The patient has partial atrophy of the deltoid muscle. Clinic and course of myotonic dystrophy. in the legs - spastic tone, increased tendon reflexes, Babinski reflex, protective reflexes; no abdominal reflexes

Igor Saprin, Male, 36 years old

At the beginning of March 2015, I hit a tree with my left shoulder when I fell. A few months later I discovered atrophy deltoid muscle. Completed a course of treatment. According to enmg, there is a conduction disorder of the axillary and suprascapular nerve. Both the radial axillary and ulnar are affected. A small atrophy in the form of a pit has formed on the palm of the wrist in the area of ​​the little finger. But it has not progressed yet. There is no pain. The strength in the hand is preserved. The same as on the right. But at night it happens that the little finger and ring finger go numb. It was as if he was lying down. As soon as I change the position of my hand, the blood flow is restored and everything becomes normal. This had never happened before before the injury. In March 2016 It will be a year. During this time I underwent treatment twice. Did needle electrical stimulation. I do it almost every day physical exercise. Biceps triceps and pectoral muscles increased. Deltoid no. I can move my arm up and to the side. Circular movements, I put them behind my back. With a five kilogram weight I raise my arm up to 20 times and moving my arm to the side I raise it up to 10 times, but I think this is all at the expense of other muscle groups. The deltoid muscle hurts during physical activity. And the sensation seems to stretch her. There is no sensitivity in the place where it connects to the biceps and triceps. Question? Muscle atrophy may continue after a year. Or the whole process is already over. And, perhaps surgical intervention. Doctors say that a nerve was pinched somewhere and a blockage formed. Both the neurosurgeon and the neurologist say that surgery is not possible. When you raise your arm up, it slightly does not reach the full vertical position. And also when lifting horizontally, it is slightly brought forward. Sometimes pain appears in the neck of the scapula and in the bend of the elbow, as if pulsating, not sharp, quickly passable, but frequent.

Hello! Judging by your description, the problem is this moment may be due to limited mobility of the scapula, which has changed the biomechanics of the shoulder joint and the entire glenohumeral complex. I recommend visiting a physical therapy doctor and an applied kinesiologist. Atrophy may continue after a year. With this problem, functional blocks inevitably develop in the cervical spine and pain in the elbow joint according to the type of epicondylitis. Patients with similar problems often come to our center. Speedy recovery!

Igor Saprin

I contacted a chiropractor. He conducted a couple of sessions and said there was nothing he could do. He also took courses in electrophoresis, ultrasound, and magnets. Also without results. Only the delta has atrophied, the muscles on the scapula normally work as expected. According to the local neurosurgeon, after the injury a hematoma formed, which subsequently began to be replaced by connective tissue, forming a scar that presses on the nerve in the area of ​​the notch of the scapula. Forming a blockade. Tell me surgical intervention is possible to release the nerve. And if atrophy in the palm continues to progress, it will affect the entire hand. Or only on the little and ring fingers. On the hand, only the muscle that runs along the hand to the little finger atrophies.

For a more specific description of the picture of the disease, we provide data on the patient observed in our clinic.

Patient A., 37 years old, was admitted to the clinic with complaints of significant weakness, fatigue, especially when walking, difficulty opening her hand clenched into a fist. The patient has lost 18 kg in weight over the past 10 years, despite a normal diet. In addition, she complained of attacks of intense pain in the epigastric region.

According to the patient and her relatives, family members did not experience any myotonic phenomena, muscle atrophy, cataracts, or significant endocrine pathology. The patient got married at the age of 21; I was not pregnant after my first abortion.

At the age of twenty, I noticed that when shaking hands, I held someone else’s hand because I could not unclench my fingers; Later she noticed that after a long silence she could not immediately open her mouth; after a long stay in sitting position it was difficult to get out of the chair. At first the patient did not pay any attention to all these phenomena. special attention and considered myself practically healthy.

At the age of 27, attacks of pain appeared in the epigastric region, spreading to the entire abdomen. Each such attack lasted about 6 hours. Over the next 7 years, she had 4 similar attacks of extremely intense pain. During one of them she experienced symptoms of collapse.

The patient is extremely asthenic, with a long thin neck and sunken cheeks; the face therefore appears sharply flattened; the upper jaw is somewhat prognathic; the skin is pale, there is slight bilateral exophthalmos. The hair on the head is thin, very sparse, with a lot of gray hair. The upper eyelids are slightly drooping. The area of ​​the temporal muscles is sunk, they are very faintly palpable when the mouth is tightly closed; The masseters are noticeably atrophic; when teeth are bared, the lips barely part, and smiling is impossible due to atrophy of the facial muscles.

The patient's voice is weak, hoarse, and aphonic. There is a sharp atrophy of the sternocleidomastial muscles, they can barely be felt; The neck extensor muscles are also atrophic. When throwing her head back, the patient can only move her out of this position with the help of her hands. Muscle atrophy is also noted shoulder girdle, to a lesser extent the legs and pelvic girdle. Tendon and periosteal reflexes in the hands are not evoked, Achilles are absent, knee reflexes are very low. When you hit the tongue with a hammer, a depression and a sharp ridge are formed; when hitting the thenar, the thumb is adducted and opposed to the hand for a few seconds. Fingers clenched into a fist with difficulty and slowly unbend. When the muscles of the hand and forearm are stimulated by galvanic and faradic current, a myotonic reaction is observed. Chronaximetric examination of the orbicularis oris muscle and flexor digitorum superficialis demonstrates a slight increase in the excitability threshold with normal chronaxia. During myographic recording: contraction of the flexor of the third finger in response to irritation by an induction current sometimes lasts known time after the cessation of irritation, forming a small plateau on the myogram.

The sensitivity study did not reveal any noticeable deviations from the norm. The sudden coldness of the hands was noteworthy; dermographism - pale pink, unstable, Aschner's test was accompanied by a decrease in pulse by 10 beats per minute, the Chvostek phenomenon was intermittently induced on the right. Injections of pilocarpine and epinephrine did not produce a noticeable response.

Menstruation is scanty, the uterus is smaller than normal. Thyroid slightly enlarged. The sella turcica is within normal limits. The thymus gland, judging by x-ray data, is not enlarged.

Basal metabolism - minus 9%, specific dynamic effect of protein + 9%, i.e. noticeably reduced. In urine: specific gravity 1013, traces of protein, 50-60 leukocytes and 1-2 leached red blood cells in the field of view. Blood pressure 110/50. Blood test: hemoglobin 48%, red blood cells 3,600,000, color index 0.6. Leukocytes - 4800; basophils - 0, eosinophils - 5%, young - 3%, band - 5%, segmented - 47%. lymphocytes - 40%. The Wasserman reaction in the blood is negative. Residual nitrogen - 47.7 mg%. In the blood, potassium is 22.36 mg%, calcium is 14 mg%.

Palpation revealed tenderness in the area of ​​the duodenum, but x-ray examination did not reveal organic pathology of the organs abdominal cavity. Examination of gastric juice: total acidity - 78, free acid - 56, bound acid - 16, reaction to the presence of blood - negative.

The patient was discharged without noticeable improvement (treatment: strychnine injections, vitamins).

After 3 years, she was again in the clinic, and an increase in the process was noted. Three years later, the patient died of pneumonia.

In the above observation there were almost all the main symptoms of myotonic dystrophy: widespread dystrophic changes in many muscle groups, areflexia, the presence of myotonic phenomena during active movements, as well as a myotonic reaction during mechanical and electrical stimulation of the tongue and thenar muscles, ptosis of the eyelids, changes in speech, thinning of hair, vasomotor disorders, pronounced general asthenia, emaciation, decreased basal metabolic rate, slight increase in thyroid glands. Attacks of pain in the epigastric region can also be regarded as vegetative crises, given the increased acidity of the gastric contents. (In one patient, Kurschmann also noted long-term gastrointestinal disorders.)

Rohrer provided a detailed analysis of 82 cases of myotonic dystrophy. The tables he compiled make it possible to analyze a number of basic symptoms that characterize the clinical picture and course of the disease.

Based on his data, the number of women accounted for only a quarter of the total number of patients. 59 cases were sporadic, and in 23 the disease was familial. (Rorer admits that the last number should have been slightly increased due to the inaccuracy of anamnestic data; but, in any case, the number of family diseases did not exceed half of the total number of patients.)

In 72 cases there was atrophy of the forearm muscles as the initial symptom of the disease, and only in 7 cases the disease began with damage to the facial muscles. Subsequently, the muscles of the face and neck atrophied almost simultaneously and to approximately the same extent. Noticeable atrophy of the sternocleidomastial muscles and masticatory muscles was detected in 30 cases. There were indications of tongue atrophy in 8 cases. Changes in speech to varying degrees were noted in 39 patients. The leg muscles turned out to be atrophic to a greater or lesser extent in 39 patients, while the peroneal muscle group was affected earlier and more intensely. The muscles of the shoulder girdle were involved in the process only in isolated cases.

Myotonic phenomena in the muscles were noted as the primary symptom in 32 patients, and dystrophic ones in 33. Myotonic phenomena were caused by mechanical irritation on the muscles of the hand in 47, and on the tongue in 37 cases.

Testicular atrophy was found in 16 sick men (out of a total of 55).

A decrease or disappearance of tendon or periosteal reflexes was noted in 40 cases. Vasomotor phenomena in the form of acrocyanosis, coldness of the extremities - in 15 cases. Early cataract was detected in 18 patients. Chvostek's phenomenon was detected in 12 patients, a slight enlargement of the thyroid gland was found in 1/6 of the total number of patients.

From the data provided by Rohrer, it can be judged that myotonic dystrophy is obviously not such a rare disease.

Goffmann believes that symptoms of myotonic dystrophy are present in 9-10% of patients with myotonia. According to more accurate statistics, myotonic dystrophy is much more common than myotonia.

Of interest are the data of Walton and Nattras, who also provide, based on their own clinical observations, some data regarding the characteristics of the course of myotonic dystrophy. Of the 15 cases of the disease (8 men, 7 women), the onset of the disease between 20-50 years was noted in 11 patients. In 3 families, there was hereditary transmission of the disease (according to the dominant type).

All 15 patients had varying degrees and sequence of damage to the muscles of the limbs. Typically, weakness and atrophy first occurs in the extensors and flexors of the forearm, and then in the tibial and peroneal muscles. In some cases, the deltoid muscles, pectoral and anterior muscles are later involved in the process. serratus muscles, small muscles of the hand.

Myotonic phenomena in the limbs occurred in 13 cases; in one case only in cold weather.

Indications of decreased libido were found in 12 cases; testicular atrophy was found in 6 sick men (out of 8). Cataracts were found in 6 patients, and in the remaining 9 people, changes in the lens were identified during examination using a slit lamp. Tendon reflexes were completely absent in 4 patients, partially in 9. Ptosis was noted in 14 cases, fades myopatica in all cases, speech disorders in the form of dysarthria or aphonia in 14 cases. Early baldness often occurs.

Mild mental changes were observed in most cases.

Flow

Interesting data on the course of the disease. Most authors note significant preservation of motor functions for a relatively long time; patients walk and maintain a certain level of performance. The course of the disease is usually slowly progressive, without noticeable interruptions or remissions. Thus, according to Walton and Nattras, after 10 years of illness, 10 patients moved well, after 20 years - 1. Of the patients they observed, four died: one at the age of 58, the others at the age of 38-49 years.

All researchers note relatively frequent illness persons suffering from myotonic dystrophy, pulmonary tuberculosis and pneumonia. These infections in some cases cause death in patients.

answers at the end

Task 1. U a patient with lower paraparesis is determined by:

in the legs - spastic tone, increased tendon reflexes, Babinski reflex, protective reflexes; Abdominal reflexes are absent.

Task 2. The patient's neurological status is determined by tetraparesis: in the hands - hypotrophy, muscle hypotonia, absence of reflexes; on the legs - muscle spasticity, high tendon reflexes, Babinski reflex.

Explain the symptoms and indicate the location of the lesion.

Task 3. The patient has paralysis of the right arm with decreased muscle tone and tendon reflexes, fibrillary twitching, and muscle wasting.

Explain the symptoms and indicate the location of the lesion.

Task 4. The patient's left leg paresis is accompanied by wasting of the thigh and lower leg muscles, fibrillations and fasciculations.

Explain the symptoms and indicate the location of the lesion,

Task 5. The patient complains of pain in the right arm, weakness is expressed mainly in the hand. Movements in shoulder joint saved. There is atrophy of the muscles of the right hand and partially the forearm, absence of tendon reflexes from the styloid process and triceps muscle on the right, pain on palpation of the right subclavian region, disturbance of all types of sensitivity on the inner surface of the hand, forearm and shoulder on the same side. The skin on the fingers and palmar surface of the hand is thinned and pale in color.

In addition, the patient has a narrowing of the right palpebral fissure, constriction of the pupil and retraction of the right eyeball.

Explain the symptoms and indicate the location of the lesion.

Problem 6. U The patient has no movements in the legs, there is atrophy of the lower leg muscles, sagging feet on both sides, and there are no Achilles reflexes. There is a loss of sensitivity in the feet, the outer back surface of the legs and thighs, constant involuntary urine leakage, and a bedsore in the sacral region.

Explain the symptoms and indicate the location of the lesion.

Task 7. Upon examination, the patient revealed a decrease in superficial sensitivity, muscle strength, tone and tendon reflexes in the right hand, muscle atrophy and trophic disorders. areas of the right hand and forearm.

On the lower limb on the right, strength is reduced, muscle tone is increased, an increase in tendon reflexes is noted, pathological reflexes of Rossolimo and Babinsky are evoked.

Explain the symptoms and indicate the location of the lesion.

Task 8. There is a violation of pain and temperature sensitivity in the neck, arm and torso to the level of the nipple on the right, atrophy of the interosseous muscles of the right hand, decreased reflexes on the right hand, brittle nails and hyperkeratosis on the fingers of the right hand.

Explain the symptoms and indicate the location of the lesion.

Task 9. During the examination, the patient was found to have a “half-jacket” type disturbance in pain and temperature sensitivity on the left. Its lower border is at the level of the Poupart ligament. Deep sensitivity is not impaired. Tendon reflexes in the left arm are decreased. The left hand is deformed, the fingers are shortened, the skin on the palmar surface is thickened, and there are signs of hyperkeratosis. The knee and Achilles reflexes on the left are increased, and a positive Babinski sign is noted on the left.

Explain the symptoms and indicate the location of the lesion.

Problem 10. During the examination, the patient was found to have: unsteadiness when walking, especially in the dark and with his eyes closed, instability in the Romberg position, decreased muscle tone in both legs, and a crawling sensation in them. The patient confuses the name of the fingers and the directions of passive movements in them.

Explain the symptoms and indicate the location of the lesion.

Problem 11. There is weakness in the left arm and leg, atrophy of the muscles of the left arm, more pronounced in the distal parts, and absence of tendon reflexes in the left arm. Abdominal reflexes on the left are not evoked. The knee and Achilles reflexes are significantly higher on the left than on the right. There is a positive Babinski and Oppenheim sign on the left. Muscle tone increased in the left leg. Pain sensitivity is reduced on the right half of the body, on the right leg and arm. The upper limit of sensitivity disorders runs along the medial surface right hand.

Explain the symptoms and indicate the location of the lesion.

Problem 12. During examination, the patient was found to have muscle atrophy, mainly in the distal parts of the arms, fibrillary twitching in the muscles of the shoulder girdle; increased tendon reflexes in the arms and legs.

Pathological symptoms of Rossolimo, Babinsky on both sides. No sensory disturbances were detected.

Explain the symptoms and indicate the location of the lesion.

Problem 13. The patient complains of pain in the cervical spine radiating along the medial surface of the right arm to the fingers. When examining the patient, the following were found: weakness of the right arm, mild muscle atrophy, decreased reflexes from the styloid process and triceps muscle, decreased sensitivity along the medial surface of the forearm and hand. At the same time, there is a marked violation of superficial types of sensitivity on the left half of the body, left leg, from the level of the second rib and below. The knee and Achilles reflexes on the right are slightly higher than on the left.

Explain the symptoms and indicate the location of the lesions.

Problem 14. The patient was found to have: absence of movements in the arms and legs, increased muscle tone in them, high reflexes from the biceps and triceps muscles, increased periosteal reflexes from the styloid process on both sides, increased knee and Achilles reflexes on both legs, bilateral pathological reflexes of Babinsky, Rossolimo , disturbance of superficial and deep sensitivity in the neck, trunk and limbs, dysfunction of the pelvic organs. There was a history of severe breathing problems in the past.

Explain the symptoms and indicate the location of the lesion.

Problem 15. During examination, the patient was found to have: impaired pain and temperature sensitivity in the upper regions chest. On the right, the upper limit of the sensitivity disorder is at the level of the clavicles, on the left it extends to the occipital region of the head. The lower limit of sensitivity impairment is on the right at the level of the nipple, on the left 3 cm below the nipple line. In addition, the patient was found to have noticeable atrophy of the muscles of both arms and decreased tendon reflexes in the arms, somewhat more pronounced on the left. The patient can clearly distinguish passive movements of the fingers. There is a slight increase in knee and Achilles reflexes on both sides.

Explain the symptoms and indicate the location of the lesion.

Problem 16. U The patient complains of persistent pain in the cervical region and right shoulder area, which intensifies with movement, coughing, sneezing, and there is no movement in the right shoulder joint. There is pronounced atrophy of the muscles of the shoulder girdle and deltoid muscle on the right. Sensitivity is impaired on the shoulder girdle, the outer surface of the shoulder and forearm. There is a decrease in tendon reflexes in the right arm, especially in the biceps muscle. There is pronounced pain on palpation of the right supraclavicular region,

Explain the symptoms and indicate the location of the lesion.

Problem 17. The patient was admitted with complaints of sharp pain in the distal arms and legs. The slightest movements with them increased the pain.

An objective examination revealed a lack of movement in the distal limbs and muscle atrophy, more pronounced in the hands and feet on both sides. Muscle tone is reduced. Tendon reflexes are not evoked. Reduction of superficial and deep types of “glove” and “sock” type sensitivity. Pain on palpation of nerve trunks. Positive Lasegue symptom. Increased sweating and acrocyanosis in the hands and feet.

Explain the symptoms and indicate the location of the lesion.

Problem 18. During the examination, the patient was found to have no movement in the legs, increased muscle tone in them, increased knee and Achilles reflexes on both sides, bilateral pathological signs of Babinski and Rossolimo, absence of abdominal reflexes, the presence of protective reflexes and clonus of the feet and patellas on both sides. There is a violation of pain and temperature sensitivity from the level of the nipples and below, a violation of deep sensitivity in the legs, involuntary urination, bedsores in the sacrum and heels.

Explain the symptoms and indicate the location of the lesion.

Problem 19. The patient was transported by ambulance after a serious injury. An objective examination revealed: complete absence of movements in lower limbs, decreased muscle tone, absence of tendon reflexes in the legs, absence of abdominal reflexes, urinary retention, complete absence of all types of sensitivity from the level of the nipples and below.

Explain the symptoms and indicate the location of the lesion.

Problem 20. The patient is bothered by burning, excruciating pain in the left half of the face and neck, accompanied by a feeling of “fullness”, profuse sweating and pastiness in this area.

Objectively: the left palpebral fissure is wider than the right, the pupil is dilated, there is exophthalmos on the left. In the area of ​​the left half of the face and neck there is pallor of the skin, hyperesthesia with a hyperpathic component, and a decrease in skin temperature.

Explain the symptoms and indicate the location of the lesion.

Problem 21. The patient was diagnosed with: a violation of superficial types of sensitivity to the right of the level of the navel and below, a decrease in deep sensitivity to the left of the same level and weakness in the left leg, increased knee and Achilles reflexes on the left, Rossolimo and Babinsky's symptom also on the left.

Explain the symptoms and indicate the location of the lesion.

Problem 22. The patient was diagnosed with facial asymmetry on the right, cannot wrinkle his forehead, close his right eye, and when he shows his teeth, his mouth pulls to the left. The right eyeball is slightly deviated inward. There is a limitation of its mobility in the lateral direction. The patient complains of double vision. At the same time, he was noted to have impaired sensitivity on the left half of the body, and missed the finger-nose test on the left.

Explain the symptoms and indicate the location of the lesion.

Problem 23. Upon admission, the patient complained of hoarseness, difficulty swallowing solid food, and pouring liquid food through the nose.

Objectively: the voice is hoarse, with a nasal tint, the soft palate on the right is lowered, its mobility is sharply limited, the uvula is deviated to the left. The pharyngeal reflex is reduced. On the back third of the tongue on the right, the patient cannot distinguish sweet from bitter. The tongue deviates to the right when protruding. The right half of the tongue is significantly smaller than the left, lumpy, uneven, twitching of individual muscle fibers.

Explain the symptoms and indicate the location of the lesion.

Problem 24.‘ The patient was admitted with complaints of seizures accompanied by loss of consciousness, convulsive twitching of the limbs, biting the tongue and involuntary urination.

Before a seizure, he sees the faces of people of a frightening nature, feels the unpleasant smell of rot.

Objectively: he cannot see objects on the right side, weakness in the right limbs with increased tone and tendon reflexes. He understands spoken speech poorly and does not complete tasks. The patient's speech consists of a set of incomprehensible sounds that are not related to each other, and there is a rearrangement of letters and syllables in words.

Explain the symptoms and indicate the location of the lesion.

Problem 25. When examining the patient, there was a lack of movement in the right half of the face: the patient could not wrinkle his forehead or close his eyes tightly. When teeth are bared, the mouth is pulled to the left. In addition, weakness, increased muscle tone, and tendon reflexes of the left extremities were detected. On the left are positive pathological reflexes of Babinsky, Rossolimo, Oppenheim, Gordon, Zhukovsky, Bekhterev.

Explain the symptoms and indicate the location of the lesion.

Problem 26. During examination, the patient was found to have slight flattening of the nasolabial fold on the left. The tongue is slightly deviated to the left. Movements in the left arm and leg are limited, muscle tone is increased, high tendon reflexes on the left, pathological Babinski and Rossolimo reflexes on the left. Clonus of the foot and patella on the left.

In addition, a violation of superficial and deep sensitivity was detected in the left half of the face and the left half of the body.

Explain the symptoms and indicate the location of the lesion.

Problem 27. The patient complains of choking when eating, liquid food gets into the nose, and the voice has become “nasal.” Smoothness of the left nasolabial fold was noted. Voice with a nasal tint. The soft palate is motionless during phonation. The tip of the tongue deviates to the left when protruding, but there is no atrophy. There are proboscis and palmar-chin reflexes. Sometimes there is violent crying and laughter. The strength in the left arm and leg is reduced, the tone in them is slightly increased. Tendon reflexes are increased on both sides, slightly more on the left. Abdominal reflexes are not evoked. On the left there is Babinski's sign. Sensitivity is not upset.

Explain the symptoms and indicate the location of the lesion.

Problem 28. Upon examination of the patient, the following were found: right-sided ptosis, the right eyeball was slightly deviated outward, the pupil was dilated. On the left, the nasolabial fold is smoothed.

The tongue is slightly deviated to the left. Strength in the left arm and leg is reduced, there is an increase in muscle tone in them, tendon reflexes in the arm and leg on the left are higher than on the right. Severe Babinski and Rossolimo symptoms.

Explain the symptoms and indicate the location of the lesion.

Problem 29. The patient complains of staggering when walking. On examination, the following were revealed: nystagmus when looking to the sides, intention tremor during the finger-nose test, more on the left, adiadochokinesis on the left, blurriness during the knee-heel test on both sides, slightly more on the left. Severe muscle hypotonia in the left extremities. With his eyes closed, he falls to the left. Speech is drawn out with emphasis on individual syllables.

Explain the symptoms and indicate the location of the lesion.

Problem 30. The patient was diagnosed with decreased hearing in the left ear, decreased corneal reflex on the left, mild hypoesthesia in the forehead and cheek on the left. Left palpebral fissure wider than the right; when the forehead is wrinkled, the folds on the left are formed worse than on the right; the left nasolabial fold is smoothed out. During the finger-nose test, intention tremor appears in the left hand, adiadochokinesis on the left. In the Romberg position, the patient staggers to the left.

Explain the symptoms and indicate the location of the lesion.

Problem 31. During examination the patient was found to have:

right-sided ptosis, complete immobility of the right eyeball, the pupil is dilated. The patient is bothered by sharp pain in the area of ​​the right eye, there is hypoesthesia in the frontal region on the right. On the right, the corneal reflex is reduced.

Explain the symptoms and indicate the location of the lesion.

Problem 32. The patient complains of increased drowsiness. He can fall asleep at work, at the cinema, while eating, on the bus. In addition, he is bothered by double vision. An objective examination revealed: bilateral ptosis, limited mobility of the eyeballs, especially in the medial direction, anisocoria (the left pupil is wider than the right). The reaction of the pupils to light is direct and sluggish. Convergence is broken. Facial sweating.

Explain the existing symptoms and indicate the location of the lesion.

Problem 33. The patient complains of stiffness when moving, excessive salivation, difficulty speaking (pronounces words slowly), constant trembling in the hands.

Objectively: the face is amicable, the head is slightly tilted forward, the arms and legs are slightly bent at all joints, active movements are performed slowly. In the fingers the trembling is rhythmic, with a small amplitude, in the form of “rolling pills”. The tone in the arms and legs is evenly increased, there is a “gear wheel” phenomenon. Tendon reflexes are lively and uniform. There are no pathological reflexes. Sensitivity is not upset. Walks in small steps. There are no friendly movements.

Explain the symptoms and indicate the location of the lesion.

Problem 34. During the examination, the patient was found to have: euphoria, a tendency to joke, decreased criticism, unmotivated actions (urinating on the floor). When smiling, the right nasolabial fold is smoothed, tendon reflexes from the right extremities are increased. There are speech impairments: he has difficulty pronouncing words that are difficult to pronounce. Speech consists of a limited set of words; when speaking, he repeats the same word and has difficulty moving on to the next word. Grasping movements are pronounced. He understands spoken speech well. Completes the task

Explain the symptoms and indicate the location of the lesion.

Problem 35. The patient complains of increased drowsiness, a feeling of thirst, and increased appetite. Lately she has gained a lot of weight. Notes menstrual dysfunction, hair growth on the cheeks and chin. When examining the visual fields, loss of visual fields on the temporal sides was detected.

Explain the symptoms and indicate the location of the lesion.

Problem 36. The patient was admitted with complaints of seizures with loss of consciousness, convulsive twitching of the limbs, biting the tongue, and involuntary urination.

Seizures begin with turning the head and eyes to the right.

The examination revealed: deviation of the tongue to the right, smoothness of the right nasolabial fold, weakness in the right extremities with increased muscle tone, tendon reflexes and pathological reflexes of Babinsky and Oppenheim. He understands spoken speech, but cannot speak himself.

Explain the symptoms and indicate the location of the lesion.

Problem 37. A 10-year-old child developed involuntary contraction of the muscles of the limbs and face, both at rest and during movement. The patient sometimes closes his eyes, then sticks out his tongue, grimaces, then throws his arm, then his leg. When writing, he makes strokes. “Dances” when walking. Muscle tone in the limbs is reduced. Tendon reflexes are sluggish.

Explain the symptoms and indicate the location of the lesion.

Problem 38. The patient's left hand became awkward and he often dropped objects. There was a feeling that he had “two” hands, sometimes he “lost” left hand. Objectively: movements in the limbs are complete, with sufficient strength. Reflexes on the left are animated. There are no pathological reflexes. Deep sensitivity is impaired in the left hand. Does not distinguish between right and left sides, has lost the idea of ​​the position of his left hand in space. Does not perform finger-nose test on the left.

Explain the symptoms and indicate the location of the lesion.

Problem 39. Relatives noticed that, having left the room into the corridor, the patient did not know how to return back. I forgot how to put on a dress, shoes, use a cup, a spoon.

Objectively: there are no motor disorders (paresis), but the patient cannot perform the suggested actions (put on a robe, make the bed), cannot draw a plan of her room, cannot make a figure from matches.

Explain the symptoms and indicate the location of the lesion.

Problem 40. The patient experiences attacks of headaches, accompanied by paleness of the skin, tachycardia, increased blood pressure, trembling throughout the body, hyperhidrosis, and fear of death.

Explain the symptoms and indicate the location of the lesion.

Problem 41. The young woman has recently gained weight, headaches have appeared, and menstruation has stopped.

Objectively: the face is moon-shaped. Increased nutrition. There are pink transverse stripes on the stomach and thighs. Blood pressure 180/100. The voice is low. The growth of mustache and beard is noted. Amenarrea.

Explain the symptoms and indicate the location of the lesion.

Problem 42. Against the background of sharp pain in the area of ​​innervation of the first branch of the trigeminal nerve, herpetic eruptions appeared in the forehead and eye area on the left.

Explain the symptoms and indicate the location of the lesion.

Problem 43. The patient does not feel pain or temperature stimulation on the left side of the face, tactile sensitivity in this area is not impaired.

Explain the symptoms and indicate the location of the lesion.

Problem 44. The patient has right-sided hyperpathy and pain in the right extremities, intensifying with excitement and during the period of falling asleep, as well as hemianopsia and hemiataxia.

Explain the symptoms and indicate the location of the lesion.

Problem 45. The patient is bothered by paroxysmal pain in the area of ​​innervation of the lower branch of the left trigeminal nerve. When opening the mouth, the lower jaw moves to the left.

Explain the symptoms and indicate the location of the lesion.

Problem 46. The patient has impaired taste in the back third of the tongue. I am worried about pain in the area of ​​the tonsils and arches with irradiation to the left behind-the-ear area.

Explain the symptoms and indicate the location of the lesion.

Problem 47. The patient is bothered by episodic convulsions in the left half of the face and left limbs.

Explain the symptoms and indicate the location of the lesion.

Task 48. One patient complains of hand tremor at rest, another - when moving.

Explain the symptoms and indicate the location of the lesion.

Problem 49. The patient has severely impaired coordination of movements. The right hand involuntarily grasps objects placed in it. He is somewhat stunned, often jokes, sometimes rather flatly. He makes no complaints. There is no sense of smell on the left.

Explain the symptoms and indicate the location of the lesion.

Problem 50. The patient experiences pain in the lower back and left leg. Hypotonia and wasting of the muscles of the medial group of the thigh and lower leg. Positive symptoms of Neri and Dejerine, Lasegue symptom on the left. Hypoesthesia on the medial surface of the thigh and lower leg. Decreased knee reflex on the left. Explain the symptoms and indicate the location of the lesion.

Problem 51. After a febrile illness, a patient developed burning pain in the right half of the chest. Hyperesthesia in the area of ​​pain from the nipple line to the hypochondrium. A rash in the form of blisters located in groups in the same area. Hyperthermia. Explain the symptoms and indicate the location of the lesion.

Problem 52. The patient has difficulty abducting the hand to the ulnar side. There are no extension movements of the hand and fingers, abduction of the thumb is difficult. Anesthesia on the dorsal surface of the shoulder, forearm, hand, thumb and index finger. The tricepital reflex is absent, the carporadial reflex is reduced.

Explain the symptoms and indicate the location of the lesion.

Problem 53. The patient has difficulty abducting the hand to the ulnar side, difficulty flexing the 4th and 5th fingers, and adducting the thumb.

Hypotrophy of the interosseous spaces, the elevation of the 5th finger is flattened. Hypesthesia on the 5th and lateral half of the 4th fingers. In the area of ​​sensitive disorders, hyperemia and dry skin and brittle nails are noted.

Explain the symptoms and indicate the location of the lesion.

Problem 54. The patient has difficulty with flexion movements of the 1st, 2nd, 3rd fingers and pronation of the forearm. Flattening of the palm due to hypotrophy of the eminence of the 1st finger.

Hypesthesia on the palmar surface of the 1st, 2nd, 3rd fingers and the medial half. 4th finger, as well as the rear of the terminal phalanges of the named fingers. Pain in the area of ​​sensory disorders, hyperemia and dryness of the skin, brittleness, nails.

Explain the symptoms and indicate the location of the lesion.

Problem 55. The patient is unable to straighten the leg and flex the hip. Hypotrophy of the anterior thigh muscles. Anesthesia on the anterior surface of the thigh and medial surface of the leg. The knee reflex is not evoked.

Explain the symptoms and indicate the location of the lesion.

Problem 56. The patient's foot hangs down and is turned inward. Dorsal flexion and abduction of the foot is impossible. Anesthesia on the outer surface of the leg and dorsum of the foot.

Explain the symptoms and indicate the location of the lesion.

Problem 57. The patient's foot is abducted outwards. Plantar flexion and adduction of the foot are difficult. Hypoesthesia on the sole and outer edge of the foot is not caused by the Achilles reflex. Dry skin ulcers in the heel area.

Explain the symptoms and indicate the location of the lesion.

Problem 58. The patient has difficulty extending and abducting the right thigh and flexing the lower leg, and movement of the foot and fingers is impossible. Anesthesia on the foot and lower leg of the same side. Pain along the back of the thigh and lower leg. The Achilles reflex is not evoked.

Explain the symptoms and indicate the location of the lesion.

Problem 59. The patient on the left has a drooping eyelid, a constricted pupil, and a sunken eyeball. Hyperemia, lack of sweating and pilomotor reflex on the skin of the left half of the neck, chest and left arm. Pain in the same area.

Explain the symptoms and indicate the location of the lesion.

Problem 60. The patient's right shoulder is drooping. The right shoulder blade extends from the spine with its lower angle outward and upward. It is impossible to turn your head to the left. Raising the right arm above the horizontal level and shrugging the right shoulder are limited. Hypotrophy and hypotonia of the trapezius and sternocleidomastoid muscles on the right.

Explain the symptoms and indicate the location of the lesion.

Problem 61. The patient has neck stiffness. Positive Kernig's, upper and lower Brudzinski's symptoms. Tactile, pain and light hyperesthesia, headache, vomiting, and increased body temperature are noted. In the cerebrospinal fluid there is cell-protein dissociation. Explain the symptoms and indicate the location of the lesion.

Problem 62. The patient experiences headaches, dizziness, and vomiting in the morning. In this case, bradycardia is noted. In the fundus there are congestive nipples of the optic nerves.

Explain the symptoms and indicate the location of the lesion.

Task 1. Bilateral lesion of the pyramidal tract at the level of the thoracic spinal cord (segments D2-D5).

Task 2. Bilateral damage to the motor pathways (peripheral and central neurons) at the level of the cervical enlargement of the spinal cord (segments C5Sb-D1D2).

Task 3. Damage to a peripheral motor neuron: cells of the anterior horns of the spinal cord at the level of segments WITH5 WITH6 - D1D 2 on the right.

Task 4. Damage to the peripheral motor neuron: cells of the anterior horns of the spinal cord of the lumbosacral enlargement (segments L1 L2-S1S2).

Task 5. Dejerine-Klumpke palsy: damage to the lower part of the brachial plexus (segments C7-D2) on the right.

Task 6. Syndrome of complete damage to the diameter of the spinal cord. The level of damage is the lower segments of the lumbosacral thickening (L5-S2).

Task 7. Half spinal cord lesion syndrome (Brown-Séquard). The level of the lesion is the cervical thickening on the right (segments C5C6-D1D2).

Task 8. Damage to the segmental apparatus of the spinal cord: anterior, posterior, lateral horns at the level of the cervicothoracic regions (segments C3C4-D4D5) on the right.

Task 9. Predominant damage to the segmental apparatus of the spinal cord: anterior, posterior, lateral horns at the level of the cervicothoracic regions (segments C5Cb-D11D12) on the left, involving the pyramidal tract in the lateral column.

Task 10. Bilateral damage to the posterior columns (Gaull's tracts) of the spinal cord, sensitive ataxia syndrome.

Task 11. Half spinal cord lesion syndrome (Brown-Sequard). The level of damage is the lower part of the cervical thickening on the left (segments C7C8).

Task 12. Syndrome of combined damage to peripheral (anterior horns) and central (lateral columns) motor neurons. Damage level

Cervical thickening (segments C5C6-D1 D2) on both sides.

Task 13. Half spinal cord lesion syndrome (Brown-Sequard). The level of damage is the cervical thickening on the right (mainly segments C7C8-D1D2).

Task 14. Syndrome of complete damage to the diameter of the spinal cord. Damage level - cervical region— (segments C1C2C3).

Task 15. Damage to the segmental apparatus of the spinal cord: anterior, posterior, lateral horns at the level of the cervicothoracic regions (segments C3C4-D4D5) on both sides, involving the pyramidal tracts in the lateral columns.

Task 16. Damage to the right brachial plexus, mainly its upper part (Duchenne-Erb palsy).

Task 17. Multiple lesions of the peripheral nerves of the extremities (polyradiculoneuropathy syndrome).

Task 18. Syndrome of complete damage to the diameter of the spinal cord. Damage level - thoracic region(segments D4-D5).

Task 19. Syndrome of complete damage to the diameter of the spinal cord. The level of damage is the thoracic region (segments D4-D5). Spinal shock.

Task 20. Syndrome of irritation of the superior cervical sympathetic ganglion (Pourfour-Du Petit syndrome).

Problem 21. Half spinal cord lesion syndrome (Brown-Sequard). The level of damage is the thoracic region (segments D9-D10) on the left.

Task 22. Alternating syndrome. Damage to the brain stem, mainly the pons on the right.

Problem 23. Bulbar palsy. Predominant damage to the tegmentum of the brain stem at the level of nuclei 12, 9, 10 cranial nerves(medulla).

Task 24. Predominant damage to the left temporal lobe.

Task 25. Alternating Millard-Gubler syndrome. Damage to the lower part of the bridge on the right.

Task 26. Damage to the right hemisphere, mainly the internal capsule.

Problem 27. Pseudobulbar palsy. Bilateral damage to the corticobulbar tract (more pronounced on the right).

Task 28. Alternating Weber syndrome. Damage to the brain stem, mainly the base of the midbrain (peduncle) on the right.

Task 29. Predominant damage to the left hemisphere of the cerebellum.

Task 30. Left cerebellopontine angle lesion syndrome.

Task 31. Superior orbital fissure syndrome.

Task 32. Oculoletargic syndrome. Predominant damage to the oral parts of the trunk (nuclei of the oculomotor nerves), the hypothalamic region and the reticular formation of the trunk.

Task 33. Parkinsonism syndrome. Predominant damage to the pallidal system (globus pallidus, substantia nigra).

Task 34. Predominant damage to the frontal lobe on the left.

Task 35. Hypothalamic-pituitary syndrome. Predominant damage to the pituitary gland

Task 36. Predominant damage to the frontal lobe on the left (with symptoms of irritation of the second frontal gyrus).

Problem 37. Choreic hyperkinesis syndrome. Predominant damage to the striatal system (putamen, caudate nucleus).

Task 38. Disorders of muscle-articular, tactile and localization sensitivity in the left hand, disorder of the “body diagram”. Damage to the right parietal lobe, mainly the superior parietal lobule and interparietal sulcus.

Task 39. Apraxia syndrome (motor, constructive). Damage to the left parietal lobe, mainly the supramarginal and angular gyri.

Task 40. Sympathetic-adrenal crisis. Predominant damage to the hypothalamus (diencephalic region).

Task 41. Itsenko-Cushing syndrome. Damage to the pituitary-hypothalamic region.

Problem 42. Ganglionitis of the left Gasserian ganglion.

Problem 43. Lesion of the left nucleus of the spinal tract.

Problem 44′. Lesion of the left visual thalamus.

Problem 45. Damage to the lower left branch of the trigeminal nerve.

Problem 46. Damage to the glossopharyngeal nerve.

Problem 47. Motor Jacksonian epilepsy. Lesion of the right precentral gyrus.

Problem 48. The first patient suffers from the pallidal system, the second - the cerebellar system.

Problem 49. Lesion of the left frontal lobe.

Problem 50. Root damage L3- L4 s left

Problem 51. Lesion of the intervertebral ganglia D4-dr. on right.

Problem 52. Damage to the radial nerve.

Problem 53. Damage to the ulnar nerve.

Problem 54. Damage to the median nerve,

Problem 55. Damage to the femoral nerve.

Problem 56. Damage to the peroneal nerve.

Problem 57. Damage to the tibial nerve.

Problem 58. Damage to the right sacral plexus.

Problem 59. Damage to the left stellate ganglion.

Problem 60. Damage to the right accessory nerve.

Problem 61. Damage to the meninges.

Problem 62. Intracranial hypertension syndrome.

EXPLANATORY NOTE

The proposed teaching materials for the section “nervous system” orient students toward active learning of the course and promote a conscious understanding of information.

The materials are compiled for students of all specialties.

Methodological materials contain the following sections:

1. General provisions about the nervous system.

2. Functional anatomy of the spinal cord.

3. Brain development. Morphofunctional characteristics of the brain stem.

4. Morphofunctional characteristics of the telencephalon.

5. Peripheral nervous system.

6. Autonomic nervous system.

7. Higher nervous activity.

Students are offered an extract from the program. All topics are discussed in a certain sequence, in accordance with the lesson plan.

Methodological materials are intended for practical training and also help in self-preparation for this section. Here are illustrations, diagrams, poems that greatly simplify the perception of rather complex and voluminous information. To reinforce the material, students are offered “test yourself” sections, where they work in pairs. They solve tests, answer questions, and solve problems.

Anatomy and physiology teachers:

Kovrizhnykh T.V., Prikhunova E.N.

NERVOUS SYSTEM

Topic: Reflex regulation of the body. Functional anatomy of the spinal cord.

The student must know: Latin names; connection between the spinal cord and the brain; spinal cord function; the importance of the white matter of the spinal cord as conducting pathways and the gray matter as the place where excitation passes from centripetal to centrifugal nerves; superior and inferior border of the spinal cord.

The student must be able to: work with tables, supporting notes, schematic drawings; determine the puncture site during spinal puncture.

Subject. Brain development. Medulla oblongata, hindbrain. Structure, function.

The student must know: Latin names of parts of the brain; brain development; functional significance of the medulla oblongata and hindbrain; location of the pyramids, pons, cerebellum at the base of the skull.

The student must be able to: work with tables, collapsible models of the brain.

Topic: Midbrain, diencephalon. Structure, function.

The student must know: what is common and how the functions of the spinal cord and brainstem differ; that human feelings arise with the participation of the centers of the diencephalon, but they

are under the control of consciousness - the functions of the cerebral cortex.

WITH the student must be able to: using atlas drawings and collapsible models to study the parts of the brain; explain the concepts of hypothalamus, epithalamus, metathalamus, thalamus

Topic: Finite brain. Structure, function. Analyzers.

The student must know: value of cerebrospinal fluid in exchange process C.N.S; the significance of the cerebral cortex and the location of centers in it (speech, writing, hearing, etc.)

The student must have: an idea of ​​the methods used in studying the cortex; be able to work with tables, models, supporting notes.

Topic: Higher nervous activity.

The student must know: reflex is the norm of nervous activity; mechanism of operation of the central nervous system; the relationship between conditioned and unconditioned reflexes; mechanism of formation of conditioned reflexes; the importance of conditioned reflexes for humans; when conditioned reflexes appear in humans. How does it manifest itself?

activity of the first signal system; what is the activity of the second signaling system, its significance; determine a person's temperament; what interactions exist between the first and second signaling systems; types of higher nervous activity, how they are characterized; types of sleep and their physiological differences.

The student must be able to: explain the properties of unconditioned and conditioned reflexes; form conditioned reflexes on the basis of unconditioned ones; explain what instinct is, give examples; explain why unconditioned and conditioned reflexes to natural stimuli are the same in higher animals and humans, explain the importance of oral and written speech in the development and life of society; Explain how the reaction to a word in humans differs from the same reaction in animals.

Bridge–e

12- bridge, basilar groove, 13- legs of the bridge,

14 - cavity of the 4th ventricle, 15 - lower cerebellar peduncles,

21- superior cerebellar peduncles

Medulla- and

(medulla oblongata)

16- pyramids, 17- olives, 18- cross of pyramids,

19- wedge-shaped bun, 20- gentle bun

H CRANIAL NERVES

Name

plexuses

Location

Basic

Kopchikov.

Nervous system

(Latin names)

CRANIAL NERVES

check yourself

(work in pairs)

Solve problems according to spinal nerves:

1. The patient has partial atrophy of the deltoid muscle, the inability to abduct the arm to a horizontal position. Which SMN is affected?

2. The patient cannot put one leg on the other. Which SMN is affected?

3. When clenching the hand into a fist, 11 and 111 fingers do not bend. Which SMN is damaged?

4. The patient has lost the knee reflex, the anterior group of thigh muscles is partially atrophied. Which SMN is damaged?

5. When clenching the hand into a fist, it is not possible to bend the 2nd and 3rd fingers. Which SMN is damaged?

6. The patient has a “dropping” foot, sensitivity disorder on the dorsum of the foot. Which SMN is damaged?

7. The patient has a disorder of the skin sensitivity of the dorsal surface of the hand and fingers, parts 1 and 2 3. Which SMN is damaged?

8. A patient has a disorder of skin sensitivity on the lateral surface of the thigh. Which SMN is damaged?

Solve problems on cranial nerves:

1. The patient has dizziness, a feeling of instability, and falls in the Romberg position. Which branch of the ZH is damaged?

2. The patient has impaired sensitivity of the skin of the forehead. Which cranial nerve is damaged?

3. The patient's head is lowered to the chest; lifting and turning it is difficult. Which cranial nerve is damaged?

4. The patient has pain in all the upper teeth of one half, as well as in the middle parts of the face. Which cranial nerve is damaged?

5. The patient has ptosis/drooping upper eyelid/. Which cranial nerve is damaged?

6. After suffering from otitis media, the child has partially lost his taste. Which cranial nerve is damaged?

7. The patient has internal strabismus. Which cranial nerve is damaged?

8. After inflammation of the parotid gland, the child’s face became distorted. Which cranial nerve is damaged?

9. U. As a result of an osteoma/tumor of the bone tissue/base of the skull, the patient’s movements of the eyeball were impaired. Which cranial nerves are affected? Where is the osteoma located?

10. As a result of hemorrhage in the brainstem, the patient developed ptosis (drooping of the upper eyelid). Which cranial nerve is damaged? In which part of the brain stem did the hemorrhage occur?

check yourself

THE LENGTH OF THE SPINAL CORD IS

a) 35 - 40 si

b) 40 - 45 cm

c) 45 - 50 cm

INTERNAL SENSITIVE NEURONS OF THE SPINAL CORD ARE LOCATED IN THE GRAY MATTER

a) lateral horns

b) frequent horns

c) posterior horns

d) spinal nodes

IN THE WHITE SUBSTANCE OF THE POSTERIOR CORDS OF THE SPINAL CORD PASS

a) descending pathways

b) ascending pathways

c) ascending and descending paths

d) neither one nor the other.

DURING BILATERAL TRANSECTION OF THE ANTERIOR ROOT OF THE SPINAL CORD IN A DOG SENSITIVITY

a) disappears

b) decreases

c) does not change

d) increases

THE MIDNBRAIN IS CONNECTED WITH THE CEREBELLUM

a) brain sails

b) upper legs

c) middle legs

d) lower legs

IN THE GRAY MATTER OF THE SUPERIOR COLLICLES OF THE QUADRICOLMUS THERE ARE:

a) subcortical visual centers

b) subcortical auditory centers

c) red kernels

d) substantia nigra

RETICULAR FORMATION IS A STRUCTURE

a) executive (motor)

b) sensory (perceiving)

c) executive and sensory

d) tuning

THE FRONTAL LOBE IS LIMITED FROM THE PARIETAL GROOSE

a) central (Rolandic)

b) lateral (silvieaoi)

c) superior: frontal

d) precentral

THE SKIN SENSITIVITY AREA IN THE CEREBRAL CORTEX IS LOCATED IN

a) precentral gyrus

b) postcentral gyrus

c) superior temporal gyrus

d) occipital zone

NOT INCLUDED IN THE BASAL NUCLEI OF THE CEREBRAL BRAIN

a) striatum

b) amygdala

c) internal capsule.

d) fence

CORESPINAL FLUID IS FORMED

a) dura and choroid

b) arachnoid membrane

c) sinuses of the dura mater

d) choroid plexuses of the ventricles

THE MEDULA DOES NOT APPLY TO ELIZATIONS ON ITS SURFACE

a) pyramids

c) tubercles of the thin and wedge-shaped nuclei

d) quadrigeminal tuberosities

CARDIOVASCULAR REFLEXES ARE MAINLY CARRIED OUT

a) medulla oblongata

b) spinal cord

c) thalamus

NOT REFERRED TO THE HYPOTHALAMUS

a) geniculate bodies

b) gray lump with a funnel

c) mastoid bodies, optic chiasm and optic tract

Higher nervous activity (HNA)- the activity of the higher parts of the central nervous system, ensuring the most perfect adaptation of animals and humans to the external environment.

Psyche– a subjective image of the objective world, a reflection of reality in the brain.

Thinking, or rational activity - the most complex type of brain activity of the body in the process of adapting to new conditions and solving new life problems.

Rational activity allows you to capture patterns connecting objects and environmental phenomena and use them in new conditions in your behavior.

The adaptive nature of behavior is determined by the conditioned reflex activity of the body, formed on the basis of unconditioned reflexes (according to I.M. Sechenov and I.P. Pavlov).

Emotions– experiences in which a person’s attitude to the world around him and to himself is manifested.

Emotions.

Methodological materials

"To help the student"