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MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN TASHKENT MEDICAL ACADEMY Department of Infectious and Pediatric Infectious DISEASES "APPROVED" Vice-Rector for Academic Affairs TMA Professor Teshaev OR "_____" __________ 2014 Subject: Infectious diseases CASE - TECHNOLOGY on training on "measles, rubella, scarlet fever" Considered at a meeting of the SSC medical faculty TMA "___" ____________ 2014 Tashkent 2014 Compiled by: Karimov MT - Head of the Department of Infectious and Pediatric Infectious Diseases, MD, PhD Akhmedov, MD - Professor, Department of Infectious and Pediatric Infectious Diseases, MD Maksudova ZS - Assistant Professor of Infectious and Pediatric Infectious Diseases CASE solves the problem, what is the tactic of general practitioners with measles, rubella, scarlet fever Educational abstract The subject: "Infectious Diseases" Theme: "Measles, rubella, scarlet fever" The purpose of this case study: development of skills early and differential diagnosis of measles, scarlet fever and rubella in children and adults with the history and clinical and laboratory examination. Define rational therapeutic tactics and preventive measures in the hearth. Develop a sense of interest in the problem of measles, rubella, scarlet fever, a sense of responsibility for the lives of patients with measles, rubella, scarlet fever. Develop scientific, logical thinking at the bedside, creative approach to the diagnosis and treatment of patients with measles, rubella, scarlet fever. Expected learning outcomes - based on the results of work with a case, students acquire skills: Assessment and analysis of the situation and the general condition of patients with infectious measles, rubella, scarlet fever. Choosing the right algorithm of actions for diagnosis. early rational laboratory diagnosis of measles, rubella, scarlet fever independently provide emergency assistance if necessary referred to the hospital for treatment To be able to carry out qualified poststatsionarnuyu rehabilitation. For the successful solution of the case of a student should know • Conduct a professional history and examination of the patient; • give the characteristic rash; • Create a preliminary diagnosis based on the early and differential diagnosis; • appoint a targeted examination; • interpret data of laboratory and instrumental methods of examination; • own clinical decision logic (to form a definitive diagnosis, assess the severity of the patient's condition and prognosis); • diagnose emergency conditions and provide first medical aid in the prehospital phase; • Justify the need for consultation specialists, hospitalization and hospital profile. • On the forms, methods and content of work in counseling patients with the syndrome exanthema. • Determine the extent of the need for follow-up (medical and non-medical treatment) This case reflects the real situation in terms of primary care Sources of information of the case 1. Tooth TM, Ivanov KS, AP Kazantsev, Foresters AL Differential diagnosis of infectious diseases. Leningrad, 1991. 2. Vasiliev VS Mosquito VI, Tsyrkun VM The practice of infectious disease. Minsk, 1994. 3. AP Kazantsev, Tooth TM, Ivanov KS, Kazantsev VA Differential diagnosis of infectious diseases. Moscow, 1999. 4. R. Emond, Rowland H., Uelsbi F. Infectious Diseases. Color Atlas. Moscow, 1998. Additional 5. Madjidov VM Yukumli kasalliklar. Tashkent, 1992. 6. Mahmoudov OS Bolalar yukumli kasalliklari. Tashkent, 1995. 7. Uchaikin VR Guidance on infectious diseases in children. Moscow, 1999. 8. Shuvalov EP Infectious diseases. Moscow, 1999. 9. Musabaev IK "Guidelines for intestinal infections." Tashkent, 1982. 10. Pokrovsky VI, Pak SG and others. "Infectious diseases and epidemiology." Moscow, 2003. 11. Yushchuk ND, Vengerov YY "Lectures on infectious diseases." Moscow, 1999. 12. VF Uchaikin "Guidelines for Infectious Diseases in Children." Moscow, 1998. 13. Internet resources (www.medlinks.ru, www.cdc.gov, ...). Characteristics of the case according to the typological features This case is classified as a desk, a scene. He volumetric structured. This case-question. According to the didactic goals keystreningovy stimulating thinking in a real situation in a hovercraft. Case can be used in the disciplines: oncology, infectious diseases, Emergencies I CASE "Measles, rubella, scarlet fever" Introduction Characteristics of the various elements of exanthema. 1. Roseola (roseola) - a speck of light pink or red, round, vanishing when stretching the skin. 2. Spot (macula) - has an irregular shape, is the result of vasodilatation, pink and red. 3. Erythema (erythema) - large areas of congested, red skin appear at expansion vessels in the skin). 4. Hemorrhage (hamorrhagiae) - bleeding in the skin as a result of increased vascular permeability. Can be of various shapes and sizes. 5. Erosion (erosio) - defect of the epidermis, which is formed after opening the cavity of primary cells (vesicles, pustules, blisters). 6. Ulcer (ulcus) - deep skin defect, exciting epidermis, dermis, and sometimes the underlying tissues. Ulcers develop as a result of the collapse of the primary elements in infiltrating regions of deep dermis hillocks nodes at necropsy deep pustules, when anthrax - as a consequence of successive subsidiary fracture vesicles and pustules, which are formed on the edges of the ulcer, so that it seems to be growing on the periphery . Shape and edge ulcers are of great importance for the differential diagnosis. The edges of the ulcer may be podrytymi, steep, saucer, callous, soft and so on. The bottom of the ulcer may be flat, smooth (chancre), crater-like (syphiloma) on its surface can be expressed granulation (cutaneous leishmaniasis), etc. 7. papule (papula) - formed by the expansion of blood vessels and the formation of the cellular infiltrate in the upper dermis, rises above the level of the skin. 8. tubercle (tuberculum) - bespolostnoy element-inflammatory granuloma in the dermis, is different from the papules that always clearly detectable rather compact infiltrate in the skin. 9. Node (nodus) - limited education seal diameter of 1 to 5 cm extending into the skin. 10. Blister (urtica) - bespolostnoy limited swelling of the papillary layer of skin. Element quickly appears and disappears quickly, leaving no trace, accompanied by itching. 11. Vial (vesicula) - small cavernous formation containing serous, less serous-hemorrhagic fluid develops directly in the epidermis below the stratum corneum, in the middle or on the border of the dermis. 12. pustules (pustula) or abscess - festering vesicle. 13. Herpetic eruption (herpes) - a group of closely spaced small vesicles on erythematous inflammatory base. 14. Scale (squama) - there is a rash at the site of a vanished due to the rejection of the epidermis horny plates. Depending on the size of the flakes can be pityriasis peeling or plate. 15. Pigmentation (pigmentatio) - occurs at the site of a vanished rash, resulting in increased formation of skin pigment. 16. Cork (crusta) - the product of condensation and drying of various kinds of exudates other elements rash (pustules, vesicles, erosions, ulcers). 17. Scar (cicatrix) - coarse fiber connective tissue proliferation, replacing the deep skin defects. Macula-papular rash. Observed for the following diseases: measles, pseudotuberculosis (Far East Scarlatiniform fever, measles, scarlet fever, rash Boston (enterovirus), Fifth disease Rosenberg, an acute febrile phase of HIV infection, secondary syphilis, pink zoster, guttate psoriasis, urticaria, drug allergy. Maculopapular and vesicular rash. Observed at: chicken pox, herpes, shingles (herpes), impetigo, drug allergy. Haemorrhagic rash. When: drug allergy, meningokokktsemii, different vasculitis, hemorrhagic fevers. The purpose of this case study is to develop the student - user case study analysis capacity situation at admission of patients with measles, rubella skarlatinoyi. Skills selection tactics, diagnostics, emergency assistance, transportation and rational poststatsionarnoy rehabilitation measles, rubella, scarlet fever at the primary level. The decision of the case will allow prospective students to achieve the following learning outcomes: Assessment and analysis of the situation and the general condition of patients with measles, rubella, scarlet fever. Choosing the right algorithm of actions for diagnosis. early laboratory diagnosis rational cortex, rubella, scarlet fever independently provide emergency assistance if necessary referred to the hospital for treatment To be able to carry out qualified poststatsionarnuyu rehabilitation. Location: In an appointment to SVP GP patient appealed A. aged 24, complained of fever, cough, runny nose, sneezing, festering eyes, loss of appetite. At the 4-day disease rash on the face. 4 day history of the disease, never treated. Obstetric and early history without pathology. Works as a driver. By the nature of introvert. Allergies to drugs not. Epidemiological. history: in contact with infectious patients was not, did not receive blood products, at a reception at the dentist was not. Inspection: The state of moderate severity, a clear conscience. Proper physique. In the observation noted landmark spread the rash. Rash was plentiful, drain, strongly disturbed "cut" in the eyes. Temperature remained high up to 7 days of illness. Expressed intoxication - headache, vomiting, lethargy, weakness, insomnia. In the lungs, vesicular breathing. Cardiac sounds are muffled, HR 100 in 1 min. Furred tongue, we could see the small white spots on the mouth loosened congested (as semolina). Ms about the correct form, is involved in the act of breathing, with superficial and deep palpation painless, swollen belly. The liver is not increased. For other or¬ganam without pathology. Meningeal phenomena not. Surveys in MRA showed: Jabs: Hb - 128 g / l, cs - 0.91, Ayr - 4,2hYu12 / l; Lake -3,6h109 / l; p / - 1%, with / I - 42%, e - 6%, n - 42%, m - 7%, ESR - 10 mm / hour. Urinalysis was normal. Biochemistry of blood total protein - 72 g / l, thymol test - 4 units, total bilirubin - 15 mmol / l associated -3 mol / l (within normal limits). Questions and tasks 1. What kind of disease you can think of? 2. On what day of the disease appear exanthema? 3. Characteristics of the rash in measles? 4. What is the difference measles rash of rubella? 5. What is the difference scarlet rash of measles? 6. With what diseases it is necessary to carry out differential. diagnosis? Task: On the basis of the patient's condition should make a preliminary diagnosis, carry out the necessary diagnostic methods, make an informed decision for further reference to the patient. II. Methodical instructions for students 2.1 Problem: The choice of tactics and determination of the need for hospitalization of patients with measles, scarlet fever, rubella in a hovercraft. 2.2. Subproblems 1. Analysis of appearance 2. Analysis of the history and pre-event is an etiological factor in the development of the syndrome exanthema 3. Analysis inspection 4. Selection of the necessary diagnostic methods 5. Relate findings and differential diagnosis 6. Come to a specific problem-solving in a hovercraft. 2.3. Algorithm for solving 1. Analysis of appearance includes the following research - Examination of the skin and visible mucous - The face (eyes, tongue) 2. Analysis of history - Borne diseases - Family and social history - Epidemiological. history - The duration and nature of exanthema 3. Analysis inspection - Ps, BP - Auscultation of the heart and lungs - Palpation of the abdomen 4. Selection of the necessary diagnostic methods - KLA, OAM - Tsitoskopiya nasal discharge - IFA - Virological 5. Relate the results and differential diagnosis with - Infectious Diseases - Oncology - Therapeutic 6. To come to a definite decision problems under SVP - Treatment if necessary - Emergency hospitalization - Emergency care Instructions for independent work analyze and solve practical situation Sheet analysis of the situation Stages of work Hints and tips 1. Introduction to • Reading, Do not try to analyze the the briefcase first read with a case 2. Introduction to again read the information, select the paragraphs that the given situation seemed important to you. Try to describe the situation. Determine that it is important and what is secondary. 3. Identification, formulation and justification of the key problems and subproblems Problem: The choice of tactics and determination of the need for hospitalization of patients with the syndrome exanthema in a hovercraft. 4. Diagnosis of the When analyzing the situation, answer the following situation analysis questions: • What is the range of common and dangerous diseases, accompanied with the syndrome exanthema? • What nosologies need to make a differential diagnosis and to determine the most likely cause of the syndrome exanthema. • What diagnostic methods must be applied, make a plan and justify the examination at SVP and CRH. • What additional advice specialists are needed for definitive diagnosis? • Determine the extent of the need for follow-up (medical and non-medical treatment)При анализе ситуации ответьте на следующие вопросы: 5. Selection and lists all the possible ways to solve this problem in a given justification of the situation ways and means of addressing 6. Development Diagnose, resolve the problem in a hovercraft and resolve the situation III. OPTION solution to a case Teachers - KEYSOLOGOM CASE IV - TECHNOLOGY TRAINING WORKSHOP Model 4.1 technology training Subject measles, rubella, scarlet fever Number of hours - 2 hours Number of students: 20-24 people Form training session workshop to broaden and deepen knowledge, skills working out tactics of patients with measles, rubella, scarlet fever. Plan Seminar 1. Introduction to training session 2. Updating knowledge 3. Work with a case in mini - groups 4. Presentation of the results 5. Discussion, evaluation and selection of the best options strategies 6. Conclusion. Evaluation of groups and students, the degree of achievement of lesson The purpose of the lesson: to develop skills early and differential diagnosis of measles, scarlet fever and rubella in children and adults with the history and clinical and laboratory examination. Define rational therapeutic tactics and preventive measures in the hearth. Develop a sense of interest in the problem of measles, rubella, scarlet fever, a sense of responsibility for the lives of patients with measles, rubella, scarlet fever. Develop scientific, logical thinking at the bedside, creative approach to the diagnosis and treatment of patients with measles, rubella, scarlet fever. develop skills early and differential diagnosis of measles, scarlet fever and rubella in children and adults with the history and clinical and laboratory examination. Define rational therapeutic tactics and preventive measures in the hearth. Develop a sense of interest in the problem of measles, rubella, scarlet fever, a sense of responsibility for the lives of patients with measles, rubella, scarlet fever. Develop scientific, logical thinking at the bedside, creative approach to the diagnosis and treatment of patients with measles, rubella, scarlet fever. The task of the teacher: • consolidate and deepen knowledge assessment and analysis of the situation and the general condition of patients with measles, scarlet fever, rubella • develop the ability to select the correct action of the algorithm for diagnosis. • Develop skills for emergency assistance • Develop the skills of independent decision making in the management of patients with measles, scarlet fever, rubella under SVP learning outcomes: • assess and analyze the situation and the general condition of patients with measles, scarlet fever, rubella • choose the sequence of actions for diagnosis. • develop the skills of independent decision making in the management of patients with measles, scarlet fever, rubella under SVP • develop an algorithm of actions for emergency assistance if necessary Methods of teaching case studies, discussion, hands-on method Learning Tools Case, guidelines Individual form of training, front, group work Terms of training audience with technical equipment adapted to work in groups Monitoring and Evaluation Monitoring, blitz poll, presentation, evaluation Flow chart of the training session, based on the case. Stage and content of work activities Student teacher Explains the purpose of the preparatory stage of case - stage and its influence on the development of professional knowledge. Distributes the materials of the case and introduces the algorithm analysis of the situation (see. Guidelines for students). Gives the task independently analyze and record the results in the "Leaf situation analysis Listen Independently examine the contents of the case and fill the sheet individually analyzing the situation. I stage. Introduction to the training session (10-15 min) 1.1. Called theme sessions, plan, its goals, objectives and planned learning outcomes. 1.2. Introduces the operation mode of the lesson and the results of the evaluation criteria (see. Instructions for students) Listen Are the corresponding entries IIetap main 2.1 60 min. Substantiates the statement of the problem and the choice situation relevance. Conducting a quiz in order to strengthen students' knowledge on the subject (Annex №1): • List the types of elements exanthema. • What infectious disease is a syndrome exanthema? • What complications are possible with delayed diagnosis measles, scarlet fever, rubella? • What is the difference scarlet rash of measles 2.2. Divides the students into groups. Reminiscent of the content and objectives of the case. Introduces (reminds) the rules of group work and discussion rules. 2.3. Gives the task, specify the correct perception of the job (Appendix №2): • Differential diagnosis and determination of the most likely causes measles and rubella, scarlet fever • Methods of diagnosis used under SVP • Clinical management, treatment and monitoring of patients with measles, rubella, scarlet fever 2.4. Coordinates, advises, directs training activities. Evaluates the results of individual work: Sheets analysis of the situation. 2.5. Organizes presentations on the results of the work done by the decision of the case, discussion. The organizer of the discussion: asking questions, remarks, reminds theoretical material 2.6. Organizer - GP algorithm of actions in a given situation (Appendix №3) 2.7. Informs his solution of the case (Appendix №4) Answer questions, discuss, ask clarifying questions. Divided into groups Discuss, conduct a joint analysis of individual problems, determine the most important aspects of the situation, main problems and their solutions, process solutions results Are solutions to the problem Questions 10-15 minutes after the end of the presentation, choose the best option Develop a single system, the discussion III Summary of lessons, analysis and evaluation 3.1 20 min. Summarizes the results of training activities, announces assess individual with teamwork. Analyzes and evaluates the group, said positive and negative points. 3.2. Stresses the importance of case - stage and its influence on the development of future specialist to listen. Can conduct self-esteem and vzaimootsenku Express their opinions Appendix №1 Measles (morbilli) - an acute infectious disease of viral etiology transmitted by droplet infection, characterized by cyclical trends, intoxication syndrome, catarrh and exanthema. Etiology. Measles virus - Rolyinosa morbiliorum refers to a group of large miksovirusov is a single-stranded RNA, has a complex antigenic structure and has a contagious, complement-fixing, and hemagglutinating hemolysing properties. The virus has a stable antigenic structure in response to antigens in the body (or ill-vaccinated) produced by the corresponding antibodies, which may be identified by serologic reactions. Measles is unstable in the environment, sensitive to heat, UV and direct sunlight. Resistant to antibiotics. The virus has a tropism for lymphoid, reticuloendothelial tissues, epithelial cells of the respiratory tract and nervous system. Epidemiology. Measles is a very common infection throughout the world. Susceptibility to the bark almost absolute index of contagiousness is 0.96. Because of the high infectiousness and susceptibility general almost all people suffer measles in early childhood. The source of infection is the patient at the end of the incubation period, all the prodromal period and the first period of 3 days of the rash. The disease is transmitted by airborne droplets when in direct contact with the patient. Tiny droplets of mucus secreted sick when talking, coughing, sneezing, contain a large number of measles virus, which is scattered by air. Since the virus is spread by air currents in adjacent rooms through the keyhole, open doors, windows, ventilation pipes. Therefore, all susceptible to measles, located in one indoors with the patient may be infected. Autumn-winter, but you can get sick at any time of the year. Is transmitted from mother to child immunity in the event that the mother had been ill with measles or been vaccinated, the child is breastfed. In this case, children under 6 months of age do not get sick with measles. After the disease produced proof lifelong immunity. Repeated cases are extremely rare. Pathogenesis. Measles is a common generalized process with the electoral defeat of the central nervous system, respiratory system. Atrium nasopharyngeal mucosa and upper respiratory tract and possibly through the conjunctiva of the eye. Pathogenesis measles process comprises 5 phases: Phase 1 - infection and virus adaptation to lymphoid tissue, its propagation in the regional lymph nodes. 2-phase - the virus in the blood (primary viremia) and generalized lesions lymphocytic system: the virus spreads to all organs and systems, introduced in the lymphoid tissue and retikulogistiotsitarnye breeds in them, which leads to the formation of giant multinucleated cells. In this phase, the same occurs with the accumulation of immunological rearrangement of T and B lymphocytes, plasma cells and the production of measles-specific antibodies. 3phase - secondary viremia and allergic reactions: under the influence of specific antibodies and immune cells occurs cytolysis virus-containing cells. Freed the virus is introduced into nearby epithelial cells, affects them again. 4th phase - in the body parallel to develop allergic processes due to the protein components of the virus, and histamine gistaminpodobnyh substances that lead to sensitization of tissue. This dramatically damaged vessel walls, increasing their permeability, edema and exudation, especially expressed in the tissues of the upper respiratory tract, which leads to necrotic catarrhal inflammation of the mucous membranes of the oropharynx and upper respiratory tract. Each element of the rash - is the focus of inflammation around the vessel, alopecia-infiltrative character. As a result of the spread of the rash on the Malpighian and granular layer of the skin lesions occur degradation, which leads to the appearance of flaking in place of abundant precipitation. Bielsko-spots Filatova-Koplik - a superficial necrosis of the epithelium of the oral mucosa. Stages rashes associated with measles virus with the highest concentration at the gate of the infection, with the abundance of blood vessels in this area, which causes a rash on the first face, mucous membranes of the mouth, then the trunk and then the limbs. In the period rashes virus affects the nervous, endocrine system, which is manifested increase of intoxication. Functional disorders of the nervous system, in turn, contributes to the function of the adrenal glands release a large amount of blood SCS has immunosuppressive effects (measles anergy). 5th phase - the formation of a strong immunity - in the blood increases the concentration of specific antibodies and the virus is neutralized. Pathogenesis vaccination process. When vaccination of live measles vaccine virus enters the body parenterally and multiplies in lymphoid tissue, but not in the airway epithelium. Immunity depends on the initial state of the immunological reactivity of the organism, and the dose of vaccine quality, proper storage. Post-vaccination measles continue to experience mild catarrhal symptoms, absence of pulmonary lesions and nervous systems, less pronounced changes in the immune cells without the development of measles anergy. Patients with measles vaccinations free of infection. Clinic. The clinical picture of measles are 4 period of illness. The incubation period of 8-10 days, children immunized or measles immunoglobulin can be prolonged to 21 days. Catarrhal period lasts 3-4 days may be prolonged up to 5-7 days. Period rash lasts 3-4 days. Pigmentation period lasts 1-2 weeks. The clinical picture of measles supporting and leading are the following syndromes: the severity of catarrhal symptoms; the nature of the temperature curve; the severity of intoxication; Characteristic makulo-papular rash. Features catarrhal period of measles are - acute onset disease characterized by an increase in temperature to 38 ° C, and the advent of catarrhal symptoms of conjunctivitis, which progresses, nasal discharge abundant mucous, mucopurulent. Patient becomes husky voice, joins cough - dry haunting, sometimes early in the disease may occur syndrome of croup. Marked photophobia, lacrimation, conjunctival hyperemia, eyelid edema, injection of vascular sclera. Looseness of the oral mucosa, gums. Spots appear Bielsko-Koplik Filatov - on the buccal mucosa opposite the molars grayish-white dots, surrounded by flushing rim. On the soft and hard palate appears measles enanthema - small pinkish-red spots. Period rash starts with 4-5 days of illness and is characterized by the appearance of maculopapular rash. The first elements of the rash appear behind the ears, on the back of the nose, on the forehead in the form of small pinkish spots that grow very quickly, merge with each other, have an irregular shape. 2-day rash completely covers the entire body and upper arms, 3-day, the rash spreads to the arms and legs konechnosti-. Stages rash - a characteristic feature of measles. In the period of high precipitation temperature to 39-40 ° C, catarrhal symptoms worsen. The general condition of patients with severe, marked anxiety, delirium, drowsiness, may be nosebleeds. Characteristic appearance of the patient - the person puffy, pasty eyelids, nose and lips swollen, red eyes, profuse discharge from the nose. Period rash lasts 3-4 days, and then the disease goes into the next period - the period of pigmentation accounts for 6-7-day illness. During this period, measles rash starts to get dark, Buret, takes brown. Pigmentation begins in the same manner as a rash. In the field of continuous eruption may be defurfuration. Politically temperature decreases to normal values. Catarrhal symptoms diminish and disappear. Overall condition is slowly recovering. In the period of pigmentation for a long time is the state of fatigue and anergy. Clinical classification of measles: 1. The typical form: By gravity is divided into: a) light; b) moderate and c) heavy. 2. Atypical forms: a) worn (abortive); b) mitigirovannaya measles; c) hypertoxic; g) hemorrhagic (very rare). Features mitigirovannoy measles. This form of measles can occur in receiving immunoglobulin, blood products, or vaccinated. It is characterized by lengthening the incubation period to 21 days, shortening catarrhal period up to 1 day with mild catarrhal symptoms, lack enantemy and stains Bielsko-Filatov. Rashes period is shortened to 1-2 days, the rash is soft, fine in violation of phasing rashes. Pigmentation short, pale. Features abortive measles. Process, beginning as it typically breaks after 1-2 days from the appearance of the rash. The rash is small, the slim, only appears on the face and trunk, and limbs are free from rashes. Pale pigmentation, short-term (13 days). Body temperature can be increased only 1 day of the rash. Features of measles in adults. Has a high specific gravity. Proceeds with a predominance of severe and moderate forms of the disease. Severe intoxication (fever, headaches, dizziness, fainting, vomiting, nosebleeds, loss of consciousness). Expressed cough, conjunctivitis. Rashes period extended up to 4-5 days, the rash is large, bright and plentiful. Complications are rare. Mild form of measles: show moderate or mild catarrhal symptoms and intoxication, the patient's condition is satisfactory, the body temperature is not higher than 38,5 ° C. The rash can be patchy, with a weak trend towards mergers and pale pigmentation. Moderate form of measles. Intoxication sufficiently pronounced, the patient feel much disturbed, may be delirium, vomiting, body temperature rises to 39 ° C. Rash abundant, bright, makulo-papular unchanged background on skin prone to merge. Severe measles. Characterized by pronounced symptoms of intoxication, in the form of seizures, loss of consciousness, repeated vomiting, fever up to 40 ° C and above. Rash abundant, with hemorrhagic bluish tint, the drain. Pronounced catarrhal symptoms: face puffy, pasty eyelids, purulent conjunctivitis phenomenon, rhinitis, cough wet part. Frequent joining various suppurative complications. Diagnostics. Clinical and epidemiological methods. Hematologic data (leukopenia, neutropenia, lymphocytosis, ESR moderately increased). Cytological (tsitoskopiya nasal discharge for the detection of multinucleated giant cells characteristic of measles). Virological method - virus detection by immunofluorescence. Serological - TPHA, HI (detection of measles-specific antibodies by paired sera). Linked immunosorbent assay (ELISA) detection of antibodies to measles virus class IgM, IgG. The differential diagnosis. In catarrhal period - with ARI - acute onset, expressed catarrhal symptoms: tearing, photophobia, rhinitis, injections of vascular sclera, looseness of the oral mucosa, stains Belskogo- Filatov enanthema In the period of rashes with rubella - a one-time appearance of the rash, the rash is small, no pigmentation, increased neck and zadnesheynyh limfauzlov, mild intoxication and catarrhal syndrome. With pseudotuberculosis - no phasing rash, catarrhal syndrome, inflammatory changes of the oral mucosa, polymorphism symptoms. With scarlet fever - lack of catarrhal syndrome, the presence of punctate rash on hyperemic skin background with concentration in places of natural folds, sore throat, "crimson language", peeling skin, blood - leukocytosis. With meningokokktsemiey - rapid onset, hyperthermia, severe headache, vomiting, rash appears immediately on the whole body with hemorrhagic tint increases in their eyes, is localized on the buttocks and lower extremities. With allergic exanthema - do not have the inherent characteristic symptoms of measles bizarre itchy skin. Treatment. Bed rest for the entire febrile period. Caring for patients with measles: body hygiene, face, hands; toilet mouth, nose and eyes. Nutrition - lactovegetarian diet, drinking plenty of fluids. Symptomatic therapy. Antibiotics for the prevention and treatment of complications. Vitamin therapy. Indications for hospitalization: heavy and complicated forms, children up to 2 years, epidem. situation. Prevention. Active immunization of live measles vaccine (ZHKV L-16, Ruvaks, MMR (measles, rubella, mumps). The vaccination - 9 months and 16 months. Passive immunization - measles donor immunoglobulin is administered 3-5 days of contact. General control measures - isolation of patients to 5 days from the date of rash, if complications up to 10 days. Ventilate the room for 30-45 minutes. Kvartsevanie premises. Scarlet fever - an acute infectious disease characterized by general intoxication, sore throat and rash. Pathogen B-hemolytic streptococcus. The source of infection - the patient streptococcal infection. Modes of transmission - airborne, contact-household through the third person, the wound surface, nutritional. Infectious period - just not installed. Index contagious - 40%. Immunity - antitoxic resistant. Pathogenesis. 1. Causes of inflammation at the front gate of infection (sore throat). 2. The toxin enters the bloodstream and has a tropism for the central nervous system, autonomic nervous system, CCC (high fever, rash, general intoxication). Infectious allergy - (the body's sensitivity to the protein components of the microbe and its giperergicheskom reaction). Septic manifestations (suppurative processes in the pharynx, nasopharynx, paranasal sinuses, etc). Clinic. The incubation period - 2-7 days. The disease begins acutely with high fever, vomiting, sore throat. A few hours later a rash appears on the body. Punctulate hyperemic rash on the skin background with concentration in the natural folds, which disappears in 3-5 days of illness, free from rashes nasolabial triangle - a symptom Filatov. In the throat - a sore throat from bluetongue to necrotic, bright red delimited hyperemia. Increase in regional limfauzlov. Characteristic language - first illness covered with dense white bloom, 3-4 day of illness becomes a "raspberry" and lasts for 2 weeks. Cardiovascular changes in the form of "infection of the heart" are held for 2-4 weeks. In the blood - leukocytosis, neytrofillez, increased erythrocyte sedimentation rate. Clinical classification of scarlet fever: 1. The typical form, by gravity: a) light; b) Moderate; c) heavy. 2. Atypical forms: a) ekstrabukkalnaya; b) worn (scarlet fever without rash); c) hypertoxic; g) hemorrhagic. Complications: early and late. Rubella (Rubeola) - an acute infectious disease characterized by morbilliform rash, slight catarrhal symptoms from the TTP and increased peripheral limfauzlov. Pathogen - virus. The source of infection - the patient. Transmission - airborne route. High susceptibility of children - from 1 year to 7 years. Rubella is especially dangerous for pregnant women in the first 3 mes.t.k. can be a threat to congenital malformations. Infectious period - 2 weeks after illness. Immunity resistant. Virus penetrating through the VDP, enters the bloodstream, has tropism for lymphoid and fetal tissue. The incubation period is 15-24 days. The main symptom - a pink rash, papular, smaller measles. Catarrhal symptoms are mild, the general condition does not suffer Pathognomonic - increase zadnesheynyh and occipital limfauzlov. Appendix №2 Methodical instructions for students 2.1 Problem: The choice of tactics and determination of the need for hospitalization of patients with korb, rubella, scarlet fever in a hovercraft. 2.2. Subproblems 7. Analysis of appearance 8. Analysis of the history and pre-event is a causative factor in the development of measles, rubella, scarlet fever 9. Analysis of inspection 10. Selection of the necessary diagnostic methods 11. Relate findings and differential diagnosis 12. Come to a specific problem-solving in a hovercraft. 2.3. Algorithm for solving 2. Analysis of appearance includes the following research - Examination of the skin and visible mucous - The face (eyes, tongue) 2. Analysis of history - Borne diseases - Family and social history - Epidemiological. history - The duration and nature of the rash 3. Analysis inspection - Ps, BP - Auscultation of the heart and lungs - Palpation of the abdomen 4. Selection of the necessary diagnostic methods - KLA, OAM - Tsitoskopiya nasal discharge - IFA - Virological 5. Relate the results and differential diagnosis with - Infectious Diseases - Oncology - Therapeutic 6. To come to a definite decision problems under SVP - Treatment if necessary - Emergency hospitalization - Emergency care Appendix №3 Organiser (Venn Diagram) Measles (features) Similar signs Rubella (features) Appendix №4 Alternative solutions case study teacher - keysologom 1. On the basis of complaints of fever, cough, runny nose, sneezing, festering eyes, loss of appetite. At the 4-day disease rash on the face. 4 day history of the disease. Obstetric and early history without pathology. Works as a driver. By the nature of introvert. Allergies to drugs not. Epid.anamnez: In contact with infectious patients was not patient did not receive blood products, at a reception at the dentist was not. Inspection: The state of moderate severity, a clear conscience. Proper physique. In the observation noted landmark spread the rash. Rash was plentiful, drain, strongly disturbed "cut" in the eyes. Temperature remained high up to 7 days of illness. Expressed intoxication headache, vomiting, lethargy, weakness, insomnia. In the lungs, vesicular breathing. Cardiac sounds are muffled, HR 100 in 1 min. Furred tongue, we could see the small white spots on the mouth loosened congested (as semolina). Ms about the correct form, is involved in the act of breathing, with superficial and deep palpation painless, swollen belly. The liver is not increased. For other or¬ganam without pathology. Meningeal phenomena not. Jabs: Hb - 128 g / l, cs - 0.91, Ayr - 4,2hYu12 / l; Lake -3,6h109 / l; p / - 1%, with / I - 42%, e - 6%, n - 42%, m - 7%, ESR - 10 mm / hour. Survey data: the nasal discharge tsitoskopii revealed multinucleated giant cells. In enzyme immunoassay (ELISA) to detect antibodies measles virus class IgM. The diagnosis: Measles, moderate flow 2. Differential diagnosis of measles rubella is carried out, scarlet fever. 3. The general analysis of blood, urine (category 3.1); -Biohimicheskie Blood (category 3.1. +3.2); - Tsitoskopiya nasal discharge (Category 3.2) - ELISA (category 3.2); - Coprogram (Category 3.1) 4. Treatment: Bed rest for the entire febrile period. Caring for patients with measles: body hygiene, face, hands; toilet mouth, nose and eyes. Nutrition - lacto-vegetarian diet, drinking plenty of fluids. Symptomatic therapy. Antibiotics for the prevention and treatment of complications. Vitamin therapy. Indications for hospitalization: heavy and complicated forms, children up to 2 years.