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Module 2

June 28, 2024

METHODICAL INSTRUCTION FOR STUDENTS OF THE 6th COURSE

Foreign Medical Faculty

LESSON No 4 (PRACTICAL – 6 hours)

Theme 19. Differential diagnosis of acute intestinal infections in children.

Theme 20. Emergency states in acute intestinal infections in children. Diagnostic and treatment

Aim: To learn to identify different clinical variants of the course, the tactics of the patient treatment, to demonstrate the ability to fill in medical documentation, to plan a survey and interpret the results at the sick child, the differential diagnosis and set a preliminary, clinical diagnosis of acute intestinal infections, and viral hepatitis in children of different age to provide emergency assistance in the acute intestinal infections with the dehydration syndrome and neurotoxicosis, acute liver failure caused by viral hepatitis.

Professional orientation of students:

Theme 19, 20.

The most common acute intestinal infections affect children, especially the first 2 years. Often they have these diseases complicated.

When toxicosis with dehydration (as nonspecific reaction in response to an infectious agent) develops, a metabolic-related dehydration and electrolyte losses are leading mechanisms. With an increase of toxicosis with dehydration the signs of circulatory failure, tissue hypoxia and metabolic acidosis, an infectious-toxic shock, multiple organ failure develop. The ability to correctly assess the state of the sick child, to establish the type and severity of dehydration allow time to appoint adequate therapy, which prevent the development of more severe complications.

Neurotoxicosis is a generalized nonspecific response to an infectious agent or the products of its life in the event of a mass entry of toxins into the blood with the development of endotoxemia. The possibility of neurotoxicosis with severe acute intestinal infections and clinical similarity to acute neuroinfections necessitates knowledge of the neurotoxicosis clinical picture by physicians of all specialties with a view to its differential diagnosis and proper medical tactics.

Methodology of Practical Class 9.00-12.00

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

Theme 1. Differential diagnosis of acute intestinal infections in children.

Theme 2. Emergency states in acute intestinal infections in children. Diagnostic and treatment

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, decreasing of appetite, anxiety, sickliness, cramps;

· nausea, vomits, diarrhea with or without pathological admixtures: greenish, mucus, blood, “rectal spit”;

· «sprinkling», colorless, watery diarrhea without pathological admixtures;

· abdominal pain, tenesms, false urge for defecation.

· Weight loss.

· fever, chills, weakness, head ache, insomnia, muscular, joint pains, nasal congestion, pain in a throat at swallowing, bad appetite, stomach-ache, nausea, diarrhea, constipation, rashes on a skin

2. To ask anamnesis of the disease, epidemiological anamnesis

· Acute beginning of the disease from the fever, toxic syndrome, pain, dyspepsia, joining and progress of dehydration, rashes, arthralgia appear later;

· Eating of the infected products, contact with a patient who had diarrhea 2-7 days prior to the disease beginning.

· Use of products which were not cooked, from vegetable stores 3-21 days prior to the disease beginning.

· There are alike signs in surroundings, which used same products.

· Treatment in somatic, surgical, infectious departments 5-10 days prior to the disease, where the cases of hospital intestinal infections are registered.

· Conversation accomplishment

3. To examine a patient:

Physical 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)

Physical 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)

Physical 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.)

A. Inspection:

· redness of the face, babies’ scream during defecation;

· a skin is dry, pale, sunken eyes, acute lines of the face; hyperemia of perianal area;

· dry and bright mucus membranes, coated tongue;

· metheorism, or sunken abdomen.

· gaping anus, prolapsed rectum.

· 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, hands, feet – ”gloves”, ”socks”, ”hood”- symptoms; later – desquamation on them.

· conjunctives hyperemia

· changes in the throat (hyperemia of the back pharyngeal wall);

· a tongue is coated, “strawberry”.

· Edema, redness around the joints

B. Palpation:

· lowering of skin elasticity, soft tissues turgor, sunken big fontanel, weight deficit;

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

· tender abdomen, spasm of sigmoid colon, grumbling of thin intestine, hepatomegaly, splenomegaly.

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

D. Auscultation:

· increased intestinal murmurs;

· tachycardia, arrhythmia, deafness of heart tones, systolic murmur on an apex.

· hard, weakened breathing, dry dissipated wheezes, moist rales, crepitating, tachypnoe

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. To estimate the results of additional researches

· Complete blood analysis: eosynophilia, leucocytosis, neutrophilia with a shift to the left, leucopenia, lymphocytosis, ESR acceleration.

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

· Biochemical blood test: increased, normal or decreased concentration of electrolytes, increased CRP level, dysproteinemia.

· Coprogram: inflammatory changes, intestinal enzymopathy.

· Fecal culture: E. coli, Salmonella, Shigella selection.

· Y.entrocolitica selection from the feces, urea, blood, pharyngeal mucus

· Serology: AR, IHAR, CBR with specific test system, growth of antibodies title in dynamics.

· Explaining the results of examination to child s parents.

· Virology: IEA (feces investigation) with specific test system, positive.

· Conversation accomplishment

Work 2

1. Make diagnose due to clinical and laboratory data.

2. 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, rehydration therapy, correction of electrolytes; antibiotics, bacterial facilities, enzymes, detoxication, multivitamins, symptomatic medicine.

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

1. Make diagnose due to clinical and laboratory data.

2. Make treatment

1. To substantiate the diagnosis.

Planning and prediction of conservative treatment results

2. Friendly facial expression and smile.

3. Gentle tone of speech

4. Greeting and introducing

5. Explain to child s parents the necessity of further treatment directions correctly and accessibly.

6. Discuss with parents and their child the peculiarities of drug intake, duration of usage,

7. Side effects and find out weather they understand your explanations

8. Conversation accomplishment

2. To prescribe the treatment:

Basic therapy: regime, diet, vitamins, choleretics (from the 3rd week of illness), oral detoxication; parenteral detoxication, corticosteroids, hepatoprotectors, protease inhibitors, heparin, diuretics, probiotics.

Intensification: enterosorption, interferon.

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

Seminar discussion of theoretical issues (12.30-14.00).

Individual Students Program.

Theme 19. Differential diagnosis of acute intestinal infections in children.

1. Leading clinical symptoms and syndromes of acute intestinal infections: local (gastritis, enteritis, colitis) and general (toxicosis, dehydration, neurotoxicosis, toxico-septic status).

2. Clinical variants of shigellosis, salmonellosis, colibacteriosis, intestinal yersiniosis, viral diarrhea in children of different age.

3. Differential diagnosis of acute intestinal infections among themselves and with diseases of the gastrointestinal tract of non-infectious origin.

4. Treatment of children suffering from acute intestinal infections (survey, indications for hospitalization, treatment).

5. Epidemiology at the focus of infection.

Theme 20. Emergency states in acute intestinal infections in children. Diagnostic and treatment

1. Leading clinical symptoms of toxicosis with dehydration and neurotoxicosis at acute intestinal infections in children.

2. The laboratory and instrumental data in the syndrome of toxicosis with dehydration and neurotoxicosis.

3. The general practitioner tactics in the emergency states diagnosis at acute intestinal infections in children, providing emergency care.

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 19. Differential diagnosis of acute intestinal infections in children.

Theme 20. Emergency states in acute intestinal infections in children. Diagnostic and treatment

1. In a child, 7 years old, who is ill for 3 days, dysentery reveals itself by often defecation to 20-25 times per day, skin is pale, dry, elasticity is reduced, the body temperature is 38.9 ºС, repeated vomiting, colicky pain are present.

1. Put the complete clinical diagnosis in this case.

2. When patient can be discharged from the department?

2. A boy, 8 months old, entered the infectious department. The disease had acute beginning. Now: doesn’t want to drink anything; repeated vomiting, body temperature is 35.5 ºC. Objectively: skin pallor, with “marble” paint, skin and mucus membranes are dry; large fontanel is lower than skull bones; cold extremities; tachycardia, tenderness of abdomen in the left inguinal region. Feces are in a large amount, looks like mud, with mucus. In entrance room he became unconscious, tonic-clonic seizures has appeared. Body weight is 8 kg.

1. What type of dehydration has developed?

2. Account a daily amount of fluids to this child for the 1^st stage of rehydration. How many saline and water fluids must be given?

3. A boy 5 years old: appetite is absent; complaints on abdominal pain. During examination: malaise, skin is pallor, tongue is dry. Tachycardia – 130 per minute. Body temperature 37.8^° C. Abdomen is soft, tender when colon is palpated. Feces are liquid, dark yellow without blood and mucus 5 times per day.

1. What etiology of the disease?

2. Calculate the dose of furazolidone and write the recipe for this patient.

4.A boy 3 years old is ill for 2 days. Main syndromes are: toxic with hyperthermia; dyspeptic with vomiting, diarrhea (like rice-water); catarrhal changes in upper respiratory tract; moderate dehydration.

1. What infection can cause this signs?

2. How to prove the diagnosis?

Theme 19.

Student should know:

1. Leading clinical symptoms and syndromes of acute intestinal infections: local (gastritis, enteritis, colitis) and general (toxicosis, dehydration, neurotoxicosis, toxic-septic status).

2. Clinical variants of shigellosis, salmonellosis, colibacteriosis, intestinal yersiniosis, viral diarrhea in children of different age.

3. Differential diagnosis of acute intestinal infections among themselves and with diseases of the gastrointestinal tract of non-infectious origin.

4. Treatment of children suffering from acute intestinal infections (survey, indications for hospitalization, treatment).

5. Epidemiology at the focus of infection.

Student should be able to:

1. To identify the different clinical variants of acute intestinal infections in children of different ages.

2. To identify tactics for treating children at acute intestinal infections.

3. To demonstrate the ability to fill in medical documentation of children with acute intestinal infections.

4. Planning a survey of a sick child and interpret the results obtained with acute intestinal infections.

5. Conduct a differential diagnosis and set a preliminary clinical diagnosis of acute intestinal infections.

6. Diagnose and provide emergency assistance in acute liver failure caused by viral hepatitis.

Theme 20.

Students should know:

1. Leading clinical symptoms of toxicosis with dehydration and neurotoxicosis at acute intestinal infections in children.

2. The laboratory and instrumental data in the syndrome of toxicosis with dehydration and neurotoxicosis.

3. The general practitioner tactics in the emergency states diagnosis at acute intestinal infections in children, providing emergency care.

Student should be able to:

1. Diagnose and provide emergency assistance in acute intestinal infections with the dehydration syndrome and neurotoxicosis.

Correct answers of test evaluations and situational tasks:

Theme 1, 2:

Real-life situation 1:

1. Shigellosis, typical form, severe degree with prevalence of the local manifestations, acute course.

2. Clinically healthy after normalization of complete blood analysis and one negative fecal culture, done in 2 days after course of antimicrobial therapy.

Real-life situation 2:

1. Salt deficiency (hypotonic).

2. 220 ml/kg x 8 kg = 1760 ml. 1 part (600 ml) of saline fluids, 2 parts (1200 ml) of water fluids.

Real life situation 3:

Escherichia coli, enteroinvasive strains

10 mg * 20 kg =200 mg/day :4 = 50 mg dose for 4 times

Rp: Tab. Furazolidone 0.05

D.t.d. №20

S. 1 tablet 4 times per day

Real-life situation 4:

1. Rotaviral

2. Virological investigation of feces, serological reactions.

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