MEDICAL
FACULTY
LESSON ¹ 10 (PRACTICAL – 6
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.
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
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
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.
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
__________201 . Minute ¹ ___