METHODICAL INSTRUCTION FOR STUDENTS OF THE 4 COURSE
MEDICAL FACULTY
LESSON № 9 (PRACTICAL – 6 HOURS)
Theme:
1. Meningitis: purulent (meningococcal and secondary) and serous (enteroviral, lymphocytic choriomeningitis, tuberculosis)
2. Encephalitis: epidemic, spring-summer, polyseason, herpetic, rheumatic, parainfection, subacute sclerosing panencephalitis, rabies. Cerebral arachnoiditis
3. Poliomyelitis. Acute myelitis.
Aim: Students should be able to find out symptoms of meningitis and to set cure. To be able to diagnose independently different forms of encerhalitis in patients, and also to diagnose arachnoiditis, brain abscess, to prescribe treatment, develop prophylactic measures, to provide capacity examination in this category of patients. Students should be able independently to diagnose poliomyelitis, acute myelitis and to prescribe treatment and preventive measures. To fulfill medical labor examination. Students should be able to find out symptoms of ALS, to set cure.
Professional orientation of students: The pathology, symptoms and clinical course of patients with acute purulent meningitis are similar regardless of the causative organisms. Infectious diseases of CNS are met in all medical specialties, especially in emergency, because neuroinfection’s course is severe and sometimes demands urgent help. Treatment in time determines result of disease. That’s why all doctors must know diagnostic principles of meningitis. The parenchyma, the coverings and the blood vessels of the nervous system may be invaded by practically all of the pathogenic microorganisms. It is customary, for convenience of description, to divide the syndromes produced according to the chief site of the involvement. All doctors must diagnose and prescribe treatment for the patients with neuroinfection. The clinic pictures of poliomyelitis are very variable. That’s why for successful treatment and good results it is necessary to differ clinical forms of these diseases.
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. Meningitis: purulent (meningococcal and secondary) and serous (enteroviral, lymphocytic choriomeningitis, tuberculosis)
Step I. Aim: To put of clinical diagnosis. For this purpose it is necessary:
1. To examine the patient (anamnesis, somatic-neurological status).
2. To use data of additional methods of examination (clinical, biochemical, immunological blood tests, urine, cerebral spinal fluid, X-rey).
3. To provide differential diagnosis in accordance with algorithm.
Step II. Aim: To prescribe treatment. It is necessary to take into account etiopathogenesis, clinical form, and stage of infection, to define sensitiveness of microflora to antibiotics.
Prescribe etiologic (antibiotics, sulfanilamids, antiviral), pathogenetic (desintoxication, diuretics, hormones, antihistamines, nootrops, antiargegants), and symptomatic (cardiac, sedative, analgetics) cure.
Work 2. Encephalitis: epidemic, spring-summer, polyseason, herpetic, rheumatic, parainfection, subacute sclerosing panencephalitis, rabies. Cerebral arachnoiditis
Step I. Aim: To put of clinical diagnosis. For this purpose it is necessary:
1. To examine the patient (anamnesis, somatic-neurological status).
2. To use data of additional methods of examination (clinical, biochemical, immunological blood tests, urine, cerebral spinal fluid, X-rey).
1. To make differential diagnosis according to the algorithm of differential diagnosis.
Step II. Aim: To prescribe treatment. Under this it is necessary to take into account etiopathogenesis, clinical form, and stage of infection, to define sensitiveness of microflora to antibiotics.
Work 3. Poliomyelitis. Acute myelitis. Amyotrophic lateral sclerosis (ALS)
Step I. Aim: To put clinical diagnosis. For this purpose it is necessary:
1. To determine the clinical form of the poliomyelitis according to algorithm of differential diagnosis (look to references).
2. To find out clinical stages of poliomyelitis according to algorithm of differential diagnosis (look to references).
3. To localized pathological focus.
4. To determine clinical form of Amyotrophic lateral sclerosis, acute myelitis by mean of scheme of differential diagnosis.
5. To define basic clinical syndromes of locomotors, sensitive, coordinative dysfunction, cranial innervation.
6. To formulate clinical diagnosis, for example:
a) Poliomyelitis, residual stage, with deep flaccid palsy of the right foot.
Step II. Aim: To prescribe the treatment.
Step III. Aid: to study preventive measures.
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. Meningitis: purulent (meningococcal and secondary) and serous (enteroviral, lymphocytic choriomeningitis, tuberculosis)
1. Classification of meningitis.
2. Etiology and pathogenesis of meningitis:
a) causes primary and secondary purulent meningitis;
b) causes primary and secondary aseptic meningitis;
c) pathogenesis primary and secondary purulent meningitis;
d) pathogenesis primary and secondary aseptic meningitis.
3. Clinical signs of meningeal syndrome.
4. Clinical signs of acute purulent meningitis:
a) meningococcal;
b) secondary (staphylococcal, streptococcal).
5. Clinical features of acute and subacute aseptic meningitis:
a) lymphocytic choriomeningitis;
b) ECHO;
c) Coxsacie;
d) tuberculous.
6. Laboratory data of meningitis.
7. Treatment of meningitis:
a) etiologic;
b) pathogenic;
c) symptomatic.
8. Complication and sequels of meningitis:
a) acute (disseminated intravascular coagulation, convulsions, cranial nerve palsies, focal cerebral lesions, damage to the spinal cord or nerve roots, acute hydrocephalus);
b) residual (deafness, ocular palsies, blindness, changes in mentality, convulsions and hydrocephalus.
Theme 2. Encephalitis: epidemic, spring-summer, polyseason, herpetic, rheumatic, parainfection, subacute sclerosing panencephalitis, rabies. Cerebral arachnoiditis
Classification of encephalitis.
Etiology and pathogenesis of encephalitis:
a) causes primary and secondary encephalitis;
b) pathogenesis primary and secondary encephalitis;
3. Clinical signs of meningeal syndrome.
4. Clinical signs of epidemic encephalitis:
a) clinical forms of severe stage of epidemic encephalitis;
b) clinical features of chronic stage of epidemic encephalitis;
5. Clinical signs of such encephalitis:
a) clinical form of spring encephalitis in severe stage;
b) clinical form of spring encephalitis in chronic stage;
c) clinical features of rheumatic encephalitis (small chorea);
d) clinical features of zoster encephalitis;
e) clinical features of postvaccinal encephalitis.
6. Diagnostic of encephalitis:
a) role of additional examination methods in diagnostics of encephalitis (general and biochemical tests of blood, urine, serological blood tests (RCC,RN, RSGA)
b) clinical formulation of diagnosis.
7. Etiology and pathogenesis of arachnoiditis.
8. Clinical features of arachnoiditis:
a) convexital;
b) opticochiasmal;
c) arachnoiditis of posterior cranial fossa;
d) arachnoiditis of pontocerebellar angle.
10. Additional examination methods for diagnostics of arachnoiditis and brain abscess.
11. Treatment of encephalitis and arachnoiditis:
a) etiologic;
b) pathogenic;
c) symptomatic.
13. Complication and sequels of encephalitis and arachnoiditis.
13. Prophylactic measures of infections disease of the nervous system, capacity examination:
a) prognosis and prophylactic measures (specific and unspecific);
b) patients’ capacity examination;
c) military-medical examination.
Theme 3. Poliomyelitis. Acute myelitis. Amyotrophic lateral sclerosis (ALS)
1. To study poliomyelitis:
a) Etiology and pathogenesis;
b) Clinical forms;
c) Stages of disease;
d) Specific treatment according to stages.
2. Clinical picture of acute myelitis:
a) clinical signs of acute myelitis of cervical, thoracic and lumbar parts of spinal cord.
Seminar discussion of theoretical issues (12:30-14.00).
Test evaluation and situational tasks.
Tests.
1. Classification of meningitis.
2. Differential signs of CSF changes at tuberculous meningitis.
3. Clinical CSF signs of primary and secondary purulent meningitis.
4. Which pharmacological antibiotic groups are used for treatment of meningitis?
5. Antibiotic therapy prescription criteria of purulent meningitis.
6. Characteristic of cerebrospinal fluid in patients with serous meningitis.
7. What are the early signs of tuberculous meningitis?
8. Characteristic of headaches in patients with meningitis.
9. Characteristic of nausea and vomiting in patients with meningitis.
10. Characteristic of mental symptoms in patients with meningitis.
11. Name complications of meningitis.
12. Name sequels of meningitis.
13. Classification of encephalitis.
14. Classification of brain abscess.
15. Classification of arachnoiditis.
16. Clinical forms of acute stage of epidemic encephalitis.
17. Clinical forms of chronic stage of epidemic encephalitis.
18. Clinical forms of acute stage of spring encephalitis.
19. Clinical forms of chronic stage of spring encephalitis.
20. Where are the degenerative changes attached to epidemic encephalitis localized?
21. Syndromes of cerebral arachnoiditis.
22. Prescription therapy of cerebral arachnoiditis.
23. How is cyst arachnoiditis treated?
24. Which arachnoiditis (convexital, basal) causes
25. Name complications of encephalitis.
26. Name sequels of encephalitis.
27. Clinical forms of poliomyelitis.
28. Stages of poliomyelitis.
29. Preventive measures for poliomyelitis.
30. Methods of active preventive measures at poliomyelitis.
31. Name nosological forms of Poliomyelitic infection according to spreading viruses in macroorganism.
32. Common and differential signs of poliomyelitic and polyneuritic palsies.
33. Describe signs of acute myelitis, localized in thoracic part of spinal cord
34. Name complications of acute myelitis.
35. Name basic etiology and pathogenetic groups of medicines which are used for the treatment of acute myelitis during acute and remission periods.
36. Describe two basic theories of ALS.
37. Describe basic clinical forms of ALS.
38. Describe clinical features of cervical-thoracic form of ALS.
39. Describe clinical features of bulbar form of ALS.
40. Describe basic groups of medicines, which are used for the treatment of ALS. Prescribe Vit E in capsules and Retabolil in injections.
41. What motor neurons are affected at supranuclear form of amyotrophic lateral sclerosis (ALS)?
42. What paralysis (central, peripheral or mixed) is typical for the patients in agonic stage of ALS?
43. What paresis can be in patient with ALS?
44. What system is damaged at ALS?
45. What motor neuron is damaged during the first attack (A) and the end (B) of ALS?
46. Conductive symptoms of acute lumbar myelitis.
47. What paralysis (central, peripheral or mixed) occurs at polioencephalomyelitis (A), poliomyelitis (B), polyneuritis (C)?
Real-life situations to be solved:
1. Name meningeal syndromes.
2. Characterize of cerebrospinal fluid in patients with tuberculous meningitis?
3. Which symptoms are typical for acute stage of epidemic encephalitis?
4. Clinical forms of spring encephalitis in acute stage
5. To characterize Poliomyelitic palsies.
6. What symptoms belong to myelitis of thoracic part of spinal cord?
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. The scheme of the General examination of a neurological patient
2. The special symptoms of damage of different parts of nervous system
3. The determined set for analysis of neurological symptoms to make topical diagnosis
4. The basic methods of patient objective investigation and treatment at neurology diseases.
5. Classification of meningitis, encephalitis, poliomyelitis, acute myelitis and ALS.
6. Etiology and pathogenesis of meningitis, encephalitis, poliomyelitis, acute myelitis and ALS.
7. Clinical signs of meningeal syndrome.
8. Clinical signs of epidemic encephalitis, spring encephalitis, rheumatic encephalitis, zoster encephalitis, postvaccinal encephalitis.
9. Clinical features of arachnoiditis
10. Laboratory data of meningitis.
11. Treatment of meningitis
12. Clinical feature of poliomyelitis.
Student should be able to:
Examine the patients with infectious diseases of nervous system
1. To find a level of pathological focus
2. Administer additional methods of examination
3. To formulate clinical pre-diagnosis and make differential diagnostics
4. To make the topical and clinical diagnosis
5. To prescribe adequate treatment program and prophylactic measures
6. To expect the ability to work in disabled person
7. To record the patient’s Case report.
Correct answers of test evaluations and situational tasks:
1. Headaches, nausea and vomiting, common hyperestesia, rigidity of the neck, Kernig’s and Brudzinski signs, Bechterev symptom, hallucination, meningeal posture, cell-protein dissociation in the liquor.
2. An increased pressure, a slightly cloudy or ground-glass appearance to the fluid, a moderate pleocytosis (lymphocytes) varying from 25 to 500 cells per cu mm, increased protein content, decreased sugar content.
3. Narcolepsy, oculomotorial disorders, fever, vestibular disorders, hyperkinesis and hypersalivation.
4. a) Polioencephalomielitic (typical); b) Poliomielitic; c) Meningeal; d) Enchephalitic; e) Meningoenchephalitic; f) Effaced; g) Poliradiculoneuritic.
5. Flaccid, very local.
6. Pelvic disorders, lower spastic paraplegia, conductive disorders of sensibility and trophic disorders.
Independent work of students (14:15-15:00).
References:
А – Basic:
1. WEB-site of tdmu.
2. Neurology. Second Edition. John Gilroy, M.D. – McGraw-Hill International edition.- Pergamon Press.- 1992
3 Merritt’s Textbook of neurology. – 7th edition. – Edited by Lewis P. Rowland.
4 Neurology for house officer. – 3th edition.
В – Additional:
5. Handbook of Symptom Oriented Neurology/ William H. Olson, Roger A. Brumback, Generoso Gascon, Vasudeva Iyer, Year book medical publishers, Inc.
6.Neurology in lectures. Textbook. Edited by the head of Neurology Department – prof. S.І. Shkrobot. – 2005.
Methodical instruction has been worked out by: dotsent N. Sokhor
Methodical instruction was discussed and adopted at the Department sitting
29.05.2013 . Minute №
Methodical instruction was adopted and reviewed at the Department sitting
__________201 . Minute № ___
