METHODICAL INSTRUCTION FOR STUDENTS OF THE 4 COURSE
MEDICAL FACULTY
LESSON № 2 (PRACTICAL – 6 HOURS)
Theme:
1. Basal Ganglia. Internal Capsule. Syndromes of Extrapyramidal system and Internal Capsule Lesion.
2. Cerebellum. The main anatomic and physiological dates. Examination of equilibrium, coordination of movements, asynergia, nystagmus, ability to write, speech, muscular tonus. The lesion signs of cerebellum hemispheres, pathway and its worm.
3. Sensation, sorts (subjective and objective) and types of sensory disturbances. Symptoms of sensory disturbances.
Aim: Students should be able to to find out symptoms of Extrapyramidal system’s and Internal Capsule lesion, to diagnose Parkinson’s syndrome and syndrome of involuntary movements, to find out signs of lesion of cerebellum and its pathways, to determine independently disturbance of sensation in the patients. Students should be able to formulate and to explain the topical diagnosis on different level.
Professional orientation of students: The impellent and sensitive violations in patients are frequently observed as a result of lesion of the nervous system of vascular, infection, toxic and other genesis and very often result in to disability. To put clinical diagnosis the topical diagnosis has a large value alongside with an anamnesis, which is based on a neurological symptomatics. The function of cerebellum and its pathology deserves notice of clinicians and contributors. There are many links of cerebellum with different parts of the nervous system, which cause a lesion of the coordination system in various pathological processes. That’s why every doctor has to know the signs of lesion of coordination system. Correct and well-timed diagnostic – condition and warranty of rational therapy.
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.
Work 1.
Basal Ganglia. Internal Capsule. Syndromes of Extrapyramidal system and Internal Capsule Lesion.
Step II. Aim: To find out of the extrapyramidal system leading. Make the conclusion for the presence of extrapyramidal system’s lesions.
Step III. Aim: To localize processes within the separate anatomic structures of extrapyramidal system.
It’s necessary to use algorithm of differential diagnosis, which is in methodological instructions for students.
Step IV. Aim: To put topical diagnosis and explain it. To show in topical diagnosis the leading syndromes and the section of lesion of extrapyramidal system. (For ex., Parkinson syndrome, akinetic form – the pallidum lesion. Chorea – striatum lesion).
Work 2.
Cerebellum. The main anatomic and physiological dates. Examination of equilibrium, coordination of movements, asynergia, nystagmus, ability to write, speech, muscular tonus. The lesion signs of cerebellum hemispheres, pathway and its worm.
Step I. Aim: To determine the presence of signs of cerebellum lesion. For this purpose it is necessary:
1. To gather an anamnesis and to examine patient’ status.
2. To find out presence of attributes of a lesion of a cerebellum.
3. To carry out tests on synergy and coordination, change of speech, letter, muscles tone.
4. To pay attention to the appearance of the patient.
5. To formulate a conclusion about presence or absence of a disturbance of coordination.
Step II. Aim: To determine the character of cerebellum lesion. For this purpose it is necessary:
To analyse the patient’s neurological status. Make a conclusion about presence of pathology of cerebellar function.
Step III. Aim: To determine level of a lesion of the cerebellum. Make a conclusion about a level of lesion of cerebellar pathways.
Step IV. Aim: Make a differential diagnostics of pathological focus level with the help of
“Algorithm of differential diagnosis of cerebellar disturbances” or using “the Methodical indications
on theme: “A Cerebellum. The anatomic-physiological data”
Work 3.
Sensation, sorts (subjective and objective) and types of sensory disturbances. Symptoms of sensory disturbances.
Step I. Aim: To study tags of sensory disturbances in patients. For this purpose it is necessary:
1.To collect the patient’s complaints (tingling, creeping, burning and numbness sensation) and to analyze them.
2.To examine types of sensory disturbance.
3.To check up presence or absence of sensory disturbance in patient.
Step II. Aim: To determine type of sensory disturbance. For this purpose it is necessary:
1. To examine patient’s neurologic status.
2. To carry out a data analysis of inspection.
3. To make output about presence appropriate type of sensation disturbance in a patient.
Step III. Aim: To find a level of a lesion of spinal-thalamic pathway.
Step IV. Aim: To make the topical diagnosis. In topical diagnosis it is necessary to point character of sort and type of sensation disturbance, and level of a lesion of sensation explorers (cortex (postcentral gyrus and parietal lobes; radiate crown; internal capsule; thalamus; brain stem; dorsal and lateral funiculus of spinal cord; dorsal horn and ventral commeasure; dorsal roots and dorsal root ganglia; plexus and peripheral nerves).
Seminar discussion of theoretical issues (12:30-14.00).
Test evaluation and situational tasks.
Tests.
1. Name the symptoms of striatum section of extrapyramidal system’s lesion.
2. What kinds of hyperkinesis do you know?
3. Name the symptoms of rigidity.
4. Name the functions of extrapyramidal system.
5. The lesion of what part of extrapyramidal system causes oligobradikinesis, rigidity and tremor?
6. Name the symptoms of spastic tone.
7. Name vegetative disorders of Parkinson’s syndrome.
8. What are the anatomic components of striatum?
9. Enumerate the structures of pallidum.
10. What kind of hyperkinesias causes Gordon – II symptom?
11. Lesion of what structures cause Parkinson syndrome?
12. What is affected in case of hemiballism?
13. Methods of examination of extrapyramidal system pathology.
14. What is the most important function of extrapyramidal system?
15. What kind of hyperkinesis cause «eyes and tongue» symptom?
16. Between what structures internal capsule is situated?
17. Name the symptoms of total lesion of internal capsule.
18. Signs of lesion of the radiate crown on the right side.
19. Signs of lesion of the knee of internal capsule on the right side.
20. Signs of lesion of the dorsal leg of internal capsule on the right side.
21. Signs of lesion of the thalamus on the right side.
22. Signs of lesion of the medial closed loop on the right side.
23. Subjective sorts of sensory disturbances.
24. Sorts of pain.
25. Objective sorts of sensory disturbances.
26. Types of sensory disturbances.
27. Subtypes of peripheral sensory disturbances.
28. Subtypes of segmental sensory disturbances.
29. Subtypes of conductive sensory disturbances.
30. What nervous structures are damaged in case of peripheral type of sensory disturbances?
31. What nervous structures are damaged in case of segmental – dissociated subtype of sensory disturbances?
32. What nervous structures are damaged in case of by segmental – radicular subtype of sensory disturbances?
33. What nervous structures are damaged in case of conductive type of sensory disturbances?
34. Signs of lesion of a radiate crown (corona radiata).
35. Signs of lesion of a knee of internal capsule.
36. Signs of lesion of a dorsal leg of internal capsule.
37. Signs of lesion of right thalamus.
38. Signs of lesion of right medial closed loop.
39. Signs of lesion of Burdach’ pathway in spinal cord.
40. Signs of lesion of Holl’ pathway in spinal cord.
41. Signs of lesion of dorsal root.
42. Signs of lesion of dorsal horn in spinal cord.
43. Signs of lesion of dorsal root ganglion.
44. Signs of lesion of front and dorsal roots.
45. Signs of lesion of front grey soldering.
46. Signs of lesion of lateral funicular of spinal cord on right Th10.
47. What are specific methods of reactive pain examination?
48. Localization of superficial sensory disturbance at presence of intramedular pathological process.
49. How to detect sensitive ataxia?
50. Where are cell bodies of neurons of superficial and deep sensation situated together?
51. Sorts of superficial sensation.
52. Sorts of deep sensation.
53. Combined sorts of sensation.
54. Sorts of analyzers.
55. The structures of analyzers.
56. Examination of seismoanesthesia.
57. Vibration sense parameters on arms in healthy adult.
58. Vibration sense parameters on legs in healthy adult.
59. What segment is on belly-button’s level?
60. What segment is on collar’s level?
61. What segment is on nipple of men level?
62. What segment is on inguinal level?
63. What neurons form the pathway of superficial sensation?
64. What neurons form the pathway of deep sensation?
65. Name the exeroreceptors.
66. Name the proprioreceptors.
67. How sensation is divided according to biological classification?
68. Signs of lesion of the Burdach’s pathways.
69. Signs of lesion of the Holl’s pathways.
70. Signs of lesion of the dorsal root.
71. Signs of lesion of the dorsal horn.
72. Signs of lesion of the right humeral plexus.
73. Signs of lesion of the spinal funiculus.
74. Signs of lesion of the dorsal root ganglion.
75. Signs of lesion of the frontal grey soldering.
76. Signs of lesion of the lateral column of spinal cord on right Th10.
77. Signs of lesion of a spinal cord half transversal diameter at a level C5-Th2 on right side.
78. Signs of lesion of a spinal cord half transversal diameter at a level Th5 on right side.
79. Signs of lesion of a spinal cord half transversal diameter at a level L1-L2 on right side.
80. Signs of lesion of a spinal cord transversal diameter at a level C3-C4.
81. Signs of lesion of a spinal cord transversal diameter at a level C5-Th2.
82. Signs of lesion of a spinal cord transversal diameter at a level Th5.
83. Signs of lesion of a spinal cord transversal diameter at a level L1-S2.
84. Signs of lesion of a spinal cord transversal diameter at a level S3-S5.
85. Signs of lesion of horse tail (cauda equina).
86. Localization of superficial sensory disturbance at presence of intramedular focus.
87. Patient has Vernike-Mann’s sign. Where is a lesion?
88. Patient has spastic gait. Where is a lesion?
89. What are the signs of cerebellum worm lesion?
90. Where and what cerebellum disturbances are observed at lesion of the right frontal lobe?
91. Where and what cerebellum disturbances are observed at lesion of the right red nucleus?
92. The patient has cerebellar ataxia on right limbs. What structures can cause such signs?
93. Name decussating of the cerebellar correction pathway.
94. Enumerate main functions of the cerebellum.
95. Name main function of the cerebellum.
96. There are adiadochokinesis on right, intention tremor on the right. Where is the focus?
97. What is the name of the second neuron of the cerebellar correction pathway?
98. How much pairs of legs has cerebellum?
99. What is the function of cerebellum worm?
100.What is the function of cerebellum hemispheres?
101.Name the types of cerebellar ataxia.
102.Name the efferent paths of the lower cerebellar leg.
103.What are the signs of asynergia?
104.What side are cerebellar disturbances observed at lesion of frontal lobe of brain and the red nuclei?
105.The patient has tumor of the cerebellar worm. What disturbances are observed?
106.The patient has tumor of left hemisphere of cerebellum. What disturbances on which side are observed?
107.Lesion of what structures cause hypotension?
108.Where Flexig’s and Hover’s pathways are situated in spinal cord’s pass?
109.How much neurons the cerebellar correction pathway has?
110.Kinds of ataxia.
111.Differential signs of cerebellar ataxia.
112.Differential signs of sensitive ataxia.
113.Examination of hypermetria.
114.Examination of intention tremor.
115.Examination of cerebellar asynergia.
116.Examination of ataxia.
117.Examination of cerebellar pathology.
118.Examination of cerebellar hemispheres pathology.
119.Examination of cerebellar worm pathology.
Real-life situations to be solved:
1. There area total anesthesia, hypotonia and hypotrophia of right arm, tendon and periosteal reflexes are absent. What is damaged? Where is pathological focus?
2. Patient has tumor of the worm of a cerebellum. Describe clinical signs of worm lesion.
3. Describe the decussation of specific ways of the cerebellar amendment.
4. List the basic functions of a cerebellum.
5. The patient has chronic hyperkinesis, muscular hypotonia, Gordon-II symptoms. Where is the pathological focus?
6. One of the patients has a «static» arms’ tremor, and other patient has tremor while making voluntary movement. Where is lesion in both cases?
7. The patient has torsion dystonia, athetosis, the mask face, fat hair and the speech is slow and monotonous. What structures are affected?
8. Pupil of the 3-d form began to behave in an affected manner, his handwriting began to worsen, his movements at the desk spontaneous and irregular. What kind of syndrome is it? Where is the lesion?
9. There is bathyanesthesia in legs, including hip joints in patient. What pathways are damaged? Where is pathological focus?
10. There are analgesia and termoanesthesia along segments C5-Th5 on both sides in the patient. Where is pathological focus?
11. There is a lesion of spinothalamic tract on Th5 level on right in patient. What sort and type of sensation disturbance is present?
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. 1. Symptoms of Extrapyramidal system lesion
2. Kinds of hyperkinesis
3. Symptoms of lesion of internal capsule.
4. Semiology of lesion of cortical-spinal tract and sensory explorers on different levels.
5. Anatomical structures and function of the cerebellum and its pathways.
6. The function of cerebellum: a) function of the worm; b) function of the hemisphere;
7. Clinical signs of cerebellar ataxia.
8. Classification of ataxias.
9. The signs of lesion of cerebellum and its pathways on different levels.
10. Classification of sensation.
11. Anatomy of superficial and deep sensory explorers.
12. Examination of sensation.
13. Types and Sorts of sensory disturbances.
14. Semiology of sensory explorer lesion on different levels.
Student should be able to:
1. Find out the symptoms of lesion of extrapyramidal system.
2. Examine the muscular tonus and active movements.
3. To localize processes within the separate anatomic structures of extrapyramidal system.
4. Examine patient’s neurologic status.
5. Find a level of lesion of sensory tracts, cerebellum and its pathways.
6. Make the topical diagnosis.
7. Find a level of sensory pathways lesion.
8. Point character of sensory disturbance.
Correct answers of test evaluations and situational tasks:
1. Humeral plexus.
2. Static and dynamic trunk ataxia, “drunken gait”, hypotonia in extremities.
3. There are: the Verneking’s, the Monackov’s and Forel’s decussating of specific ways of the cerebellar amendment.
4. The function of cerebellum are: the regulation of equilibrium of a body and muscular tone, coordination and synergic of movements.
5. Striatum.
6. First patient – extrapyramidal system, second patient – cerebellum.
7. Extrapyramidal system.
8. Chorea. Striatum.
9. Holl’s pathways.
10. There is a lesion of dorsal horns or front grey soldering in spinal cord on segments C5-Th5.
11. Conductive type of sensation disturbance, hypoesthesia.
Independent work of students (14:15-15:00).
References:
А – Basic:
1. Basic Neurology. Second edition. John Gilroy, M.D. Pergamon press. McGraw*Hill international editions, medical series.- 1990.
2. Clinical examinations in neurology – Mayo clinic and Mayo foundation.- 4-th edition.- W.B. Saunders Compani, Philadelphia, London, Toronto.- 1976.
3. WEB-site of tdmu.
Material for practical classes
В – Additional:
3. Neurology for the house officer.- 3th edition.-Howard L. Weiner, MD and Lawrence P. Levitt, MD,- Williams& Wilkins.- Baltimore.- London.- 1980.
4. Van Allen’s Pictorial Manual of Neurologic Tests.- Robert L.Rodnitzky.- Third edition.-Year Book Medical Publishers, inc. Chicago London Boca Raton.- 1981.
Methodical instruction has been worked out by: dotsent I. Hara
Methodical instruction was discussed and adopted at the Department sitting
20.05.2013 . Minute № 9
Methodical instruction was adopted and reviewed at the Department sitting
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