METHODICAL INSTRUCTION FOR STUDENTS OF THE 4 COURSE

MEDICAL FACULTY

LESSON ¹ 10 (PRACTICAL6 HOURS)

 

Theme:

1.                Demyelination diseases of nervous system: multiply sclerosis (MS), acute disseminated encephalomyelitis (ADEM), optic encephalomyelitis, encephalomyelopolyradiculoneuritis, polyencephalomyelitis, disseminated myelitis. Acute myelitis.

2.                  Amyotrophic lateral sclerosis (ALS) 

Aim: Students should be able independently to diagnose multiply sclerosis, ADEM and other demyelination diseases, to prescribe treatment. To make preventive measures. To fulfill medical labor examination. Students should be able to find out symptoms of ALS. 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: Demyelination diseases of nervous system results in rapid disability of patients in young and mature age. ALS is very common at any age. ALS is characterized by severe changes of central nervous system. That’s why in time diagnosis Demyelination diseases of nervous system and ALS has very important meaning for the effective treatment of such patients. 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. Demyelination diseases of nervous system: multiply sclerosis (MS), acute disseminated encephalomyelitis (ADEM), optic encephalomyelitis, encephalomyelopolyradiculoneuritis, polyencephalomyelitis, disseminated myelitis. Acute myelitis.

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

1.        To determine clinical form of multiply sclerosis, acute disseminated encephalomyelitis, amyotrophic lateral sclerosis, acute myelitis by mean of scheme of differential diagnosis.

2.        To define basic clinical syndromes of locomotors, sensitive, coordinative dysfunction, cranial innervation.

3.        Carry out differential diagnosis between multiplex sclerosis and acute disseminated encephalomyelitis.

4.        To formulate clinical diagnosis, for example:

a)       Multiply sclerosis, cerebral-spinal form with presence of lower spastic paralysis, degree III, progradientive course

b)       Acute disseminated encephalomyelitis (encephalomyelopolyradiculoneuritis) with presence of mixed tetraparesis and disturbed sensation of radicular and polyneuritic type.

Step II. Aim: To prescribe therapy. For this it is necessary to pay attention to pathogenetic mechanism of demyelination diseases of nervous system, clinical forms, course of disease, presence of remission, acute periods, est.

For the treatment of multiply sclerosis prescribe:

-          general-clamping drags (ATPh, Cocarboxylase);

-          vitamins group B (B1, B6, B12), ascorbinic acid (Vit C), nicotinic acid (PP);

-          hormones (prednisolone, metipred, dexamethazone, polcortolone) in onset of disease;

-          desensibilisation drugs (dimedrol, pipolphene, diazoline, claritin, hormones);

-          immunostimulators (T-activine, Thymaline, Sinacten-depo, Echinacea);

-          pyrogenic drugs (pyrogenal);

-          immunodepressors (hormones, asathyoprine);

-          myorelaxation drugs (Midocalm, Mellictine, Bactrophene);

-          biostimulators (aloe, vitreous body);

-          plasmapheresis.

In causes of ADEM also it is necessary to prescribe course of antibiotics therapy (series of penicillin, cephasolin), enzymes (desoxyribonucleinase, ribonucleinase) and antivirus remedies such as Reapherone, Acyclovir, Zovirax, hormones, desensibilisation medicines. Independently prescribes medicines for therapy of amyotrophic lateral sclerosis.

Step III. Aim: To fulfill preventive-examinative measures.

On reason from clinical diagnosis and effect of therapy to define prognosis about life, work, recovering, to take preventive measures, to fulfill medical labor examination and military medical examination.

Work 2. 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 ALS according to algorithm of differential diagnosis (look to references).

2.        To localized pathological focus.

3.        To define basic clinical syndromes of locomotors, cranial nerves innervations dysfunction.

4.        To formulate clinical diagnosis, for example:

a)       ALS, cervical-thoracic form, with deep flaccid palsy of the arms, central on 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. Demyelination diseases of nervous system: multiply sclerosis (MS), acute disseminated encephalomyelitis (ADEM), optic encephalomyelitis, encephalomyelopolyradiculoneuritis, polyencephalomyelitis, disseminated myelitis. Acute myelitis.

Etiology and pathogenesis of demyelination diseases.

1.        Clinical pictures of MS:

a) clinical pictures of early signs of diseases;

b)clinical forms

c) lesion degree, course.

2.        Clinical picture of ADEM:

a)             clinical forms of ADEM,

b)                  version of course

3.        Differential diagnosis of MS and ADEM:

a)                   take care on early signs, character of course, basic clinical syndrome

4.        Clinical picture of acute myelitis and ALS:

a)                   clinical signs of acute myelitis of cervical, thoracic and lumbar parts of spinal cord

b)                  clinical forms of ALS, course.

5.        Diagnose of MS, ADEM, ALS, acute myelitis:

       a) role of additional methods examination (clinical and biochemical blood, urine analysis, peculiarities of eye grounds, changes of visual field, immunological examination of blood);

 b) formulation of clinical diagnosis.

6.        Treatment of demyelination diseases:

a)                   ethiopathogenetic and symptomatic therapy of  MS, ADEM, ALS, acute myelitis (with prescriptions);

b)                   physiotherapeutic treatment (thermal and electro procedures, massage, remedial gymnastics).

7.        Prevention of MS, ADEM, AM and their complications, medical labor examination:

a)       prognosis and prophylaxis of MS, ADEM, ALS, AM;

b)       medical labor examinations;

c)       military medical examinations;

Theme  2. Amyotrophic lateral sclerosis (ALS)

1.        To study  ALS:

a)                   Etiology and pathogenesis;

b)                  Clinical forms;

Clinical picture.

Treatment, course.

 

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

Test evaluation and situational tasks.

Tests:

1.       Basic theory of etiology and pathogenesis of Multiply sclerosis (MS).

2.       Beginning signs of MS.

3.       Name the clinical forms of MS.

4.       Describe basic clinical signs of cerebellar form of MS.

5.       Describe basic clinical signs of spinal form of MS.

6.       Describe damage degree of MS.

7.       Name main clinical forms of MS.

8.       Describe changes of eye grounds during MS.

9.       Describe Sharcot’s triad.

10.    Describe Marburg’s pentad.

11.    What structures of nerve system demyelinizates more frequently during MS?

12.    What structures of visual analyzer earlier affected during MS?

13.    Enumerate main groups of medicines which are used for the pathogenetic therapy of MS in aggravation period.

14.    Enumerate basic groups of medicines, which are used for the pathogenetic therapy of MS in onset of the disease. Prescribe Pyrogenal, Propermil.

15.    Enumerate main groups of medicines which are used in remission period. Prescribe Thymaline, T-activine.

16.     Describe signs of acute myelitis, localized in thoracic part of spinal cord

17.    Name complications of acute myelitis.

18.    Name basic etiology and pathogenetic groups of medicines which are used for the treatment of acute myelitis during acute and remission periods.

19.    Describe two basic theories of ALS.

20.    Describe basic clinical forms of ALS.

21.    Describe clinical features of cervical-thoracic form of ALS.

22.    Describe clinical features of bulbar form of ALS.

23.    Describe basic groups of medicines, which are used for the treatment of ALS. Prescribe Vit E in capsules and Retabolil in injections.

24.    Name basic clinical forms of acute dissemination encephalomyelitis.

25.    Describe basic clinical features of polyencephalomyelitic form of ADEM.

26.    Describe basic clinical features of meningoencephalomyeloradiculoneuritic form of ADEM.

27.    Enumerate basic clinical features of opticomyelitic form of ADEM.

28.    Name basic pathogenetic groups of medicines for treatment ADEM. Prescribe Ribonucleinase and Reapherone.

29.    What physiotherapeutic methods are used for the treatment of chronic dissemination encephalomyelitis?

30.    What clinical forms of neurosyphilis are?

31.    Clinical classification of early meningeal-vascular syphilis.

32.    Clinical classification of late parenchymatous syphilis.

33.    To name the specific serologic tests for syphilis.

34.    To name clinic symptoms of syphilitic meningoencephalitis.

35.    What is characteristic feature of vascular syphilis?

36.    What stages of Tabes dorsalis do you know?

37.    Specific treatment of early (mesodermal) neurosyphilis. Prescribe aqueous penicillin G.

38.    Specific treatment of late (parenchymatous) neurosyphilis. Prescribe Amoxicillin.

39.    Clinical picture of neurological symptoms of AIDS.

40.    Clinical picture of optic fundus in tabes dorsalis.

41.    Name the clinical signs of chronic syphilitic meningitis.

42.    Clinical forms of neurosyphilis.

43.    Differential signs of syphilitic and vertebral radiculopathy.

44.    The signs of neuralgic stage of tabes dorsalis.

45.    The signs of ataxic stage of tabes dorsalis

46.    The signs of “upper tabes”.

47.    The signs of “lower tabes”.

48.    What motor neuron is damaged at amyotrophic syphilis?

49.    What motor neuron is damaged at spastic spinal palsy?

50.    Clinical features of hypertension syndrome.

51.    Name the drugs which cure hypertension syndrome.

52.    Clinical features of status dysrhaphycus.

53.    Clinical forms of syringomyelia.

54.    Clinical symptoms of syringomyelia.

 

Real-life situations to be solved:

1.        Signs of Sharcot’s triad, pentad of Marburg’s.

2.        Clinical forms of ADEM.

3.        What symptoms belong to myelitis of thoracic part of spinal cord?

4.        How neurosyphilis is classified now?

5.        What stages of tabes dorsalis do you know?

           

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 demyelination diseases

2. Clinical features of demyelination diseases

3. Clinical forms of demyelination diseases

4. Differential diagnosis of MS and ADEM

5. Clinical feature of neurosyphilis.

6.        Clinical signs of neurological symptoms of AIDS.

7.        Clinical features of status dysrhaphycus.

8.        Clinical forms of Syringomyelia

9.        Clinical symptoms of Syringomyelia

 

Student should be able to:

1.        Examine the patients with demyelination diseases

2.        Administer additional methods examination

3.        Administer treatment of demyelination diseases

4.        Determine prophylaxis of MS, ADEM, ALS, AM and their complications.

5.        Make a correct topical diagnosis

6.        Make a correct clinical diagnosis

7.        Prescribe treatment

 

Correct answers of test evaluations and situational tasks:

1.        A – nystagmus, scanning speech, intention tremor.

B – nystagmus, scanning speech, intention tremor, absence of abdominal reflexes, atrophy of optic disk.

2.  A – encephalomyelopolyradiculoneuritis;

     B – polyoencephalalitis;

C – opticoencephalitis and opticomyelitis;

D – disseminated myelitis.

3. Pelvic disorders, lower spastic paraplegia, conductive disorders of sensibility and trophic disorders.

4. Early (mesodermal) and late (parenchymatous).

5.Neuralgic, ataxic, pseudoparalitic.

 

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

 

References:

À – Basic:

1.     WEB-site of tdmu.

Material for 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 in neurology – Mayo clinic and Mayo foundation.- 4-th edition.- W.B. Saunders Compani, Philadelphia, London, Toronto.- 1976 y.

 – Additional:

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

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

7.        Neurology in lectures. Textbook. Edited by the head of Neurology Department - prof. S.². 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 ¹

Methodical instruction was adopted and reviewed at the Department sitting

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