolated defeat of CNS at parotit illness, encephalopathy at bark To conduct the clinical inspection of patient with the defeat of the nervous system. Dermatology Pathogeny, clinical To recognize a rash for description of еczantems. a patient with кір, german measles. Surgery clinical-laboratory signs of defeat of pancreas and оrchitis are epidemic parotitis. Propedevtic internal illnesses In good time to diagnose these complications, appoint the proper inspection. of Methods and basic stages To collect anamnesis, of clinical inspection of conduct the clinical patient. inspection of patient, 89 find out pathological symptoms and syndromes. To analyse findings. Next disciplines Family medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of measles, german measles, epidemic parotitis are possible. Adults have features of clinical motion of these infections. Principles of prophylaxis and treatment. To conduct differential diagnostics of illnesses. To recognize measles, german measles, epidemic parotitis; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. intradiscipline integration Infectious diseases Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory diagnostics, complications of measles, german measles, epidemic parotitis are possible. Adults have features of 90 To conduct differential diagnostics of child's крапельних infections with other infectious diseases. To recognize measles, german measles, epidemic parotitis, their complication; to interpret information of laboratory inspection. To appoint treatment. To render the first aid clinical motion of on the before measles,german measles, hospitalization stage. epidemic parotitis . Principles of prophylaxis and treatment. 91 3.2 Structurally logical chart of maintenance of theme of employment Chart of diagnostics and treatment of measles (Morbillis) Epidemiology anamnesis: - contact with a sick man – from closing 2 dates of latent period to the 5th day of appearance of rash; absence of vaccination of measles for children after 12 months - sharp beginning, fervescence to 380C, rhinorea, cough, photophobia, puffiness of person, edema never, turning of conjunctiv, spot of Belskogo-Filatov-Koplika (pink spots with the dots of gum-blush in a center on the internal surface of cheeks opposite lower molyares) red, stain enantema on the mucus shell of soft palate; on the 3-4th day of illness the state gets worse, a temperature rises to 40 0 C, the catarrhal phenomena, symptoms of intoxication, grow; -ekzantema: as a pinky spots appears out of ears, for a day long spreads on a person, neck and overhead part of breasts and back, on a 2th day – on a trunk and overhead extremities, on a 3th day – lower extremities; the elements of rash are increased in sizes, rise above the level of skin, transform in stain papular, become crimson, arise up on a background the unchanged skin, with unequal edges, have a tendency to confluence kept 3-4 days, go out during 2-3 days, disappear in the same sequence, as well as poured leave pigmentation, bran-like shelling; expressed conjunctivitis; increase a back of neck , cervical, lymphatic knots of arm-pits virologic research (selection in the first days of virus from the epipharyngeal washing off, to the secret of conjunctiva on the culture of tissue or by the method of immunofluorescence); serum methods (RN, CFT,reaction braking hemaglutination, reaction undirect hemaglutination, immuno enzyme analysis with a morbillous antigen in the dynamics of illness) are an increase title of antimorbillous antibodies in 4 times and anymore; a blood test is leykopenia, limfocytes, decline of amount of eozinofiles, monocytes, ESR is moderato accelerated - determination of final diagnosis of illness, weight, complications Differential diagnosis with a flu, other acute respiratory viral desease , german measles, еnterovirus (boston’s) еkzantem,infectious mononucleosis, meningococcemia, allergic еkzantems, a scarlatin - mainly in home terms, except for patients with complications and after epidemic requirementes; isolation in a separate, well ventilated, room; bed mode 7-10 days, valuable feed, plenty of liquid; a care is of skin and mucus shells; symptomatic therapy (at a festering conjunctivitis is solution natrii sulfacilum , for a rhinorea – in a nose Protargolum, galazolin; for a cough – bromgeksin, libeksin); antihistaminic preparations of heavy forms; antibioticoterapy for complications -not early than a 4th day from the beginning rashing, of complications – not early than a 10th day - for clinical requiremenes 92 Plan of diagnostics and treatment of german measles (Rubeola) Epidemiology anamnesis: contact with a sick man at the end of latent period and during 2-5 days from the beginning of rash; a disease of mother is on a german measles during pregnancy; a contact is with patients with congenital german measles (contagiose for 2 years) - beginning the gradual, general state is broken insignificantly; for 1-2 days of appearance of rash there is a cough; during a rash the temperature of body increase to 380C (it can be normal); increase of posterior neck, back of head,back of ears and other lymphatic knots; a rash appears in the first day of illness, thick, as pinky, round or oval spots, shallow or large, during a few hours appears on face of neck and spreads on all body with overwhelming localization on extensor surfaces of extremities, back, stomach, buttocks, on the unchanged background of skin, does not have a tendency to confluence, sticks to 1-3 days, does not abandon pigmentation and shelling; enantema is possible: separate pink spots are on soft palatine; adults carry a german measles heavier, with the expressed fever, head pains, intoxication, a rash is more thick, sometimes with propensity to confluence, anymore expressed limfadenit; for the patients of expectant mothers a fetus is struck; in a clinic analysis of blood is leykopenia, neutropenia, relative limfocytes ,monocytes ( for 20% and higher) and presence of plazmatic cells and cells of Turk (to 10 – 25%) ... - virologic method-selection of exciter from blood, epipharyngeal washings off, urine, in the first 5-7 days of illness; are serum methods – reaction braking hemaglutination, CFT,RN (increase a title of antibodies in 4 times at research pair wheys of blood with an interval in 10-14 days); it is an exposure in blood of antibodies of class IGM Differential diagnosis with infectious mononukleosis, scarlatin, toksikoalergic dermatosiss, enterovirus ekzantem, measles - determination final diagnosis of illness, weight, complications - for the uncomplication form of german measles treatment in home terms; it is the bed mode in all period of rash, large volume of liquid, care for a skin and mucus shells; - medications in most cases are not used; - during considerable intoxication and thick rash – desintoxication and symptomatic therapy - for the clinical requirementes of months - not early than a 5th day from the moment of pouring out 93 plan of diagnostics and treatment of parotit illness (Morbus parotitis) Epidemiology anamnesis: -seasonality is end of the winter and spring; -it is a presence of direct contact with a patient for 1-3 weeks; it is absence in anamnesis ranishe the carried parotitis illness beginning of illness is sharp; general signs: fever to 38-390C, indisposition, sickliness, head pain, pain, in neck muscles. Glandular form: defeat of parotid salivary glands ( Filatov’s syndrome, signs of Mursu), more frequent in 6-8 days defeat of pancreas, orkhitis. Nervous form: meningitis, meningoencefalit (general cerebral, hypertensive, meningeal, likvor syndromes, syndrome of focal changes). Combined forms (defeat of glandular organs and CNS) -reaction braking hemaglutination, diagnostic title 1:80 (pair wheys); - CFT (pair wheys, increase of title in 4 times);immuno enzyme analysis, PCR; it is a blood test: leykopenia, relative lymphocytosis, for the complicated motion leykocytosis with the change of formula to the left, acceleration of ESR - formulation of clinical diagnosis is with determinations of form, distribution and localization of process, weight, complications Differential diagnosis with a citomegalovirus infection, festering and toxic parotitis, saliva-stone illness, tumours, limfadenitis, meningitises, and meningoencefalitis of other etiology - hospitalization heavy and complicated motion, and also for epidrequirements; - the bed mode for normalization of temperature; -diet 5, 5a; - for a boys-carrieing suspenzory; -care cavity of mouth (rinse natrii hydrocarbonate a 2% solution, furacilinum 1:5000); -nosotropic therapy: dezintocsication, desensibilisation, vitamins; -inhibitors of enzymes (trasilol, kontrikal, gordoks); - symptomatic therapy (febrifuge, antiinflamation, analgetic preparates); - inductors- to the interferon ( mefenamova acid - disappearance of clinical symptoms not before, than on a 9th day from the beginning of disease - patients are subject with complications of parotitis illness: with carried orkhitis (through a month review of urologist); persons which carried meningitis are subject a supervision for a neurologist 94 3.3. Literature is made to order Basic Vozianova zh.I. the Infectious and parasitogenic diseases: 3 Т. Kyiv: Health, 2001. - T.1. - p. 234-241. Superviser for infection diseases / for editor U.V. Lobzina.– 3 publish., supplement. and change .SPB: Foliant, 2003. - p. 99-102. Shuvalova E.P. Infection diseases.Rostov l/d.: Feniks. - p. 111114. Additional • Gavrisheva N.A., Antonova T.V. Infection process.Clinical and pathophisiologic problems. - Spb.: Special literatures, 1999. - p. 54-57, 6064. • Immunology of infection process:Superviser for doctors /for editor V.I. Pokrovskogo, S.P. Gordienko, V.I. Litvinova - M.: RAMN, 2000. - p. 113-120. • clinical-laboratory diagnostic infection diseases: Superviser for doctors. - Spb.: Foliant, - p. 98-103. 3.4 Materials are for self-control 3.4.1 A question is for self-control 1 What group of infectious diseases does measles, german measles,parotit illness belong to after the source of infection? 2 Ways of passing measles, german measles,parotit illness? 3 Factors of pathogenicity of exciters measles, german measles, epidemic parotitis. 4 Stages of pathogeny of measles, german measles, epidemic parotitis. 5 Morphological changes on a skin of measles and german measles. 6 Stages of cyclic clinical motion of measles, german measles, epidemic parotitis. 7 Basic symptoms of measles, german measles, epidemic parotitis, are in an initial period of illness. 8 Supporting symptoms of measles, german measles, epidemic parotitis, are in full play of illness. 95 9 Description, term of origin and loud speaker of rash for a patient with measles and german measles. 10 Clinical displays of оrchitis of epidemic parotitis. 11 Adults have features of motion measles, german measles, epidemic parotitis. 12 Features of motion measles, german measles, epidemic parotitis, are in modern terms. 13 Adults have consequences of measles, german measles, epidemic parotitis. 14 Specific complications of epidemic parotitis. 15 There is a plan of inspection of patients with child's drop’s infections. 16 Methods of diagnostics of typhoid. Interpretation of results is depending on the term of illness and material for research. 17 Adults have principles of nosotropic and symptomatic therapy of “child's” drop’s infections. 18 Governed excerption of reconvalescentes from permanent establishment. 3.4.2 Tests are for self-control To choose right answers 1 What term does a patient with measles become contagious from? A - from the first day of illness; B - from the first 2th days of latent period; C - from the last 2th days of latent period; D - from the 3th day of illness; E - from the 5th day of illness. 2 A basic link in pathogeny of disease on measles is: A viremia; B toxemia; C defeat of central and peripheral departments of the nervous system; D bacterimia; E - all of answers are faithful. 3 In the clinic of measles it is possible to select such periods : 96 A latent period; B - prodromal; C period of pouring out; D period of pigmentation; E - all of answers are faithful. 4 Duration of latent period of measles: A - 6-7 days; B - 9-17 days; C - 17-21 day; D - 3-9 days; E - 17 days. 5 For measles not characteristically: A sharp beginning; B considerable catarrhal signs; C fever; D hepatolienal syndrome; E- еkzantema and еnantema. 6 The pathognomic symptom of german measles is: A increase of peripheral lymphonoduss; B increase of liver; C increase of spleen; D psilosis; E - all right. A latent period lasts at a german measles: A - 5-6 days; B - 15-24 days; C - 6-10 days; D - 10-15 days; E - 4-10 days. 8 A latent period lasts at a parotit infection: A - 11-21 days; B - 12-15 days; C - 6-8 days; D - 20-28 days; E- 10-24 days. 97 9 The source of infection of parotit infection is: A animal; B bacillicarrier; C sick man; D finfishess; E - all right. 10 The exciter of parotit illness is: A virus; B bacteria; C spirochets; D ricketsias; E mushrooms. 11 All belong before complications of measles, except for: A pneumonias; B - encephalitis; C - otitis; D - pancreatitis; E - laryngitis. 12 The virus of measles belongs to to: A - аrbovirus; B - eogavirus; C - calcivirus; D - paramyxoviruss; E - picornaviruss. 13 Most credible gate of infection been measles : A skin is damaged; B intestinal; C lights; D glandulars; E conjunctiva of eye. 14 Ways of transmission of parotit infection: A - air-drop; B - sullage-oral; C - sexual; D pin; 98 E- all right. 15 Treatment of measles can be: A - etiotropic; B - with application of antibiotics; C - nosotropic; D - symptomatic; E - all right. 16 On what term does set a quarantine of parotit infection? A - 21 day; B - 22 days; C - 18 days; D - 15 days; E - 23 days. 17 Duration of postvaccinal immunity makes of parotit infection: A - 2-4 years; B - 3-6 years; C - 2-4 months; D - 3-6 months; E - 2-4 weeks. 18 The virus of german measles belongs to family: A - picornaviruss; B - herpesvirus; C - mixovirus; D - аrbovirus; E - enteroviruss. 19 What day of illness does a rash appear on at a german measles? A - 1-2th day; B - 2-3th day; C - 3-4th day; D - 5-6th day; E- 6-7th day. 20 The virus of epidemic parotitis has tropic for: A - glandular tissue; B - intestinal; C - lights; 99 D is a pochard; E - all right. Standards of faithful answers 1 - C; 2 - A; 3 - E; 4 -; 5D; 6 - A; 7 -; 8 - A; 9 - C; 10 – A; 11 D; 12 D; 13 - E; 14 - A; 15 - E; 16 - A; 17 -; 18 - C; 19 - A; 20 - A. 3.4.3 Tasks are for self-control Task 1 Sick K., 27 years, works as a nursery governess in preschool, hospitalized in an infectious separation on the 4th day of illness. A disease was begun sharply with a fervescence to 38,5 0С, febricula, cough. On the 3th day of disease a temperature was normalized. The sick did not apply to the doctor, but on the 4th day of illness again the temperature of body rose to 39 0С, the catarrhal phenomena, symptoms of intoxication, increased. Pinky spots after ears, which for a day long spread on a person, appeared on a 4th day, sew overhead part of breasts and back.heart rate 108/minute, ABP 120/70 mm h.с. Tones of heart are clean. Breathing of везикулярне. In a clinical blood test:leucopenia, lymphocytosis, decline of amount of eosinophiles,monocytes,ESR 20 mm/hour. 1 To formulate a diagnosis 2 To work out a plan of inspection sick 3 To work out a plan of treatment Task 2 Patient G., 35 years, nursery governess of preschool, hospitalized in an infectious separation with complaints about a weakness, head pain, chill, insomnia and pouring out. A disease began gradually, there was a cough to appearance of pouring out. After appearance of pouring out the temperature of body rose to 38 0С. General state of sick middle weight. Pouring out as shallow pinky round spots during a few hours appeared on face, neck, spread on all of body with overwhelming localization on the розгинальних surfaces of extremities, placed on the unchanged background of skin, meet placed, does not abandon pigmentation and shelling. At sick : behind the ears and cervical posterior lymphatic knots is megascopic. In a 100 clinical blood test:leucopenia, neutropenia,monocytosis, presence plasmatic cages and cages Tyurka, to 20 %. 1 To formulate a diagnosis 2 To work out a plan of inspection sick 3 To work out a plan of treatment Task 3 For the nursery governess of preschool a disease was begun with a fervescence to 39 0С, appearances of cough, нежитю, to the conjunctivitis. A temperature remained enhanceable three days, the catarrhal phenomena grew. On the 4th day of illness during a review marked conjunctivitis,blepharospasm, on mucus company еnantema, spots of Belskogo-filatova-koplika. On the skin of person, after ears there is a stain-papular rash. 1 To formulate a diagnosis 2 To work out a plan of inspection sick 3 To work out a plan of treatment Standards of answers are to the tasks Task 1 1 German measles, typiform, middle hard degree of weight. 2 General clinical analyses of blood, urine, coprogram. Exposure in blood of antibodies class IgM by the method immuno enzyme analysis, RGGA, CFT, RN by the method of research of pair wheys. 3 bed’s routine, desensitizing preparations, vitamins. Task 2 1 measles, typiform,middle hard ran across. 2 general clinical blood, urine, excrement tests. Serum methods: RN, CFT, RGGA with pair wheys. 3 There is an isolation of patient in got a lot of fresh air; bed mode; a care is of skin and cavity of mouth; symptomatic therapy (anticough, drops in a nose), antihistaminic preparations. Task 3 1 measles, typiform,middle hard ran across. 2 general clinical blood, urine, excrement tests. Serum methods: RN, CFT, RGGA with pair wheys. 101 3 There is an isolation of patient in got a lot of fresh air; bed mode; a care is of skin and cavity of mouth; symptomatic therapy (anticough, drops in a nose), antihistaminic preparations. 4 Materials are for audience independent work 4.1 List of educational practical tasks which must be executed on practical employment To lay hands on the method of clinical inspection of patient with measles, german measles, parotitis. To conduct a curation of patient To appoint laboratory and additional researches, interpret results. To work out a plan of laboratory inspection To recognize complication To work out a plan of treatment sick To define medical tactic in the case of origin of the exigent states. To design a medical document 4.2 A professional algorithm is in relation to forming of skills and abilities of diagnostics of child's drop’s infections № Task Sequence of A remark, warning, is implementation in relation to selfcontrol 1. To lay hands on the method of clinical inspection of patient with measles, german measles, parotitis. I to Find out the To separate complaints complaints of which characterize patient. syndromes: - general intoxication - organ defeats To pay a regard to II to Find out gradual beginning; term, anamnesis: sequence of origin, 1 Anamnesis of dynamics: illness - fevers; - head pain; - to the rash; - other symptoms To find out the carried 102 illnesses. To find out information in relation to realization 3 Epidemiology of air-drop’s mechanism anamnesis of transmission. 2 Anamnesis of life 2. To conduct a III to Conduct an To remember: a curation of objective inspection. presence, expressed, patient dynamics of symptoms, is predefined a term and weight of flow of illness, depend on age sick, concomitant pathology. 1 General review: To pay attention on: - general state of - languor, adynami, patient; dormancy of patient; - temperature of body; - color of skin; skin, mucus - presence, localization, ротоглотки; character of rash. To pay attention on: - tachicardia; 2 Cordially is the vascular system: - oscillation of A/t; - pulse; - arteriotony; - moderate deafness of - cardiophony. tones of heart. 3 Respiratory To pay attention on: system: - dry wheezes often - аuscultation of dissipated; lights; - hyperemia of зіва, - review of зіва. енантему. 103 3. To appoint 1 General analysis To pay a regard to laboratory and of blood. typical additional changes:leucopenia, researches. to limphomonocytosis, interpret аneosinophilia results. (leucocytosis, anaemia, acceleration of ESR, arise up in the case of development of 2 General analysis complications). of urine. Absence of considerable changes is at typical 3 Serum methods: motion. - RNGA, CFT Appointed in the pair wheys of blood with an - Immuno enzyme interval 10 days; growth analysis (IGM). of title in 4 times. 4 Virologic research. A selection a virus is on the culture of fabrics. Materials of after audition independent work Subject of UDRS and NDRS: • Features of motion of child's drop’s infections are in modern terms. • Modern methods of diagnostics. • Problems of etiotropic treatment of child's drop’s infections today. • Modern looks are to pathogeny of child's drop’s infections. 104 Topic. DIPHTHERIA. DIFFERENTIAL DIAGNOSTICS OF SYNDROME IS «QUINSY» Duration - 2 hours. 1 Actuality of theme. At the end of 70th it was succeeded practically to liquidate diphtheria. It was registered as single cases (in Ukraine an index of morbidity on diphtheria in 1981 was 0,06 on a 100 000 population). However much illness periodically reminded about itself in different, even developed, countries. Yes, for example, in 1984-1985 y. there was a small flash of diphtheria in Geteborzi (Sweden), with which succeeded comparatively quickly to manage due to the active measures conducted in good time. Regularly enough registered in the countries of Africa different, mainly dermic, forms of diphtheria, however much an infection belonged to fully guided did not cause a large alarm. And even then, when from the beginning of 80th gradual growth of morbidity began to be registered, mainly in the East-European region, it did not cause an alarm at our health protection. And from the end of 80th - the epidemic of diphtheria which overcame almost all of republics of former Soviet Union (over 95 % all of diseases, incorporated in Europe) began beginning of 90th, максимум was morbidity on Russia and Ukraine. Yes, already in 1991 morbidity in Ukraine was 2,2 on a 100 000 population, continuing to grow. Yet and presently, almost in 10 years, to overcome fully an epidemic not succeeded. The feature of this epidemic is considerable advantage among diseased grown man population above a child (correlation 7:1-5:1). The greatest morbidity is registered in cities (Moscow, saint Petersburg, Kyiv). An exposure, treatment of patients, prophylactic measures, need large financial charges. In addition, the real danger of distribution of infection is created in other countries. A situation which arose up with diphtheria testifies that the guided infections remain on control only until about them remember, engaged in them. Failure to observe of the graph of inoculations, a waiver is groundless of them, plenty of contra-indications immediately result in activating of еpidprocess. In fact, from data of 105 WHO, scope the prophylactic planned inoculations of children by age 12-23 months in the different regions of the world are 11-70 %. Even in the USA in 1980 only 37,5 % children were valuably instiled. Presently there was such situation, that the forgotten infection reminded about itself, taking away hundreds of human lives already. The level of the real morbidity on diphtheria yet and is presently unknown, as even in the developed countries only 11-63 % cases of disease get to official statistics. 2 Whole lessons (with pointing of level of mastering which is planned) 2.1 A student must know: etiology of diphtheria, factors of pathogenicity of exciter; epidemiology of diphtheria; pathogeny; clinical displays of diphtheria are at typical motion; clinical displays of syndrome ?ангіна? clinical-еpіdemiologic features of diphtheria; pathogeny, term of origin and clinical displays of complications of diphtheria; laboratory diagnostics of diphtheria; principles of treatment; principles of prophylaxis; tactic in the case of origin of the exigent states; prognosis of diphtheria; governed excerption of reconvalescentes from permanent establishment governed the health centre system of reconvalescenres; differential diagnostics of syndrome «quinsy». 2.2 A student must be able: to adhere to the basic rules of work near a bed sick; to collect anamnesis of illness with the estimation of epidemiology information; 106 to inspect a patient and find out basic symptoms and syndromes of diphtheria, ground a clinical diagnosis for timely direction of patient in permanent establishment; to conduct differential diagnostics of diphtheria and syndrome «quinsy»; on the basis of clinical inspection in good time to recognize possible complications of diphtheria, exigent states; to design a medical document in fact of establishment of previous diagnosis "diphtheria" (an urgent report is in SES); to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; to work out an individual plan of treatment taking into account epidemiology information, weight of the state, presence of complications, allergist anamnesis, concomitant pathology; to render the first aid on the before hospitalization stage; to work out a plan of disease and prophylactic measures in the hearth of infection; to give recommendations in relation to the mode, diet, inspection, supervision, in the period of reconvalescence. 3 Materials are to audience independent work 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) Discipline To know Able Previous disciplines Microbiology Properties Corynebacterium diphtheriae, methods specific diagnostics diphtheria Physiology Parameters of physiology To 107 of of of of To interpret the results of specific methods of diagnostics of diphtheria estimate norm of organs and information of systems of man; indexes of laboratory inspection laboratory inspection are in a norm (general аnalysis of blood, urine, biochemistry of blood, parameters of KOS, electrolytes and others like that) Physiopathology A mechanism of violation of functions of organs and systemsof the pathosiss of different genesis To interpret pathological changes as a result of clinical and laboratory inspection Immunology and Basic concepts of object, allergology role of the system of immunity in an infectious process, influence on the term of еlimination of exciter from the organism of man To estimate information of immunological researches Epidemiology An epidemic process (source, mechanism of infection, ways of transmission) is at diphtheria; prevalence of pathology in Ukraine and in the world To collect epidemiology anamnesis, conduct disease and prophylactic measures in the hearth of infection Neurology Pathogeny, clinical To conduct the clinical syndromes of disease inspection of patient with the defeat of the nervous system 108 Propedevtic of Basic stages and methods To collect anamnesis, internal illnesses of clinical inspection of conduct the clinical patient inspection of patient, find out pathological symptoms and syndromes. To analyse findings. Clinical pharmacology Pharmakokinetics and pharmacodynamics, side effects of facilities of specific and nosotropic therapy To appoint treatment depending on the degree of weight, individual features of patient. To write recipes Next disciplines family medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of infectious diseases are possible. Principles of prophylaxis and treatment. 109 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. To render the first aid in the case of necessity. Intradiscipline integration Infectious diseases Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory diagnostics, complications of infectious diseases are possible. 110 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. To appoint treatment. To render the first aid on the before hospitalization stage. 3.2 Structurally logical chart of maintenance of theme of employment Chart of diagnostics and treatment of diphtheria (Diphtheria) Epidemiology anamnesis: - contact with a patient with diphtheria in the nearest 14 days, contact with a rekonvalescence-transmitter or with a healthy transmitter; -absence of inoculations against diphtheria - beginning of illness is sharp, moderate phenomena of intoxication, a pharyngalgia is insignificant; at the review of fauces: stagnant dim hyperemia is with the cyanochroic tint of mucus; glandulars fillings out, on their surface continuous gum-blush with a mother-of-pearl tint fibrinose raids which go out outside glandulars spread on handles, tongue, soft palate; badly taken off a spatula, here inferior a by spatulas; through 15-20 minutes. after greasing 2 % solution of tellurite potassium tape turns black; regional lymphonoduss are megascopic, moderato sickly mucus shell bleeds (“symptom of bloody dew”); diphtherial tape sinks in water, not ground between - microscopy of stroke from fauces and nose; - bacteriologic examination of stroke from fauces and nose; - reaction undirect hemaglutination with antigen of Corinebacterium diphtheriae, Immuno enzyme analysis Differential diagnosis with quinsies, infectious mononukleosis, scarlatin, pseudotuberculosis, anginal-bubonic by the form rabbit-fever, mycotic defeat of glandulars, adenovirus infection, sharp leucosis and agranulocytosis - determination of weight, distribution of process, character of raid, as an exciter, complications - antitoxic antidifteria whey (10000-150000 OD); -antibiotics (benzilpenicilin cefalosporini, makrolides); -desintoxication therapy; - glucocorticosteroides; - symptomatic therapy - disappearance of clinical symptoms; negative results of two bacteriologic examinations of mucus from fauces and nose on the exciter of diphtheria with a two-day interval - reconvalescentes are under surveillance doctor of clinic infectious department; they rid of going in for sports of hard physical work during a 3-6 months.; for presence complications of supervision for a cardiologist and neurologist for a year 111 Chart of diagnostics and treatment of quinsy (Angina) Epidemiology anamnesis: - contact with a patient or rekonvalescent on a quinsy or other streptococcus infection; - contact with a healthy transmitter gemolitic streptococcus; -stay in the recently formed collectives (child, soldiery, student) sharp beginning, fever, tonsillitis, regional limfadenitis -Clinical analysis of blood , urine; -Bacteriologicexamination of mucus from the surface of glandulars a final diagnosis is with determination clinical form, degree of weight, exciter, complications Differential diagnosis with chronic tonsillitis, with the noncommunicative form of diphtheria oropharynx, with a scarlatin, infectious mononucleosis, anginal form of rabbitfever, acute respiratory viral infection, a leucosis - etiotropic therapy (antibiotics, Sulfanilamidums); -nosotropic (rinse fauces of antiseptics solutions); - antihistaminic preparations, vitamins; - physiotherapy (Ultra high frequency, tubus-quartz) - disappearance of clinical simptomatic; -normalization indexes of blood, urine - during a month (a review of doctor is 1 time on 10 days, obligatory non-permanent research of urine, blood) 112 3.3 Literature is made to order Basic • Vozianova Z.I. the Infectious and parasitogenic diseases:3т. Kyiv: Health, 2001. - Т 1.– p. 190-216 • Superviser for infection diseases /for editor U.V. Lobzina. 3publish.,supplement and change. - Spb.: Foliant, 2003. –1020 p. • Shuvalova E.P. Infection diseases.Rostov L/Д.: Feniks, 2001.959 p. Additional • Clinical-laboratory diagnostic infection diseases:Superviser for doctors. - Spb.: Foliant, 2001. – p.406-412. • Infectious diseases: Situatioonal tasks: Train aid/M.D. Chemich, N.I. Ilina, Sumy: publish house SUMDU, 2000. – 175 p. 3.4 Materials are for self-control 3.4.1 A question is for self-control 1 Features of exciter of diphtheria. 2 Description of еczotoxin. 3 Source of infection and factors of transmission. 4 Pathogeny of diphtheria. 5 Classification of diphtheria. 6 Basic clinical syndromes of diphtheria. 7 Clinical displays are depending on weight of motion. 8 Specific complications of diphtheria. 9 Differential diagnosis of diphtheria and syndrome of mангінаm. 10 Differential diagnostics of syndrome is a «quinsy». 11 There is a plan of inspection patient with diphtheria. 12 Methods of specific diagnostics of diphtheria. Interpretation of results of laboratory research. 13 Specific therapy of diphtheria: doses, way of introduction, duration of treatment. 14 First aid to the patient with diphtheria. 15 Governed excerption of reconvalescentes from permanent establishment. 16 A prophylaxis and measures is in a cell. 3.4.2 Tests are for self-control 113 To choose right answers Variant 1 1. Diphtheria belongs to to: A - food toxicoinfection B - bloody infections C - enteroideas D - air-drop’s infections E - food intoxications 2 Exciter of diphteria: A treponema pallidum B - C.diphtheriae C - Vibrio cholerae D - Clostridium of perfringens E- Clostridium of botulinum 3 What toxins are selected by the exciter of diphtheria? A еndotoxin B - neyraminidase, gialuronidase, hemolizinum C a toxoid D - does not select E еkzotoxin 4 A source of infection is at diphtheria: A are food products B is a man C is water D is weed-eaters E are the canned products 5 Factors of transmission are at diphtheria: A is a direct contact with the respiratory secret of patients or from by the exsudate of the staggered areas of skin B are of poor quality green-stuffs C are unwashed fruit D - all is transferred E are chhanas 6 What is a starting mechanism in pathogeny of diphtheria? 114 A - a toxin is able to stipulate the infection of skin and mucus shells B is a defeat of cholinergic departments of the nervous system a toxin C is a defeat of the digestive system a toxin D is penetration of vegetative forms of exciter from bowels in organs and tissues E is a defeat of аdrenergic departments of the nervous system a toxin 7 Duration of latent period is at diphtheria: A - 2 – 10 days B -1 month C - all right D - 2-3 hours E- 6-24 hours, possibly continuation to 10 days 8 What research is basic in confirmation of diagnosis of diphtheria? A is research of strokes of mucus from fauces, nose, excretions from wounds, ulcers, conjunctiva of eye (of external pharyngeal form), to find out еkzotoxin of C.diphtheriae B is research of urine for the exposure of еkzotoxin C is a hemanalysis,vomiting, scourages of stomach, emptying, tailings of meal, with the purpose of exposure of diphtherin D is research of products for the exposure of C.diphtheriae E is a bacteriologicexamination of blood,vomiting, scourages of stomach, emptying, tailings of meal, by sowing on clear soup of Khotingera 9 Is there what multipleness of introduction of PDS at the middle hard form of diphtheria? A- 12 hours B-24 hours C - 6 hours D - 2 hours E- 4 hours 115 10 Is there what multipleness of introduction of PDS at the heavy form of diphtheria? A- 12 hours B-24 hours C - 6 hours D - 2 hours E - 4 hours Variant 2 1 Does meet nystagmus at diphtheria? A - no B - only for children C - so D - only at heavy motion E- only for people old years 2 What types are groats meet at diphtheria after character of motion? A-stormy making progress B - slowly making progress C - noncommunicative D– widespread 3 How can a pulse change at the asphyxial stage of diphtheria? A is a fall of pulse wave on height of breath B fall of pulse wave on height of breath out C tachicardia D bradicardia E arrhythmia 4 What term of vaccination of children a diphtherial toxoid, in default of contra-indications? A - 5 - months B - 3-5 months C - 6-7 months D - 2 -3 months E - there is not a faithful answer 5 What term of revaccination by the diphtherial toxoid of children in default of contra-indications? A - 18 months, 11, 14, 18 years 116 B - 12 months, 4, 8, 12 years C - 18 months, 4, 8, 12 years D - 12 months, 11, 14, 18 years E- there is not a faithful answer 6 Most effective antibiotic at treatment of transmitters of toxigenic corynebacteria: A еrytromicinum 98 % B - gentamicinum C ampicillin D- riphampicinum E- there is not a faithful answer 7 Therapy of transmitters of toxigenic corynebacterii includes: A antibiotic during 7 days B nistatinum C local sanation of ротоглотки and nose D- antihistaminic preparations E - all is transferred 8 How is the cardio-vessels system struck at diphtheria? A is paretic expansion of shallow vessels B is sharp myocarditis C are deep degenerative changes in myocardium D is a diffuse sclerosis of myocardium as a result of sharp myocarditis E- all is transferred 9 Name the supporting symptoms of diphtheria in full play disease: Ais the sharp beginning B is heavy toxicosis C is a diphtherial croup D is the combined forms as combination of a few heavy variants of illness E - all is transferred 10 Term of brief bacteriacarry: A - to 2 weeks B - from 2 weeks to 1 month C - from 1 to 6 months D - more than 6 months 117 E - there is not a faithful answer Variant 3 1 Name the clinical displays of beginning of toxic form of diphtheria: A is head pain, dizziness B is a "net", "fog" before eyes C is a head stomach-ache, temperature of 39° of S,slabkist', anorexia, vomit, pain D is a nystagmus, dizziness, rapid fatigue E is a diplopia, nystagmus and dryness, in a company iF is is dryness in a company, paresis of soft palate, violation of act of swallowing 2 0to -particular raid at diphtheria: A - dense, grey fibrinotic B is a surface brilliant,comb-like appearances C - formed after 2 -3 days, at first web-like D - often go beyond anatomic limits E is «dew», without therapy appears again F is - all is transferred 3 Basic nourishing environments are for cultivation of exciter of diphtheria: A environment of Klauberga - 2 B gelose on clear soup of Khottingera C - 10 -15 % blood hemolyzes D - 0.03 - 0.04 % telurit potassium E is an environment of Tinsdeyla F is - all is transferred 4 The main criterion of weight of diphtheria glandulars and pharynx is: A degree of toxicosis B - feet of dehydration C degree of intoxication D right answer “c” E - there is not a right answer 5 What preparation is utillized for etiotropic therapy at diphtheria? A - Laevomycetіmi succіmatis solubil. 1,0 intramuscular 3 times per days 118 B - Visllipi-5 intramuscular for 1500000 OD 1 time per days C - Sol. gentamycini sulfatis 4 % intramuscular for 1 ml 3 times per days D еrytromicynum,ryphampicynum E - tab. Rovamicini for 3000 MО 3 times per days 6 What is a starting mechanism in pathogeny of diphtheria? A - a toxin is able to stipulate the infection of skin and mucus shells B is a defeat of cholinergic departments of the nervous system a toxin C is a defeat of the digestive system a toxin D is penetration of vegetative forms of exciter from bowels in organs and fabrics E is a defeat of аdrenergic departments of the nervous system a toxin 7 How is it possible to neutralize diphtherial еkzotoxin? A - to enter a medical antidiphteria whey B - hemosorbcia C - to do a cleansing siphon enteroclysis D - to enter sorbentes in a stomach E is the зондове washing of stomach 5 % by soluble-sodium hydrocarbonat 8 How is a antidiphteria whey entered? A - the dose of whey is dissolved in 5% solution glucose B - the dose of whey is dissolved in isotonic solution NaCl 1:2 C- prednisolonum in the dose of 2 mg /kg D - warm up and enter with speed of 40- 60 drops/1 minute. E- all is transferred faithful 9 What the combined form of diphtheria? A - discover for the uninstiled children different age B - more frequent all in age 1 – 5 C is combination of diphtheria glandulars and diphtherial croup D rapid formation of fibrinotic tapes not only in a larynx but also in a trachea, bronchial tubes E combination of «syndrome of quinsy» from the defeat of larynx F -all the faithful is transferred I0 What clinical forms does diphtheria have? A diphtheria of glandulars 119 B nasopharyngeal diphtheria C hypertoxic form D diphtherial croup E combined forms of diphtheria F - all of answers are faithful Standards of faithful answers Variant 1: 1 D; 2 -B; 3 -B, E; 4 -B; 5 - A; 6 - A; 7 - A; 8 - A; 9 ; 10 C. Variant 2: 1 - A; 2 - A,; 3 - A; 4 -; 5 - A; 6 - A, D; 7 - E; 8 - E; 9 - E; 10 - A. Variant 3: 1 - C; 2 - G; 3 - G; 4 - A; 5 D; 6 - A; 7 - A; 8 - E; 9 G; 10 - G. 3.4.3 Tasks are for self-control Task 1 A patient is 40 years accepted in an infectious separation on the 4th day of illness. A disease was begun with a fervescence to 39 0С, febricula, head pain. The next day a pharyngalgia appeared at swallowing. A temperature did not go down the last 2 days, arrived at 39-40 0С, there was repeated vomit. Objectively: patient of аdynamic, the pallor of skin, hyperemia of mucus shell and considerable edema of glandulars, is expressed, palatal handles, tongue, soft palate. Aglandulars is megascopic, on their surface there is dense tape of rather yellow grey color, which is not taken off a tampon and goes out outside glandulars. Regionarni lymphatic knots are megascopic to 1,5 sm, dense, sickly of palpation. The edema of hypoderm is expressed to the middle of neck, a sweetish smell is felt from a mouth.heart rate 120/minute., ABP 90/60 mm h.с. At a hemanalysis found out leucocytosis,trombocytopenia,ESR 20 mm/hour. 1 To formulate a diagnosis 2 To work out a plan of inspection sick 3 To work out a plan of treatment Task 2 Patient 20 years in the 1th day of illness grumbles about a pharyngalgia, temperature of 39°С, weakness, head pain, nasality of 120 voice. Objectively: адинамічне pale person. Bilateral painless edema of neck. Mucus shell of mouth-pharynx, pharynx, moderato hyperemia, considerable edema and increase of glandulars with tape of dirty-grey color, which is not taken off. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 3 Youth 20 years complains on, heartburn in a right eye, mucous festerings excretions from an eye. Objectively: it was swollen never, point hemorrages on the conjunctiva of sclerotica of right eye, on mucus eyelids are present grey for a gum-blush tapes which was hardness taken off a wadding tampon. A conjunctiva bled here. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 4 A child is 5 years ill 2 days. Temperature of body 38,0 °С, languor, pain at swallowing. Migdaliki fillings out, with dirty-grey raids which are not taken off a spatula, submandibular lymphatic knots are megascopic. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Standards of answers Task 1 1 Pellicle diphtheria of glandulars is noncommunicative middling heavy motion. 2 General analyses of blood, urine. A backterioscopy of stroke is from glandulars; a bacteriologicexamination of mucus is from a pharynx and nose; serum researches (RNGA with pair wheys), immuno enzyme analysis, ECG. 3 Antitoxic antidiphteria whey 60 000 OD i/v;benzylpenicillini 200 000 OD/kg i/c 4 hours during 5-6 days, desintoxic and symptomatic therapy. 121 Task 2 1 Pellicle diphtheria of glandulars, a form is noncommunicative, middle hard ran across. 2 General analyses of blood, urine. A backterioscopy of stroke is from glandulars; a bacteriologicexamination of mucus is from a pharynx and nose; serum researches (RNGA with pair wheys), immuno enzyme analysis, ECG. 3 Antitoxic antidiphteria whey 60 000 OD i/v; - benzylpenicillini 200 000 OD/kg i/c 4 hours during 5-6 days - desintoxication and symptomatic therapy. Task 3 1 Pellicle diphtheria of right eye, a form, easy motion, is noncommunicative. 2 General analyses of blood, urine. A backterioscopy of stroke is from a right eye; a bacteriologicexamination of excretions is from an eye; serum researches (RNGA with pair wheys), immuno enzyme analysis, ECG. 3 Antitoxic antidipheria whey 40 000 OD i/v; - benzylpenicillini 200 000 OD/kg i/c 4 hours during 5-6 days - desintoxication and symptomatic therapy. Task 4 1 Diphtheria of mouth-pharynx, a form is noncommunicative,middle hard ran across. 2 General analyses of blood, urine. A backterioscopy of stroke from gandulars; a bacteriologicexamination of mucus is from a pharynx and nose; serum researches (RNGA with pair wheys), immuno enzyme analysis, ECG. 3 Antitoxic antidiphteria whey 60 000 OD i/v; - cefazolin of 1,0 2 р в/м. during 5-6 days; - desintoxic and symptomatic therapy. 4 Materials are for audience independent work 4.1 List of educational practical tasks which must be executed on practical employment To lay hands on the method of inspection patient with diphtheria. 122 To conduct a curation of patient with diphtheria. To conduct differential diagnostics of diphtheria and syndrome «quinsy». To work out a plan of laboratory inspection. To interpret the results of specific inspection of patient with diphtheria. To recognize complication of diphtheria. To work out a plan of treatment patient with diphtheria. To define medical tactic in the case of origin of the exigent states. To design a medical document in fact of establishment of diagnosis «diphtheria». 4.2 Professional algorithm in relation to forming of skills and abilities of diagnostics of diphtheria and syndrome «quinsy». № Task Sequence of A remark, warning, is in п/п implementatio relation to self-control n 1 To lay hands 1 Complaints on the method of clinical inspection of 2 Anamnesis patient with illnesses diphtheria 3 Anamnesis life To separate complaints which characterize syndromes: - general intoxication; - organ defeats. To pay a regard to beginning, term, sequence of origin of symptoms, their dynamics: - sharp beginning; - moderate pains are in mouthpharynx at swallowing; - shortness of breath. - nasality of voice (palatoplegia ). To find out the carried illnesses To find out information in 123 4 Epidanamnez relation to realization повітряно-краплинного mechanism of transmission. 2 of To conduct To conduct an To remember: the expressed, курацію of objective dynamics of symptoms, is patient inspection: predefined a term and weight of flow of illness. 1 General To pay attention on: review: - languor, аdynami, dormancy - general state of patient; of patient; - temperature of body; - skin, mucus - pallor of skin, small cyanosys; mouth-pharynx. presence, localization, character of raid; - increase of submandibular lymphatic knots; oedematousness of submandibular area. 2 Digestive To pay attention on: system: - a language is assessed, lips are - review of dry, chappy; language; - stomach-ache, more frequent - percusion of sharp, sudden; stomach - закреп, vomit. - palpation of stomach - character of emptying. To pay attention on: 3 Nervous - dystrophic and necrotizing system changes; - paresis of soft palate; - cacesthesias; - defeat of CNS, was swollen, hemorrages; 124 - comma. To pay attention on: 4 cardio-vessels - decline of AT; system - tachicardia (does not answer a temperature); - myocarditis is with an asequence cardiac rhythm; - DVZ- syndrome. 5 Respiratory To pay attention on: system - shortness of breath in a state of rest; - paradoxical type of breathing (defeat of diaphragm). 3 To appoint 1 General laboratory analysis of and blood additional researches To pay attention on: - neutrophilic leucocytosis with the change of leucocytic formula to the left; - megascopic ESR. - maintenance of albumen is 2 General enhanceable (to a 10 analysis of urine gramme/л); - cylinders (gialin and grainy); - single changed red corpuscles; - high specific closeness. Necessary in the case of determination of degree of 3 Biochemical violation of activity of different hemanalysis organs and systems. (ASAT, LDG, acid-basic status, electrolytes, coagulogram, kidney tests, to Presence of exciter 125 рН-blood) 4 Bakterioskopiya of secret of mouth-pharynx Growth of title of antibodies and nasal motions. 5 Serum Presence in 24 hours of research of коринебактерій diphtheria. RPGA 6 Bakteriologichna diagnostics Materials of after audition independent work Subject of UDRS and NDRS: • Features of motion of diphtheria are in modern terms. • Modern methods of specific diagnostics of diphtheria. • Problems of etiotropic treatment of diphtheria today. • Modern looks are to pathogeny of diphtheria. 126 Topic. A MENINGEAL SYNDROME IN THE CLINIC OF INFECTIOUS DISEASES. DIFFERENTIAL DIAGNOSTICS OF SEROSAL AND FESTERINGS MENINGITIS. MENINGOCOCCUS INFECTION Duration – 2 hours. 1 Actuality of theme. Presently a meningococcus infection as sporadic cases or small epidemic flashes is registered in entire countries. In 80% cases primary bacterial meningitis has meningococcus etiology. As a result of high sensitiveness to to children and young people are ill mainly meningococ. High step of contagiose instrumental in the origin of epidemics, and investigation of it are enormous economic expenses. A disease can run across hardness with high lethality. A meningococcus infection so far remains incomplete guided, as there is not a vaccine created against all of groups meningococcus. Questions of pathogeny are not enough studied, in particular, reasons of forming of fulminante and chronic forms. Taking into account lightness of distribution of infection, unforeseeableness of its motion, registration, all are subject it clinical forms – from a transmitter to fulminante. 2 Whole lessons (with pointing of level of mastering which is planned) 2.1 A student must know: etiology of meningococcus infection, factors of pathogenicity of exciter; epidemiology of meningococcus infection; pathogeny; clinical displays of meningococcus infection are at typical motion; clinical-еpіdemiologic features of meningococcus infection; pathogeny and clinical displays of complications of meningococcus infection; pathogeny and clinic of edema and swelling of cerebrum; 127 laboratory diagnostics of meningococcus infection; principles of treatment; principles of prophylaxis; tactic in the case of origin of the exigent states; prognosis of meningococcus infection; governed extracts of reconvalescentes from permanent establishment; governed the health centre system of reconvalescentes 2.3 A student must be able: to adhere to the basic rules of work near a bed sick; to collect anamnesis of illness with the estimation of epidemiology information; to inspect a patient and find out basic symptoms and syndromes of meningococcus infection, ground a clinical diagnosis for timely direction of patient in permanent establishment; to conduct differential diagnostics of meningococcus infection; on the basis of clinical inspection in good time to recognize possible complications of meningococcus infection, exigent states; to design a medical document in fact of establishment of previous diagnosis "meningococcus infection" (an urgent report is in SES); to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; to work out an individual plan of treatment taking into account epidemiology information, weight of the state, presence of complications, allergist anamnesis, concomitant pathology; to render the first aid on the before hospitalization stage; to work out a plan of disease and prophylactic measures in the hearth of infection; to give recommendations in relation to the mode, diet, inspection, supervision, in the period of reconvalescentes. 3 Materials are to audience independent work 128 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) Discipline To know Able Previous disciplines Microbiology Properties of meningococces, methods of specific diagnostics of meningococcus infection Physiology Parameters of physiology To estimate information norm of organs and of laboratory inspection systems of man; indexes of laboratory inspection are in a norm (заг. ан. to blood, urine, biochemistry of blood, parameters of KOS, electrolytes and others like that) Physiopathology A mechanism of violation of functions of organs and systems is at the pathosiss of different genesis Immunology and allergology To interpret the results of specific methods of diagnostics of meningococcus infection To interpret pathological changes as a result of clinical and laboratory inspection Basic concepts of object, To estimate information role of the system of of immunological immunity in an infectious researches process, influence on the term of еlimination of exciter from the organism of man 129 Epidemiology An epidemic process (source, mechanism of infection, ways of transmission) of meningococcus infection; prevalence of pathology in Ukraine and in the world To collect epidemiology anamnesis, to conduct disease and prophylactic measures are in the hearth of infection Neurology Pathogeny, clinical To conduct the clinical syndromes of disease inspection of patient with the defeat of the nervous system Propedevtika of Basic stages and methods To collect anamnesis, internal illnesses of clinical inspection of conduct the clinical patient inspection of patient, find out pathological symptoms and syndromes. To analyse findings. Clinical pharmacology Pharmakokinetics and pharmacodynamics, side effects of facilities of specific and nosotropic therapy Next disciplines 130 To appoint treatment depending on the degree of weight, individual features of patient. To write recipes family medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of infectious diseases are possible. Principles of prophylaxis and treatment. To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. To render the first aid in the case of necessity. intradiscipline integration Infectious diseases Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory diagnostics, complications of infectious diseases are possible. 131 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. To appoint treatment. To render the first aid on the before hospitalization stage. 3.2. Structurally logical chart of maintenance of theme of employment Chart of diagnostics and treatment of meningococcus infection (Morbus meningococceus) Epidemiology anamnesis: socializing with patients nasopharingitis or other patients with an enhanceable temperature; it is intercourse from rekonvalescentami or by the healthy transmitters of meningococcus sharp or quick as lightning beginning with a high temperature, moderate head pain, by pain in muscles and joints; - tachicardia, low blood pressure; a presence of hemorrhages, more frequent hemorragic rash of wrong form as a stars through 5-15 hour from the beginning of disease on extremities, back, buttocks; -total cyanosys with the so-called of a corpse spots (ITSH); presence of herpes; -meningeal signs, hyperaestezia, violations of consciousness; -development of sharp insufficiency of bark adrenal glands - -study of gemogram and neurolymph; backterioscopy of neurolymph; a bacteriologic examination of neurolymph, mucus, from nasopharynx, blood; luminescent microscopy; research of eyeground; serum researches; lateks-agglutination; immune enzyme analysis, PCR - determination of the final unfolded diagnosis is taking into account a form, weight of motion, complications Differential diagnosis with tubercular, pnevmokokovim, staphylococcus but other by meningitises, and also with a subarachnoidite hemorrhage, sepsis, medicinal illness, spotted fever, flu, leptospirosis, hemorragic fevers, thrombocytopenic purpuroy, rheumatoceils, illness of Verlgofa - etiotropic (antibiotics, Sulfanilamidums); -nosotropic therapy:desintocsication, degidrataction, corticosteroides, anticoagulants; -anticonvulsant preparations, oxigenotherapy; - reanimation measures of heavy motion and development of complications clinical and laboratory convalescence - for clinical requirementes for a year researching a neurologist 132 Plan diagnostics and treatment of hemophilic infection (Haemophilus of infectio) Epidemiology anamnesis: a presence of contact with a patient (more frequent all – by a child) with the sharp inflammatory process of organs breathing or CNS; stay in the places of large accumulation people; to put in age 6-8 months; winter-spring seasonality; presence of immunodeficit, sickle-like cellular anaemia, megacaryoblastoma, after a splenectomy and chemotherapy - stering meningitis: sharp beginning from catarrhal symptoms, then symptomatic of bacterial meningitises, heavy motion; sometimes joining of festering arthritis, inflammation of epiglotitidis; to celulit. -Hemophilic pneumonia: focal or croupous, very often with joining of festering pleurisy; possible complications are festering pericarditis, inflammation of middle ear; can have the protracted motion. -Hemophilic sepsis: symptoms of heavy septicemy with stormy motion and septic shock; septicopyemias not observed. -Celyulit: more frequent localized on face, begun with the picture of ARD: characterized the limited slight swelling, hyperemia with a cyanochroic tint; localization-a cheek or eye socket; a temperature subfebril, intoxication is not expressed. -Inflammation of epiglottiditis: sharp beginning, rapid fervescence, considerable intoxication, quickly making progress; often bakteriemia. -Festering arthritis: often with osteomielitom, other displays rarer - selection of exciter (from a pus, sputum, neurolymph, material, from a mucus shell); - determination of capsule AG hemophilic stick in a neurolymph (sometimes in urine) in the reaction of counter immunoelectrophoresis or immune enzyme analysis determination of the eventual unfolded diagnosis (form, degree of weight, complications Differential diagnosis with meningitises and sepsis of other etiology, arthritis and osteomielites of other etiology, with a flu and other acute respiratory viral infection, pneumonias obligatory hospitalization; -etiotropic therapy: antibacterial preparations – cefalosporini (at obligatory determination of sensitiveness of exciter to the antibiotics) mainly intravenously, for easy forms - makrolides, phtorchinolones, - desintocsication therapy; - desensitive preparations; - vitamins; -symptomatic therapy - disappearance of clinical symptomatic; - normalization of laboratory indexes -for a clinical requirementes 133 3.3 Literature is made to order Basic • Vozianova zh.I. the Infectious and parasitogenic diseases: 3 Т. – K.: of Health, 2001. Т 1. - p. 433 – 457 • Infectious diseases. Textbook / For editor M.B. Titova – K.: Higher school, 1995. – p. 89 - 97 • Superviser for infection diseases / for editor U.V. Lobzina - Spb: Foliant, 2003. – 1040 p. • Shuvalova e.P. Infection diseases. Rostov l/d.: Feniks, 2001. – 959 p. Additional • Gavrisheva N.A., Antonova T.V. Infection process.Clinical and pathophisiologic problems.-Spb.: Special literature, 1999. – 255p. • Clinical-laboratory of diagnostic infection diseases: Suoerviser for doctors. - Spb.: Foliant, 2001. – 384 p. 3.4 Materials are for self-control 3.4.1 A question is for self-control Control questions are for the preparatory stage of employment 1 Features of exciter of meningococcus infection. 2 Description of еndotoxine. 3 Source of infection and factors of transmision. 4 Pathogeny of meningococcus infection. 5 Classification of meningococcus infection. 6 Basic clinical syndromes of meningococcus infection. 7 Clinical displays are depending on weight of motion. 8 Specific complications of meningococcus infection. 9 Differential diagnosis of meningococcus infection. 10 Plan of inspection sick on meningococcus infection. 11 Methods of specific diagnostics of meningococcus infection. Interpretation of results of laboratory research. 12 Pathogeny and clinical displays of NNGM. 13 Modern classification of NNGM. 14 Specific therapy of meningococcus infection: doses, way of introduction, duration of treatment. 15 First aid to the patient with a meningococcus infection. 134 16 A plan of conduct sick is from NNGM. 17 Governed extracts of reconvalescenes from permanent establishment. 18 A prophylaxis and measures is in a cell. 3.4.2 Tests of 2th level To choose right answers Variant 1 1 A menigococcus infection belongs to to: A – infections of respiratory tracts B - bloody infections C - enteroideas D – infections of external covers E– slow an infection 2 A mechanism of infection is at a meningococcus infection: A – vertical B – transmisive C – pin D is sullage-oral E – aerogene 3 A latent period of meningococcus infection: A – 2 – 15 days B – 1 – 10 days C – 2 -3 weeks D – 45 – 90 days E – 20 – 25 days. 4 There is characteristic nasopharyngitis for a meningococcus infection? A – so B – no C – only for children D – only for a patient with chronic Ringo E – only for patients with the heavy flow of illness. 5 What temperature is needed for cultivation of meningococcus? A – 10-15 0С B – 0 0С 135 C – 40-45 0С D – 36-37 0С E – 38-39 0С 6 What materials from a patient do undertake for bacteriological confirmation of meningococcus infection? A a pleura liquid, excrement B sputum C – washing water of stomach D urine, sputum E strokes from the back wall of nasopharynx, blood, neurolymph 7 What illnesses is it needed to differentiate meningococcus meningitis with? A – with a psittacosis B – with infectious mononucleosis C – with tubercular meningitis D – with illness of Lime E– with a topsail fever. 8 There is characteristic neutrophilic pleocytosis for meningococcus meningitis? A – so, all of period of illness B – no C – so, at the beginning of illness D – so, at the end of illness E – so, for some patients 9 Day's dose penicillinum to the patient with meningococcus meningitis: A – 1000000 – 2000000 Od/ of kg of mass / days B - 10000 – 50000 Od/ of kg of mass / days C - 1000000 – 500000 Od/ of kg of mass / days D - 200000 – 500000 Od/ of kg of mass / days E - 50000 – 100000 Od/ of kg of mass / days 10 Term of looking after the epidemic hearth of meningococcus infection: A – 10 days after the isolation of patient B – 10 days after the beginning of the first disease 136 C – 10 days after the isolation of the last patient D – 24 days after the isolation of the last patient E – 24 days after the beginning of the first disease 11 Clinical displays of NNGM: A sharp head pain B a motive anxiety C disorders of breathing D is cramps E – all right 12 NNGM arises up as a result of: A – toxication B – the fixed diuresis C – to the hyperproduction neurolymph D - cramps Standards of right answers 1 - A; 2 - E; 3 -; 4 - A; 5 - C; 6 - E; 7 - C; 8 - A; 9 D; 10 - A, 11 E, 12 - A. 3.4.3 Situatioonal tasks of the second level of mastering Task 1 In an infectious hospital delivered a patient in a grave condition. Sick suddenly, when a temperature rose to 39,30 С, head pain appeared, artralgias, bloking nose, with mucous festerings excretions. Objectively: a skin is pale, on-the-spot buttocks, shins, feet the abundant rash of wrong star’s form takes a place, by sizes from петехій to large еcchimoses diameter 4 – 7 sm. Elements are dense, a bit come forward above the surface of skin. On the mucus shell of oral cavity, scleroticas and conjunctiva, hemorrhages. ABP 90/50 mm.h.с., deafness of cardiac tones, arrhythmia,heart rate 110 /minuteхв. 1 Formulate a diagnosis. 2 Classification of this disease. 3 Specific prophylaxis. 137 Task 2 An ambulance to the induction centre is deliver a patient in a grave condition. According to native, захворів sharply 2 days ago, head pain appeared, the temperature of body rose to 38,90 С; vomit which did not bring a facilitation appeared the next day. Patient of аdynamic, consciousness, stored, meningeal signs appear: symptoms of Brudzinsk, Kernig, rygid of cervical muscles; reflexes are lowspirited, asymmetric. On the skin of shins, buttocks, forearm of petechial, rash wrong star form. ABP 110/60 mm. h .c,heart rate 95/minute ., breath rate 24/minute. 1 Formulate a diagnosis. 2 Specific diagnostics. 3 Complication of disease 4 Differential diagnostics of disease. 5 Etiotropic and nosotropic treatment. Task 3 In permanent establishment hospitalized a patient is with complaints about a fervescence to 38,00 С, weakness, head pain, non-permanent vomit, pharyngalgia at swallowing and to wheezing voice. Objectively: the state of patient is relatively satisfactory, pays attention on itself herpetic pouring out on lips, закладеність nose with mucous festerings excretions. Mucus nose the bloodshot, mucus shell of back wall of pharynx is bloodshot with the hypertrophy of follicles and «festering path». In a clinical blood test moderate neutrophilic leucocytosis. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Standards of answers Task 1 1 Meningococcemia, heavy motion. Complication: ITSH, sharp myocarditis. 2 A. Lokalisation forms: meningoccarry, nasopharyngitis. 138 3 B. Generalisation forms:A) typical meningococcemia; B) аtypic meningococcemia (without metastases in internalss, with metastases in internalss); C) meningoccus meningitis. V. Combination forms. After the degree of weight: easy, middle, heavy, as heavy as lead. 3 A specific prophylaxis is provided a vaccine. Lead nonpermanent в/м, dose accordingly age. Vaccines which contain capsule polisacharide of meningococcus of type A, С are made, V, W135, there are monovaccines (A and С); bivalent (A+s); quart of vaccine (A+s+v+w135). A-vakcina provides securing for 2 years, Son 2-4 years. Task 2 1 Sharp meningococcus meningoencephalit, middle weight. 2 Bakterioskopichne of hemanalysis, neurolymph, urine,synovial, pericardiac, pleura liquid, strokes, from a nose and mouth-pharynx. Serum methods: CFT, RPGA, RA, immuno enzyme analysis, PLR. 3 It was swollen a brain, wedging of prolate brain in the large cervical opening, syndrome of cerebral hypotension,ependimatitis, subdural sweat, deafness, epilepsy, hydrocranium, death. 4 Tubercular meningitis, subarachnoidal hemorrhage, comatose states. 5 Penicillin 24 000 000 OD/day, ampicillinum 400 mg/kg/day, solution of levomicetin succinate to 4 gr/days, Oxacillinum 300 mg/kg/day,ceftriaxonum,cefotaximum, Tetracyclinum. GKK: Dexamethazonum 2-3 mg (8-10mg) i/v 4-6 days. Diuretic: 15 % solution manitol, 30 % solution of urea is combined from 20 % solution of аlbumin. Parentetal detoxication, correction of acid-basic status, oxigenitherapy salt solutions. Task 3 1 Sharp meningoccus nasopharyngitis, middle weight. 2 Clinically blood test, clinical uranalysis, bacteriologicexamination of strokes, from a nose and mouthpharynx, CFT, RA, immune enzyme analysis, PLR. 3 Respirator viruses (flu, parainfluenza, аdenovirus, rhinovirus), antritis, diphtheria of mouth-pharynx. 139 4 Levomicetin is 0,75 g 4 times per days, ampicillin 0,5 gr 4 times per days 5 days. Rinse of throat by solutions furacillinum, of natrii hydrocarbonatum. 4.1 List of educational practical tasks which must be executed on practical employment To lay hands on the method of inspection patient with a meningococcus infection to Conduct a curation of patient with a meningococcus infection. To conduct differential diagnostics of meningococcus infection. To work out a plan of laboratory inspection. To interpret the results of specific inspection of patient with a meningococcus infection. To recognize complication of meningococcus infection. To work out a plan of treatment patient with ameningococcus infection. To define medical tactic in the case of origin of the exigent states. To design a medical document in fact of establishment of diagnosis «meningococcus infection». 4.2 A professional algorithm is in relation to forming of skills and abilities of diagnostics meningococcus infection № Task Sequence of A remark, warning, is in п/п implementatio relation to self-control n 1 To lay hands 1 Complaints on the method of clinical inspection of patient with a meningococcus infection 2 Anamnesis of illness 140 To separate complaints which characterize syndromes: fervescence; general cerebral ; - meningeal signs. To pay a regard to beginning, term, sequence of origin of symptoms, their dynamics: - violation of cardiac activity; - general cerebral; - violation of breathing. To find out the carried illnesses 3 Anamnesis of life 4 Epidanamnesis 2 To find out information in relation to realization of airdrop’s mechanism of transmission. To conduct 1 To conduct The expressed, dynamics of курацію of an objective symptoms, is predefined a patient inspection term and weight of flow of illness. 2 General To pay attention on: review consciousness; a rash is on a skin, his character, form, size. 3 Digestive To pay attention on: system mucus shell, hemorrhages are possible; vomit which does not bring a facilitation. 4 Nervous To pay attention on: system - meningeal signs (symptom of Brudzinskogo, Kernig, rygid of cervical muscles); - decline of reflexes, their asymmetry; - violation of breathing. To pay attention on: 5cardio-vessels - muffling of tones of heart; 141 system - tachicardia; - decline ABP. 6 Respiratory To pay attention on: system - violation of breathing rhythm (аpnoae); - increase of breathing frequency. 3 To appoint 1 General laboratory and analysis of additional blood researches To pay attention on: - neutrophilic leucocytosis with the change of leucocytic formula to the left; - megascopic ESR. Presence of meningococcus 2 Serum endotoxine hemanalysis, neurolymph, pleura,sinovial, pericardiac liquid. 3 acid- basicstate Materials of after audition of independent work Subject of UDRS and NDRS: • Features of motion of meningococcus infection are in modern terms. • Modern methods of specific diagnostics of meningococcus infection. • Problems of etiotropic treatment of meningococcus infection today. • Modern looks are to pathogeny of meningococcus infection. 142 Topic. EXIGENT STATES FOR PATIENTS WITH INFECTIOUS DISEASES WITH THE AIR-DROP’S MECHANISM OF TRANSMISSION. ITSH. REAL CROUP. UNREAL CROUP. ACUTE RESPIRATORY INSUFFICIENCY Duration - 2 hours. 1 Actuality of theme. The exigent states for infectious patients develop often, especially at the heavy flow of illness. Wrong diagnostic decisions result not only in ineffective and uneffective medical measures, but make a threat for life sick. Than it is before diagnosed presence or threat of development for the patient of critical condition and the leadthrough of reanimation measures is before begun, the greater probability of success is in treatment. Knowledge of the exigent states for infectious patients needs the doctors of all of specialities, especially that, who works in many prophiles and rural medical establishments. They often remain in private with problems which arise up for a patient suddenly. Life of man depends on speed of decision-making, rightness of actions of doctor. 2 Whole lessons (with pointing of level of mastering which is planned) 2.1 A student must know: а-2 infectiously toxic shock, sharp respiratory insufficiency, real and unreal croup: determination, etiology; pathogeny of the exigent states; clinical and laboratory diagnostics of water-electrolyte violations; differential diagnostics of the exigent states with the shock states of other genesis; principles of treatment, first aid by a patient on the before hospitalization stage. 2.3 A student must be able: а-3 to adhere to the basic rules of work near a bed sick with the exigent states; 143 to collect anamnesis of illness; to inspect a patient, ground a diagnosis; to conduct differential diagnostics of the exigent states; to work out a plan of laboratory and additional inspection of patient; to interpret the results of laboratory inspection; to work out an individual plan of treatment taking into account epidemiology information, stage of illness, to render the first aid on the before hospitalization stage; to give recommendations in relation to the mode, diet, inspection, supervision, in the period of reconvalescence. 3 Materials are to audience independent work 3.1 Base knowledges, abilities, skills, necessary for a study themes (interdiscipline integration) Discipline To know Able Previous disciplines Microbiology Properties of C. To interpret the results of diphteriae, S. aureus, H. specific methods of influenzae. Methods of diagnostics specific diagnostics Physiology Parameters of physiology To estimate information norm of organs and of laboratory inspection systems of man;indexes laboratory inspection in a norm (general аnanalysis of blood, urine, parameters of acid-basic state, electrolytes and others like that) 144 Physiopatholog A mechanism of violation y of functions of organs and systems is at the pathosiss of different genesis To interpret pathological changes as a result of clinical and laboratory inspection Immunology Basic concepts of object, To estimate information and allergology role of the system of of immunological immunity in an infectious researches process, influence on the term of елімінації of exciter from the organism of man Epidemiology Epidemic process (source, mechanism of infection, ways of transmission) at the exigent states, prevalence of pathology in Ukraine and in the world To collect epidemiology anamnesis, conduct disease and prophylactic measures in the hearth of infection Propedevtika of Basic stages and methods To collect anamnesis, internal of clinical inspection of conduct the clinical illnesses patient inspection of patient, find out pathological symptoms and syndromes. To analyse findings Clinical pharmacology Pharmakokinetics and pharmacodynamics, side effects of facilities of specific and nosotropic therapy Next disciplines 145 To appoint treatment depending on the degree of weight of motion, individual features of patient. To write recipes family medicine Pathogeny, epidemiology, dynamics of clinical displays, complications of infectious diseases are possible. Principles of prophylaxis and treatment. To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. In good time to hospitalize a patient in infectious permanent establishment. To render the first aid in the case of necessity. intradiscipline integration Infectious diseases Features of infectious diseases. Principles of diagnostics, treatment, prophylaxis of infectious diseases. Pathogeny, epidemiology, dynamics of clinical displays, laboratory diagnostics, complications of infectious diseases are possible. 146 To conduct differential diagnostics of illnesses of different genesis. To recognize an infectious disease, his complication; to interpret information of laboratory inspection. To appoint treatment. To render the first aid on the догоспітальному stage. 3.2. Structurally logical chart of maintenance of theme of employment plan of diagnostics and treatment of infectiously toxic shock Epidemiology anamnesis: -a patient has a presence of focal infection; patients with the high degree authenticity of shock reactions (generale form of meningococus infection, sepsis and other ); -introduction of large doses of antibiotics bactericidal action patients from bakterimia Early phase (I stage): Massive operating on the organism of microbal toxins, intoxication, fever, chill, head pain, pain, in an abdominal region; skin usually color, dry, heat; The arterial pressure sistolic - 90-140 mm h. c of diminishing of pulse pressure; slowing down diuresis; shock index 0,7-1,0. Expressed shock (II stage): decline of temperature, violation of consciousness; a skin is pale, moist, cold, cyanosys increases; Arterial pressure sistolic < 90 mm h. c, pulse 120-140 / minute; shock index 1,0-1,4; shortbreathing, intersticial pulmonary edema; oligoanuria (a selection urine less than 25 ml/gramme); metabolic acidosis. Late phase of shock (III stage): a skin is cold, earthy tint, gemoragies round joints; temperature below 36,00 S; a pulses- threadlike, arterial pressure sistolic of critical level; shock index 1,5 and higher, disorders of breathing, anury; loss of consciousness ... - bacteriologic examination of blood, neurolymph, urine, bile and other biological substances; general analysis of blood (leucocytosis, erytrocytosis, trombocytopenia, acceleration of ESR); a presence of changes in urine (red corpuscles, leucocytes, albumen, cylinders); biochemical blood test (enhanceable indexes of bilirubin, kreatinine, indikan, urine); coagulogram (violation of rolling function of blood); determination of the acid-base state (acidosis) -to formulate a diagnosis with pointing of basic disease, which became complicated infectiously toxic by shock, degree of weight A differential diagnosis is with shocks of other etiology, DVZ-syndrome, bacillosiss which are accompanied a fever - forbidden to transport patients; desintocsication therapy; etiotropic therapy (antibiotics of bakteriostatic action); glyucocorticoides (II-III stage of shock); correction of micromicrocirculation (heparin, trental); diuretic (manitol, Mannitum); inhibitors of proteases; vitaminotherapy - disappearance of clinical symtomatic of basic disease; normalization of laboratory indexes - in obedience for a basic disease 147 Sharp respiratory insufficiency Еtiopathogenesis Lungs causesі sharp сstenosis larynx, laryngotracheobronchitis Оbstruction high Respiratory ways extralungs causes decrease functional volume of lungs restruction high Respiratory ways Аctive lighting process damage breathing of nose,and і sick breathing mouth cavity edema of lungs poliomelitis, правець difuse type respiratory insufficiency paralise action on musc le neuroparalitic type res piratory insufficiency damage winking еpitelium of bronch , trachea, larynx damage drenage function of lungs sharp lungs insufficiency edema mucous and submucous coats laryngs annd high delay in high r Respiratory way dense saliva drying saliva Appear closely peel Оbstruction high respiratory ways Sharp respiratory insufficiency 148 Edema of lungs Еtiopathogenesis hyperhydratation hypertoxic shock hyperproteinemia Intensive replication ,storing up viruses in respiratory ways decrease оncodenic pressure of blood increase hydrostatic pressure diphteria,leptospirosis meningococcus іnfection and other. infection miocarditis damage of microcirculation increase penetreting capilares in lungs circulation- deficte surfactant insufficiency leftventricule increse hydrostatic pressure in a small blood transudacia decrease, colaculation аlveoles Еkzotoxin, еndotoxine difuse lung vasculite edema іntersticiallungs storing up ня liquor in аlveoles hypoxia Аcydosis freeing vasoactive peptides metabolicі damage in tissue poliorgans insufficiency Sharp respiratory insufficiency 149 DVSsyndrom 3.3 Literature is made to order Basic Vozianova Z. I. Infectious and parasitogenic illnesses : In 3 т. – K.: Healthy I, 2001- Т. 3- p. 296-466. Ivakhiv O.L., Grishko R.U., Kiselik I.O. infectious Room of diseases: Train aid.- Ternopil, 2006.- 350 p. Infectious diseases are in general practice and family medicine / For editor M.A. Andreychina. –Ternopil: TDMU, 2007.470 p. 3.4 Materials are for self-control 3.4.1 A question is for self-control 1 What characteristically for the initial phase of shock? 2 What illnesses does it follow to differentiate ITSH with? 3 Governed setting of antibiotics. 4 Principles of therapy are in the conditions of permanent establishment. 5 Gemograma of patient is from ITSH. 6 Pathogeny of acute respiratory insufficiency. 7 What complications do arise up acute respiratory insufficiency ? 8 A complex of medical measures is acute respiratory insufficiency . 9 What vaccines do utillize for the prophylaxis of flu? 10 What additional methods of inspection do utillize for diagnostics of acute respiratory insufficiency ? 11 Differential diagnostics of the real and unreal croup. 12 The first aid is in the case of acute respiratory insufficiency . 3.4.2 Tests are for self-control To choose right answers: Variant 1 150 1 What preparations do appoint at laryngospasm? A - Natrii oxibutiratis B - to sodium chloride C vitamin of С D a heparin E is a phentanyl. 2 How many degrees of stenosis of larynx? A-2 B-4 C-3 D-6 E-1 3 Can the syndrome of croup arise up at? A - sharp enteroideas B - the meningococcus infection C - diphtheria D - acute respiratory disease E - all right. 4 What additional methods of diagnostics of croup? A is an echoencephalography B is medullispinal punction C - еlectroencephalography D - all correctly E is sciagraphy 5 What characteristic information does have an important value for diagnostics of acute respiratory insufficiency ? A is a level of glucose of blood B is a level of haemoglobin C is determination of рСО2 р O2 of blood D - all right 6 The syndrome of croup develops in : A - women B - children to 3 C - men D - adults 151 E – old people 7 Reason of development of croup is: A is a flu B is a parainfluenza C аdenovirus D is a bacillosis E - all right 8 A near-term measure is in treatment of croup: A - аtroventum B - Natrii oxibutiratum C tracheotomy D аerosol-paroxigen mixture E - salbotamolum Variant 2 1 The basic clinical signs of croup is; A is a rough barking cough B - wheezing voice C is the loud breathing with the laboured inhalation D is an indrawing of intercostal intervals E - all right 2 I the degree of stenosis of larynx is characterized : A - blowing wings of nose B - by cyanosys of naso-lip’s triangle C - by a “barking cough” D - a shortness of breath is not E - all right 3 What degree of stenosis of larynx is the inciter shortness of breath expressed at in a spacehold? A-1 B-2 C-3 D -4 4 Sodium hydrocarbonatis is appointed with a purpose: A - desintoxication B are prophylaxises 152 C decline of ABP D corrections of аcidosis E - against cramps 5 What diseases is it needed to differentiate acute respiratory insufficiency with? A - by a quinsy, psittacosis,measles B - by a sepsis,meningoencephalitis C - measles, german measles D - psittacosis, sepsis, by a german measles 6 In the phase of the expressed shock: A is diminishing of amount of thrombocytes B is diminishing of time of hemopexis C hyperkaliemia D is an increase of urea, kreatin well E is a hyperglycaemia 7 For the initial phase of ITSH characteristically: A is an increase of urea, kreatinine B is diminishing of time of hemopexis C is a hyperglycaemia D is lactatacidemia E - hyperenzynemia 8 Kontrikal appoint for : A is diminishing of blood volume B are normalizations of hemodynamics C are corrections of acid-basic equilibrium D is oppression of enzyme’s activity E is a leadingout of liquid Standards of right answers Variant 1: 1 – A; 2 –B; 3D; 4D; 5 D; 6 –B; 7 – E; 8 D. Variant 2: 1 - E; 2 - E; 3 - C; 4 D; 5 - A; 6 - A; 7 -; 8 - C . 3.4.3 Situatioonal tasks Task 1 Patient A, 40 years, delivered in an infectious hospital. Third day illnesses, temperature 39,9 0С. Sharp the signs of respiratory insufficiency are expressed: frequency of breathing/40 minute, 153 diffuse cyanosys. A cough attack is permanent, periodically, with passing to the stuffiness.Sputum is festering-mucus, departs hardness. In lights hard breathing, differentdiameter moist and dry wheezes. On a sciagram: signs of bronchitis. Blood test: eryth -4,0 10/l, l – 6,0 10/l, general protein - 120 g/l,ESR - 14 mm/hour. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 2 In the separation of intensive therapy a patient is delivered In., 35 years, with complaints about feeling of insufficiency of air, shortness of breath of inciter character. great pain behind sternum, dry cough, increase of temperature, is to 37,6 0С. Objectively: a patient is uneasy, a skin is pale, covered a death-damp, neck veins swell,breathing rate 30/minute., in lights hearkened to the dry whistling wheezes. ABP 100/60 mm hidrargium column ,heart rate 100/minute..A cardiac shove is increased. Granici of heart is declined on the right. Anamnesis of disease: ill sharp that is why, when pain after a breastbone and shortness of breath appeared suddenly, lost consciousness then. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 3 Sick к., 38 years, illnes suddenly. A disease began a трясучим chill and sharp fervescence to 390 С. Great head pain, nausea, vomit, attacks of tonic and clonic cramps, appeared. The symptoms of Kerniga and Brudzinskogo are sharply expressed. A patient lies with the neglected head, feet are arcuated in knee-joints. Found out a paropsis, cross-eye, diplopia, paresis of muscles of person, shortness of breath, arrhythmia. A person is bloodshot, covered sweat with the herpetic pouring out on the mucus shell of lips, nose. Blood test:leucocytosis 4,0 10/l,ESR 40 mm/hour. A neurolymph is turbid, festering, flows out with enhanceable pressure (600 mm waters 154 column), cellular-albuminous dissociation, albumen 2,5 grammes/л, the amount of sugar and chlorides is mionectic. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 4 Boy Н., 1 year 4 misses, delivered in permanent establishment with complaints about the increase of temperature, hoarse of voice, frequent barking cough, shortness of breath. Zakhvoriv sharply at night, when in sleep there was an attack of strong cough, hoarse of voice, in two hours the temperature of body rose to 380С, the shortness of breath and child was increased was delivered in permanent establishment. At a review: the state is heavy. Temperature of body of 38,8 0С. Skin is pale, clean, expressed perorbital and peroral cyanosys. In a pharynx hyperemia, voice is hoarse, a cough is rough, «barking», breathing whistling, to hear in the distance, an auxiliary musculature takes part in the act of breathing. Breathing rate 60/minute. Perkutorno: above lights pulmonary sound. Auskul'tativno: leading dry wheezes on either side, tones of heart are hyposthenic,heart rate 140/minute. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Task 5 Patient A. hospitalized in an infectious separation with a diagnosis meningococcus infection. On a 3th day the state of patient was worsened. Pains appeared in muscles, joints, stomach, cyanosys of lips, nail phalanxes. A patient is excited, a hemorragic rash appeared on a skin. Enhanceable AP,tachicardia. 1 To formulate a diagnosis. 2 To work out a plan of inspection sick. 3 To work out a plan of treatment. Answers are to the tasks Task 1 155 1 A flu is hypertoxic. Sharp laryngotracheobronchitis, acute respiratory insufficiency 2 power . 2. Luminescent microscopy, virologic methods of research, serum reactions (CFT, RGGA). 3. Remalloy 0,1 3 times per days,leucocytic interferon. Task 2 1 Tromboemboly pulmonary artery, sharp motion,acute respiratory insufficiency 2 power,middle hard form. 2 General analyses of blood and urine, biochemical blood (general protein,protein factions, seromucoid, haptoglobin,coagulogram, ALAT, ASAT), ECG test, sciagraphy of lights. 3 NaCl, phentanyl,droperidolum,heparin,еuphilinum,streptokinasa,oxygen inhalation therapy. Zadcha 3 1 Meningococcus infection, meningitis, heavy motion, complicated an edema and swelling of cerebrum, stage of subcompensation. 2Craniografy,electro-encephalography, echoencephalography,bacterioscopic and bacteriologicexamination of neurolymph, thick drop of blood, bacteriologicexamination of mucus, from nasopharynx, RNGA. 3 Desintoxication,dehidratation,endocrinotherapy, anticonvulsant facilities, facilities, for excitation of respiratory center. Task 4 1 acute respiratory viral infectious.Stenosis laryngotracheitis 2th power (subcompensated). 2 Luminescent microscopy, virologic methods of research, serum reactions (RZK, RGGA). 3 Remalloy 0,1 3 times per days,leucocytic interferon. Task 5 1 Meningococcus infection,meningococcemia, ITSH of 1th degree 2 General analysis of blood and urine, biochemical blood test, blood test, on sugar, serum diagnostics (RGGA, RNGA, IFA ). 156 3 Etiotropic therapy (ceftriaxonum), antihistaminic preparations, desintoxication therapy, diuretic . 4 Materials are for audience independent work 4.1 List of educational practical tasks which must be executed on practical employment To lay hands on the method of inspection of patients with the exigent states. To conduct differential diagnostics of the exigent states To work out a plan of laboratory inspection. To interpret the results of specific inspection. To define medical tactic in the case of origin of the exigent states. To design a medical document. 4.2 A professional algorithm is in relation to forming of skills and abilities of diagnostics № Task Sequence of A remark, warning, is in п/п implementation relation to self-control 1 To lay hands on the method of clinical inspection of patients with the повітрянокраплинним mechanism of transmission with the невідкладними states (ITSH, real croup, unreal croup, GDN) I to Find out To separate complaints which the complaints characterize ITSH, real croup, of patient. unreal croup, GDN. To pay attention on: sequence II to Find out of origin, dynamics of anamnesis: symptoms, peculiar for ITSH, 1 Anamnesis of real croup, unreal croup, GDN illness 157 2 To conduct a 2 Anamnesis of To find out the carried curation of life illnesses. patient 3Epidanamnesis Find out information in relation to realization airdrops mechanism of transmission, to pay a regard to stay of patient in regions with the enhanceable risk of infection on infectious diseases with the aid-drops mechanism of transmission II to Conduct To remember: a presence, an objective expressed, dynamics of inspection symptoms, is predefined a term and weight of flow of illness, depends on age sick, concomitant pathology. To pay attention on: 1 General - languor, аdinamy, dormancy review: of patient; - general state - temperature of body; of patient; - cyanosys of skin, a turgor is - skin, mucus sharply mionectic; shell of oral - symptoms of ITSH. cavity. 2 Digestive system: To pay attention on: - review of - a language is covered a language; white raid; - dryness of language; -percution and - dysperistalsis intestine; palpation of stomach; - an amount, character, -characteristic inclination,to diarea 158 emptying. (appearance of melena testifies to the enterorrhagia). 3 Sercevosudinna system: - pulse; - arteriotony; - cardiophony. 3 To pay attention on: - tachicardia; - moderato mionectic AP (a considerable decline testifies to complication); - moderate deafness of tones of heart. To appoint 1 General laboratory and analysis of additional blood. researches, interpret results To pay a regard to typical changes: -leucopenia or leucocytosis, lymphocytosis, аneosinophilia, trombocytopenia (leucocytosis, anaemia,ESR, arise up in the case of development of enterorrhagia). 2 General Symptom of toxic bud. analysis of urine. Materials of after audition independent work Subject of UDRS and NDRS: Pathogeny of infectiously toxic shock, sharp respiratory insufficiency, real and unreal croup. 159 Topic. CONCLUDING SESSION OF THE SEMANTIC MODULE 2: infectious diseases with the air-drops mechanism of transmission Reference list of questions to the concluding session of the semantic module 2: 1 General description of infectious diseases of respiratory tracts. 2 Flu: etiology, epidemiology, pathogeny, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. A testimony is to hospitalization. 3 Parainfluenza: etiology, epidemiology, pathogeny, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. A testimony is to hospitalization. 4 Adenovirus illness: etiology, epidemiology, pathogeny, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. A testimony is to hospitalization. 5 RS-іnfectious: etiology, epidemiology, pathogeny, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. A testimony is to hospitalization. 6 Rhinovirus infection: etiology, epidemiology, pathogeny, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. A testimony is to hospitalization. 7 Classification of herpesviruss man. General characteristic of herpesvirus illnesses. 8 Herpetic infection: etiology, epidemiology, pathogeny, classification, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. A testimony is to hospitalization. 9 Windy pox. Girdle herpes. Etiology, epidemiology, pathogeny, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. Testimony to hospitalization, governed extracts of patients from permanent establishment. 10 Infectious mononucleosis: etiology, epidemiology, pathogeny, classification, clinical motion, laboratory diagnostics, differential 160 diagnosis, complication, treatment, prophylaxis. A testimony is to hospitalization. 11 Features motion of herpesvirus infections for patients on HIV/AIDS. 12 Measels: etiology, epidemiology, pathogeny, classification, clinic, features of motion, for adults, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. Testimony to hospitalization, governed extracts of patients from infectious permanent establishment. 13 German measles: etiology, epidemiology, pathogeny, classification, clinic, features of motion, for adults, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. Testimony to hospitalization, governed extracts of patients from infectious permanent establishment. 14 Parotitis virus: etiology, epidemiology, pathogeny, classification, clinic, features of motion, for adults, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. Testimony to hospitalization, governed extracts of patients from infectious permanent establishment. 15 Diphtheria: etiology, epidemiology, pathogeny, classification, clinical motion, laboratory diagnostics, differential diagnosis, complication, treatment, prophylaxis. Order of hospitalization, governed extracts from infectious permanent establishment. 16 Meningococcus infection: etiology, epidemiology, pathogeny, classification, clinical motion, laboratory diagnostics, differential diagnosis, complication, principles of treatment of different clinical forms, first aid, is on the before hospitalization stage, prophylaxis. Order of hospitalization, governed extracts of patients from infectious permanent establishment. 17 ITSH: determination of concept, pathogeny, classification, clinical and laboratory diagnostics, principles of treatment, first aid, is on the before hospitalization stage. 18 NNGM: determination of concept, pathogeny, classification, clinical and laboratory diagnostics, principles of treatment, first aid, is on the before hospitalization stage. 161 19 Respirator micoplasmosis: etiology, epidemiology, pathogeny, classification, clinical motion, laboratory diagnostics, differential diagnosis, complication, principles of treatment of different clinical forms, prophylaxis. A testimony to hospitalization. 20 Psittacosis: etiology, epidemiology, pathogeny, classification, clinical motion, laboratory diagnostics, differential diagnosis, complication, principles of treatment of different clinical forms, prophylaxis. A testimony to hospitalization. 21 Legionelosis: etiology, epidemiology, pathogeny, classification, clinical motion, laboratory diagnostics, differential diagnosis, complication, principles of treatment of different clinical forms, prophylaxis. A testimony to hospitalization. 22 Sharp respiratory insufficiency: determination of concept, classification, pathogeny, clinical and laboratory diagnostics, principles of treatment, first aid, on the before hospitalization stage. 162 LIST OF PRACTICAL SKILLS 1. A skin allergic test with ornitinum. 2. A skin allergic test is with a tuberculin (at tuberculosis). 3. Method of introduction of medical wheys. 4. A fence of blood is for serum researches. 5. A fence of material is for research on viruses. 6. Spinal punction. 7. Cannulation of urinary bladder. 8. A testimony to hospitalization of patients in permanent establishment. 9. Nondirect massage of heart. 10. Intubation of trachea. 11. Artificial ventilation of lights. 12. Punction of pleural cavity. 163 Educational edition M MEETTH HO OD DIIC CA ALL R REEC CO OM MM MEEN ND DA ATTIIO ON NSS FFO OR RB BEEFFO OR REE C CLLA ASSSS PPR E P A R A T I O N T O P R A C T I C A L C L A S S E S O F REPARATION TO PRACTICAL CLASSES OF IIN NFFEEC CTTIIO OU USS D DIISSEEA ASSEESS ((M O D U L E 2 ) MODULE 2) for the students of senior courses of higher medical establishments of formation of III-IV of levels of accreditation Accountable for the issue M.D. Chemych Editor Computer making up of I.V. Pavlovska Pidp. before a seal 09.09.2009, poses. Format 60х84/16. Paper . Garniture of Times New Roman Cyr. Seal of офс. Mind. seal. арк. Drawing of 150 пр. . Obl.-publish. арк. . A prime price is a kind. . Zam. № A publishing house SUMDU is at the Sumy state university 40007, м. Sumy, streets of R.-korsakov, 2 Testifying is to bringing of subject of publishing business in the State register DK № 3062 from 17.12.2007. It is printed in the printing-house of SUMDU 40007, Sumy, streets of R.-korsakov, 2. 164 165