LESSON № 8 (PRACTICAL – 6 HOURS)

June 2, 2024
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LESSON8 (PRACTICAL6 HOURS)

 

Theme: Cerebral vascular diseases of the Brain and Spinal cord. Hemorrhagic strokes  (subarachnoid hemorrhage, intracerebral hematoma (or apoplectic stroke) and ventricular hemorrhage). Etiology and pathogenesis, clinical characteristics, diagnosis and treatment of strokes.

 Clinical observation of the patients. General examination of a patient and filling in the

patient’s Case Report.

           

Aim: Students should be able independently to diagnose, to prescribe treatment. To make   preventive measures. To fulfill medical labor examination. To study etiology and pathogenesis of disturbances of cerebral circulation, strokes, clinical characteristics and the maieurological signs of strokes, which are necessary to put a correct diagnosis and to administer emergency treatment of acute disturbance of the cerebral circulation.

Students should be able by themselves to examine neurological patient, to make the topical and clinical diagnosis, to prescribe adequate treatment, and to record the patient’s Case report.

 

Professional orientation of students: Medical service of a modern level demands experts who independently are able to diagnose and give the help to the patient with neurological pathology. Lesion of the nervous system caused by different pathology of infection, vascular, endocrinal, traumatic, tumor and other character. All specialists of medicine must make a correct topical and clinical diagnosis for adequate pharmacotherapy. General examination of a patient and filling in the patient’s Medical Card is done by all the doctors (independently from specialty) according to determined set. Careful history, subjective and objective clinical symptoms of a disease is the base for correct topical and clinical diagnosis and adequate treatment scheme for each patient. To form proper clinical thinking and deontology. 

 

Methodology of Practical Class (9:00-12:00).

Algorithm of students’ communication with patients with pathology in subject (communication skills):

Complaints and anamnesis taking in patients

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing

4. Find a contact with a patient, try to gain his/her confidence

5. Correct inquest, listening to the patient’s explanation.

6. Conversation accomplishment.

 

Physical methods of examination

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing

4. Find a contact with a patient, try to gain his/her confidence

5. Explain to the patient the nessessity of the examination and its aim, get his/her informed consent

6. Explain to the patient examination details, its safety and possible sensations

7. Prepare for the examination (clean, warm hands, ets.)

8. Explain to the patient results of his/her tests correctly and accesibly

9. Conversation accomplishment.

 

Informing about the results of examination

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing

4. Interpretation of test results

5. Calm a patient in the case of precense of pathological changes, inform about the following actions

6. Assure in positive changes and favourable prognosis at implementation of all of the medical recommendations

7.Conversation accomplishment

 

Work 1.

Hemorrhagic strokes (subarachnoid hemorrhage, intracerebral hematoma (or apoplectic stroke) and ventricular hemorrhage). Etiology and pathogenesis, clinical characteristics, diagnosis and treatment of strokes.

Step I.  Aim: To make the clinical diagnosis. For this purpose it is necessary:

To determine types of acute disorders of the cerebral circulation.

To determine Carotid or Vertebrobasilar vessels distribution.

To find the reasons to cause disorders of cerebral circulation.

To determine types of stroke and find the periods of stroke.

To formulate the diagnosis, for example: Intracerebral subarachnoid hemorrhage, acute period, aneurysm of cerebral vessels.

 

Step II. Aim: Administer emergency treatment. For this purpose it is necessary to choose:

1.      Undifferentiated emergency therapy of strokes

2.      Differentiated emergency therapy of Hemorrhagic stroke.

3.      Differentiated emergency therapy of Subarachnoid hemorrhage.

4.      Rehabilitation and prophylactic programs for cerebrovascular patients.

 

Step III. Aim: To conduct expert-preventive measures. Outgoing from the clinical diagnosis and taking into account effectiveness of treatment to form prognosis, providing of preventive measures, to provide expertise of workability, military-medical expertise.

 

Work 2.

Clinical observation of the patients. General examination of a patient and filling in the patient’s Case Report.

Step I:  Aim: To make clinical pre-diagnosis, to find a level of a pathological focus.

Step II: Aim: To introduce dates of special methods of patient objective investigation, to make differential diagnostic and to output correct clinical diagnosis. 

Step III: Aim: 1.To argument treatment program and prophylactic measures for each patient.

Step IV: Aim: To expect the ability to work in disabled person.

 

Individual Students Program.

You should be prepared for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

Theme 1. Cerebro-vascular diseases

1. Epidemiology of strokes.

2. The components of the stroke-phone profile.

3. Etiology and pathogenesis of strokes.  The risk factors of hemorrhage stroke.

4. Clinical characteristic and main vascular signs of apoplectic stroke.

a)subarachnoid hemorrhage, b) intracerebral hematoma (or apoplectic stroke), c) ventricular hemorrhage

5. Examination program.

          to determine pathological focus in acute phase

          special methods of neurological paraclinical examinations (EEG, brain Scan, Sonar A (echo) Scan, arteriography, lumbar puncture ets.)

6. Undifferentiated emergency therapy of strokes.

7. Differentiated emergency therapy of infarction of the brain.

8. Follow-ups of acute disturbance of the cerebral circulation.

 

Theme 2. Clinical observation of the patients. General examination of a patient and filling in the patient’s Case Report.

Outline for the Neurologic Evaluation

History

Patient’s passport

Full Name

Age (date of birth)

Home address

Sex

Family status (married or got married, single, divorced)

Occupation, place of employment, total years of service.

Disability (total, industrial, as a result of war, because of a disease, from work)

Chief complaint (pain, headache, giddiness, nausea, vomiting, ets)

History of the present illness

Neurologic review

Past medical history

Life history (patient’s habits; labor activities, industrial hazards, professional record of service, work regime; allergological and pharmacologic history; epidemiological history)

Family history (parents, children, heredity)

Social history (house or flat, housing and living conditions)

General physical examination

Neurologic examination

Mental status examination

Speech, orientation, current events, judgment, insight, abstraction, vocabulary, perception, emotional response, memory, calculation, object recognition, praxis

Cranial nerve examination

Olfaction

Visual activity, ophthalmoscopic exam, visual fields

III, IV, VI. Pupils, eye movements

V. Corneal reflex; jaw jerk; sensation – face, scalp; motor function – muscles of mastication.

VII. Motor function – facial muscles; taste – anterior 2/3 tongue

VIII. Hearing, equilibrium

IX, X. Motor function, palate and pharynx, phonation, taste, posterior third of tongue.

XI. Motor function – sternocleidomastoid and trapezius.

XII. Motor function – tongue

Motor

Inspection, posture, tone, and power

Coordination

Rapid alternating movements, finger-to-nose and heel-to-shin tests

Gait and station

Gait testing, tandem gait, walking on heels and toes, Romberg test

Sensory

Touch, pinprick, vibration, position, and temperature senses

Reflexes

Stretch reflexes, plantar response, abdominal reflexes, release phenomena

Vegetative reactions.

 

Seminar discussion of theoretical issues (12:30-14.00).

Test evaluation and situational tasks.

Tests:

1.      Clinical differentiated signs between cerebral hypertensive crisis and subarachnoid hemorrhage.

2.      When can we localize the pathological focus of apoplectic stroke (or in which stage of process)?

3.      Name three main reasons of acute disturbances of the cerebral circulation.

4.      The components of the stroke-phone profile.

5.      Name agents which reduce cerebral edema.

6.      Name vasodilators.

7.      Name agents which decrease blood pressure.

8.      Name the metabolic agents.

9.      Name the calcium antagonists.

10.  Periods of stroke.

11.  Stages of acute period of stroke.

12.  Mortality of apoplectic stroke.

13.  Clinical differentiated signs of apoplectic stroke in acute stage.

14.  Clinical differentiated signs between subarachnoid hemorrhage and ventricular hemorrhage.

15.  Rehabilitation and prophylactic programs for apoplectic stroke patients.

16.  Differentiated emergency therapy of apoplectic strokes.

17.  Undifferentiated emergency therapy of strokes in acute stage.

18.  Therapy of strokes in chronic stage.

 

Multiple Choice.

1. What are the main causes of acute disturbances of the cerebral circulation?

a) Atherosclerosis

b) Hypertensive disease

c) Atherosclerosis and hypertensive disease

d) Age, sex and race

e) Chronic stress

2.  What are the main causes of strokes?

a) atherosclerosis

b) hypertensive  disease

c) atherosclerosis and hypertensive  disease

d) age, sex and race

e) chronic stress

3. What are the differentiated signs between cerebral hypertensive crisis and subarachnoid hemorrhage?

a) local neurological signs are absent

b) local neurological signs may be present for minutes or hours before stroke

c) local neurological signs may be present for minutes or hours  but not more than 24 hours

d) cerebral hypertensive crisis and subarachnoid hemorrhage haven’t differentiated signs

e) grossly bloody in cerebrospinal fluid (CSF)

4. What groups of medicine are used for treatment of both types of stroke?

a) anticoagulation medicines.

b) surgery benefits the patients with occlusion of one carotid.

c) agents which reduce cerebral edema.

d) cerebral vasodilators and calcium antagonist, which may help to reduce cerebral arterial spasm.

e) all answers are true.

5. What groups of medicine are used for treatment of hemorrhagic stroke?

a) anticoagulation medicines.

b) surgery benefits the patients with nondominant putamen hemorrhages and intracerebral hematoma not over 150 ml.

c) agents which reduce cerebral edema.

d) cerebral vasodilators and calcium antagonist, which may help to reduce cerebral arterial spasm.

e) all answers are true.

 

Real-life situations to be solved:

1. The patient has acute headache on the back of the head, which were accompanied by dizziness and vomiting and meningeal syndrome. But other local neurological signs are absent. What type of stroke has been occurred in patient?

a)      ischemic embolic stroke

b)      ischemic thrombotic stroke

c)      subarachnoid hemorrhage

d)     intracerebral hemorrhage

e)      ventricular hemorrhage.

 

Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.

 

Student should know:

1. Etiology and pathogenesis of strokes.

2. Clinical classification of cerebrovascular diseases.

3. Clinical characteristic and main vascular symptoms of the apoplectic stroke.

4. Examination program for these patients.

6.  The scheme of the General examination of a neurological patient

7. The special symptoms of damage of different parts of nervous system

8. The determined set for analysis of neurological symptoms to make topical diagnosis

9. The basic methods of patient objective investigation and treatment at neurology diseases.

 

Student should be able to:

1.      To examine neurological patient

2.      To make a history taking

3.      To formulate clinical pre-diagnosis and make differential diagnostics

4.      To find a level of pathological focus

5.      To introduce dates of special methods of patients’ objective investigation

6.      To make the topical and clinical diagnosis

7.      To prescribe adequate treatment program and prophylactic measures

8.      To expect the ability to work in disabled person

9.      To record the patient’s Case report.

10.  Examine the patients with stroke

11.  Administer emergency treatment

 

Correct answers of test evaluations and situational tasks:

Multiple Choice:

      1.  b; 2. b; 3. e, 4. c; 5. d

Real-life situations:

1. c

Independent work of students (14:15-15:00).

 

References:

А – Basic:

1. WEB-site of tdmu.

Material for practical classes

2. Basic Neurology Second Edition. John Gilroy, M.D.- McGraw-Hill international editions, medical series, 1990.

3. Methodological instructions for general clinical examination of a neurology patient and filling in the patient’s Case Report.

4. Clinical examinations ieurology – Mayo clinic and Mayo foundation.- 4-th edition.- W.B. Saunders Compani, Philadelphia, London, Toronto.- 1976 y.

В – Additional:

4.      Neurology for the house officer.- 3th  edition.-Howard L. Weiner, MD and Lawrence P. Levitt, MD,- Williams &Wilkins.- Baltimore.- London.- 1980 y.

5.      Van Allen’s Pictorial Manual of Neurologic Tests.- Robert L.Rodnitzky.- Third edition.-Year Book Medical Publishers, inc. Chicago London Boca Raton.- 1981y.

6.      Neurology in lectures. Textbook. Edited by the head of Neurology Department – prof. S.І. Shkrobot. – 2007.

 

 

Methodical instruction has been worked out by: dotsent N.R. Sokhor

                           

Methodical instruction was discussed and adopted at the Department sitting

29.05.2013 . Minute9

Methodical instruction was adopted and reviewed at the Department sitting

__________201 . Minute № ___

 

 

 

 

 

 

 

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