КУТОВОЙ ИГОРЬ АЛЕКСАНДРОВИЧ: +38 050 300-25-50; +38 098 447-26-32 город Харьков, ул. Акад. Павлова, 46 Государственное учреждение "Институт неврологии, психиатрии и наркологии НАМН Украины"
web: kutovoy.umi.ru
mail: igorKutovoy@gmail.com

Class 4

Class 4

Methodological recommendations on the theme:

Clinical detour. An examination. A spelling of the case record”

  1. 1.                 Urgency of a subject: Clinical detour during which students of 5-th course get acquainted with a contingent of patients of a neurosurgical hospital very useful form of carrying out of practical employment during which the professional outlook extends and to students skills of clinical medical thinking take root. The doctor should be able to put the presumable clinical diagnosis at primary examination of the patient with a pathology of the central and peripheral nervous system and to render adequate medical assistance.
  2. 2.                 The purposes of employment:

2.1. The educational purposes:

To familiarize students with a contingent of the patients, demanding the specialized neurosurgical medical aid.                         II level

-                                             the student should know the basic clinical groups of diseases of a neurosurgical structure.                                                   I a level

-                                             the student should be able to examine the patient with a neurosurgical pathology, to render the urgent help on a place of incident, in the term(period) of transportation and a reception.                                         III level

-                                             to learn the student to make algorithm of inspection of the patient from CCI, a tumour head and a spinal cord, a cerebrovascular pathology.         III level


2.2. The educational purposes: To take part in formation at students of principles of a deontology, medical ethics, the professional responsibility in general and at contact to patients of a neurosurgical structure, in particular.

3.3. Specific goals: to know:

-                                             1. Principles of a formulation of the diagnosis of the neurosurgical patient

-                                             2. Classification of gunshot wounds of a skull and a brain.

-                                             3. Clinical attributes of the CCCT and the OCCT.

-                                             4. A clinical picture of fracture of the basis of a skull.

-                                             5. Classification and principles of a formulation of the diagnosis нейроонкологического the patient.

-                                             7. Algorithm of inspection from CCI, a tumour of the CNS, a cerebrovascular pathology.

3.4. On the basis of theoretical knowledge - to be able:

  1. To examine the patient with a pathology head and a spinal cord of the neurosurgical plan.
  2. To analyse the data of clinical methods of inspection.
  3. To estimate the data of radiological inspection.
  4. To know the order of carrying out of primary surgical processing of a wound of a head.
  5. Under the direction of the teacher to execute a lumbar puncture.


  1. 4.                 Interdisciplinary integration.


 To know

 To be able


Human anatomy


Topographical anatomy with operative surgery.





Nervous illnesses

General surgery






Nervous illnesses


Anatomy of a skull and brain.

To know the basic surgical approaches

To know clinical attributes of a typical neurosurgical pathology


To know principles of carrying out of primary surgical processing of wounds of a skull and a brain





To state principles of the basic surgical approaches at a pathology of a skull and a brain.



To be able to examine the patient, to study the psychoneurologic status at patients with a pathology of a skull and a brain


To be able to collect an anamnesis, to carry out general clinic inspection and to plan the plan of special inspection of the patient with a pathology head and a spinal cord.


  1. 5.                 The maintenance of employment. During carrying out of practical employment students together with the teacher examine patients, get acquainted with special methods of inspection in conditions of a neurosurgical hospital. Work in dressing, operational, roentgen, on a computer tomograph, in electrophysiological laboratory. By the example of the concrete patient concrete clinical situations understand.


The chart of case report.



Department of Neurosurgery

Chief of department

Professor V.Pyatikop




Surname of patient, name, patronymic name _____________________________________________


Clinical Diagnosis:


                                                                           Surname and name of student,




Kharkiv -2013


Case report №

Surname, name, patronymic name of the patient_______________________________________________________________

By whom the patient is directed __________________________________________________________________

Age______________________ Female/Male_________

Occupation  ___________________________________________________________________

Domestic address_____________________________________________________________

Date of hospitalization______________ Date of discharge from the hospital __________________

Diagnosis during hospitalization

Diagnosis clinical

Concomitant diseases

Operation (date)_______________________________________________________________________________________________________________________________

Complication (date) _________________________________________________________________

Postoperative diagnosis___________________________________________________________

Result (convalescence, improvement, without the changes, worsening, death) Capacity (well-kept, reduced, lost (temporally, forever)


Complaints of patient during hospitalization in the moment of review

Anamnesis of nowaday disease (time of disease, first symptoms of disease, loud speaker of development of symptoms, conducted treatment to hospitalization in a clinic, his results. In the case of trauma - to mark the date of trauma, circumstances and mechanism of trauma, given first help.

Anamnesis of life.

I. General examination.

Common state of patient (build, features of structure of body, position of patient at bed)

Form, size and position of head

Skinning covers and visible mucous membranes

Lymphatic knots

Cardio-vascular system

Breathing organs

Organs of abdominal region

Local changes (trophic disorders, wounds, scars, defects of bones, bedsores and other)

Bloody pressure _______ Pulse__________Breathing rate ____________________

II. Special exemination (information of neurological review).

І. General cerebral symptoms (headache, nausea, vomitting, discomfort and other)

2. State of consciousness (orientation in a place and time). Conduct at the inspection, attitude toward the disease. __________________________________________________________________


3. Meningeal symptoms (rigid neck of muscles of the back of head, the Kernig, Brudzinsky symptoms)

2. Cranial nerves.

I pair. Olfactory nerve. Verification on either side

II pair. Visual nerve. Field and sharpness of sight

III, IV, VI pair. N. oculomotorius, n, trochleares, n.abducens. Form and size of pupils, reaction on light, convergence, accommodation. Width of eyeing slit. Motion of eyeballs, presence of cross-eye, doubling of objects

V pair. Tregeminal nerve. Sensitiveness on face. Morbidity of points of output of branches of trigeminal nerve. Corneal and conjunctival reflexes. State of masticatory musculature ________________________________________________

VII pair. Facial nerve.  Symmetry  of person. Wrinkle (up) one's forehead, screwing up of eyes. Presence of asymmetry of nasolabial folds at mimic tests _________________

VIII pair. N. vestibulo-cochlearis. (sharpness of ear, nystagmus)

IХ, X pairs. N. glossopharingeus, N. vagus. State of swallowing and phonation. Nasal tint of broadcasting, mobility of soft   palate. Reflexes from a soft palate and from the back wall of gullet. Taste.

XI pair. N. abducens.  State  of груднино-ключично-papillary muscle,  turn of head in sides and down, raising of shoulders. _____________________________

XII pair. N. hypoglossus. Pulling out of tongue, declination of him in sides. State of muscles of tongue, atrophy, fibrilar twitch(ing) _______________________________

3. Motor sphere.

Volume of active motions in the joints of hands and feet. Muscular force (force of symmetric groups which are explored; estimation is given after the fiveball system). Passive motions, their volume. Muscular tone and his changes. Atrophy of muscles. Fibrilar and fascicular twitch(ing). hyperkinesis, their character, localization and degree of expression. ____________________

4. Reflexes.

To the tendon reflexes (from two-headed and tricepses, knee and achill). Periostal reflexes (from subulate sprout of radial bone). Skinning reflexes (abdominal, sole). _________________________________

Pathological reflexes (extensive – Babinsky’s, Gordon”s, Sheffer”s symptoms; bending –Rossolimo”s, Bechterev”s etc., protective reflexes; clonus of patella) ________________________________________


5. Sensitiveness.

Superficial types of sensitiveness. Muscular-joint feeling. Vibration feeling and feeling of pressure. Difficult types of sensitiveness (stereognosis, discrimination of two points. Awareness of position of body and his parts in space).

Morbidity of nervous trunks.

6. Coordination of motions.

Static   test   (the Romberga’s symptom ). Locomotoric tests (finge-nose probe, khee- calcaneal probe). diadochokinesis. Step (hemiplegic,spastic, heretic).______

7. Speech (scansion, disartria,anartria, with a nasal tint)

Aphasia (motor, sensitive, amnestic)

8. Letter, reading, accounting.

9.Vegetative nervous system (dermografismus, hyperhydrosis)..

Functions of pelvic organs.

III. Previous diagnosis. (substantiation of the topic  and nosology diagnosis)

IV. Plan of diagnostics. (substantiation of the  necessity of the performing  methods for clarification of diagnosis, choice of tactic of treatment)


1. Review of adjoining specialists: ophtalmologict, otoneurologist, physician etc.

2. Diagnostic methods.


laboratory (blood test, urines, CSF), X-Ray methods, EchoEG, EEG, LP (liquor pressure, liqurodinamic tests)

contrasting methods of research, their grounds (angiography, pneumoencephalography, ventriculography, cystography, myelography)

CT, MRI, radioisotope methods


V. Differential diagnosis (4-5 nosology , which have similar symptoms)

VI. Clinical diagnosis (final)

VIITreatment:  surgical (substantiation of the operation, protocol of operation);

Conservative treatment (general principles and prescriptions of 4-5 medicines)

VIII. Clinical flow of illness (2-3 diaries)

IX. Epicrisis

X. Recommendations at the discharge from the hospital

XI. Autopsy protocol in the case of death of patient


Signature of doctor


  1. 6.                Materials of methodical maintenance of practical employment.

6.1.                                 Materials of the control of the final stage: tests of a final level

6.2.                                 The information necessary for self-checking of an initial level of knowledge – skills can be found in tutorials:

The basic:

  1. Иргер И.Н. Нейрохирургия, М., Медицина, 1982
  2. Лебедев В.В., Быковников Л.Д. Руководство по неотложной нейрохирургии. – М.: Медицина. – 1987. – 336 с.
  3. Неврология / Под ред. М.Самуэльса. – М.: Практика, 1997. – 640 с.
  4. Цимбалюк В., Хонда О., Третяк І., Авад М. Нейрохірургія. Курс лекцій. – Київ, 1998. – 206 с.
  5. Полищук Н.Е., Старча В.И. Огнестрельные ранения головы.- Киев: Изд – во ТОВ «Тон», 1996. – 72 с.



  1. Руководство по нейротравматологии / Под ред. А.И.Арутюнова. – М.: Медицина, 1980. – Ч.11. – 392 с.
  2. Полищук Н.Е., Верхоглядова Т.В. и др. Клиника и судебно – медицинская экспертиза черепно–мозговых повреждений – К.: Изд. ТОВ «Тон», 11996. – 119





A. Control questions:

1)      Open CCI – This is:....?

1)                              Classification of gunshot wounds of a brain?

2)                              What clinical attributes of traumatic damage of a brain?

3)                              What data specify a compression of a brain?

4)                              What auxiliary methods of research are applied at traumatic damage of a brain?

5)                              What can cause a compression of a brain?

6)                              Optimum terms of primary surgical processing of wounds of a skull and brain.

7)                              General brains symptoms of tumours of a brain.

8)                              The most informative symptoms of tumours of a brain.

9)                              Indications and contra-indications to carrying out of a lumbar punctute.

10)                         Hypertension - liquor syndrome, its clinical attributes.


Problems for self-checking with standards answers. - Situational problems in frameworks “Kroc -2” (are applied)


1.1.                                 The list of educational practical tasks:

  1. To examine the patient from the OCCT.
  2. To analyse the radiological data.
  3. To take part in carrying out of primary surgical processing a wound of a head.
  4. To take part in carrying out of a lumbar punctute.