COMMUiN I CABLE DI SEASES STUDENT TEXT 1980 Rural Health Development Project Ministry of Health and Social Welfare Maseru, Lesotho ACK NOWLE;DGEMEN:'TS Nurse C.inician tVaini.nq mateL ial :;are Lesotho adaptations based upon the ME:DiEX proLotype curriculum for L'a.inin mid-Lo vol health workers. ['le prototype MiDEX matLerials 'or developed by Lhe Halth Manpowe r DovelO\opient Sta :ff of the ,Iohn A.Itirls School Med f iie, Univrsity of Iawai . The or.'ig.nili .1 prototypeS we re based on ttraini.nq ex2.U, IiiOn Ce in over a dozen third-world ccuntrios. These were reviaed on the basis of MDS experienaace in Micronesia, Till.and, Pakistan, and Guy ana beftore being made availab.Le to Lesotho under ai UI.S.A.I.D. funded 'ontract. Major adaptation in lesotho began at: the National Nurse Clini~cian T'ira. ninq " ,oqraimmo Curr iculum Adaptation Works:l'.hopt ld a, , 'Mzv.od in ,.nuary L98G. The ncar.y Li fty parti2i.paniLa uce senLtd alI majcr halth and ;i'ualth related ativ iuLits in Lesotho, hoth G ove rnienL and prIvate. h'iie'e participants and othrs workinj as irdividuas and tLhen as rvrev, i commi tees have adapted the Nurse Cli.niciai traini 1 aterLj.sL to eeLt the conditions and nee:ds of Lesoatho. The 6overnment of lenotho and particularly the staff of the Nurse C linir'i.an traini.ing 'rogrmme are grateful to IlMDS for :supilyin, the proottype materials and to a].]. thos individuals h.;Io have nelped in the Lesotho adaptation ioI. scs. Ii ast ILion M' 1980 TABLE OF CONTENTS LIST OF REFERENCES . .. .. .. .. .. .. 1 SCHEDULE . 2 MENINGITIS, TETANUS . 3 Meningitis .......................... 5 Tetanus ....... ................... 11 LEPROSY ......... ..................... 17 DIAGNOSTIC SKILL: Examining Lesions for Absence of Feeling (Anaesthesia) ...... ............... .. 27 Examining Patient for Enlarged Nerves .... 28 Performing Skin Smear .... ............ .32 TYPHUS AND DIPHTHERIA ..... .............. .44 Typhus ........ .................... 48 Diphtheria ........ .................. 50 Module Phase Skill Evalua ion ... .......... 53 Performance Evalu1ation Checklist ... ......... .. 54 REFERENCES USED IN TIHE COMMUNICABLE DISEASE MODULE General References Manson-Bahr, V. 1I. Manson's Troical Diseases, 16th. ed. Williams and WiLkins, Baltimore, 1966. Sloan, N.R., eL al. AcedapLsone in Le)osy,. Chemoprophy oxis: Yield Trial. Davidson, Israel; Hacnry, J.13. (eds. Clinican Diaqnosis 1. Laboratory Methods, (14th.Edition) W.B.Saunders Company, 1969. "Drugs for Parasitic Infections," '[he Medical Letter on Drugs and Therapeutics, Vol.20, No.4 (issue 499), February 24, 1978. "The Choice of Antimicrobial Drugs," The Medical Letter on Drugs and Therapeutics, Vol.'20, No.1 (Issue 496), January 1.3, 1978. Harrison's Principle; of Internal Medicine, (8th. Edition) McGraw-Hill, New York, 1.977. Berelson, Abram S. Control of Communicable Diseases in Man, APIHA, 12th. Edition, 1975. Leprosy Chart Leprosy Card, Community Medicine, Medical Faculty, Dar es Salaam. Leprosy Charts, Leprosy Mission in Lesotho, Maseru, Lesotho. .2'AZ2 i b":" 3 {DAY 4 I I NA 3 STUDENT GUIDE MENINGITIS AND TETANUS I Entry Level Knowledge and Skills Before starting this unit, you should be able to: 1. Describe the associated anatomy and physiology of the nervous system including: -innervation of muscles -brain and spinal column and their relationship to the fontanelles -and respiration 2. Explain infection process (bacteria and virus) including spread by droplet and wound contamination. 3. Actions and dosages of the following drugs: Ampicillin, Sulfadimidine, Penicillin, Chloromyctin 4. Recognize and describe: headaches, fever, photo­ phobia, seizures, infection of the ear, throat and/or lungs and spa sm1s. 5. Demonstrate wound cleaning and debridement (See Emergency Module). 6. Discuss active and passive immunizations and anti­ bodies. 7. Pirst aid for convulsions (See Emergency Module). I. Objectives: Using the information and experiences provided by the instructor and module text, you will be able to: 1. Identify the pnysical signs and complications associated with meningitis and tetanus. 2. Demor trate physical exam procedures associated with meningitis and tetanus. 3. Describe general characteristics and course of the following diseases including the discriminations: -Meningitis: Neck stiffness, bulging anterior} fontanelle in children, levels of consciousness. -Tetanus: Jaw muscle spasm, localized vertebral pain with muscle spasm. 4. Describe the management procedures for meningitis and tetanus. 5. Explain the spread of meningitis from person to person and how this can be prevented. 6. Discuss the etiology, transmission and risk factors of tetanus. 7. Discuss the immunization and prevention principles of tetanus. III. Evaluation: Module Phase: Upon completion of the module you will be assessed on: 1. Knowledge: Written test based upon contents of unit in module text. Acceptable performance, 802. 2. Skills: Your ability to recognize siyns and symptoms of meningitis and tetanus. Your ability to desceibe management and prevention procedures for each of the above listed diseases. Rotation Phase: Upon completion of the rotation phase, you will be assessed on: 1. Your ability to diagnose and manage the following diseases with the use of appropriate protocols and treatment guides. 2. Your ability to perform physical examination indicated for meningitis and tetanus. IV. Activities you will be using to accomplish the objectives: 1. Read module text and answer review questions. Discossion. 2. Instructor demonstration of physical exam pro­ cedures for meningitis (stiffness of neck or back and bulging fontanelle). 3. Students practice examination of discriminations for meningitis and tetanus. 4. Student groups write and present conuunity pre­ venLion methods for meningitis and tetanus. 5. Clinical practice for students to idertify abnormal signs associated with meningitis and tetanus. 5 MiN 1ING [GTIS Genera]. Cons .Lderations Mengnitis i; the i.,i[Laimuation of the niemb canes c(o)vO r 1.1i, the brain and :s;I il I L cord. Those membranes arc tough, fibrous sheath;s Liat protect thLe central nervous system. "'Ale momb ra n(s can ho;come intecLed by almost any ha tor1. or virus. Me iugn igLis can resu It rom a '.pread ilng bacterial infection. The most common :ause i. ; )y a type of bacteria tLhat c'n also cau:se sore thlroats, liddl.e ear infections, (r pieullmllolli-. The !;ymptoIlls are theisa regal-dl.ess of which bacteria or virus causes the 1ienill­ gilis. Meningi tis ca also be caused by tuberculos;, especially in cnildren aged i to 5 years. In this case, the symptoms Iiiay have -- more ( tl:dli .sot. le:g rd less,; of which type of infection c auses inening t is, when tle membranes Lecomo infected they become inflamed, so any movement which streLLches them bccomes very painful . As a defence against this pain, the body'i; .uscles ill the neck, back and legs tigh ten to "splint" or prevent move­ meint of tie spine. Therefore, a patient: wi. Li men ingitis is Very tincollol( L'ab.le and si(:1 wi. Li a iIghi fe:;ver from the widespread infection d ilhas ecve 7e ih . ILit lliovelilel t of Lteir neck 17 back. Unless Lr(a ted, the patient may nc- Comlle drowsy, !;(.?Ill iCola Os2 or on%'l COml1,1tso and may die Meuningiti,; n:r; il.l over the world, in all ages. The 1)-ic tera or v i 175:; en: us i I(tlllelli llig -i: , is usual Ly passed in dropletL-:.; of 5; ii.,ii, when l)cipLe breathe and cotigh min r each o-her [luopui.e luau t aI ;il; 2 qot menii ngi. tis are those who ar2 already weak ors ici:. b:ILdren exposed to soiieOfl]o having ttieircu e 10:;7i:;a.o iklo.y to get tuberculosis meningiLi; tLhan adulL;. O(ne of the be. ; L I'teI.i ids of p;7r'. ing men ingitis from spreading .:; eirl' h Leetucti en and treatment. J:-i t..I!; :i. hi.; c ;.i1 ~t: To exaline for neck 017 spinie stiffness, have the patient lie on his bick oil the examin ing table while you support hi.s head. (A sira]1.. ciii.].d can Lie ol ii s mother's lap, his. s iouders :; ul)oI: tCd Oil her knees ) loidH. tile patiellt 's head wiLii (i(! h (l aimid ent ly bend it forward (chin oward chest). (See i'i.gtLlr: CD 1) ,'/ Figure J o~fockPit'! f;t i.j,?18, If tnere is neck stiffness, you will feel tightened muscles resisting the bending, and the patient may com­ plain of pain. If there is spine muscle stiffness, the patient's knees may draw up when you try to bend the neck forward. If you are in doubt for example, (the neck does bend, but seems stiff or the patient complains of even mild pain), consider this to be stiffness and refer the patient. Summ-ry: 1. Have the patient lie on his back with one hand behind his head which you support with your hand. 2. Gently try Lo bend the neck, bringing patient's chin to his chest. 3. If tue ;ueck will not bend, feels stiff, causes pain, or the knees bend up, there is neck stiffness. 2. In Child up to 6-months old, Palpation of the Fontanelle The anterior fontanolle is the front, diamond-shaped soft spot on the tLot) of a baby's head where the skull bones have not yet fu'sed. In a quiet baby, the fontanelle feels like a soft, diamond-shaped indentation. When a healthy baby cries or coughs, the anterior fontaneile bulges, so the exain must be done when the baby is quiet. When a baby has meningitis, a bulging fontanelle that feels full and tense may be present. (See Figure CD 2) If the soft spot is SWOLLEN, >1 . thle baby ­ may have MENINGITIS Figurec CD 2 Summary: 1. When the baby is quiet, feel the fontanelle.