Exercises for nursing, dentistry and medical students with an environmental approach

Health and disease are not two phenomena set apart, but they are the result of the interaction between man and the environment which surrounds him. We cannot see man as an isolated entity; he is submitted to different environmental aggressions, so that he responds to these according to his capacity.

The best doctor not only performs a correct diagnose and provides an adequate treatment but he should rehabilitate his cured patients.

The best doctor is the one who worries about there will be no diseases.

Objectives

To design and implement an English exercise proposal to find a way out to the English language curricula strategy and to the environmental health.

Development

Cholera

Read the following text carefully.

Cholera is an acute intestinal infection caused by the bacterium Vibrio cholerae. It has a short incubation period, from less than one day to five days, and produces an enterotoxin that causes copious, painless, watery diarrhoea that can quickly lead to severe dehydration and death if treatment is not promptly given. Vomiting also occurs in most patients.

Most persons infected with V. cholera do not become ill, although the bacterium is present in their faeces for 7-14 days. When illness does occur, more than 90% of episodes are of mild or moderate severity and are difficult to distinguish clinically from other types of acute diarrhoea. Less than 10% of ill persons develop typical cholera with signs of moderate or severe dehydration.

Cholera is spread by contaminated water and food. Sudden large outbreaks are usually caused by a contaminated water supply. Only rarely is cholera transmitted by direct person-to-person contact. In highly endemic areas, it is mainly a disease of young children, although breastfeeding infants are rarely affected.

Vibrio cholera is often found in the aquatic environment and is part of the normal flora of brackish water and estuaries. It is often associated with algal blooms (plankton), which are influenced by the temperature of the water. Human beings are also one of the reservoirs of the pathogenic form of Vibrio cholera.

When cholera occurs in an unprepared community, case-fatality rates may be as high as 50% — usually because there are no facilities for treatment, or because treatment is given too late. In contrast, a well-organized response in a country with a well-established diarrhoeal disease control programme can limit the case-fatality rate to less than 1%.

Most cases of diarrhoea caused by V. cholera can be treated adequately by giving a solution of oral rehydration salts (the WHO/UNICEF standard sachet). During an epidemic, 80-90% of diarrhoea patients can be treated by oral rehydration alone, but patients who become severely dehydrated must be given intravenous fluids.

In severe cases, an effective antibiotic can reduce the volume and duration of diarrhoea and the period of vibrio excretion. Tetracycline is the usual antibiotic of choice, but resistance to it is increasing. Other antibiotics that are effective when V. cholera are sensitive to them include cotrimoxazole, erythromycin, doxycycline, chloramphenicol and furazolidone.

When cholera appears in a community it is essential to ensure three things: hygienic disposal of human faeces, an adequate supply of safe drinking water, and good food hygiene. Effective food hygiene measures include cooking food thoroughly and eating it while still hot; preventing cooked foods from being contaminated by contact with raw foods, including water and ice, contaminated surfaces or flies; and avoiding raw fruits or vegetables unless they are first peeled. Washing hands after defecation, and particularly before contact with food or drinking water, is equally important.

The International Certificate of Vaccination no longer provides a specific space for recording cholera vaccinations.

Task I

1.1 Read the information again and find in the text the words or expressions that match the definitions provided.

• a) It is an acute intestinal infection caused by the bacterium Vibrio cholera.___________________________.

• b) The usual antibiotic of choice is called ______________________.

• c) Loss of a lot of water and salts ___________________________.

• d) Polluted water________________________________

• e) Management done daily. _____________________________

• f) Vaccination document._________________________.

1.2 Consult your answers with your classmate.

Task II

1.2 Answer the questions below according to the information above.

a) Define the medical term cholera.

b) How is it transmitted?

c) Could you mention the possible causes of it?

d) What are the most common signs and symptoms?

e) Can you state a differential diagnose?

f) What are the most frequent complications a patient would suffer from?

g) Provide an effective treatment for a patient who is suffering from this terrible illness.

Task III

As a doctor you have been assigned a community in the district of Siboney belonging to Rene Vallejo policlinic in Bayamo municipality which is suffering from cholera. Fill in the chart.

Task IV

1.-According to the information you already have about this disease prepare a doctor- patient conversation with your classmate. Be ready to dramatize it.

2. – After being analysed the epidemiological vulnerable geological zone which has a terrible health situation in the Siboney neighbourhood and taking into consideration the morbidity and mortality factors. Prepare a doctor-doctor discussion. Suggest a possible solution for this disease taking into account the environmental conditions of the area you are working in.

3. – Write a case report about a patient who suffered from cholera recently in Siboney area. Take into consideration the details you have already analysed in the reading.

Name: Luke Last name: Goss Age: 45 Sex: M Occupation: Police officer.

C/O: copious diarrhea and vomiting

Site: center of abdominal pain.

Radiation: migrates to his back.

Character: severe.

Onset: an hour ago.

Aggravating factors: after eating greasy meals.

Precipitating factors: appears after drinking coffee.

HPI: on admission denied dehydration on earlier occasions.

Other symptoms: Nausea/cramp abdominal pain.

PMH: Surgically treated/tonsillitis one year ago.

FM: His mother died of Myocardial Infarction/78 years old.

SH: +++ alcohol drinker and cigarette smoker/stressful job.

O.E: Tachycardia/weakness/emaciation/severe dehydration

T: 39.6 ?C.

B.P: 180/90mm Hg/ lost 6Kg/abdomen tender to palpation.

Ix: Hb ———————- 9.9 g/l

Stool culture ——— parasites.

Dx? DDx? Rx? Complications? Prognosis?

4. – Promote a health campaign against cholera in your community identifying the environmental factors influencing in it.

Dengue fever

Read the text carefully.

Dengue fever (UK: /'d??ge?/, US: /'d??gi?/), also known as break bone fever, is an infectious tropical disease caused by the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles. In a small proportion of cases the disease develops into the life-threatening dengue hemorrhagic fever, resulting in bleeding, low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs.

Dengue is transmitted by several species of mosquito within the genusAedes, principally A. aegypti. The virus has four different types; infection with one type usually gives lifelong immunity to that type, but only short-term immunity to the others. Subsequent infection with a different type increases the risk of severe complications. As there is no vaccine, prevention is sought by reducing the habitat and the number of mosquitoes and limiting exposure to bites.

Treatment of acute dengue is supportive, using either oral or intravenous rehydration for mild or moderate disease, and intravenous fluids and blood transfusion for more severe cases.

Signs and symptoms

Virology

Dengue virus

The mosquito Aedesaegypti feeding off a human host

Dengue virus is primarily transmitted by Aedes mosquitoes, particularly A. aegypti.[2] They bite primarily during the day. Humans are the primary host of the virus,[2][1] but it also circulates in nonhuman primates.[5] An infection can be acquired via a single bite.[16] A female mosquito that takes a blood meal from a person infected with dengue fever becomes itself infected with the virus in the cells lining its gut. Aedesaegypti prefers to lay its eggs in artificial water containers, to live in close proximity to humans, and to feed off people rather than other vertebrates.[7]

The diagnosis of dengue is typically made clinically, on the basis of reported symptoms and physical examination; this applies especially in endemic areas.[1] However, early disease can be difficult to differentiate from other viral infections.[5] A probable diagnosis is based on the findings of fever plus two of the following: nausea and vomiting, rash, generalized pains, low white blood cell count, positive tourniquet test, or any warning sign (see table) in someone who lives in an endemic area.[2] Warning signs typically occur before the onset of severe dengue.[8] It can be difficult to distinguish dengue fever and chikungunya, a similar viral infection that shares many symptoms and occurs in similar parts of the world to dengue.[7] Often, investigations are performed to exclude other conditions that cause similar symptoms, such as malaria, leptospirosis, typhoid fever, and meningococcal disease.[5]

Classification

The World Health Organization's 2009 classification divides dengue fever into two groups: uncomplicated and severe.[1][3]

Laboratory tests

Dengue fever may be diagnosed by microbiological laboratory testing.[3] This can be done by virus isolation in cell cultures, nucleic acid detection by PCR, viral antigen detection or specific antibodies (serology).

Prevention

A 1920s photograph of efforts to disperse standing water and thus decrease mosquito populations

There are no approved vaccines for the dengue virus.[1] Prevention thus depends on control of and protection from the bites of the mosquito that transmits it.[14][27] The World Health Organization recommends an Integrated Vector Control program consisting of five elements: (1) Advocacy, social mobilization and legislation to ensure that public health bodies and communities are strengthened, (2) collaboration between the health and other sectors (public and private), (3) an integrated approach to disease control to maximize use of resources, (4) evidence-based decision making to ensure any interventions are targeted appropriately and (5) capacity-building to ensure an adequate response to the local situation.[4]

The primary method of controlling A. aegypti is by eliminating its habitats.[4] This is done by emptying containers of water or by adding insecticides or biological control agents to these areas,[4] although spraying with organophosphate or parathyroid insecticides is not thought to be effective.[3] Reducing open collections of water through environmental modification is the preferred method of control, given the concerns of negative health effect from insecticides and greater logistical difficulties with control agents.[4] People can prevent mosquito bites by wearing clothing that fully covers the skin, using mosquito netting while resting, and/or the application of insect repellent (DEET being the most effective).[6]

Management

There are no specific treatments for dengue fever.[1] Treatment depends on the symptoms, varying from oral rehydration therapy at home with close follow-up, to hospital admission with administration of intravenous fluids and/or blood transfusion.[2] A decision for hospital admission is typically based on the presence of the "warning signs" listed in the table above, especially in those with preexisting health conditions.[5]

Epidemiology

See also: Dengue fever outbreaks

Dengue distribution in 2006.Red: Epidemic dengue and Ae. AegyptiAqua: Just . Aegyptiyearsearlier.[1]

Research

Research efforts to prevent and treat dengue include various means of vector control,[3] vaccine development, and antiviral drugs.[7]

With regards to vector control, a number of novel methods have been used to reduce mosquito numbers with some success including the placement of the guppy (Poeciliareticulata) or copepods in standing water to eat the mosquito larvae.

Task I

1. – Say true, false, or IDK .In case the answer is false. Support your respond.

a) ______ Dengue fever also known as break bone fever.

b) ______ It isn´t an infectious tropical disease caused by the dengue virus.

c) ______ Symptoms include fever, headache, muscle and joint pains.

d) ______ Dengue virus is primarily transmitted by Aedes mosquitoes, particularly A. aegypti.

e) ______ There are specific treatments for dengue fever.

f) ______ The World Health Organization's 2009 classification divides dengue fever into four groups.

g) ______ With regards to vector control, a number of novel methods haven´t been used to reduce mosquito numbers.

2. – Fill in the blanks identifying the correct ideas according to the information from the text.

2.1 Symptoms include _______, ________, ___________and__________________, and a characteristic ________________.

2.2 Dengue hemorrhagic fever, resulting in___________, ___________________________and blood plasma leakage, or into dengue shock syndrome, where _______________________________occurs.

2.3 The virus has four different types; infection with one type usually gives lifelong ____________to that type, but only short-term immunity to the others.

2.4 Treatment of acute dengue is supportive, using either oral or intravenous ________________for mild or moderate disease, and __________________________and ________________________ for more severe cases.

2.5 Humans are the primary ______of the virus, but it also circulates in nonhuman _______________.

2.6 _____________________ prefers to lay its eggs in________________________________, to live in close proximity to humans, and to feed off ___________rather than other vertebrates.

2.7 The diagnosis of dengue ________________________clinically, on the basis of reported symptoms and ____________________________.

2.8 The primary method of controlling A. aegypti is by eliminating its _____________. This is done by __________________________________or by adding ________________________________________to these areas.

2.9 Reducing __________________________________________through environmental modification is the preferred method of control.

Task II

1.1 Taking into consideration the reading information.

• Talk about signs and symptoms, cause and diagnosis.

• Compare dengue with cholera. Establish a differential diagnosis.

• What are the most common complications?

• What kind of investigations would you order to a patient who is suffering this disease?

• What are the risk factors?

a) How would you prevent this disease?

b) What´s the management for a patient who has been admitted to the hospital with this disease?

c) Suggest ways to control the vector. Support your choice.

Task III

• Report the following case. Mrs Kim a pregnant woman of thirty years old who came to the hospital suffering from fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles. Follow the model below.

• Comment on the different environmental factors influencing on the contribution to the proliferation of this pathology. Add it to your case report.

Mr /Mrs / Miss————-is a ——-year-old, black / white, male / female, married / single, occupation.(Gravid—–for——–abortions—–with a gestational age of——–weeks). Who came to the clinic complaining of————————-for————days / weeks / months. This pain is located in———————.The pain goes to the————–.It usually appears———————.H/She also suffers from—————–.The patient doesn´t smoke. H/She smokes cigars/She smokes—–cigarettes a day for——–years. H/She usually drinks coffee in the morning. H/She likes to drink alcohol every day / on —————-.H/She prefers to have some beers at ————–,on weekends. This patient has suffered from—————————-for——-years / months. His / her only serious medical history is—————-.and H/She has been treated with————–. H /She is allergic to penicillin. His / Her father / mother has suffered from——————–for——– years. Her/ His father / mother died of———————–.

On physical examination the positive signs are / were———-, ————, ——

On physical exam I find / found ———————–.

The patient is / was anxious. H /She is / was cooperative and alert. The temperature is / was——-degrees. His / Her BP is / was——/—–.The pulse is / was——and regular or irregular. His / her respiratory rate is / was —— per minute. The rest of the physical exam is / was negative / within normal limits.

(On abdominal exam the uterine height is / was—–cm. abdominal circumference is / was—cm. fetal heart sounds are / were ——-per minute. Fetal movements are / were present / absent. the position of the fetus is / was to the right / left, with cephalic / vertex / bleach presentation. Uterine tone is / was decreased / increased. On vaginal exam I found———-. The uterus is / was dilated—–cm)

We ordered the routine tests…………..

The————is / was normal / low / very high. The———- is / was———–.

The——————-shows / showed / revealed / demonstrates / demonstrated—————————–.

The patient may have————–because——————–.I am sure h /she has———————-.

In the differential diagnosis we should include———————————-.

The presence / absence of ————————- is against / in favour of a diagnosis of————————–

The patient should follow a proper diet. It should be rich in fruits and vegetables, low / normal in———–.H/ she shouldn´t drink alcohol. H/ she should cut down coffee / sugar /salt. H/ she should practice exercises.

H/ she must take these medications————————-.

The treatment is———————————–.

The patient may have some complications such as————————-.The most common complications are———————————.Complications are not usual in this kind of patients.

The prognosis is / may be reserved / bad if h/she has any complication. The prognosis depends on the complications and the patient´s response to the treatment. The prognosis is good if h /she follows the treatment correctly.

Task IV

• Prepare a doctor-doctor discussion taking into consideration the case report above. Work in pair.

1.2 It can be difficult to distinguish dengue fever and chikungunya, a similar viral infection that shares many symptoms and occurs in similar parts of the world to dengue.

• a) How would you distinguish dengue from chikungunya? Explain to your partner.

• b) Recommend your co-worker ways to prevent this terrible illness taking into account the different environmental factors influencing in the proliferation of this disease. Be ready to answer any question regarding this topic.

• c) Could you mention the different environmental factors? Write different measures for a campaign to fight Aedes mosquitoes, share them with your classmates. Work in team.

• d) Provide an environmental approach which helps to find an effective way out to this problem.

• e) Is there any similarity between dengue and chikungunya ? Back your answer up with no less than five statements.

Ebola

• I. Read the fallowing text carefully

Electron micrograph of Ebola virus.

What is Ebola haemorrhagic fever?

Ebola haemorrhagic fever is one of the deadliest of a group of diseases called viral haemorrhagic fevers. They range in seriousness from relatively mild illnesses to severe and potentially fatal diseases. All forms of viral haemorrhagic fever begin with fever and muscle aches. Depending on the virus, the disease can get worse until the patient becomes very ill with breathing problems, severe bleeding (haemorrhage), kidney problems, and shock.

Viral haemorrhagic fevers are caused by viruses from four families: filoviruses, arena viruses, flaviviruses, and bunya viruses. The usual hosts for most of these viruses are rodents or arthropods (such as ticks and mosquitoes). In some cases, the natural host for the virus is not known. 

The incubation period for Ebola HF ranges from 2 to 21 days. The onset of illness is abrupt and is characterized by fever, headache, joint and muscle aches, sore throat, and weakness, followed by diarrhea, vomiting, and stomach pain. A rash, red eyes, hiccups and internal and external bleeding may be seen in some patients.

Researchers do not understand why some people are able to recover from Ebola HF and others are not. However, it is known that patients who die usually have not developed a significant immune response to the virus at the time of death.

Diagnosing Ebola HF in an individual who has been infected only a few days is difficult because early symptoms, such as red eyes and a skin rash, are nonspecific to the virus and are seen in other patients with diseases that occur much more frequently. However, if a person has the constellation of symptoms described above, and infection with Ebola virus is suspected, isolate the patient and notify local and state health departments and the CDC.

What laboratory tests are used to diagnose Ebola haemorrhagic fever?

Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM ELISA, polymerase chain reaction (PCR), and virus isolation can be used to diagnose a case of Ebola HF within a few days of the onset of symptoms. Persons tested later in the course of the disease or after recovery can be tested for IgM and IgG antibodies; the disease can also be diagnosed retrospectively in deceased patients by using immunohistochemistry testing, virus isolation, or PCR.

How is Ebola haemorrhagic fever treated?

There is no standard treatment for Ebola HF. Patients receive supportive therapy. This consists of balancing the patient"s fluids and electrolytes, maintaining their oxygen status and blood pressure, and treating them for any complicating infections.

How is Ebola haemorrhagic fever prevented?

Health-care providers must also have the capability to perform diagnostic tests and be ready to employ practical viral haemorrhagic fever isolation precautions, or barrier nursing techniques. These techniques include the wearing of protective clothing, such as masks, gloves, gowns, and goggles; the use of infection-control measures, including complete equipment sterilization; and the isolation of Ebola HF patients from contact with unprotected persons. The aim of all of these techniques is to avoid any person"s contact with the blood or secretions of any patient. If a patient with Ebola HF dies, it is equally important that direct contact with the body of the deceased patient be prevented.

Ebola Hemorrhagic Fever 

• Ebola [ee-BO-luh] haemorrhagic fever is a deadly disease that has occurred in outbreaks in Central Africa.

• Ebola haemorrhagic fever is caused by several Ebola viruses. The source of these viruses in nature is not known.

• People can get Ebola haemorrhagic fever by direct contact with virus-infected blood, body fluids, organs, or semen.

• There is no known cure or treatment.

• Recent outbreaks in humans have occurred in areas where medical supplies and care were inadequate.

• The outbreaks were controlled by using barrier nursing techniques.

• Under normal circumstances, travellers are at low risk of getting the disease. To eliminate the risk, travellers should avoid areas where Ebola outbreaks are occurring.  

People get the disease by direct contact with virus-infected blood, body fluids, organs, or semen.

The disease is spread mainly by close person-to-person contact with severely ill patients. This happens most often to hospital-care workers and family members who care for an ill person infected with Ebola virus. Close personal contact with persons who are infected but show no signs of active disease is very unlikely to result in infection.

Ebola virus can be spread from person to person through sexual contact. Persons who have recuperated from an illness caused by Ebola virus can still have the virus in their genital secretions for a short time after recovery and can spread the virus through sexual activity. 

People infected with Ebola virus have sudden fever, weakness, muscle pain, headache, and sore throat, followed by vomiting, diarrhea, rash, limited kidney and liver functions, and both internal and external bleeding. Death rates range from 50% to 90%. 

Symptoms begin 2 to 21 days after infection. 

Diagnosis requires specialized laboratory tests on blood specimens. Handling blood from persons infected with Ebola virus is an extreme biohazard and can be done only in specially equipped laboratories. Diagnosis in patients who have died can be made by testing tissue samples. 

• Persons travelling to areas where Ebola haemorrhagic fever is occurring

• Hospital staff and family members who care for patients with Ebola haemorrhagic fever

• Central African residents of rural areas and small towns  

There is no known cure or treatment. Severe cases need intensive supportive care. 

Under normal circumstances, travellers are at low risk of getting the disease. To eliminate the risk, travellers should avoid areas where Ebola outbreaks are occurring.

Task I

• Answer the following questions about the reading.

• Is Ebola haemorrhagic fever infectious?

• Can a patient die because of it?

• Where it was found for the first time?

• Who is at risk for Ebola haemorrhagic fever?

• How soon after exposure do symptoms appear?

• What is the infectious agent that causes Ebola haemorrhagic fever?

II. – Complete the ideas taking into account the reading information.

• Ebola haemorrhagic fever is __________________________ of a group of diseases called ____________________________.

• They range in seriousness from__________________________________ severe and potentially fatal.

• The disease can also be diagnosed retrospectively in deceased patients by using _____________________________________________.

• Techniques include the ___________________________________________________________.

• Can be used to diagnose a case of Ebola HF within a few days of the onset of symptoms using different lab tests such as _________________________________________________________________________.

• The disease is spread mainly by _______________________________________________ .

Task II

• Recreate the consultation.

You have a patient who is suffering from fever, headache, joint and muscle aches, sore throat, and weakness, followed by diarrhea, vomiting, and stomach pain. A rash, red eyes, hiccups and internal and external bleeding.

• a) How is Ebola haemorrhagic fever treated?

• b) What laboratory tests are used to diagnose Ebola haemorrhagic fever?

• c) How can Ebola haemorrhagic fever be prevented?

• d) What are the precipitating factors?

• e) What are the aggravating factors?

• f) What are the relieving factors?

• g) What are the risk factors?

• Make the differential diagnosis for Ebola disease.

• Prepare a doctor- patient discussion with your classmate, taking into account different environmental conditions.

Task III

1.1 Write a case report with the information from this clinical chart. Follow the hints.

Mary Stuart Married. Job Teacher Age 45

CO: several episodes of headache, joint and muscle aches, sore throat, and weakness, followed by diarrhea, vomiting, and stomach pain. A rash, red eyes, hiccups and internal and external bleeding.

Onset A-12

HPI On admission denied fever.

PMH: Surgically treated gallbladder stones two years ago.

FH Significant father died dengue some years ago, sister diagnosed haemorrhagic fever.

SH: +++ heavy smoker and coffee drinker. Sometimes alcohol.

O.E: Weakness, external bleeding.

B.P: 140/100mm Hg/lost 5 Kg last month followed by vomiting.

Ix: Hb_________________ 10.7g /l

Antigen-capture enzyme-linked immunosorbent assay

(ELISA) testing, IgM ELISA, polymerase chain reaction (PCR).

DDx: ? Dx: ? Rx: ? Complications? Prognosis?

1.2 After being analysed the doctor- patient discussion, the reading and the case report prepare a doctor-doctor discussion with your classmate.

a) Get into small groups and discuss about prevention of Ebola in the community you are working at.

b) What would you suggest to the population?

c) What challenges remain for the control and prevention of Ebola haemorrhagic fever?

d) What environmental factors would you take into consideration to fight this disease?

Task IV

1.3 How do people get Ebola haemorrhagic fever?

1.4 What are main causes of this pathology?

1.5 Answer the patient´s questions. Work in pair.

• What is Ebola?

• How is it spread?

• How long after infection do symptoms appear?

• How long will symptoms last?

• What should I do if I think I may have Ebola?

• How is Ebola hemorrhagic fever diagnosed?

• What is the treatment for it?

• My child does not have diarrhea, but was recently diagnosed as having Ebola. My health care provider says treatment is not necessary. Is this true?

• If I have been diagnosed with Ebola, should I worry about spreading the infection to others?

• How can I prevent Ebola infection?