Tashkent medical academy

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Ministry of Health of Uzbekistan



           Vice Rector for Academic Affairs

Professor ___________ OR Teshaev

"____" ___________ 2012

Department: PEDIATRICS GPs

Item: Outpatient Pediatrics


on practical training on the topic: IVBDV.Diareya. Assessment and classification. Dehydration his stepeni.Zatyazhnaya diarrhea, blood in stule.Lihoradka (acute, protracted). Symptoms kori. practically skills: Defining the severity Dehydration. differential diagnosis rashes.


Compiled by:

Latipova Sh - MD, PhD,

Education technology approved:

At the faculty meeting protocol number from "___" ____________ 2012

Topic: IVBDV.Diareya.Otsenka иклассифицирование.Обезвоживание his stepeni.Zatyazhnaya diarrhea, blood in stule.Lihoradka (acute, protracted). Symptoms kori.Prakticheskie skills: Defining the severity обезвоживания.Дифференциальная diagnosis rashes.

1. Location classes

    GP Department of Pediatrics, family health center.

2. Duration of study subjects

Number of hours - 8.5

3. Purpose of the lesson.

The World Health Organization and UNICEF developed a strategy for the integrated management of childhood illness (IMCI) strategy to reduce global child mortality.

4. Pedagogical objectives:

1. Consider the program to prevent and control anemia (CPAA)

2. -To teach safe immunization program (PBI)

3. Consider monitoring the growth and development of the child

4. Consider the Integrated Management of Childhood Illness (IBVD)

5. Breast-feeding

6. Safe Motherhood

5. Learning outcomes

The student should know:

-Anatomical and physiological characteristics


-Criteria for diagnosis

-Major complications.

-Principles of treatment and prevention.

-Indications for consultation.

The student should be able to:

That's right to collect medical history and complaints of the patient, to interpret them.

-Interpret the results of clinical, instrumental and radiographic studies on the disease.


-Assignment of treatment depending on the disease

-Principles of clinical examination and rehabilitation of children

6. Methods and techniques of teaching

The method of "Doctor and Patient", "Sputnik expectations"

7. Learning Tools

Manuals, training materials, slides, video, audio, medical history

8. Forms of learning

Individual work, group work, team

9. Conditions of Learning

Classroom, office, GPs.

10. Monitoring and evaluation

Oral control: control issues, the implementation of learning tasks in groups, performing skills, CDS

11. Motivation

The World Health Organization and UNICEF developed a strategy for the integrated management of childhood illness (IMCI) strategy to reduce global child mortality.

12. Intra and interdisciplinary communication

Teaching of the subject is based on the knowledge of students the basics of anatomy, physiology, pathophysiology, pathology, microbiology, biochemistry, internal medicine, propaedeutics childhood diseases, clinical pharmacology. Acquired during the course knowledge will be used during the passage of the GP - pediatrics and other clinical disciplines.


             The loss of fluids and electrolytes in diarrhea, even with adequate filling it does not exclude children malnutrition.

When diarrhea reduces the amount of food consumed, reduced absorption of nutrients, but the demand for them increases sharply, leading to a loss of heat and mass growth arrest. The initial decrease in supply exacerbated the dire state of diarrhea.

In these cases, the WHO recommends: - Continue to give your child a rich nutrient food both during and after diarrhea

- Provide nutrition according to age, when he was still healthy.

Zinc is a result of the randomized controlled trials of enrichment supply of zinc, it was found that zinc supplementation at 10-20 mg. A day significantly reduces the severity and duration of diarrhea in children under 5 years old, 10-14 days of treatment for 2-3 months.

It is known that zinc plays an important role in the formation metillofer-ments, polyribosomes, the cell membrane, participating in the growth and reproduction of cells and the immune system. The use of antimicrobials should be differentiated, that is, take into account the clinical form of diarrhea and antibiotic sensitivity to agents causing diarrhea.

        Bloody diarrhea caused by dysentery or shigella, Vibrio cholerae requires the appointment of antibiotics, and in front of diarrhea caused by Cryptosporidium rotovirusomi and are not effective in antibiotic therapy. And treatment is expensive.

Assessment of a child with diarrhea.

Consists of studying the history of the disease, functional studies include the following questions and survey methods.

The mother of the child is necessary to clarify: the presence of blood in the stool, duration of diarrhea, the number of watery defikalii per day, the number of liquid vomit, presence of fever, cough, cramps, measles cases, feeding practices before the onset of illness, variety and volume of fluid intake, medications, immunizations in history.

 3.1 Methods of studying the general condition during the inspection:

The general condition, the activity of the child's anxiety, and irritability. Lethargy or he is unconscious. Sunken eyes

As the patient drinks, refuses, guzzles, can not drink,

The study of skin turgor: crease in the skin between two fingers, and there is time straightening: fast, slow, very slow (> 2 seconds), chair of the Child Study: Does the mucus in the stool blood? Are there signs of malnutrition assessed the relationship of body weight for age and height on the map to the physical razvitiyaImeetsya a cough in a child? Count the respiratory rate, compared to a rate of inspection of the chest may reveal chest indrawing in the intercostal spaces

The study of the body temperature. Increased body temperature may be due to: severe dehydration, pneumonia, malaria, gastrointestinal infections.

            3.2. Determining the degree of dehydration and the choice of the treatment plan.

Signs of dehydration will not, if the child is active, the eyes sunken, drinking normally, no thirst. The average is determined by the degree of dehydration signs - restless child, eyes sunken, guzzles. Severe dehydration is when a sick child is lethargic, his eyes sunken, can not drink at all.

A plan for the prevention and treatment of dehydration.

      In the absence of signs of dehydration treatment recommended in the home to prevent dehydration and reduced supply. With some signs of dehydration need treatment - oral regidrotatsiya. At these shows signs of dehydration intravenous regidrotatsiya.

Rating deficit fluid intake.

         Determining the degree of dehydration must be done with the specification of body weight and age.

Calculation taking into account the degree of dehydration to produce, knowing about fluid deficit as a percentage of the weight of the body. In the absence of signs of dehydration may be fluid deficit to 5% of body weight. Restores the volume should be of not less than 50 ml per 1 kg body weight of the child, ie with a weight of 5 kg, complementary volume is 250 ml.

At some dehydration deficit of approximately up to 10% of body weight, so fill up that amount will be at the rate of 50-100 ml per 1 kg. Weight.

Dehydration, severe deficit of over 10% and filling must be at least 100 ml per 1 kg. Weight.

In assessing the overall condition of the child it is important to diagnose other important issues: the diagnosis of dysentery made on finding blood in the stool

Persistent diarrhea - is diarrhea for 14 days and there is no trend towards improvement.

 The diagnosis of malnutrition is set at the presence of edema in the extremities, muscle atrophy and with clear evidence of cachexia.

            The diagnosis of severe infection, is not associated with the gastrointestinal tract is made by the signs of pneumonia or sepsis.

- Is a fever, lethargy, heart failure, which requires immediate hospitalization.


- Protective and adaptive response of the body that occurs in response to pathogenic stimuli and characterized by the restructuring processes of thermoregulation leads to an increase in body temperature that stimulates the natural reactivity.


- Subfertil temperature - 37.2 - 38.0 C

- With low febrile -38,1-39,0

- High febrile - 39.0 - 41.0 C

Fever above 41.1 C is called hyperthermic - hyperthermia.

Pyrogenic reactions - are caused by exogenous pyrogens: toxins, protein substances, breakdown products of tissues, severe metabolic disorders, allergic reactions, etc. - enabling products in the hypothalamic thermoregulatory center prostanglandina E2. Last change "mode of installation," increasing heat production - increased metabolism, muscle tremors, and reducing heat-spasmodermia, while there, tachycardia, increased consumption of O2 and production SO2.Takaya fever rarely exceeds 40 C, its horoscho tolerate, but children risk of complications.

Malignant hyperthermia - in patients with congenital myopathies, the application of anesthetics and chlorpromazine (chlorpromazine).

Hyperpyrexia - above 41 C - not usually associated with the hypothalamic response occurs when overheating - heat stroke, increased muscle work, while reducing heat loss due to microcirculatory disorders.

Distinguish between "red" and "white" hyperthermia.


      Prognostically favorable "red" Hyperthermia: moderately hyperemic skin, hot, humid, warm extremities, increased heart rate and breathing corresponds to an increase in temperature (for each degree above 37 C respiration rate increased by 4 per minute, and heart rate, at 20 per minute); normal behavior of the child, despite the febrile.

      "White" is characterized by: pale skin, "marble", with cyanotic shade of nail lodges and lips, a positive sign of the "white spots", the extremities are cold, excessive tachycardia, dyspnea, impaired behavior of the child - apathy, lethargy, possible - excitement, delirium , ship horns. The effect of antipyretics - is not sufficient.

       WHO recommends that antipyretic treatment initially healthy children at t = 38,5 C. However, if the child has a fever in the background, regardless of the degree of hyperthermia observed: deterioration, chills, myalgia, impaired health, pale skin, and other manifestations of toxicity - antipyretic treatment administered immediately.

       Children from the "at risk of developing complications during rush" needed antipyretics at the "red" fever - t = above 38 C, and when the "white» t = even with low-grade fever.

      This group includes children who: a history of febrile convulsions, central nervous system pathology, chronic heart or lung disease, hereditary metabolic diseases.


        When "red" hyperthermia - physical methods of cooling:

- Expands the child, provide fresh air

- Drink plenty of liquids - 0.5 - 1 liter more age norm

- Shoes fan, cool wet bandage on his forehead, cold (ice) on the area of ​​large vessels of the head (at a distance of 10-15 cm), increase heat vodka-acetic rubdown - repeat 2-3 times

- Paracetamol, acetaminophen, Panadol, kalpol, efferalgan and others, at a dose of 10-15 mg / kg orally or rectally in suppositories in a dose of 15-20 mg / kg, a single dose of ibuprofen - 5.10 mg / kg

           If for 30-45 min t body is reduced to:

- Antipyretic mix / m - 50% solution of sodium metamizol (analgin) in a dose-0.1 ml / year of life (up to 1 year, 0.01 ml / kg) + 2.5% solution of promethazine (pipolfen , Promethazine) at a dose of 0.1 - 0.15 ml / year of life, but no more than 2 ml (1 year, 0.01 ml / kg). If no effect within 30-60 minutes after administration of the mixture can be repeated.

        When "white" hyperthermia - antipyretics + sosudoras an expanding drugs inside or / m:

- Papaverine or drotaverine (no-spa) in a dose - 1 mg / kg orally or 2% solution of papaverine at 0.1-0.2 ml / year of life or rr drotaverine (no-spa) - 0.1 ml / year of life

- Used as 0.25% solution droperidol 0.1-0.2 ml / kg (0.05-0.2 mg / kg) / m

- The normalization of microcirculation - physical cooling methods

       Aspirin because of the syndrome Ray in children under 15 years old with the flu, chickenpox, and other viral infections to reduce t do not apply!. Rejecting the use of dipyrone, especially inside linked to the risk of agranulocytosis.

A child with a fever is malaria, measles, or other serious illness. A child with a fever can be a usual cough, cold or other viral infection.


Igeneralizovannaya fever rash are the primary symptoms of measles. Measles - highly infectious disease. Maternal antibodies to protect the baby from measles during the first 6 months, then the protection of endangered, so basically there is measles at the age of 6 months to 2 years.

Measles - caused by a virus that attacks the skin and the layer of cells lining the lungs, stomach, eyes, mouth and throat. It affects the immune system for a few weeks after the onset of the disease, which leads to a weakening of the body and increases the child's risk of other infections.

The most important complications of measles:

- Diarrhea (prolonged diarrhea and dysentery)



-Mouth ulcers

-Ear infection

-Severe eye infection (ulceration of the cornea and loss of vision)

Encephalitis (infection of the brain) - there may be some common signs of danger as convulsions, lethargy or unconsciousness.

      A child with a fever and stiff neck may be meningitis. If the neck muscles are strained and you feel resistance when bent, so the child has a stiff neck, he often cries when you try to bend his neck. A child in need of anti-bacterial drugs, and immediate hospitalization.

      With measles disturbed nutrition, because it causes diarrhea, high fever and mouth ulcers - which interferes with normal feeding, especially in children with vitamin A deficiency

       Generalized rash with red measles - begins behind the ears and on the neck, then spread on the face, the next day - all over. Fades for 4-5 days, the skin may peel. The rash does not form vesicles or pustules (pustules), does not cause itching.


- Chicken pox, generalized rash with blisters

-Scabies rash - on the hands, feet, knees, elbows, buttocks and axillae - itchy

- Red tropical sudamen - in the form of generalized rash + + small blister bubbles that cause itching child is not sick.

      Cough, runny nose or red eyes + generalized rash, fever-looking features of attributing oneself with measles.


      Sores in the mouth - can be red or covered with white bloom, in severe cases glubokik and extensive. Treatment: gentian violet, vitamin A

     Koplik's spots - small irregular, bright red spots with a white dot in tsenre on the inside of the cheeks in the early stages of measles.

    Purulent conjunctivitis eye infection of the conjunctiva, the inner surface of the eyelids and the sclera. During sleep, the pus dries to form a crust and "glues" ever.

    Clouding of the cornea - can be caused by vitamin A deficiency, measles, and reinforced if not promptly treated corneal ulcers, can develop blindness. Treatment, tetracycline ointment, vitamin A.

      If a child he suffered from measles or measles in the last 3 months - give vitamin A


The teacher can prepare a set of questions with short answers (eg, true / false), which reveal important aspects of the topic. Students are asked to individually or in pairs to answer these questions as accurately as possible before you start the main part of the session. Actually it means a preliminary diagnosis on the topic of the forthcoming sessions. Technically, it is easier to implement through the use of oral test questions with answers "Yes" and "No" or "True" and "False". In this case, an approximate estimation of the entire group in% can be done by raising the students hands on this answer "Yes" or "right." This method allows the teacher to get feedback on the awareness of the audience on the topic. At the end of the class students return to these issues, to ensure that you changed their point of view and the approach to the solution.

Using the 'doctor-patient'

The purpose of this technique is to create a situation where a student can feel in the role of patient, physician, and observer. Group share of 3-4 subgroups. In each subgroup defined by the doctor, the patient and the expert. Each group provides case studies that they have to play in accordance with the role. Particular attention should be paid to experts physician communication skills with the patient, the diagnosis, treatment and appointment of the Council in accordance with the situation.

The analytical part of


13.2.1. Case studies:

  Case studies are in the IMCI program step by step and have the conditions and responses

Case studies:

1. Gulchatoy 2 years. The girl has no general danger signs. The body temperature is found purulent discharge from the ear. Mother said she had not seen purulent until today.

- Your diagnosis

- Tactics doctor

2. A child of 7 months. The girl is a common sign of danger she letorgena. She deareya with severe dehydration and no other severe classification.

- What's the plan would have chosen a medical professional

- Do I need to send a child to the hospital.

14. Control forms of knowledge, skills and abilities

- Oral

- Decision of situational problems

- Demonstration of practical skills


15. The evaluation criteria of the current control

15.Kriterii assessment monitoring

Progress in (%) and points...


The level of knowledge of the student



fine «5»

Sums up and makes decisions

creative thought

own analyzes

Into practice

Shows high activity, creativity during interactive games

Correctly solve situational problems with full justification response

Understand the subject matter

Knows, says confidently

Has a faithful representation



creative thought

own analyzes

Into practice

Shows high activity, creativity during interactive games

Correctly solve situational problems with full justification response

Understand the subject matter

Knows, says confidently

Has a faithful representation



own analyzes

Into practice

Shows high activity, creativity during interactive games

Correctly solve situational problems with full justification response

Understand the subject matter

Knows, says confidently

Has a faithful representation




Into practice

Shows high activity during interactive games

Correctly solve situational problems, but the answer is not sufficient justification for a complete

Understand the subject matter

Knows, says confidently

Has a faithful representation



It is active during online games

Correctly solve situational problems, but the answer is not sufficient justification for a complete

Understand the subject matter

Knows, says confidently

Has a faithful representation



Correctly solve situational problems, but the answer is not sufficient justification for a complete

Understand the subject matter

Knows, says confidently

Has a faithful representation



satisfactorily «3»

Correctly solve situational problems, but the answer is not sufficient justification for a complete

Understand the subject matter

Knows, says confidently

Has a faithful representation



Making mistakes in solving situational problems

Knows tells not confident

Has a faithful representation on certain issues threads



Knows tells not confident

Has a partial view


54 and below




It does not accurately represent

Do not know

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