METHODICAL INSTRUCTION FOR STUDENTS OF THE 5 COURSE
FOREIGN STUDENTS’ FACULTY
MODULE 1. Common questions of occupational diseases. Occupational diseases, caused by influence of industrial aerosols, physical and chemical factors.
Сontent module 4. Diseases with predominant affection of nervous systems and diseases caused by influence of occupational factors with allergic and carcinogenic action.
LESSON № 4 (PRACTICAL – 6 HOURS)
Theme 4. Occupational neurotoxicosis (intoxication by mercury, tetraethyllead, manganese). Intoxication by agriculture chemical poisonings
(chlororganic compounds, organophosphorus compounds, mercuric organic compounds, compounds which contain arsenic).
Aim: to develop skills and to acquire experience relevant to management of patients with occupational diseases, in particular those with intoxication by tetraethyllead, by manganese, and by mercury.
To study etiology, pathogenesis, clinical picture and stages of the intoxication, diagnostics, treatment and prophylaxis of intoxication by tetraethyllead, by manganese, and by mercury. To study etiology, pathogenesis, clinical picture and stages of the intoxication, diagnostics, treatment and prophylaxis of intoxication by chlorinated hydrocarbon. Examination of working capacity.
To develop skills and to acquire experience relevant to management of patients with occupational diseases, in particular those with intoxication by agriculture chemical poisonings.
To study toxicological characteristics of phosphorus organic and arsenic substances, chlorine organic and mercury organic substances that is used in agriculture. To study their etiology, pathogenesis, clinical picture, diagnostics, to make differential diagnostics and to prescribed treatment, to make examination of working capacity. To study the main principals of emergency treatment of acute professional intoxications in place of accident and in hospitals.
Professional orientation of students. Professional neurotoxicosis – it is chronic professional intoxications in the clinical picture of which are prevailed by neurological symptoms. Before their development bring poisoning over of mercury pair, by a tetraethyllead, manganese, chlorinated hydrocarbon.
Wide spread agriculture is connected with usage of pesticides and diseases of agricultural cultures. That’s why there are many peoples, who contacts with pesticides. Under certain consequences of their usage intoxication may appear, that why doctors should know about toxic properties of pesticides, their action on organism and be able to diagnose intoxications.
During last years with development of chemical industrials and using of chemical substances which has contain influence into the organism there are cases of acute and professional intoxications. That’s why doctors must know treatment of acute professional intoxications.
Methodology of Practical Class
Introduction by the teacher, control the initial level of knowledge – 09.00-09.30
Individual students’ work with patients – 09.30-12.00
Break – 12.00-12.30
Seminar (discussion of theoretical questions, practical work with patients) – 12.30-14.00
Break – 14.00-14.15
Individual work 1415-1500 (students who didn`t pass the tests in Moodle system, complete the individual work).
Algorithm of students’ communication with patients with pathology in subject (communication skills):
During examination of the patient students have to use such communicative algorithm:
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take complaints and anamnesis in a patient.
5. Explain to the patient results of his/her lab tests correctly and accessibly.
6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient, what examinations will be carried out and get his/her informed consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the examination.
7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).
8. Examination (demonstration of clinical skill).
9. Explain to the patient results of his/her lab tests correctly and accessibly.
10. Conversation accomplishment.
Estimation of laboratory and instrumental investigations
Informing about the results of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient results of his/her lab tests correctly and clearly.
5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).
Planning and prognosis the results of the conservative treatment
Friendly facial expression and smile.
1. Gentle tone of speech.
2. Greeting and introducing.
3. Correct and clear explanation of necessary treatment directions.
4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.
5. Conversation accomplishment.
Work 1. Work at the patient’s ward. The student collects the complaints, anamnesis of disease and life, perform objective examination of the patient, identify the main syndrome, formulate preliminary diagnosis and prescribe plan of investigations.
Work 2. The student estimates results of laboratory and instrumental investigations, makes a differential diagnosis and formulates the clinical diagnosis, based on the diagnostic criteria of the disease.
Work 3. The student prescribes appropriate treatment and defines individual management program for patient.
Individual Students Program
· Under the tutor’s supervision students should be able to elicit the patient’s chief complaint, history of present illness, past medical history, social, family, occupational histories and complete a review of systems.
· Perform a physical examination in a logical, organized and thorough manner.
· Demonstrate the ability to construct an assessment and plan for an individual patient organized by problem, discussing the likely diagnosis and plan of treatment.
· Demonstrate the ability to record the history and physical in a legible and logical manner.
· Demonstrate the ability to write daily progress notes on the ward and appropriate outpatient progress notes.
· Orally present a new patient’s case in a focused manner, chronologically developing the present illness, summarizing the pertinent positive and negative findings as well as the differential diagnosis and plans for further testing and treatment.
· Orally present a followup patient’s case, focusing on current problems, physical findings, and diagnostic and treatment plans.
· Diagnostic Decision Making
· Formulate a differential diagnosis based on the findings from the history and physical examination.
· Use the differential diagnosis to help guide diagnostic test ordering and its sequence.
· Participate in selecting the diagnostic studies with the greatest likelihood of useful results.
· Recognize that tests are limited and the impact of false positives/false negatives on information.
· Test Interpretation
· Describe the range of normal variation in the results of a complete blood count, blood smear, electrolyte panel, general chemistry panel, electrocardiogram, chest X-ray, urinalysis, pulmonary function tests, and body fluid cell counts.
· Describe the results of the above tests in terms of the related pathophysiology.
· Understand test sensitivity, test specificity, pre-test probability and predictive value.
· Understand the importance of personally reviewing X-ray films, blood smears, etc., to assess the accuracy and importance of the results.
· Therapeutic Decision Making
· Describe factors that frequently alter the effects of medications, including drug interactions and compliance problems.
· Formulate an initial therapeutic plan.
· Access and utilize, when appropriate, information resources to help develop an appropriate and timely therapeutic plan.
· Write prescriptions accurately.
· Monitor response to therapy.
Seminar discussion of theoretical issues
1. Pathogenesis of intoxication by tetraethyl lead, by manganese, by mercury.
2. Clinical picture and forms of intoxication by tetraethyl lead, by manganese, by mercury.
3. Diagnostics of intoxication by tetraethyl lead, by manganese, by mercury.
4. Treatment and prophylaxis of intoxication by tetraethyl lead, by manganese, by mercury.
5. Examination of working capacity.
6. Toxicological characteristics of chemical poisonings.
7. Classification of chemical poisonings.
8. Etiology and pathogenesis of intoxication by chlororganic compounds, organophosphorus compounds, mercuric organic compounds, compounds which contain arsenic.
9. Clinical picture and stages of intoxication by chlororganic compounds, organophosphorus compounds, mercuric organic compounds, compounds which contain arsenic.
10. Diagnostics.
11. Treatment of the patients with intoxication by chemical poisonings.
12. Prophylaxis of intoxication.
13. Examination of working capacity.
14. Methods of stopping entering into the organism toxic substances.
15. Methods of getting from the organism toxic substances.
16. Methods of antidote therapy.
17. Symptomatic therapy.
Test evaluation and situational tasks.
Choose the correct answer/statement:
Choose the correct answer/statement
1. What clinical syndrome prevails at the II stage of chronic intoxication by mercury?
A. Astenoneurotic
B. Toxic encephalopathy
C. Astenoorganic
D. Astenoneurotic and Astenoorganic
2. For which intoxications is characteristic syndrome of neutitis (erithism)?
A. Lead
B. Mercury
C. Tetraethillead
D. Pesticides
3. The most characteristic syndrome of intoxication by manganese is:
A. Mercury neuritis (erithism)
B. Parkinsonism
C. Toxic comma
D. Epilepsy syndrome
4. For which intoxication is characteristic extrapyramide syndrome?
A. Lead
B. Mercury
C. Manganese
D. Pesticides
A. I – st stage
B. II – nd stage
C. III – rd stage
6. Syndromes of vegetovessels distonia, encephalopathy, stomatitis, functional violations of heart system, dyskinesia of intestine meet at intoxication:
A. Lead
B. Mercury
C. Berilium
D. Manganese
7. What substance can cause the defeat of kidneys?
A. Lead
B. Connections of mercury
C. Manganese
D. Iron
8. Indicate the typical triad of symptoms of initial stage of chronic intoxication by tetraethyllead:
A. Tachycardia, hypertension, rise of tone of muscles
B. Hypotension, bradycardia, hypothermia
C. Tachycardia, hypertension, hypersalivation
D. Pain in epigastrium, nausea, vomits
E. Hypertension, hyperthermia, bronchorea
9. Which from the resulted medications are instrumental in getting out from organism mercury?
A. Cuprenil
B. Tetacin-calcium
C. Unitiol
D. Pentacin
E. Chromosmon
10. Which symptoms are most characteristic for acute intoxication of tetraethyllead?
A. Disturbance of sleep
B. Arterial hypertension
C. Hallucinations
D. Parestesias with feeling of presence “hair in a mouth”
11. At poisoning what metal the phenomena of Parkinsonism are?
A. Manganese
B. Mercury
C. Lead
D. By Iron
12. At the expressed stage of manganese intoxication applies:
A. Spasmolitics
B. Diuretics
C. Central holinolitics
D. Corticosteroids
13. What substance, that has high toxic, getting in an organism through a gastrointestinal tract, does not cause the signs of intoxication?
A. Manganese
B. Mercury
C. Chrom
D. Lead
14. Which substance causes most heavy affection of central nervous system that is accompanied by psyhosensoric disorders?
A. Phosphor
B. Sulphuric anhydride
C. Tetraethyllead
D. Arsenic
Real life situations to be solved
1. Patient, 46 years-old during 10 years worked on making of “high-quality electrolytes”. During a medical observation was found monotonous language, dizarthria, micrography, hipomimia, bradycinesia, tremor of extremities, slow step, hypersalivation, uncritical attitude toward the state. During physical observation from the side of internal organs there is not pathology. Put your previous diagnosis.
3. Mechanician, during 10 years had a contact with metallic mercury, which sometimes exceeded maximum permissible concentration in 3-4 times. Objectively: expressed asthenia, constant headache, stable disturbances of sleep, increased irritability, tendency to depression, touchiness, syndrome of erethism, expressed tremor of fingers, gingival hemorrhage. For what stage of chronic mercury intoxication these symtoms are characteristic?
4. Machine operator from mercury metallurgical plant, aged 38, with working experience of 13 years. After the data from sanitary-hygienic characteristics it was fixed mercury concentration in the air of working place is from 0,02 to 0,3 mg/m3 (maximal permissible concentration (MPC) is 0,01 mg/m3). After periodical medical checkup he was directed to the clinics of occupational diseases institute with complaints on headache, irritability, troubled sleep, rapid fatigability, heart-beating, hyperhidrosis, metallic taste in the mouth, numbness in the extremities. On objective examination: expressed emotional lability, general hyperhidrosis, stable red dermographism. BP 120/80 – 140/90 mm Hg, pulse rate 86 b.p.m. Tendon reflexes are expressed. Unsteadiness in Romberg’s posture, eyelids and fingers tremor. Intention tremor in finger-nose test. Signs of gingivitis. What laboratory investigations should be performed to prove the diagnosis.
5. Female, aged 42, laboratorian, working experience of 21 years. She has a contact with mercury. She complains of a headache, memory impairment, irritability, pathetic mood, decrease of earning capacity, sleep disturbances, fingers tremor. Objectively: uniform labile tendon reflexes by the functional type, tremor of fingers, asymmetric read dermographism. Put the diagnosis.
6. Patient of 36 years old, entered into the hospital with complaints for acute weakness, dizziness, headache, nausea, vomit, stomach-ache. Two hours before to it he worked on a vegetable garden, treated by karbofos. Objectively: constricted pupils, hiperhidrosis of skin, bronchorea, bradycardia, fibrilation of separate muscles, BP- 160/80 mm of Hg. Stridor breathing, and many moist rales. Put the diagnosis.
7. Patient of 28 years’ old treated fruit-trees and corn by pesticides. During 2 months felt healthy. Before haven’t any diseases. He does not smoking. Later him began to disturb sharp pain in eyes, pain in throat, appeared rhinitis with transparent liquid, sneeze. Later appeared dry cough with periodically hard breathing, headache, dizziness, fatigueability is enhanceable. Objectively: hyperemia of eyes and nose of mucosa, in lungs dry rales. Hiperhidrosis, light tremor of fingers of hands, pain of nerve trunk. By what insecticides chronic intoxication take place in this case?
8. Patient R., 37 years old, complains of a rapid weakness, dizziness, nausea, vomiting, sweetish taste in mouth, feeling of fear, shaking and painful cramps. Patient also had signs of burning in the eyes, tearing, cold sneezing, edema of mucous membranes of nose, cough sometimes with hemoptysis. Which form of arsenic poisoning is present in patient?
9. Worker from a chemicals warehouse performed the pesticides unloading. It was appearing a headache, hypersalivation, lacrimation, dyspnea after several hours since start of working. Objective examination: general state is of moderate severity. The patient is excited. Skin is wet. Miotic pupils. Convulsions in separate face muscles. Hard breathing, dry and sonorous big-bubbling moist rales. Respiration rate– 26 /min. Heart tones are muted, rhythmic. Pulse – 100 b.p.m., of weak filling. Arterial blood pressure – 120/70 mm Hg. Make a provisional diagnosis
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions (the instructor has tests & situational tasks)
Students should know:
1. Relevant terminology, definitions and classifications of intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
2. Chief complaints of patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
3. Evaluation of basic signs and symptoms of intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
4. Methods of physical examination of patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
5. Methods of laboratory evaluation of patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
6. Methods of instrumental evaluation of patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
7. Principles of management patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
8. Relevant terminology, definitions and classifications of intoxication by agriculture chemical poisonings.
9. Chief complaints of patients with intoxication by agriculture chemical poisonings.
10. Evaluation of basic signs and symptoms of intoxication by agriculture chemical poisonings.
11. Methods of physical examination of patients with intoxication by agriculture chemical poisonings.
12. Methods of laboratory evaluation of patients with intoxication by agriculture chemical poisonings.
13. Methods of instrumental evaluation of patients with intoxication by agriculture chemical poisonings.
14. Principles of management patients with intoxication by agriculture chemical poisonings.
15. Methods of stopping entering into the organism toxic substances.
16. Methods of getting from the organism toxic substances.
17. Methods of antidote therapy.
18. Symptomatic therapy.
Students should be able to:
1. To study professional route of the patient with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
2. To make the examination of working capacity of patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
3. To make on objective examination and laboratory and instrumental examination of the patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
4. To make differential diagnosis of intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
5. Prescribe the treatment to patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
6. Examination of working capacity of patients with intoxication by tetraethyllead, by manganese, by mercury and chlorinated hydrocarbon.
7. To study professional route of the patient with intoxication by agriculture chemical poisonings.
8. To make the examination of working capacity of patients with intoxication agriculture chemical poisonings.
9. To make on objective examination and laboratory and instrumental examination of the patients with intoxication by agriculture chemical poisonings.
10. To make differential diagnosis of intoxication by agriculture chemical poisonings.
11. Prescribe the treatment to patients with intoxication by agriculture chemical poisonings.
12. Examination of working capacity of patients with intoxication by agriculture chemical poisonings.
Correct answers of test evaluations and situational tasks:
Multiple Choice. 1 – C; 2 – B; 3 – B; 4 – C; 5 – C; 6 – B; 7 – A, B; 8 – B; 9 – A, B; 10 – A, C, D; 11 – A; 12 – C; 13 – B; 14 –C.
Real life situations. 1 – Chronic intoxication by manganese; 2 – Chronic intoxication by tetraethyllead of the first stage; 3 – Second (moderate) stage of chronic mercurialism; 4. Reveal the content of mercury in daily urine; 5 – Chronic mercury intoxication, light form; 6 – Poisoning by phosphorus organic connections of middle degree of severity; 7 – Chlorine organic; 8 – Catarrhal form; 9 – Acute intoxication by phosphororganic chemicals.
References:
A – Basic:
1. Davidson’s Principles and practice of medicine (21st revised ed.) / by Colledge N.R., Walker B.R., and Ralston S.H., eds. – Churchill Livingstone, 2010. – 1376 p.
2.
3. The Merck Manual of Diagnosis and TherapyRobert S. Porter., 19th Revised edition. –
4. Web -sites:
a. www.tdmu.edu.ua: Occupational neurotoxicosis (intoxication by mercury, tetraethyllead, manganese).
b. http://emedicine.medscape.com/
c. http://meded.ucsd.edu/clinicalmed/introduction.htm
B – Additional:
5.
6. Lecture “Neurotoxicosis”
Methodical instruction has been worked out by: assist. prof. L. M. Migenko
Methodical instruction was discussed and adopted at the Department sitting
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