Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
MINISTRY OF PUBLIC HEALTH OF UKRAINE Vinnitsa National Pirogov Memorial Medical University "Approved" on the methodical council of the Department of Tuberculosis, Clinical Immunology and Allergy „29___” _avgusta 20 13 yr. Protocol № Head of the Department Professor B. Pukhlic Manual FOR Students for preparing to practical classes (in English) Learning discipline Module №1 Thematic module №1 Topic of lesson Course Faculty Phthisiology (Tuberculosis) Phthisiology (Tuberculosis) Tuberculous meningitis. Tuberculosis of the pleura. Curation of patients with pulmonary tuberculosis. Tuberculous meningitis. Examination of patients with tuberculous meningitis. Diagnosis, treatment. Differential diagnosis with meningitis of other etiology. Tuberculous pleurisy (pleural empyema) Pathogenesis, pathomorphism, clinicoroentgenologic version, clinical picture and diagnostical aspects, differential diagnosis, treatment, conseceqences. Management of tuberculosis patients. Defence of case history. 4th General medicine Edited by Andriy Dudnyk Vinnitsa 2013 Background: Tuberculosis of the central nervous system remains to the present time one of the most severe forms of tuberculosis. The compromise of the central nervous system occurs in two basic forms: meningoencephalitis and intracranial tuberculoma. Since the introduction of modern chemotherapy and especially massive BCG vaccination, a lower proportion of the meningoencephalitis has been observed, but the frequency of this form of TB is higher among young adults with HIV/AIDS. Pleural tuberculosis. This is the most common form of extrapulmonary TB, and can either result from the rupture of a primary subpleural lung focus (evident or not on conventional chest X-ray) or be secondary to lymphohematogenic dissemination. The presence of a pleural TB effusion has also been related to hypersensitivity (Light 1990). Most cases occur several months after the primary infection, and frequently the patient relates having contact with an active pulmonary TB case in the two years preceding the current episode. 1. Educational aims Students need to know: Features of pathogenesis and pathomorphology of tuberculous meningitis and meningoencephalitis. Peculiarities of tuberculous meningitis (meningoencephalitis), his clinical symptoms. How to diagnose tuberculous meningitis? How to differentiate the diagnosis of tuberculous meningitis and meningitis of other etiology? Modern methods of treatment of tuberculous meningitis. Features of etiology and pathogenesis of pleurisy. The mechanism of pleural exudation in normal and by various pathological processes. Etiology of pleural effusion. Clinical and radiographic manifestations of pleurisy. Tactics of treatment of tuberculous pleurisy. Possible consequences of tuberculous pleurisy and their description. Students should be able to: To collect case history and examine patients with tuberculous meningitis. To distinguish tuberculous meningitis and meningitis that have similar clinical picture. To determine the activity of tuberculosis. To recognize the clinical forms of tuberculous meningitis. To prescribe treatment and calculate of the daily dose of anti-TB drugs for individual patients. To collect history and examine the patients with tuberculous pleurisy. To distinguish tuberculous pleurisy with pleurisy of other etiologies. To determine the activity of tuberculous pleurisy. To prescribe treatment of tuberculous pleurisy patients. 2. Interdisciplinary integration Name of discipline Human Anatomy Pathological Physiology Pathological Anatomy General and Clinical Pharmacology Propedeutics of Internal Medicine Operative surgery and topographic anatomy Neurology Necessary skills Nervous System. Shells of the brain and spinal cord. Pathways of the brain and spinal cord. The structure of the cranial nerves. Features of the blood supply of the brain and spinal cord. Lymphatic vessels of the head and neck. Inflammation. Tuberculous inflammation. Exudative and productive processes. The blood–brain barrier. Morphological manifestations of tuberculous inflammation in organs and tissues, residual tuberculous changes. TB chemotherapy, classification, dosage, methods of administration. Pharmacokinetics of antituberculosis drugs. Adverse reactions to antibacterial drugs, prevention and elimination. Methods of physical examination of patients. Diagnostic value of epidemiological history, physical methods of examination of patients, puncture of pleural cavity, microscopic examination of fluid for M. tuberculosis. Methods of pleural and spinal puncture puncture of a lymph node, thoracoscopy with biopsy. Somatic status. Neurological status: cranial nerves, motor functions, sensitivity, reflexes, coordination and gait, higher cortical function, autonomic nervous system, the function of the pelvic organs. Paraclinical tests: complete blood count, spinal fluid, electroencephalography, rheoencephalography, computer tomography. 3. Tasks The specific term 1. Meningitis 2.Meningoencephalitis Definitions Inflammation of the membranes of the brain and spinal brain The transition of the pathological process of the vessels in the pia mater to the brain tissue 3.Meningeal syndrome 4. Pleuritis 5. Dry pleuritis 6. Exudative pleuritis It consist of headache, vomiting, neck stiffness, Kernig’s sign, Brudzinski’s sign Kernig’s sign, changes in CSF. Inflammation of pleura Inflammation of pleura with sedimentation of fibrin on pleural layers Inflammation of pleura with pleural effusion 4. Theoretical questions for preparing to class: 1. What are the criteria and characteristics that define tuberculosis of nervous system? 2. What are the causes and factors may be important in the development of relapse of tuberculous meningitis? 3. What are the clinical forms of tuberculous meningitis? 4. Describe the physical properties, chemical, biochemical and biological composition of spinal fluid in tuberculous meningitis? 5. Treatment and rehabilitation of patients with tuberculous meningitis. 6. Pathogenesis and morphological manifestations of tuberculous tuberculous pleurisy 7. What is the clinical classification of pleurisy? 8. What are the basic principles of treatment of patient with tuberculous pleurisy? 9. What are the possible consequences of tuberculous pleurisy? 5. Write correct answers Objectives 1. What are the criteria and characteristics that define tuberculosis of nervous system? 2. What are the possible variants of penetration of Mycobacterium tuberculosis in the meninges and central nervous system? 3. What are the causes and factors may be important in the development of tuberculous meningitis? 4. How long is prodromal period of tuberculous meningitis? 5. What symptoms are persistent on late prodromal period of illness? 6. What are the clinical forms of tuberculous meningitis? 7. What are the symptoms of tonic Etalon of answer tension of muscles that most often observed in tuberculous meningitis? 8. What cranial nerves are most commonly affected with tuberculous meningitis and which the mechanism of their injury? 9. Describe the physical properties, chemical, biochemical and biological composition of spinal fluid in tuberculous meningitis? 10. What values reaches content of cellular elements in the cerebrospinal fluid of patients with tuberculous meningitis? 11. What measures should be included in the complex treatment of patients with tuberculous meningitis? 12. What are the consequences of the tuberculous meningitis? 13. Is the tuberculous pleuritis primary or secondary process? 14. What proportion of tuberculous pleurisy among other clinical forms? 15. What are the main ways of penetration of infection in the pleura? 16. What is the possible character of exudate in tuberculous pleurisy? 17. What is the classification of pleurisy by depend on the location of fluid? 18. List the clinical syndromes which are specific to tuberculous pleurisy? 19. What are the characteristic changes in the pleural fluid in tuberculous pleurisy? 20. What changes in patient complaints will be appear if dry pleuritis is transformed into exudative? 21. List the diseases that have clinical and radiological picture similar to tuberculous pleurisy? 22. What are the basic principles of treatment of patient with tuberculous pleurisy? 23. What are bacteriostatic drugs that are used in the treatment of patients with tuberculous pleuritis? 24. What are the features of admission of medications in patients with tuberculous pleurisy? 25. What are the possible consequences of tuberculous pleurisy? 6. Practical tasks 6.1. Interview and clinical examination of patient with tuberculous meningitis. 6.2. Analysis of thematic case history. 6.3. Describe of changes in CSF. 6.4. Interview and clinical examination of patient with tuberculous pleuritis. 6.5. Describe of changes in pleural fluid. 7. Tasks for control of quality knowledge and skills during learning activities: № 1. 2. 3. 4. 5. 6. question What research gives accurate information about etiology of inflammation of the meninges? What are the requirements for the diagnosis of tuberculosis of nervous system in TB clinics? What are the clinical and laboratory findings can indicate about transition of tuberculous meningitis under meningoencephalitis? Principles of treatment of tuberculous meningitis patients. What anti-TB drugs used in patients with tuberculous meningitis and their daily dose for adults? Which meningitis of other etiology carry differential diagnosis of tuberculous meningitis? answer 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. In the girl 9 years was appeared meningeal symptoms. For 2 months before admission to the hospital primary tuberculous complex in phase infiltration was diagnosed. She was treated at home irregularly. Food was insufficient. Five days later came the headache, vomiting, convulsions and therefore the patient was hospitalized. Mantoux test - 13 mm papule. Blood: Leukocytes -11.5 x 10 / l, left shift, lymphopenia, monocytosis, ESR - 27 mm / h. а). What should be done to clarify the diagnosis? When symptoms of tuberculous meningitis disappear during an antibacterial treatment? In some cases the most favorable prognosis of tuberculous meningitis? What research gives accurate information about etiology of exudative pleurisy? List the major clinical symptoms of dry pleurisy. List the major clinical symptoms of pleural effusion. What auscultatory features in dry pleurisy? In which side is observed shift of the mediastinum with pleural effusion? Name the place often accumulation of effusion? What is the nature of exudate in tuberculous pleural empyema? 8. Supervision of patients with pulmonary tuberculosis. Interview (collection) complaints, all anamneses (vitae, morbi, epidimiologic composion of case), inspectation and physical examination of the patient (revealing of abnormalities in organs and systems). *mastering to analyze and interpret results of the patient examination, data of chest X-ray, laboratory & instrument investigation *mastering to grounding of diagnosis of the patient, prescribe adequate chemotherapy, detect of prognosis as to life and recovery. 9. Recommended reading list 1. Juan Carlos Palomino et al Tuberculosis 2007 From basic science to patient care www.TuberculosisTextbook.com 2. American Thoracic Society. Diagnostic standards and classification of tuberculosis in adults and children. Am J Respir Dis Crit Care Med 2000; 161: 1371-95. 3. Brodie D, Schluger NW. The diagnosis of tuberculosis. Clin Chest Med 2005; 26: 247-71. 4. Busi Rizzi E, Schinina V, Palmieri F, Girardi E, Bibbolino C. Radiological patterns in HIV-associated pulmonary tuberculosis: comparison between HAART-treated and non-HAART-treated patients. ClinRadiol 2003; 58: 469-73. 5.Петренко, В.І. Phthisiology — Фтизіатрія: Підручник / В.І. Петренко. — К.: Медицина, 2008. — 288 с. 6. World Health Organization. Stop TB partnership. Tuberculosis in Countries. www.stoptb.org./countries/. Date last accessed: May. 8:2007. 7. National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. NICE clinical guidelines no 33. Royal College of Physicians, 2006. 8. Toman K. How does pulmonary tuberculosis develop and how can it be detected at an early stage? In Toman K. Toman’s Tuberculosis. Case detection, treatment, and monitoring—questions and answers. 2nd ed. World Health Organization, 2004:66-71. 9. Lectures.