METHODICAL INSTRUCTION FOR STUDENTS OF THE 4 COURSE

June 3, 2024
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METHODICAL INSTRUCTION FOR STUDENTS OF THE 4 COURSE

MEDICAL FACULTY

LESSON1 (PRACTICAL6 HOURS)

 

Theme:

Clinical anatomy of spinal cord. Spinal reflex arch. Reflexes and methods of examination. Active movements, types of paralysis, syndromes of movement disturbances. Syndromes of lesion of Cortical-Muscular Tract on different levels

 

Aim: Students should be able to cause unconditioned reflexes (deep and superficial) and pathologic reflexes and to explain them. Students should be able to determine independently disturbance of movement on the patients, character of paralysis (paresis) and level of the pathological process (focus). Students should be able to formulate and to explain the topical diagnosis in case of lesion of cortical-muscular tract on different level.

 

Professional orientation of students: Conditioned and unconditioned reflexes are the main anatomic, physiologic and functional structures of nervous system. Motor dysfunction may result from involvement of muscle, neuromuscular junction, peripheral nerve, or central nervous system. Although lesion of almost any portion of the central nervous system may result in a disturbance of muscular performance, obviously, certain portions of the nervous system are concerned primarily with muscular activity. There are the pyramidal, the lower motor neurons in the brain stem and the spinal cord.

 

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

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

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.

Clinical anatomy of spinal cord. Spinal reflex arche. Reflexes and methods of examination

Step I.  Aim: To research patient’s reflexes. For this purpose it is necessary:

1.      To cause all superficial and deep reflexes.

2.      To check up presence or absence of pathological plantar reflexes: flexing (Rossolimo, Jukovski,  Bechterev’s, Mendel – Bechterev’s reflexes) and extensing reflexes (Babinski, Oppenheim’s, Gordon’s , Shtrumpel, Grossman, Sheffer, Chaddock’s, Puusepp’s and Redlich).

Step II. Aim: To describe unconditioned reflexes: living, hyperreflexia, torpid, presence of pathological reflexes, foot and patellar clonuses.

Step III. Aim: 1.To formulate output about presence or absence pathology according to patient’s reflexes.

2. To make recording about uniformity of reflexes or anizoreflexia.                                     

3. To make output about a level of lesion of nervous system (sectional or subsectional)

Work 2.

Active movements, types of paralysis, syndromes of movement disturbances

Step I.  Aim: To determine presence or absence of disturbance of movements in patients. For this purpose it is necessary:

1.      To collect the patient’ complaints (limitation of active movements, weakness of the extremities).

2.      To examine strength of muscles and volume of active movements, volume of passive movements.

3.      To cause all superficial and deep reflexes.

4.      To check up presence or absence of paresis (paralysis) in patient.

Step II. Aim: To determine character of paralysis (paresis). For this purpose it is necessary:

1.        To examine patient’s neurologic status.

2.        To carry out data of analysis of inspection, using the given below criteria:

Central (spastic) paralysis (paresis) criteria:

a)      hyperreflexion

b)      muscular hypertonia (spastic muscular contraction)

c)      pathologic reflexes

d)     protective reflexes

e)      synkinesis

Peripheral (flaccid) paralysis (paresis) criteria:

a)      hyporeflexion

b)      muscular hypotonia

c)      hypotrophy

d)     response of a degeneration of muscles

    3. To make output about presence of flaccid or spastic paresis.         

Step III. Aim: To find level of lesion of Pyramidal tract.

Step IV. Aim: To make the topical diagnosis. In topical diagnosis it is necessary to point character of paralysis (spastic or peripheral), level of Pyramidal tract lesion.

Work 3.

 Syndromes of lesion of Cortical-Muscular Tract on different level

Step I.  Aim: To determine presence or absence of paresis or paralysis in the patients. For this purpose it is necessary to hold examination, stipulated by the first stage of the methodical instruction.

Step II. Aim: To determine character of paralysis (paresis) in patients. For this purpose it is necessary to hold examination, stipulated by the first stage of the methodical instruction.

Step III. Aim: To find level of lesion of Pyramidal tract.

Step IV. Aim: To make the topical diagnosis. In topical diagnosis it is necessary to point character of paralysis (spastic or peripheral) and level of lesion of nervous system.

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

 

Test evaluation and situational tasks.

Tests:

1.      Characteristic of unconditioned reflexes

2.      Characteristic of conditioned reflexes

3.      Reflex arch and muscles of a corneal reflex

4.      Reflex arch and muscles of subeyebrows reflex

5.      Reflex arch and muscles of mandibular reflex

6.      Reflex arch and muscles of palatal (palatine) reflex

7.      Reflex arch and muscles of biceps reflex

8.      Reflex arch and muscles of triceps reflex

9.      Reflex arch and muscles of carporadial reflex

10.  Reflex arch and muscles of patellar (knee) reflex

11.  Reflex arch and muscles of Achilles reflex

12.  Reflex arch and muscles of upper abdominal reflex

13.  Reflex arch and muscles of middle abdominal reflex

14.  Reflex arch and muscles of lower abdominal reflex

15.  Reflex arch and muscles of cremasteric reflex

16.  Reflex arch and muscles of anal reflex

17.  Reflex arch and muscles of pharyngeal reflex

18.  Reflex arch and muscles of pupil reflex

19.  Reflex arch and muscles of plantar reflex

20.  Where are the levels of reflexes arch from upper extremities?

21.  Where are the levels of reflexes arch from lower extremities?

22.  Where are the levels of abdominals and cremasteric reflexes arch?

23.  Where are the levels of corneal, subeyebrows and mandibular reflexes arch?

24.  Signs of a peripheral (flaccid) paralysis (paresis).

25.  Signs of a central (spastic) paralysis (paresis).

26.  What pathways are formed by the first neuron of active motor system?

27.  What pathways are formed by the second neuron of active motor system?

28.  Patient has Wernicke-Mann’s sign. Where is a lesion?

29.  Patient has “cock’s” gait. Where is a lesion?

30.  Patient has spastic gait. Where is a lesion?

31.  Specific methods of determination of paralysis.

32.  Specific methods of determination of paresis.

33.  Specific methods of examination of synkinesis.

34.  Examination of muscular tonus.

35.  Examination of strength of muscles.

36.  Examination of movement disturbance.

37.  What are the signs of lesion: a) central neuron cell body; b) lower motor neuron’ cell body.

38.  What muscles are paralyzed in case of hemiparalysis?

39.  What system’ is damaged in case of presence of defence reflexes?

40.  What types of gait do you know in case of movement disturbance?

41.  Signs of lesion of a radiate crown (corona radiata).

42.  Signs of lesion of a knee of internal capsule.

43.  Signs of lesion of a dorsal leg of internal capsule.

44.  Signs of lesion of front and dorsal roots.

45.  Signs of irritation of the lower parts of central gyruses of dominant hemisphere.

46.  Signs of irritation of the middle parts of central gyruses of dominant hemisphere.

47.  Signs of stimulation of the upper parts of central gyruses of dominant hemisphere.

48.  Signs of lesion of the lower parts of central gyruses of dominant hemisphere.

49.  Signs of lesion of the middle parts of central gyruses of dominant hemisphere.

50.  Signs of lesion of the upper parts of central gyruses of dominant hemisphere.

51.  Signs of lesion of the radiate crown on the right side.

52.  Signs of lesion of the knee of internal capsule on the right side.

53.  Signs of lesion of the dorsal leg of internal capsule on the right side.

54.  Signs of lesion of the right humeral plexus.

55.  Signs of lesion of the spinal funiculus.

56.  Signs of lesion of the lateral column of spinal cord on right Th10.

57.  Signs of lesion of a spinal cord transversal diameter at a level C3-C4.

58.  Signs of lesion of a spinal cord transversal diameter at a level C5-Th2.

59.  Signs of lesion of a spinal cord transversal diameter at a level Th5.

60.  Signs of lesion of a spinal cord transversal diameter at a level L1-S2.

61.  Signs of lesion of a spinal cord transversal diameter at a level S3-S5.

62.  Signs of lesion of horse tail (cauda equina).

63.  Signs of irritation of the frontal horns of spinal cord.

 

Real-life situations to be solved:

1. The patient has pathologic focus on level of Th7. What pathology will be observed?

2. The patient has Facial neuropathy. Which reflexes will be changed? How?

3. There are absence reflexes of the upper limb, knee and Achilles are increased, and plantar reflexes are absent. Where is focus?

4. Patient (50 y. o.) complains on limitation of active movements and weakness of the right leg.  Physical examination has revealed: he raises right leg on 300 in bed. There are hyperreflexion on right leg and Babinski sign on right, muscular hypertonus. Abdominal reflexes are absent. Make the topical diagnosis and argue it.

5. Patient (64 y. o.) complains on limitation of active movements and weakness of the right extremities.  Physical examination has revealed: the smoothed dowasal-labial fold on the affected side, deviation of tongue towards right, expressive limitation of active movements of right leg and arm. There are weakness of the right extremities and increased muscular tonus, increased of tendon and periosteal reflexes of the right extremities, more hyperactive on the right than on the left. There is a Wernicke-Mann’s sign. Make the topical diagnosis.

6. Patient (32 y. o.) complains on weakness and pain of the right leg.  Physical examination has revealed: there are atrophy of femoral muscles, absence of knee-jerk reflex. What type of lesion is revealed in patient? Where is a pathological focus?

7. There area total anesthesia, hypotonia and hypotrophia of right arm, tendon and periosteal reflexes are absent. What is damaged? Where is pathological focus?

8. There is a central paralysis of right arm, a smoothed dowasolabial fold on the right side, tongue deviation on right, total anesthesia on the face, neck and right arm.  Where is pathological focus?

 

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. Anatomy of spinal cord.

2. Determination of reflex and reflex arch.

3. Characteristics and classification of unconditioned reflexes.

4. Unconditioned reflex arch.

5. Pathologic plantar reflexes.

6. Pathologic oral reflexes.

7. Anatomic structures and physiologic function of the cortical-muscular tract.

8. Determination of paralysis (paresis).

9. Signs of central (spastic) paralysis (paresis)

10. Signs of peripheral (flaccid) paralysis (paresis)

11. Signs of a cortical-spinal tract lesion on different levels.     

 

Student should be able to:

1.      Examine the neurology patients.

2.      Cause the physiological reflexes and pathological reflexes.

3.      Make the conclusion about pathology of reflexes.

4.      Make the record about anizoreflexia (D=S, D<S, D>S).

5.      Examine patient’s neurological status.

6.      Find a level of lesion of motor tract.

7.      Make the topical diagnosis.

8.      Point character of paralysis (spastic or peripheral).

Correct answers of test evaluations and situational tasks:

Real-life situations:

1.      Absence of abdominal, plantar reflexes, hyperreflexia of patellar and Achilles reflexes, Babinski sign.

2.      Absence of corneal and subeyebrows reflexes.

3.      C5-Th2

4.      Patient has central paresis of right leg.  There is lesion of central neuron of cortical-spinal tract in lateral funiculus of spinal cord on thoracic level.

5.      There is a lesion of left internal capsule.

6.      Patient has peripheral paralysis. There is a lesion of Femoral nerve.

7.      Humeral plexus.

8.      Middle and lower parts of central gyruses of left hemisphere.

 

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 ieurology/Mayo clinic and Mayo foundation.- 4th edition.-W.B. Saunders Company, Philadelphia, London, Toronto.-1976.

3. WEB-site of tdmu.

Material for practical classes

 В – Additional:

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

3.      Van Allen’s  Pictorial Manual of Neurologic Tests.- Robert L. Rodnitzky.-  3 edition.-Year Book Medical Publishers, inc. Chicago London Boca Raton.- 1981.

 

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

 

Methodical instruction was discussed and adopted at the Department sitting

20.05.2013 . Minute9

Methodical instruction was adopted and reviewed at the Department sitting

 

 

 

 

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