The tashkent medical academy depatment«infectious diseases and pediatrics» case technology



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REPUBLIC UZBEKISTAN MINISTRY OF HEALTH

THE TASHKENT MEDICAL ACADEMY

DEPATMENT«INFECTIOUS DISEASES AND PEDIATRICS»

CASE - TECHNOLOGY

On an educational theme «the Rickets. Etiopathogenesis, clinic, diagnostics, the differential diagnosis, treatment and preventive maintenance. Tactics GP»


CASE

Tactics of the doctor of the general practice solves a problem, what at rickets

TASHKENT 2012

REPUBLIC UZBEKISTAN MINISTRY OF HEALTH

THE TASHKENT MEDICAL ACADEMY

DEPATMENT«INFECTIOUS DISEASES AND PEDIATRICS»


I "CONFIRM"

The pro-rector on study

professor Teshaev O.R.
___________________
____ ___________ 2012

CASE - TECHNOLOGY

On an educational theme «the Rickets. Etiopathogenesis, clinic, diagnostics, the differential diagnosis, treatment and preventive maintenance. Tactics GP»

The composer: PHD Khalmatova B.T.

The pedagogical summary
Subject: "Pediatrics"
Theme: «The Rickets. Etiopathogenesis, clinic, diagnostics, the differential diagnosis, treatment and preventive maintenance. Tactics GP»

The purpose of the given case:

to Discuss principal causes of development of a rickets;

to Train the student in criteria of diagnostics of a rickets

to Show principles of carrying out of differential diagnostics;

to Show the basic methods of treatment of a rickets;

to Consider methods of preventive maintenance of a rickets;

to Train students in scheduling of improving actions

Planned educational results - by results of work with case students get skills:

the Estimation and the situation analysis.

the Choice of correct algorithm of actions for diagnosis statement.

Independently to appoint treatment

to Spend ante and postnatal rickets preventive maintenance

To be able to spend the qualified rehabilitation.



For the successful decision of the given case the student should know

anatomo-physiological features of bone-muscular system;

to know an aetiology and links pathogenesis;

criteria of diagnostics of a rickets depending on an illness phase;

rickets classification;

the basic clinical displays;

algorithm of carrying out of differential diagnostics;

treatment and preventive maintenance principles;

indications for consultation of narrow experts.

The given case reflects a real situation in the conditions of a primary link

Sources of the information of a case

The case record

1. Children's illnesses. Daminov T.A., Khalmatova B.T., Boboeva U.R., Tashkent, 2012

2. Pediatrics. N.N.Shabalov. S-peterburg, 2010

3. Propaedeutics of children's illnesses. A.A.Baranov. М, Medicine, 2007

4. The directory of the family doctor (Pediatrics), - Minsk, 2000, - s.390-398, 417-420.

5. The five Minute child Health Advisor/-M. William Schwartz, MD., - 1998, USA

6. A therapist’s guide to pediatric assessment, - Linda King-Thomas, Bonnie J. Hacker, 1987, USA

7. Pediatrics, - Margaret C. Heagarty., William J. Moss,-1997, USA

8. www.medafarm.ru

9. www.tma.uz

10. www.medlincs.ru

11. www.medlincs.ru>

The case characteristic according to typological signs

The given case concerns a category room, subject. It volume, structured. It is a case - a question.



On the didactic purposes a case тренинговый, stimulating thinking in a real situation in the conditions of WMP.

The case can be used on disciplines: Pediatrics, orthopedy, neurology
I CASE

«A rickets. An aetiology, патогенез, clinic, diagnostics, treatment and preventive maintenance. Tactics GP»

Introduction

The rickets is the broken mineralization of a growing bone, the leader to infringements of formation of a skeleton in the early childhood. A rickets - polyaethiological the exchange disease caused by discrepancy between high requirement of the growing organism in salts of phosphorus, calcium and others ostheotropic mineral substances, and also many vitamins, including vitamin D, and insufficiency of the systems providing their transport and inclusion in a metabolism.



The decision of a prospective case will allow students to reach following educational results:

the Estimation and the situation analysis.

the Choice of correct algorithm of actions for diagnosis statement.

to Spend the differential diagnosis.

Independently to appoint treatment.

To be able to carry out preventive actions.



Situation

To the child of 10 months. Was born early, with weight 2300 г, from 1 month there are on artificial feeding, walks on 1 hour 2-3 times a week, feedings up are given from 6 months in the form of semolina and rice porridges, sometimes vegetable mashed potatoes. Has transferred: pneumonia, ­staphylococcal enters colitis. Objectively: a condition satisfactory, the expressed frontal and parietal hillocks, costal beads, диастаз direct muscles of a stomach, "a rachitic hump," looseness of joints, match wet, adinamya are marked.


Questions:

  1. What your diagnosis also prove it?

  2. What researches are necessary for spending for ­diagnosis acknowledgement­?

  3. With what diseases it is necessary to spend the differential diagnosis?

  4. Specify tactics of the doctor of the general practice.


The task: On the basis of the analysis of a condition of the patient it is necessary to make the preliminary diagnosis, to spend necessary methods of diagnostics, to make the proved decision for the further conducting the patient.
II. Methodical instructions for students

2.1 Problem:

Choice of tactics of diagnostics and definition of principles of treatment in the conditions of WMP.



2.2. Sub problem:

1. The appearance analysis

2. The analysis of the anamnesis and the preliminary events which are etiological the factor in occurrence of disease

3. The survey analysis

4. A choice of necessary methods of diagnostics

5. To correlate the received results and to carry out differential diagnostics

6. To come to the certain decision of a problem in the conditions of WMP

2.3. Algorithm of the decision

1. The appearance analysis includes following research:

- Survey of a skin and the visible mucous

- A condition of bone-muscular system

2. The anamnesis analysis

- Features of the period of pregnancy and till the moment of the reference to the doctor

- Duration and character of disease

3. The survey analysis

- Ps, LB.

- A condition of bone-muscular system

- Percussion and auscultation lungs

- Percussion and auscultation hearts

- Palpation a stomach

4. A choice of necessary methods of diagnostics

- CAB, CAU

- The biochemical analysis of blood (definition of level of calcium, phosphorus and alkaline phosphates)

5. To correlate the received results and to carry out differential diagnostics with:

- As rickets diseases.

6. To come to the certain decision of problems in the conditions of WMP

- Treatment appointment

- Councils about a food of the child

The instruction to independent work under the analysis and the decision of a practical situation
Sheet of the analysis of a situation


Work stages


Recommendations and councils

1. Acquaintance with a case

At first familiarise with a case

Reading, do not try to analyze a situation at once



2. Acquaintance with the set situation

Once again read the information, allocate paragraphs which have seemed to you important.

Try to characterise a situation. Define that in it important, and that is minor.



3. Revealing, formulation and substantiation of a key problem and sub problem


Problem:

Choice of tactics of conducting and definition of tactics of treatment in the conditions of WMP.




4. Diagnostics of the analysis of a situation.


At the situation analysis answer following questions:

What diseases, are accompanied with changes to bone-muscular system?

With what nosologic it is necessary to carry out differential diagnostics and to define the most probable reasons of occurrence of rickets.

What methods of diagnostics are necessary for applying, make and prove the inspection plan at level WMP.

What additional consultations of narrow experts are necessary for statement of the definitive diagnosis?

Define degree of necessity of the subsequent supervision (medicamentous and not medicamentous treatment).



5. Choice and substantiation of ways and means of the decision of a problem.


List all possible ways of the decision of the given problem in the given situation.


6. Working out and permissions of a problem situation


Diagnose, will solve a problem in the conditions of WMP.



The instruction to group work under the analysis and the decision of a practical situation


Work stages


Recommendations and councils

The representation coordination about a situation and a problem

Discuss and co-ordinate various representations of members of group about a situation, a problem and about sub promblem.

The analysis and estimation of the offered ways and means of the decision of a problem, choice of priority idea of the decision of a problem.


Discuss and estimate the offered variants of ways and means of the decision of a problem. Choose priority, in your opinion, idea of the decision of a problem.


Working out of a mutually acceptable variant of the decision of a problem and detailed working out of its realisation.


Develop a mutually acceptable variant of the decision of a problem and detailed working out of its realisation.

Prove your diagnosis;

Prove your tactics of actions.


Preparation of presentation

Issue results of work in the form of oral presentation on behalf of group. Discuss and will solve a question that will represent results of group work: the leader or all group with division of functions between participants (supporting reports) depending on the problems solved by them during the analysis and the decision of a problem.

Prepare illustrative materials in the form of posters, slides or multimedia.

By message preparation, first of all, plan the approximate scheme of that you will speak, do not go deep into details!



Sheet of the analysis and the decision of a problem situation


The name of a stage of work with a case


The maintenance of a stage of works


Acquaintance with the set situation in a case


The review of the set concrete situation and definition of a problem of the information essential to the decision.


Analyses of situation




At the situation analyses answer following questions: the Analysis of the anamnesis and the preliminary events which are этиологическим the factor in occurrence of rickets. The analysis of objective survey. A choice of necessary methods of diagnostics. To correlate the received results and to carry out differential diagnostics. To come to the certain decision of problems in the conditions of WMP



Problem substantiation


Substantiation of a key problem and its components.


Choice of alternatives of the decision of a problem


The formulation of possible alternatives of the decision of a situational problem.


Working out and substantiation of the decision of a problem

Detailed working out and substantiation of the concrete decision.



III. THE VARIANT OF THE DECISION OF THE CASE

THE TEACHER - КЕЙСОЛОГОМ

IV CASE - TECHNOLOGY OF TRAINING AT THE SEMINAR


    1. Model of technology of training




The Theme

Rickets

Quantity of hours - 2 hours


Quantity of the trained: 10 persons


The form of educational employment

Seminar on expansion and deepening of knowledge, working off of abilities to tactics of conducting patients with a rickets

Plan of the seminar


Introduction in educational employment Actualization of knowledge Work with a case in mini- groups of Presentation of results Discussion, an estimation and a choice of the best variant of strategy the Conclusion. An estimation of activity of groups and students, degrees of achievement of the purpose of educational employment

The purpose of educational employment: Deepening’s of knowledge on tactics of conducting children with rickets. Development of ability of an estimation, the analysis of a situation, a choice of tactics of conducting, to diagnostics, differential diagnostics, treatment appointment at level of a primary link.

Problems of the teacher:

to fix and deepen knowledge by an estimation and the analysis of situations and the general condition of patients with rickets.

to develop ability of a choice of correct algorithm of actions for diagnosis statement.

to Develop skills to destination treatments

To develop skills of independent decision-making at conducting children with a rickets in the conditions of WMP.


Results of educational activity:

estimate and analyze a situation and the general condition of children with a rickets

choose algorithm of actions for diagnosis statement.

develop skill of independent decision-making at conducting children with a rickets in the conditions of WMP

develop the treatment plan


Training methods


Cases-stages, discussion, a practical method


Tutorials

Case, methodical instructions


The training form


Individual, face-to-face, work in groups


Training conditions


Audience with a hardware, adapted for work in groups


Monitoring and estimation


Supervision, blitz interrogation, presentation, an estimation


Technological card of the educational employment based on a case


Stage and the work maintenance


Activity


The teacher


Students


Preparatory stage


Explains appointment a case - stages and its influence on development of a professional knowledge. Distributes materials of a case and acquaints with a situation analysis algorithm (Methodical instructions for students see). Gives the task independently to carry out the analysis and to bring results in «Sheet of the analysis of a situation»


Listen Independently study the maintenance of a case and individually fill sheet of the analysis of a situation.


I stage.

Introduction in educational employment

(10-15 mines)



1.1. Name an employment theme, the plan, its purpose, problems and planned result of educational activity.

1.2. Acquaints with an operating mode on employment and criteria of an estimation of results (instructions for students see)




Listen

Conduct corresponding records





II stage

The basic

60 mines


2.1. Proves statement of a problem and a situation choice - an urgency. Spends a blitz-interrogation on purpose to make active knowledge trained on a theme (the appendix №1): Why there is a rickets? List the reasons of occurrence of a rickets? What complications are possible at wrong treatment of a rickets?
2.2. Divides students into groups. Reminds the maintenance and case problems. Acquaints (reminds) with work rules in group and discussion rules.

2.3. Gives the task, specifies correctness of perception of the task (the appendix №2): With what нозологиями it is necessary to carry out differential diagnostics and to define the most probable reasons of occurrence of a rickets at children. The methods of diagnostics applied in the conditions of WMP Tactics of conducting and treatment of children with a rickets.

2.4. Co-ordinates, advises, directs educational activity. Estimates results of individual work: Sheets of the analysis of a situation.

2.5. Will organise presentations following the results of the done work under the case decision, discussion. The organizer of discussion: sets questions, remarks, reminds a theoretical material

2.6. An organizer - algorithm of actions GP in the given situation (the appendix №3)

2.7. Informs the variant of the decision of a case (the appendix №4)




Answer questions, discuss, and set specified questions.

Share on groups


Discuss, carry out the joint analysis of an individual problem, define the major aspects of a situation, the basic problems and ways of their decision, make out results of the decision


Represent variants of the decision of a problem of 10-15 mines


Questions after the presentation termination, choose an optimum variant

Develop uniform system, discussion




III stage

Employment summarising, the analysis and estimation

20 mines


3.1. Generalises results of educational activity, declares estimations individual from teamwork. Analyzes and estimates group, marks the positive and negative moments.

3.2. Underlines value of a case-stage and its influence on development of the future expert




Listen.

Can spend a self-estimation and both- estimation express the opinion






The appendix №1.

Theoretical part
Rickets. An aetiology, pathogenesis, clinic, diagnostics, treatment and preventive maintenance. Tactics GP»
The rickets is the broken mineralization of a growing bone, the leader to infringements of formation of a skeleton in the early childhood. A rickets - polyaethiologicalе the exchange disease caused by discrepancy between high requirement of the growing organism in salts of phosphorus, calcium and others osteotropic mineral substances, and also many vitamins, including vitamin D, and insufficiency of the systems providing their transport and inclusion in a metabolism. At children is more senior 1 year and adults a similar condition name остеомаляцией and an osteoporosis (last years in some countries there was a tendency the term "rickets" to replace with the "osteosinging" term even at chest children).

Rickets - frequent disease of children of the first year of a life. Though its true prevalence is unknown, at many children reveal those or other residual phenomena of this disease (anomalies of a bite and growth of a tooth, deformations of a skull, a thorax, the bottom finiteness’s and others). Children, suffering rickets, are included further into group of often ill children.



Aetiology and pathogenesis.

For the first time the rickets has been in detail described in ХVII a century in England. Though at that time the reason of its development was unknown, has been noticed, that disease occurrence is promoted by a lack инсоляции. In 30th years of the XX-th century vitamin D has been opened. Then have established that under the influence of UVI there is its synthesis in a skin. Within the next 60 years considered, that the leading reason of a rickets - deficiency of vitamin D. On the other hand, vitamin D as a medical product has appeared only about 80 years ago, but also in the remote past children from the provided families did not suffer rickets. Last years when there was possible a concentration definition метаболитов vitamin D in blood, it has appeared, that gypovitaminosis D - only one of the reasons leading to development of a rickets. Principal causes of deficiency of phosphates, salts of calcium and others osteotropic macro-and micro elements, and also vitamins at children of early age the following:

1. Deficiency of a solar irradiation and stay on fresh air as 90 % endogen formed vitamin D in an organism are synthesised in a skin under the influence of a solar irradiation. It is proved, that daily stay on the sun during 1-2 ч with an irradiation only the person and brushes it is enough for maintenance of normal level метаболита vitamin D in blood a current of week.

2. Food factors: the increase in frequency and weight of rickets in groups of children is established:

1) Being on artificial feeding by the not adapted mixes in which vitamin D, in particular, is not added;

2) It is long being on dairy feeding with late introduction of feedings up, at a defective food of mother;

3) Receiving, mainly, vegetarian feedings up (porridges, vegetables) without animal protein enough (an egg yolk, meat, fish, cottage cheese), oils.

3. Недоношенность which contributes to rickets. It is caused by that the most intensive receipt of calcium and phosphorus from mother to a fruit occurs last months pregnancy, and the child gestation already at a birth has less than 30 weeks to osteosinging - decrease in weight of a bone fabric. At the same time at faster rates of growth, than at доношенных children, early born child calcium and phosphorus considerable quantities in food are required. Also it is necessary to notice, that irrational food and a mode of a life of the pregnant woman can lead to smaller stocks of vitamin D, calcium and phosphorus at a birth and at доношенного the child.

4. A syndrome malarbsorbtion, for example, at seliakia at which it is broken sacking nutrients in intestines. Insufficient activity lactase also promotes infringement of recycling of food components.

5. Chronic diseases of a liver and kidneys which lead to decrease in intensity of formation of active forms of vitamin D.

6. Ecological factors. Surplus in soil so, and in water, a foodstuff of strontium, lead, zinc and other metals leads to partial replacement of calcium by them in bones and promotes rickets development.

7. Hereditary anomalies of an exchange of vitamin D and a kaltsievo-phosphoric exchange.

8. Hereditary anomalies of a metabolism.

9. Poligypovitaminosis.

10. Chronic infectious processes.

11. Insufficient impellent activity owing to prenatal damages of nervous system or absence to a family of elements of physical training (massage, gymnastics, etc.).

The vitamin D exchange in an organism is rather combined. Initial forms - ergocalsiferol (vitamin D2) and holicalsiferol (vitamin D3), arriving with food - biologically small activ. The first initial forms of vitamin D with their transformation in intermediate (transport) metabolite, named 25-gidroholekaltsiferolom, occurs in a liver. 25-gidroholekaltsiferolom in 1,5-2 times is more active than the initial form. Then there is a transport 25-gidroholekaltsiferola in kidneys where it is exposed again hydroxyls and turns in active hormonal metabolites 1,25-digidroholekaltsiferol and 24,25-digidroholekaltsiferol. These metabolites together with hormones parathyroid and thyroid glands provide fosforno-kaltsievyj an exchange Value has not so much true exogenesis deficiency of the vitamin D, how many insufficient инсоляция as more than 90 % of vitamin D are synthesised in a skin at UVI, and 10 % arrive with food, i.e. skin synthesis is capable to cover requirement of an organism completely. 10 minute irradiation of a part of a body is enough for synthesis of quantity of vitamin D necessary for an organism. Among children with a rickets only at 6 % concentration decrease метаболитов vitamin D in blood is revealed.

Rickets classification

Till now the classification of a rickets offered in 1974 г by S.O.Dulitskim is most extended




The illness period


Weight of a current


Character of a current


The initial


I degree - easy


The sharp

Illness heat


II degree - average weight


Reconvalesent

III degree - heavy


The sub sharp

The residual phenomena



Clinical picture

Initial stage. Disease first signs arise usually on 2-3rd month of a life. The behaviour of the child changes: there is an anxiety, fearfulness, hypererethism, starts at external irritator. The dream becomes superficial and disturbing. Amplifies watt, especially on a skin hears head and person parts, mark proof red demographics. Sweat has a sour smell and irritates a skin, causing an itch. The child rubs a head about a pillow; there are sites loosing hear on a nape. The physiological hypertonic of muscles, characteristic for this age, is replaced by a muscular hypotonic. There is a pliability of seams of a skull and edges big, on edges thickenings are outlined in places edge-hrjashchevyh joints («rachitic beads»).

On roentgenograms of bones of a wrist reveal insignificant depression of a bone fabric. At biochemical research of blood find out normal or even the raised concentration of calcium and decrease in concentration of phosphates, increase of activity alkaline phosphates is possible. In the urine analysis reveal phosphatsurina, increase in quantity of ammonia and amino acids.



The heat period is necessary more often on the end of the first half of the year of a life and is characterised by even more considerable frustration from nervous system and the support-impellent device. Processes osteomalation, especially strongly pronounced at a sharp current of a rickets, lead to a softening of flat bones of a skull with the subsequent, often

Unilateral flat a nape. There is a pliability and deformation of a thorax with press in the bottom third of breast («a breast of the shoemaker») or it act ("chicken" a breast). It is characteristic O-shaped (less often H-shaped) a curvature of long tubular bones. It is formed narrowed плоскорахитический a basin. As a result of the expressed softening of edges there is a deepening in the area of a diaphragm attachment (Harrison a furrow). Hyperplasia osteoid the fabrics, prevailing at sub sharp a rickets current, appears formation of the hypertrophied frontal and parietal hillocks, a thickening in the field of wrists, edge-hrjashchevyh joints and interphalanx joints of fingers of hands with formation so-called «bracelet», «rachitic beads», «pearls threads».

On roentgenograms of long tubular bones are visible glass’s expansions metaphysic, degradation and an illegibility of zones preliminary.

Are distinctly expressed hypophosfataemia, moderated hypocalcaemia, hyperactivity alkaline phosphates.



The period reconvalesention is characterised by improvement of state of health and a condition of the child. Static functions improve or normalised. On roentgenograms find out changes in a kind of non-uniform consolidation of zones of growth. The phosphorus maintenance in blood reaches norms or exceeds it a little. Small hypocalcaemia can remain, and even sometimes amplify.

The period of the residual phenomena. Normalisation of biochemical indicators and disappearance of symptoms active rickets testify to transition of disease from an active phase in inactive - the period of the residual phenomena. Signs of the transferred rickets (residual deformations of a skeleton and a muscular hypotonya) can is long to remain.


Diagnostics and differential diagnostics

The diagnosis put on the basis of a clinical picture and confirm with the biochemical analysis of blood (definition of concentration of phosphorus, calcium and activity alkaline фосфатазы). Dynamics and a parity of these indicators allow specifying the disease period. Concentration of phosphorus at a rickets can decrease to 0,65 mmol/l (norm at children till 1 year of 1,3-2,3 mmol/l), concentration of calcium makes 2-2,3 mmol/l (norm of 2,5-2,7 mmol/l). An activity alkaline phosphate rises. For rickets changes on roentgenograms of bones are characteristic: in metaphysics to a zone the crack between epiphyses and diaphyses increases; epiphysз gets as saucers the form, ossification kernels come to light vaguely, zones preliminary washed away and indistinct, an osteoporosis. During the period reconvalescent zones the rough. Fringed at the expense of non-uniform consolidation. Infringements in growth zones are characteristic for deficiency of phosphorus and calcium.

Differential diagnostics of rickets spend with so-called as rickets diseases. In practical activities often it is necessary to differentiate rickets with prenatal defeat SNS. Besides it is necessary to exclude the secondary rickets developing at long application of some medical products, for example glucocorticoids (antagonists of vitamin D on influence on calcium transport), heparin (interferes with adjournment phorphor-kaltsievyh salts in bones), furosemid, phosphates, magnesium and antacid, containing aluminium.

Treatment

Treatment should be complex, long and directed on elimination of the reasons which have caused it. Now major importance give to the nonspecific treatment including eutrophy of the feeding woman with constant reception of a mineral and vitamin complex, rational feeding of the child, the organisation of the mode corresponding to its age, long stay on fresh air with sufficient инсоляцией, medical gymnastics and massage, the temper, treatment of accompanying diseases.

Specific treatment of a rickets includes appointment of vitamin D, preparations of calcium, phosphorus and others микронутриентов.
Medical doses of vitamin D


Rickets severity level


Daily dose of vitamin D, IP


Duration of a course, day

I degree

1000 – 1500

30

II degree

2000 – 2500

30

III degree

3000 - 4000

45

After the termination of course of treatment appoint vitamin D in preventive doses (100-200 Me/sut, no more than 400 IU/day). It is necessary to remember, that the increase in a preventive dose can lead hypervitaminoses D. Many pediatrists suggest appointing to children not vitamin D, and a complex of vitamins as the rickets is often accompanied polygypovitaminosis.



Preventive maintenance

Now recommend to do the basic emphasis on nonspecific methods of preventive maintenance of rickets both to, and after a birth of the child.

Antenatal rickets preventive maintenance includes a high-grade food of the pregnant woman, long walks on fresh air, employment by physical culture, constant reception of a complex of vitamins for pregnant women with microcells. To pregnant women do not appoint UVI and vitamin D in the big doses as there are data, that at children which mothers received during pregnancy UVI, prenatal defeats SNS develop more often and proceed more hard. Vitamin D in the big doses can lead to damage of a placentary barrier and a delay of pre-natal development of a fruit. The hyper sensibility to vitamin D at children which mothers purposefully received it during pregnancy is noted. In micronutrients complexes of last generation for pregnant women the vitamin D maintenance is lowered with 400 to 200-250 IU.

Postnatal rickets preventive maintenance includes constant reception by feeding mother of the mineral and vitamin complex, natural feeding, observance of a mode of day, закаливание, massage and gymnastics, walks on fresh air.



The forecast

The forecast at rickets depends on severity level, timeliness of diagnostics and adequacy of treatment. If the rickets is revealed in an initial stage and adequate treatment with the account polyaethiological diseases is spent, consequences do not develop. In heavy cases the rickets can lead to heavy deformations of a skeleton, delay of psychological and physical development, sight infringement, and also it is essential to aggravate a current of a pneumonia or diseases ЖКТ. However heavy consequences develop in extreme situations (in the conditions of war, hunger, etc.) is more often. In usual conditions at suspicion on such consequences of rickets first of all it is necessary to exclude other reasons of similar changes.



HYPOVITAMINOSES D

Pediatrists speak: «the small rickets, than hypervitaminoses D is better». Hypervitaminoses D (an intoxication vitamin D) - a condition caused as direct toxic action of a preparation on cellular membranes, and the raised concentration in blood of salts of the calcium postponed in walls of vessels of internal bodies, first of all kidneys and heart. Hypervitaminoses D arises at overdose of this vitamin or an individual hypersensibility to it. Allocate a sharp and chronic intoxication with vitamin D.



Clinical picture

The sharp intoxication vitamin D develops at children of the first half of the year of a life at massive reception of vitamin D during rather short time interval (for 2-3 нед) or individual hypersensitivity to vitamin is more often. Thus there are signs neurotoxicosis or an intestinal toxicosis: appetite is sharply lowered, the child torture thirst often arises vomiting, the weight of a body quickly decreases, dehydration develops, and there are locks. At some children register short-term loss of consciousness, are possible toniko-klonicheskie spasms.

The chronic intoxication vitamin D arises against long (6-8 months and more) preparation applications in moderated, but all the same doses exceeding physiological requirement. The clinical picture is expressed less distinctly and includes the raised irritability, a bad dream, weakness, pains in joints, gradual increase of a dystrophy, premature closing big, and changes from cardiovascular and uric systems.

Treatment spends in a hospital. Cancel vitamin D and insolation, appoint vitamins A and Е, infusion therapy in a combination with urinoway. In heavy cases appoint prednisolone a short course.

The forecast is serious. Development nephrocalsinoses and a chronic pyelonephritis with subsequent development Chronic nephritic insufficiency is the most adverse.

The appendix №2
The instruction to independent work on

To the analysis and the decision of a practical situation
Sheet of the analysis of a situation


Work stages


Recommendations and councils

1. Acquaintance with a case

At first familiarise with a case Reading, do not try to analyze a situation at once

2. Acquaintance with the set situation


Once again read the information, allocate paragraphs which have seemed to you important. Try to characterise a situation. Define that in it important, and that is minor.

3. Revealing, a formulation and a substantiation of a key problem and subproblem

Problem: the Choice to tactics of conducting and definition of tactics of treatment in the conditions of WMP.



4. Diagnostics of the analysis of a situation

At the situation analysis answers following questions: What diseases, are accompanied with changes to bone-muscular system?

With what нозологиями it is necessary to carry out differential diagnostics and to define the most probable reasons of occurrence of rickets.

What methods of diagnostics are necessary for applying, make and prove the inspection plan at level WMP.

What additional consultations of narrow experts are necessary for statement of the definitive diagnosis? Define degree of necessity of the subsequent supervision (medicamentous and not medicamentous treatment).



5. A choice and a substantiation of ways and means of the decision of a problem

List all possible ways of the decision of the given problem in the given situation


6. Working out and permissions of a problem situation

Diagnose, will solve a problem in the conditions of WMP.


The appendix 3
KLASTER

КLASTER - a way of drawing up of a card of the information - gathering of ideas round any major factor for focusing and definition of sense of all design

Stimulates actualisation of knowledge, helps freely and to involve openly in thought process new associative representations on a theme











Differential diagnostics of rickets with as rickets diseases and osteopathy

Diseasis


The basic differentiating signs

Type

inheritance

Demonstration terms


Clinical displays


Radiological signs


Exchange infringements


Rickets of children of early age (classical)


In 3-6 mounts

• the Bone deformations caused остеомаляцией and hyperplasia osteoid of a fabric

• a hypotonia of muscles, weakness of the copular device

• moderate vegetative frustration


• «as saucer» expanded methaphysis

• absence of an accurate line preliminary

• an osteoporosis


In blood: phosphorus level is moderately lowered, calcium - is lowered or in norm, activity of enzyme alkaline phosphatesis raised


Multifactorial disease


Vitamin-D-depended rickets

In 3-6 mounts

• the Expressed bone deformations, characteristic for a "blossoming" classical rickets

• varus deformations of the bottom finitenesses

• backlog of rosto-weight indicators

• the expressed delay of motor development

• changes of the central nervous system: dream infringement, irritability, tearfulness, appetite decrease, sweating


• the System osteoporosis

• expressed thinking cortical a layer

• rachitic changes metaphysis and epiphyses lines preliminary


• In blood: phosphorus level is lowered or in norm, calcium - is sharply lowered, activity alkaline phosphates is sharply raised

• common peryaminoaziduria




Autosomno-retsessivnyj


Vitamin-D-resistents rickets (phosphatdiabetis)


In 1-1,5 years

fast progression varus

(0-shaped) deformations of feet, gait infringement, «rachitic beads, bracelets» - low growth at normal weight of a body





• Rough as glasses deformations metaphysis curvatures and thickenings of long tubular bones for the account one-hundred (medially го) thickenings corcing a layer periostium

• rough trabecular bone drawing



• In blood: phosphorus level is lowered, calcium - in norm, activity alkaline phosphates is raised

• phosphaturia




Prepotent, linked to the H-chromosome


Illness dе Toni-Debre-Fankoni

In 1-2 years

• Mixed (H - and 0-shaped) deformations of feet

• backlog of rosto-weight indicators

• causeless liftings of temperature

• polyuria, polydipsya

• muscular pains

• an arterial hypotonia, exchange infringements in a myocardium

• liver increase

• locks


• the Expressed osteoporosis

• trabecular drawing in distal and proximal departments diaphyses





• In blood: phosphorus level is lowered, calcium - is lowered or in norm, kaliy and sodium is lowered

• a proof uric syndrome

• glucosuria

• common peryaminoaziduria

• genetic function of kidneys is broken аммониоацидо


Autosomno-retsessivnyj


Nephritic tubular acidosis

In 5-6 months - 2-3 years


• the Expressed backlog of rosto-weight indicators

• a muscular hypotonia up to adynamic, muscular pains

• "rachitic" bone deformations and valgus deformation of feet

• irritability, tearfulness, swating, dream infringement

• an arterial hypotonia, changes in a myocardium


• the General system osteoporosis

• expanded metaphysis with indistinct contours and absence of a zone preliminary drawing

• a concentric atrophy of a bone


• In blood: levels of phosphorus, calcium, kaliy and sodium are lowered

• an uric syndrome

• calsiuria

• function of kidneys is lowered asidogenetics




Autosomno-retsessivnyj


Imperfect osteogenesis


On the first year of a life


• Plural bone crises with displacement

• backlog of growth

-weight indicators

• blue eyes, a bluish border on a teeth

• in more advanced age - otosclerosis, hearing deterioration


• the Expressed osteoporosis

• thincing cortical a bone layer

• crises with various degree of consolidation

• normal borders between epiphyses and diaphyses



In blood: calcium and phosphorus - in norm, activity alkaline phosphatase

- in norm




In most cases autosomno-prepotent, at congenital forms - autosomno-retsessivnyj


Xondrodystrophya

On the first year of a life


• Shortening of hands and feet at normal length of a trunk, a brush in the form of a trident, lumbar лордоз

• skin folds over joints

• a delay in development статокинетических functions


Long tubular bones are truncated, blacked intensively out", their heads are increased, as mushroom are blown up

In blood: calcium and phosphorus - in norm, activity alkaline phosphatase

- in norm




There are forms with autosomno-prepotent and autosomno-retsessivnym inheritance types


Hypophasphatis

On the first year of a life


• the Spherical form of a skull, гипофосфатемия (краниотабес)

• the expressed "rachitic" bone deformations

• backlog in growth

• a hypotonia of muscles

• backlog in development статокинетических functions


• the System sharp osteoporosis, bones almost

• wide "light" metaphysis spaces with short cylinders stiffened diaphyses and narrow epiphyses strips



In blood: calcium and phosphorus levels are raised or in norm, activity alkaline phosphatase

is lowered





Autosomno-retsessivnyj



The appendix №4
Variant of the decision of a case the teacher-kejsologom
1. Symptoms listed in the given situation are specified by that at the child

Rickets of II degree, the heat period, under a sharp current.


2. Недоношенность, artificial feeding, wrong introduction of a feeding up, frequent diseases promoted rickets development.
3. For diagnosis acknowledgement it is necessary to carry out the blood analysis on level of calcium, phosphorus and alkaline фосфатазы
4. Differential diagnostics with: as rickets diseases (the group hereditary tubulopthia which clinical picture in early terms of disease simulates a rickets, but is not connected with deficiency of vitamin D arriving in an organism; their leading syndrome are anomalies of a skeleton).
5. In the conditions of WMP it is necessary to appoint a vitamin D course in a dose 2000-4000 IU a day to 1-2 months, ­ polyvitamins.
6. Mother needs to give advice about eutrophy of the child.






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