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b) compliance with the rules of personal hygiene: washing hands with soap before eating and after using the toilet, the frequency of changing of underwear and bed linen, the presence of pediculosis in the family;
c) the workplace of the sick person; general hanger, towel, dishes and other household items; toilet, its type, sanitary condition;
d) dates for visiting cultural and public places;
e) nutritional conditions: where the patient was fed within 35 days before the disease. Who prepared the food and where the food was taken, their storage. Sanitary condition of the canteen. When a patient has liquid stool, vomiting, abdominal pain, indicate that he had eaten a week before the disease with an emphasis on the last two days (list all products, their organoleptic properties, focus on eating curd, sour cream, milk from not thermally processed, as well as unwashed vegetables and fruits). Who else ate these foods, their well-being;
f) water use conditions: sources of water supply and use of boiled water;
g) departure outside this area, departure and return dates, type of transport, living conditions, water use, hygiene rules (see clauses a, b, e)
h) arrival of unauthorized persons to the patient, terms, degree of contact;
i) terms of stay in endemic regions for hemorrhagic fever with renal syndrome, tick-borne encephalitis, tularemia, malaria, etc .; mosquito bites, gadflies, sucking ticks;
j) terms of bathing in open reservoirs and drinking water;
k) transfusion of blood, plasma, blood substitutes; surgeries, instrumental examinations, injections, blood donation, treatment and removal of teeth, manicures and other manipulations for the last 6 months before the disease.
3. How has vaccination been subjected to over the past year?
Epidemiological analysis: a conclusion about the source of infection, factors, ways and mechanism of transmission of infection.
Objective examination data
General condition (satisfactory, moderate, severe, very severe). Position (active, passive, forced). Body type. Weight. Color sclera, vascular injection. Face: skin color, puffiness. Skin turgor, moisture, scars, scratching marks, erythema palmar, spider veins, varicose veins. Rash: localization, nature, number of elements. Mucous membrane of the oral cavity: condition of tonsils, pharynx, pharynx, teeth. Subcutaneous tissue: development, edema. Peripheral lymph nodes. Osteo-articular and muscular systems.
Nervous system
Consciousness. Mind. Cranial nerves. Meningeal symptoms. Corneal, pharyngeal, skin, tendon reflexes. Pathological reflexes. Dermographism.
Respiratory system
Vote. The shape of the chest. The width of the intercostal spaces. Type of breathing. The number of breaths per minute. Data percussion and auscultation of the lungs. Bronchophony and voice tremor.
Cardiovascular organs
Apical thrust. Data percussion and auscultation of the heart. Pulse rate and its characteristic. Arterial pressure.
Digestive apparatus
The state of the language. Abdomen configuration. These superficial and deep palpation of the stomach, pancreas and intestines. The shape, thickness, mobility, pain of the colon. Free fluid in the abdominal cavity. Stool.
Hepatolienal system
Liver percussion: the upper and lower borders along the anterior midline, mid-clavicular and anterior axillary lines. Palpation: how many centimeters is the liver below the costal arch, its edge, surface, consistency, and pain. Symptom Grekov-Ortner. Soreness in cystic point, Courvosier's symptom, phrenicus-symptom. Percussion of the spleen: diameter - mid-axillary line, dlinnik - along the X edge; palpation; how many centimeters below the costal arch, consistency, pain.
Urinary organs
Swelling of the kidney area. Palpation of the kidneys. Soreness and projections of ureters. Palpation and percussion of the bladder. Symptom of Pasternack. Urine color (based on personal examination). Daily diuresis.
Endocrine system
Thyroid gland, its size, consistency. Secondary sexual characteristics.
Provisional diagnosis
Provisional diagnosis (indicating the nosological and clinical forms, the severity and period of the disease).
Complications.
Concomitant diseases.
Provisional diagnosis diagnosis without justification.
Curator's signature
Survey plan
General analysis of blood, urine, feces on helminth eggs, blood group and Rh factor, blood to Wasserman reaction, fluorography, ECG (if indicated). Additional and special research methods (biochemical, bacteriological, virological, serological, allergological, instrumental, etc.) to confirm the diagnosis and conduct a differential diagnosis. Consultations of various specialists (oculist, otolaryngologist, etc.)
Curator's signature
Treatment plan
1. Mode, its justification
2. Table number (features of the designated food regime, list the products that can be consumed to the patient).
3. Medical purposes, which must be rational and adequate to the disease of the supervised patient and conform in form and content to the requirements of the Pharmacopoeia. The drugs are written out in Latin, indicating the single and daily doses, the method of administration, the duration of the course of treatment. To substantiate the pathogenetic effect of all prescribed drugs.
Curator's signature
A diary
| Date Temperature in the morning and in the evening Pulse Pressure | Complaints of the patient. Assessment of the general condition. Description of the state of the activity of organs and systems in a sequence corresponding to the section of the medical history “Objective examination data” Reflection of the daily dynamics of the main clinical manifestations of the disease. Stool. Diuresis. | Medical and diagnostic appointments for this day. |
Laboratory and instrumental data
Inclusion in the history of the disease the results of laboratory, radiological and other special studies with the date, as well as these consultations of specialists.
Conclusion on the analysis - note the identified changes.
Differential diagnosis
The basis is a leading syndrome or symptom of a disease in a given patient (fever, intoxication, jaundice, gastroenterocolitis syndrome, meningeal syndrome, renal, hemorrhagic, etc.). The differential diagnosis is carried out by comparing the symptoms that exist in the supervised patient with the clinical picture of a disease. The cyclicity in the development of the disease, age, sex, season of the year are taken into account. Objective data and laboratory results are compared. The epidemiological history is taken into account. Differential diagnosis is carried out in 3 - 5 diseases. The clinical diagnosis is established.
Rationale for clinical diagnosis
It is carried out on the basis of symptoms or syndromes characteristic of a given disease and their cyclicity, pathological changes in the body, detected during an objective examination, data from laboratory and instrumental methods of investigation, and epidemiological history. The form of the disease, the severity of the disease (according to the clinical classification) are separately substantiated.
Complications (justify).
Concomitant diseases (transfer).
Curator's signature
Epicrisis
Patient name, age, entered the clinic of infectious diseases (date) on ____ day of illness with complaints ______________________________________
Directional diagnosis_________________________________________________
Provisional diagnosis_________________________________________________
Reasons for his statement (complaints, history of the disease, epidemiological history, objective data and laboratory, if they were carried out before hospitalization).
What diseases were used for differential diagnostics ________________
Clinical diagnosis __________________________________________________________
Grounds for his statement (complaints, history of the disease, epidemiological history, objective, laboratory, instrumental, radiological and other used examination methods). If the clinical diagnosis coincides with the preliminary, then in the justification we exclude complaints, history of the disease, epidemiological history, objective data.
The dynamics of the disease, especially the course, complications.
Concomitant diseases_____________________________________________________
Treatment: etiotropic (indicating the course dose of antibiotics, sulfonamides, immunoglobulins, etc.), pathogenetic (if CGS is used, then indicate the course dose), symptomatic, local.
The condition of the patient at the time of termination of the supervision or discharge.
Forecast (nearest and remote) in relation to life, disability. VVE (for curators of the Navy).
Rules of discharge according to the orders of the Ministry of Health of Russia.
Medical recommendations at the time of discharge.
Clinical examination.
Curator's signature
Current disinfection in the outbreak
Prevention
Annex 1
Accounting form 58
Emergency Notification of Infectious Disease
1. Diagnosis ____________________________________________________________
2. Surname, name, patronymic _______________________________________________
3. Husband, female (emphasize). 4. Age of _________ 5. Address: populated area _______________ district ___________ ___________ street No. _____ sq. _______
6. Name and address of the place of work, study (for children - children's institution), position _______________________________________________
7. Date of illness ________________________________________________________
8. Date of initial treatment (for this disease) __________________
9. Place and date of hospitalization ______________________________________________
10. If poisoning - indicate where it happened and what _____________________________
11. Conducted primary anti-epidemic measures and additional information _____________________________________________________________________________________________________________________________________________
12. Date and time of primary signaling of the disease in sanitary-epidemiological service
Last name of the person who reported _______________
Who received the message ________________________
Appendix 2
Hematological parameters of a healthy person
| Indicators | Normal values |
| Erythrocyte male female | 4,0 – 5,0 ⃰ 10 12/л 3,7 – 4,7 ⃰ 10 12/л |
| Hemoglobin male female | 130 – 160 г/л 120 – 140 г/л |
| White blood cells | 4,0 – 9,0 ⃰ 10 9/л |
| Basophilic relative absolute | 0 – 1 % 0 – 0,3 ⃰ 10 9/л |
| Band kernels | 1 – 6 % |
| Segmental | 45 – 70 % |
| Lymphocytes | 18 – 30 % |
| Monocytes | 2 - 9% |
| Color indicator | 0,8 – 1,1 |
| Reticulocyte | 2 – 10 % |
| Platelets | 114 – 335 ⃰ 10 9/л |
| Erythrocyte sedimentation rate male female | 1 – 10 мм/час 2 – 15 мм/час |
Appendix 3
Urine test results
| Indicators | Normal values |
| Colour | Straw yellow |
| Urine density | 1,008 – 1,022 |
| Protein | Negative |
| Bile pigments | Negative |
| Sugar | Negative |
| White blood cells | 0 – 5 in sight |
| Red blood cells | 0 – 1 in sight |
| Epithelium | 0 – 5 in sight |
| Cylinders | Negative |
| Alpha amylase | 7,2 – 44 мг (с.л.) |
| 17 - ketosteroids | Male 28 – 8 mkmol/day female 15 – 55 mkmol/day |
The content of uniform elements in 1 liter of urine
| In the Nechiporenko trial | In the Kakovsky-Addis trial |
| Leukocytes not more than 4.0 ⃰ 10 5 / l | Leukocytes 2 ⃰ 10 6 - 4 ⃰ 10 6 / day |
| Red blood cells no more than 1 ⃰ 10 5 / l | Erythrocytes 1 ⃰ 10 6 - 2 10 6 / day |
| Cylinders | Cylinders 2 ⃰ 10 6 / day |
The study of daily variations in the density of urine in the sample Zimnitsky
Urine density 1,008 - 1,025
Daily diuresis more than daily
Total diuresis 800 - 1600 ml / day
Appendix 4
Serum protein fractions
| Albumins | 61 – 63 % |
| Globulins α1 α2 β1 β2 | 39 – 37 % 5,5 – 6,0 % 6,5 – 7,0 % 9 – 10 % 15 – 16 % |
I
Indicators of biochemical studies of blood serum
| Indicators | Normal values |
| Residual nitrogen | 14,3 – 28,5 mmol/l |
| Alanine aminotransferase | 0,1 – 0,68 mmol |
| Aspartate aminotransferase | 0,1 – 0,45 mmol |
| Amylase | 3,3 – 8,9 mg |
| Common protein | 65 – 85 g/l |
| Bilirubin | 8,5 – 20,5 mkmol/l |
| Glucose | 3,3 – 5,5 mmol/l |
| Creatinine male female | 44 – 100 мкмоль/л 44 – 88 мкмоль/л |
| Urea | 2,5 – 8,3 mmol/l |
| Potassium | 4,1 – 5,6 mmol/l |
| Sodium | 134 – 169 mmol/l |
| Sialic acid | 135 – 200 ed |
| Alkaline phosphatase | 139 -360 mmol |
| Chlorides | 95 – 110 mmol/l |
| Total cholesterol | 3,0 – 6.2 mmol/l |
| Sublimate test | 1,8 – 2,2 ml |
| Thymol test | 0 – 4 еd |
| β - lipoproteins | 3,0 – 4,5 g/l |
| Prothrombin index | 80 - 100% |
| Fibrinogen | 2,0 – 4,0 g/l |
| Antistreptolysin | 50 – 250 еd |
| C-reactive protein | Negative |
| Antistreptokinase | До 128 еd |
| Alkaline reserve | 420 -460 мг % NaOH |
