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Module 2

June 8, 2024

METHODICAL INSTRUCTION FOR STUDENTS OF THE 6th COURSE

Foreign Medical Faculty

LESSON No 1 (PRACTICAL – 6 hours)

Theme 15. Differential diagnosis of infectious diseases with exanthema syndrome

Aim: to learn to identify different clinical variants and complications, the tactics of the patient treatment, medical documentation writing, to examine a sick child, and interpret the results, perform the differential diagnosis and set a preliminary, clinical diagnosis, to provide emergency assistance during emergency situations in children with the most common infectious diseases with the exanthema syndrome, childhood respiratory infections.

Professional orientation of students:

Theme 15.

Exanthema – a rash on the skin that occur in many infectious diseases. There is a rash, which is characteristic only for a particular infectious disease. In other infectious diseases, the nature and severity of exanthema can be varied. They differ in the nature of the rash elements, localization, time of appearance, phasing, dynamics of some elements. The diagnostic process is important to study and diseases identification that occur with exanthema.

Methodology of Practical Class

9.00-12.00

Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):

Theme 15. Differential diagnosis of infectious diseases with exanthema syndrome

Work 1. To ask complaints, disease history, and epidemiological history, examine the child

Complaints and anamnesis taking iewborns and infants

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing.
Tactful and calm conversation with the parents of sick child.
Explanation of future steps concerning the child (hospitalization, some methods of examination, etc)

Complaints and anamnesis taking in toddlers and preschoolers (children aged from 1 to 6 years)

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing.
By means of game playing find a contact with a child.
Tactful and calm conversation with the parents of sick child.
Explanation of future steps concerning the child (hospitalization, some methods of examination, etc)

Complaints and anamnesis taking in school age children

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing.
Tactful and calm conversation with sick child his/her parents
Explanation of further steps to child and his/her parents (hospitalization, some methods of examination, etc.)

1. To ask complaints:

· fever, chills, weakness, head ache, insomnia, muscular, joint pains,

· nasal congestion, pain in a throat at swallowing,

· purulent exudates from ocular slots, photophobia.

· dry barking or moist cough, hoarseness of the voice, dyspnea,

· poor appetite, stomach-ache, nausea, vomiting, diarrhea, constipation,

· rashes on a skin,

· jaundice of skin, mucus membranes, dark coloring of urine, brightens of excrements.

2. To ask disease history, epidemiological history:

· an acute beginning of the disease from catarrhal, fever, toxic syndrome, sore throat, abdominal, dyspeptic syndromes;

· rashes, jaundice, arthralgia appear later; the day, when they appear,

in 11-21 days before the disease contact with a patient who had the same disease;

· Contact with a patient with streptococcal infection within 7 days.

Alike signs in surrounders, which also used those products.

· Use of products which were not cooked, from vegetable stores 3-18 days prior to the disease beginning (in case of pseudotuberculosis).

· absence of the vaccination by MMR-vaccine.

· Conversation accomplishment

3. Clinical examination of the child:

Clinical methods of examination of newborns and infants

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing.
Explain to the parents what examination should be performed and obtain there informed consent.
Prepare for examination(clean and warm hands, warm phonendoscope, etc)

Clinical methods of examination of toddlers and preschoolers

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing.
Explain to the parents what examination should be performed and obtain there informed consent.
Find a contact with a child; try to gain his/her confidence.
Prepare for examination(clean and warm hands, warm phonendoscope, etc)

Clinical methods of examination of school age children

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing.
Explain to the parents what examination should be performed and obtain there informed consent.
Find a contact with a child; try to gain his/her confidence.
Prepare for examination (clean and warm hands, warm phonendoscope, use the screen if necessary etc.)

Inspection:

hyperemia of the face, conjunctiva, injection of sclera’s vessels, purulent exudates from ocular slots.
Rashes on the skin (spots, papules, petechia, vesicles, pustules, crusts), their localization, color, color of the surrounding skin. Hyperemia of the oral mucosa, Koplick’s spots. Rashes on the mucus membranes (spots, papules, vesicles, pustules, erosions). Hyperemia and exanthema on palatal arch, back pharyngeal wall, graininess of back pharyngeal wall. Great mucus and purulent nasal discharge.

· pin-point, maculous, papulous rash (on a red base of the skin, intensified in folds, around the joints, on the lateral surfaces of neck, trunk, lumbar region, lower part of abdomen), description of dermographism;

· a skin is pale, yellow, rough, hyperemia of the face, or pallor of perioral triangle, hands, feet; later – desquamation on them.

· changes in the throat (hyperemia of the throat marked off a hard palate, pin-point enanthema, hypertrophied tonsils, tonsillitis: catarrhal, follicle, lacunar, necrotizing, hyperemia of the back pharyngeal wall);

· a tongue is coated, “strawberry”.

· Edema, redness around the joints

B. Palpation:

enlarged anterior and posterior cervical, occipital, submandibular, supra- and subclavicular, axillar, inguinal lymph nodes.

· tenderness at abdomen palpation in a right inguinal area, grumbling of the intestine, hepatomegaly, splenomegaly.

C. Percussion: bandbox sound, dullness, dilation of the cardiac dullness, dullness of the lung sound.

D. Auscultation: harsh breathing, weak breathing, dry dissipated wheezes, moist rales, crepitating, tachypnoe, tachycardia, arrhythmia, dullness of the heart tones, systolic murmur on the heart apex.

Conversation accomplishment

Informing about the results of examination

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing
Explain to a child and his/her parents what examinations should be performed and obtain their informed consent
Involve adolescent and his/her relatives in to the conversation (compare present examination results with previous ones, clarify weather your expectations are clear for them or not)
Conversation accomplishment.

4. Laboratory examination:

· Complete blood analysis: leucopenia, lymphocytosis, the ESR acceleration (in viral infections); eosynophilia, leucocytosis, neuthrophilia with a shift to the left, the increased ESR (in bacterial infections).

· Urinalysis: proteinuria, leucocyturia, erythrocyturia, casts, bacteriuria, urobilinuria, bilirubinuria.

· Biochemical blood test: increase of the CRP level, dysproteinemia, increased direct bilirubin, ALAT, ASAT, increased tymol test.

· Bacterial culture: Y.pseudotuberculosis selection from the feces, urea, blood, pharyngeal mucus.

· Virology: selection of virus from the nasopharyngeal smears, IF test, PCR.

· Serology: PHAR, SHAR, AR, IHAR, CBR with specific diagnostic test systems, growth of antibodies title in the dynamics.

· Explaining the results of examination to child’s parents.

· Conversation accomplishment

Work 2

1. Make diagnose due to clinical and laboratory data.

2. Make treatment

Planning and prediction of conservative treatment results

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing
Explain to child s parents the necessity of further treatment directions correctly and accessibly.
Discuss with parents and their child the peculiarities of drug intake, duration of usage,
Side effects and find out weather they understand your explanations
Conversation accomplishment

To prescribe treatment: regime, diet, antibiotics in case of bacterial infection, bacterial complication, antihistamines, detoxication, corticosteroids (in severe cases), NSAIDs, and symptomatic treatment.

Informing about treatment prognosis

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing
Correct and clear explanation of expected results of treatment.
Discuss with the parents and their child the importance of continuous treatment, following the treatment scheme; make sure that your explanations are properly understood.
Conversation accomplishment

Work 2

3. Make diagnose due to clinical and laboratory data.

4. Make treatment

1. To substantiate the diagnosis.

Planning and prediction of conservative treatment results

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing
Explain to child s parents the necessity of further treatment directions correctly and accessibly.
Discuss with parents and their child the peculiarities of drug intake, duration of usage,
Side effects and find out weather they understand your explanations
Conversation accomplishment

2. To prescribe the treatment: regime, diet, antidiphtheric serum, antibiotics, antihistamines, detoxication, corticosteroids (in sever cases), and complications’ therapy.

Informing about treatment prognosis

Friendly facial expression and smile.
Gentle tone of speech
Greeting and introducing
Correct and clear explanation of expected results of treatment.
Discuss with the parents and their child the importance of continuous treatment, following the treatment scheme; make sure that your explanations are properly understood.
Conversation accomplishment

Individual Students Program.

Theme 15. Differential diagnosis of infectious diseases with exanthema syndrome

1. Leading clinical symptoms and variants of infections with exanthema syndrome (measles, rubella, chicken pox, scarlet fever, pseudotuberculosis).

2. Differential diagnosis of exanthema syndrome in various infectious and noninfectious diseases.

3. Tactics of patients treatment, the organization of anti-epidemic measures in the focus of the exanthema infection.

Seminar discussion of theoretical issues (12.30-14.00).

Test evaluation and situational tasks (14¹⁵ – 15⁰⁰).

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)

TASKS (REAL SITUATIONS) EXAMPLES

Theme 15. Differential diagnosis of infectious diseases with exanthema syndrome

1. The child, 5 years old, has measles for 10 days. He complains of increasing of the body temperature to 39 ºС, general weakness, and periodic moist cough with discharge of the mucous phlegm. Objectively: the general condition is moderate; skin is pale with pigmented rashes. In lower parts of lungs – dull sound, small moist rales.

1. Put the correct clinical diagnosis.

2. Account the dose of cefazoline to this child.

2. The Physician is called to the boy, 5 years old. Patient is ill during 4 days: increased the temperature to 38.2º С, rash has appeared on skin since the first day of the disease. During examination is noted polymorphic rash (the papules, vesicles, crusts) on the whole body, there are several vesicles with purulent contents and hyperemia around them. He visits kindergarten.

1. Put clinical diagnosis.

2. What is the duration of quarantine in a group?

3. A mother has addressed to physician with the girl, 5 years old. The mother complains of raised temperature in child and multiple vomiting. The disease has begun suddenly. During examination: dry lips, sclera injection, hyperemia of the pharynx, the tongue is covered by white stratification, small point-like rash oeck, upper part of the trunk, in skin folds. The pulse is small, heart tones are deaf.

1. What form of the scarlet fever has this child?

2. What clinical signs will prove this diagnosis?

4. To pediatrician has addressed a girl, 12 years old, who had increased body temperature to 38.2-39.4 ºC during 8 days. In 5 days from the disease beginning rashes had appeared around knees and feet, and lower part of the abdomen, in skin folds. It looks like red spots and papules. Mild jaundice of the skin had appeared.

Name the diagnosis.
What investigation will prove the diagnosis, name its’ title?

Theme 15. Differential diagnosis of infectious diseases with exanthema syndrome

Student should know:

1. Leading clinical symptoms and variants of infections with exanthema syndrome (measles, rubella, chicken pox, scarlet fever, pseudotuberculosis).

2. Differential diagnosis of exanthema syndrome in various infectious and noninfectious diseases.

3. Tactics of patients treatment, the organization of anti-epidemic measures in the focus of the exanthema infection.

Student should be able to:

1. To identify the different clinical variants and complications of the most common infectious diseases with exanthema syndrome.

2. To identify the treatment tactics of the patient with the most common infectious diseases with exanthema syndrome.

3. To demonstrate the ability of medical documentation writing in children suffering from infectious diseases with exanthema.

4. To plan a survey of a sick child and interpret the obtained results in the most common infectious diseases with exanthema syndrome.

5. To perform a differential diagnosis and set a preliminary clinical diagnosis in the most common infectious diseases with exanthema.

Answers for the real situations:

Theme 15:

Real life situation 1:

1. Measles, typical form, moderate severity, pigmentation period. Complicated by the community acquired bilateral acute pneumonia.

2. Rp.: Cefazoline 1.0

D.t.d. N 20

S.: Dissolve the content of the flacon by 5 ml of 0.5% Novocain solution, I/M b.i.d. (2 times per day).

Real – life situation 2:

Chickenpox, typical form, moderate degree, complicated by pustules.
From 9^th till 21st day after the contact with ill boy.

Real life situation 3:

1. The severe toxic form.

2. Multiple vomiting. The pulse is small, heart tones are deaf.

Real-life situation 4:

Pseudotuberculosis, typical jaundice form, moderate degree.
Serological reactions (IHAR with specific erythrocyte test system), diagnostic title 1:200.

References:

1. Manual of children’s infectious diseases / O. Ye. Fedortsiv, I. L. Horishna, I. M. Horishniy. – TERNOPІL : UKRMEDKNYHA, 2010. – 382 p. – ISBN 978-966-673-145-9

2. Manual of Childhood Infections: The Blue Book (Oxford Specialist Handbooks in Paediatrics) by Mike Sharland, Andrew Cant and al. Published by Oxford University Press Inc., New York, 2011 , p. 881 ISBN: 978-019-957-358-5.

3. Illustrated Textbook of Paediatrics, 4th Edition. Published by Lissauer & Clayden, 2012, p. 552 ISBN: 978-072-343-566-2.

4. Nelson Textbook of Pediatrics, 19th Edition Kliegman, Behrman. Published by Jenson & Stanton, 2011, 2608. ISBN: 978-080-892-420-3.

5. Oxford Textbook of Medicine: Infection by David Warrell, Timothy M. Cox, John Firth and Mili Estee Torok , Published by Wiley-Blackwell, 2012