Social Medicine

Course of education: 3rd course Semester: Vth semester Exam: after the Vth semester Auditorium credit hours: 60 hours Lecturer: Prof. Dr. Rumen Stefanov, DM

CIRRICULUM Course hours Type of courses V semes- VІ semes- Credits weekly All ter ter. Lecture courses 2 30 30 - Practical courses 2 30 30 3,2 All 4 hours 60 hours - 60 hours

ANNOTATION: Basic concepts of health and disease. Regularities and trends of public health. Public health organization and Public health systems. Health promotion. New strategies of Public health management. COURSE OBJECTIVES: Acquisition of knowledge and capabilities concerning the three basic aspects of the public health: demography, incidence and physical development. Profound analyze of problems connected with Pubic health level in Bulgaria and other world regions with an accent to Health promotion and prevention, epidemiology and health services management. COURSE TASKS:  Introducing of demographic and incidence indices.  Studying the incidence with temporary working incapacity and disability aiming to receive practical abilities for assessing patient’s temporary and permanent working incapacity.  Public health systems – structure, organization, financing.  Studying the different types of epidemiological studies and their application in daily practice for proper planning of population needs or population group needs.  Studying the organization of children and mothers public health and assimilation of approaches for solving problems in this area.  Contemporary interpretation of quality and price of life.  Introduction of current health legislation.  Studying newest health activities management aiming to receive and apply adequate professional manager’s capabilities. TRAINING METHODS: Lectures, discussions, practical cases, group working, individual work, developing a disease social history at clinical department. TECHNICAL EQUIPMENT APPLIED IN THE TRAINING: multimedia, films, training programs.

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CONTROL AND EVALUATION:  Ongoing evaluation – oral examinations, colloquia on different syllabus sections.  Final evaluation –written test, oral examination, solving tasks and practical cases. CONTROL METHODS: tests, writing, analysis, discussing problem situations and practical cases, solving tasks. OBLIGATORY COMPETENCIES: acquiring approaches of analysis and assessment of public health, health promotion and prophylaxis. Competence for assessment of temporary and permanent working disability. Having knowledge of contemporary public health legislation, of different types of epidemiological studies and their daily practice implementation. Making adequate medical and ethical decisions concerning problem situations of the clinical practice.

LECTURES COURSE SYLLABUS LECTURE №1: Social medicine as a science. Development, definition and object of social medicine. Structure and functions of social medicine. Methods of social medicine. LECTURE №2: Demography. Demographic processes as public health assessment tool. Demographic policy. World population status. Demographic prognoses till 2050. Population static and dynamic. Medico – social aspects of birth rate and mortality. Average continuity of im- pending life. LECTURE №3: Individual, group and public health. Incidence, basic terminology of incidence, International classification of diseases, medico- social aspects of incidence. Physical development, indices of the physical development of the population. Health indicators. LECTURE №4: Epidemiology. Principles. Causality. Risk factors. Measuring of diseases and exposure. Epidemiology definition and scope. Measuring of diseases and exposure. LECTURE №5: Epidemiological studies. Epidemiology of socially significant diseases. Types of epidemiological studies – cross-sectional studies, follow-up studies, case-reference studies, clinical studies. Epidemiology of socially significant diseases. LECTURE №6: Public health systems. Health policy and reform in Bulgaria. National health strategy. Public health systems – structure, organization and financing. Health policy substance and priorities in Bulgaria. Health policy substance and priorities in developed countries. LECTURE №7: Public health International collaboration. European Union Health Poli- cy.World health organization (WHO). WHO – aims, mission and programs. European Union Health Policy. Public health International collaboration programs and priorities. LECTURE №8: Health legislation in Bulgaria. (Part I) Health act. Law for medical establishments. LECTURE №9: Health legislation in Bulgaria. (Part II) Health insurance act. Drug policy. LECTURE №10: Preventive medicine. Health promotion. Occupational medicine. Medical labour assessment.

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Types of prophylaxis. Rise, nature and development oh Health promotion conception. Health promotion principles. Health motivation. Health upbringing – nature, models, principles and means. Medical labor assessment. LECTURE №11: Primary medical help. Dispensory surveyllance. General practitioner functions and obligations. Dispensary method nature. Dispensary types. LECTURE №12: Mothers and children public health. Medico – social problems of children. “Children public health” program of National Health Insurance Fund. Medico-social problems of women and motherhood. “Mothers public health” program of National Health Insurance Fund. LECTURE №13: Health management. (Part I) Health management basic principles. Management of human resources. LECTURE №14: Health management. (Part II) Managing team. Management of financial resources. Management of organizational change. Marketing. LECTURE №15: Public health planning and economy. Public health planning basic aspects. Public health planning bodies. Public health economy – definition and object.

PRACTICAL COURSE SYLLABUS

PACTICAL CLASS №1 – 2 Hours: Indices characterizing population health status. Demograph- ic indices. PACTICAL CLASS №2 – 2 Hours: Indices characterizing population health status and international classification of diseases. Incidence indices. The physician and registration of births and deaths. PACTICAL CLASS №3 – 2 Hours: Basic terms in epidemiology. Cause-effect relation. Risk factors and risk assessment. PACTICAL CLASS №4 – 2 Hours: Epidemiological study types. Practical implementation. PACTICAL CLASS №5 – 2 Hours: Health legislation. Health act and Law for medical establishments. PACTICAL CLASS №6 – 2 Hours: Population health insurance. National health insurance fund functions and activity. PACTICAL CLASS №7 – 2 Hours: Primary medical help. Primary medical help services for the population. Indices. General Practitioner’s tasks. PACTICAL CLASS №8 – 2 Hours: Hospital services for the population. Medico-protective regime. Indices. PACTICAL CLASS №9 – 2 Hours: Dispensary services for the population. Dispensary method. Indices. PACTICAL CLASS №10 – 2 Hours: Medico – social problems of children. Medico-social problems of women and motherhood. Mothers and children public health. Indices. PACTICAL CLASS №11 – 2 Hours: Social history of the patient. Family anamnesis. /this class is taking place in clinical environment/. PACTICAL CLASS №12 – 2 Hours: Seminar over “Health problems and problems of health services”. Учебна програма за специалност “Медицина” 129

PACTICAL CLASS №13 – 2 Hours: Assessment of temporary and permanent working incapacity. Analysis of incidence with temporary working incapacity. Indices. PACTICAL CLASS №14 – 2 Hours: Sociological methods of medical studies. Inquiry method. Surveillance method. PACTICAL CLASS №15 – 2 Hours: Sociological methods of medical studies. Interview and documentary method.

C O N S P E C T U S OF SOCIAL MEDICINE FOR ІІІ COURSE - MEDICINE

1. Social medicine as a science – foundation, development, object, tasks and methods. 2. Nature and importance of social etiology, social prophylaxis, social therapy and social rehabilitation of the diseases. 3. Basic aspects of human health. Social factors of health and disease – classification and mechanism of influence. 4. Individual health. Criteria of health and disease. Health classification. 5. Group and public health – definition, basic groups of indices. Factors and trends of group and public health. 6. Health determinants. Health indicators. 7. Medical demography – historical development, divisions. Demographic transition model. 8. Demographic policy. Family planning. 9. Medical demography. Mechanical movement of the population: nature, types and health aspects. 10. Medical demography. Natural movement of the population: birth rate, mortality rate, natural growth. Indices. 11. Factors for birthrate and mortality. Reasons for death cases. Registration. Indices. 12. Children mortality. Reasons. Dynamics. Medico – social prophylaxis. Indices. 13. Physical development. Acceleration. 14. Risk factors, causality. Bradford – Hill’s criteria. 15. Measurement of diseases and exposure. Risk assessment. 16. Incidence and prevalence – definition. Sources and methods for incidence’ study. Indi- ces. World classification of diseases. 17. Epidemiology – definition, tasks, methods. Natural history of the disease. 18. Epidemiological studies – surveillance studies. 19. Epidemiological studies – experimental studies. 20. Epidemiology of socio-significant diseases – medico-social aspects. 21. Public health – nature, structure, factors, principles. Interdepartmental collaboration. 22. Public health systems – types, advantages and disadvantages. 23. Health policy and reform in Bulgaria. National health strategy. 24. Health legislation in Bulgaria. Health act. 25. Health legislation in Bulgaria. Law for medical establishments. 26. Health legislation in Bulgaria. Health insurance law. 27. Public health international collaboration. WHO. Programs and priorities. 28. European union health policy. Programs and priorities.

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29. Health culture and health behavior. Definition, significance and basic direction for establishing health culture. Health amateur activities of the population. 30. Health education: basic principles, methods and organization forms. 31. Sociological methods of medical studies. Inquiry method. Surveillance method. 32. Sociological methods of medical studies. Interview and documentary method. 33. Social history of the patient. Family anamnesis. 34. Family and health – basic ways and mechanisms for health and disease influencing over the family. Physician’s role in problem families (unequal, mixed and dissolved marriages, living together without marriage, families with chronic or terminal patients). 35. Physician’s role for family planning. Prophylaxis of congenital diseases, prenatal and postnatal screening. 36. Occupational medicine – nature, principles, organization in Bulgaria. 37. Medical labor assessment – assessment of temporary working incapacity. Indices. Anal- ysis of incidence with temporary working incapacity. 38. Medical labor assessment – assessment of permanent working incapacity. Territorial expert physician committee. 39. Contemporary conception of primary medical help. General Practitioner’s functions. Home stationary. 40. Preventive medicine nature and basic aspects. Primary, secondary and tertiary prophylaxis. Health promotion. 41. Dispensary method, Dispensary types and dispensriesed patient. Indices. 42. Hospital. Functions, structure and organization. Indices. 43. Hospitalization: factors and indications for hospitalization. Medico-protective regime. Indices. 44. Particularities of hospitalized patients as social group; family and discharged patient; opinion of patients and their relatives for hospital services. Methods of studying and significance. 45. Medico-social problems of women and motherhood. “Mothers public health” program of National Health Insurance Fund. 46. Medico – social problems of children. “Children public health” program of National Health Insurance Fund. 47. Medico – social problems of motherhood and childhood – abortions, sterility, lonely mother, not wished children, children with chronic diseases, adopted children and treatment of children without physician prescription. Sexual education. 48. Medico – social problems of adolescence – acceleration problems, alcoholism and drugs. Prophylaxis of most common diseases till 18 years of age. 49. Health management – basic principals. Management of human resources. 50. Health management. Managing team. Management of financial resources. Manage- ment of organizational change. 51. Public health planning, economy and marketing.

C O N S P E C T U S FOR THE STATE EXAM OF SOCIAL MEDICINE

3. Basic aspects of human health. Social factors of health and disease – classification and mechanism of influence. Individual health. Criteria of health and disease. Health classification. Health determinants. 4. Group and public health – definition, basic groups of indices. Factors and trends of group and public health. Health indicators. 5. Medical demography – historical development, divisions. Demographic transition model. 6. Medical demography. Mechanical movement of the population: nature, types and health aspects. 7. Medical demography. Natural movement of the population. Indices. Factors for birth rates and death rates. Death reasons, death registration. Children mortality – reasons and dynamics. 8. Incidence and prevalence – definition. Sources and methods for incidence’ study. Indices. World classification of diseases. 9. Physical development. Acceleration. 10. Epidemiology – definition, tasks, methods. Natural history of the disease. 11. Risk factors, causality. Bradford – Hill’s criteria. Measurement of diseases and exposure. Risk assessment. 12. Epidemiological studies – surveillance studies. 13. Epidemiological studies – experimental studies. 14. Public health – nature, principles. Health service – definition, factors, structure and functions. Interdepartmental collaboration. 15. Public health systems – types, advantages and disadvantages. 16. Health policy and reform in Bulgaria. National health strategy. 17. Health legislation in Bulgaria. Health act. 18. Health legislation in Bulgaria. Law for medical establishments. 19. Health legislation in Bulgaria. Health insurance law. 20. Public health international collaboration. WHO. Programs and priorities. 21. European Union health policy. Programs and priorities. 22. Health culture and health behavior. Definition, significance and basic direction for establishing health culture. Health education: basic principles, methods and organization forms. 23. Sociological methods of medical studies. Inquiry method. Surveillance method. 24. Sociological methods of medical studies. Interview and documentary method. 25. Social history of the patient. Family anamnesis. 26. Physician’s role for family planning. Prophylaxis of congenital diseases. Problem families (unequal, mixed and dissolved marriages, families with patients with chronic diseases). 27. Occupational medicine – nature, principles, organization in Bulgaria. 28. Medical labor assessment – assessment of temporary working incapacity. Indices. Analy- sis of incidence with temporary working incapacity. 29. Medical labor assessment – assessment of permanent working incapacity. Territorial expert physician committee. 30. Preventive medicine nature and basic aspects. Primary, secondary and tertiary prophylaxis. Health promotion. 31. Dispensary method, Dispensary types and dispensriesed patient. Indices. 32. Hospital. Functions, structure and organization. Indices. Factors and indications for hospitalization. Medico-protective regime. 33. Medico-social problems of women and motherhood. Motherhood protection. “Mothers public health” program of National Health Insurance Fund.

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34. Medico – social problems of children. “Children public health” program of National Health Insurance Fund. 35. Health management – basic principals. Management of human resources. 36. Health management. Managing team. Management of financial resources. Management of organizational change. 37. Basic stages of statistical study. Content of the plan and the program. Gathering of statis- tic material and processing of the information. 38. Variation analysis. Formulation of varying ranges. Average quantities and technique of calculating them. Assessment of the statistical study results’ reliability. Reliability interval for the population 39. Alternative analysis. Comparing of relative parts. Reliability interval. 40. Nonparametric analysis. Assessment of hypothesis. Pirson’s criteria. 41. Moral aspects of physician – patient relationship. Behavior models. Informed consent. Conflict situation in physician – patient relationship. The physician as a patient. 42. Medical mistakes – deontological and legal aspects. Medical secret. 43. Physician’s behavior when servicing patients with chronic diseases. Approach to incura- ble patient. Euthanasia. 44. Moral and social – legal aspects of donation and transplantation of tissues and organs. Transplantation Law in Bulgaria.

BIBLIOGRAPHY: 1. Stefanov R. Social medicine: lecture course 2. Stefanov R. Social medicine, on-line edition 3. Boniota R, Beaglehole R. Basic epidemiology 4. Preston S. Demography

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MEDICAL UNIVERSITY – PLOVDIV MEDICAL FACULTY

PROGRAMME OF

HYGIENE AND ECOLOGICAL MEDICINE

Accepted from Department council on 29.06. 2012

Approved from Faculty council on………………… 2012

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MEDICAL UNIVERSITY - PLOVDIV MEDICAL FACULTY

Name of the science: Hygiene and ecological Medicine

Form of the science according united state requirements: obligatory

Level of education: Маster /М/

Forms of education: Lectures, practical exercises, self-training

Duration of education: Two semesters

Academic hours of the auditory lessons /horary/: 60 academic hours lectures, 60 academic hours practical exercises

Technical devices using in the education: Multimedia presentations during the lectures and practical exercises, demonstration of different devices and equipment during the practical exercises.

Forms of evaluation: Current control - tests, 2 colloquiums during winter and summer semesters .

Formation of the estimation: Average current evaluation for every semester.

Aspects by the formation of the estimation: Discussion participation, tests.

Semester examination: Yes / an incomming test, examination in writing/.

State examination: Yes / writing and oral examination /.

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Leading lecturer: Lecturer having academic rank in the Department of Hygiene and Ecological Medicine, Medical University, Plovdiv.

Department: Hygiene and Ecological Medicine

ANNOTATION The educational program of hygiene and ecological medicine contains current information about negative effects of environmental factors and working conditions, which lead to health disturbances and decreases in the working ability. Hygiene investigates the positive effects of some environmental and social factors, which lead to health promotion too. Ecology is the science of interrelationships of the natural environment: the dependency of one organism to another, and the ultimate dependency of all, including man, on various components of the physical environment.

AIM AND MAIN TASKS OF THE EDUCATION PROGRAMME

Hygiene is one of the main objects of the preventive medicine. The hygiene is a medical science that studies a relationship of the environment to humans from the point of view of the correct development, preservation, strengthening and improving of the human health and to ensure active longevity. The aim of this teaching program for medical students is to give them theoretical knowledge and practical ability in the field of the hygienic science and prevention against the negative effects of different environmental factors and working conditions.

MAIN TASKS:

1. Hygienic assessment of the environmental factors and living conditions ( physical factors, such as barometric pressure,air temperature, noise,vibrations et al.; chemical factors –content of chemical substances in air, water, soil; ergonomic problems; biological agents, psycho-social factors; investigation of the effects of all factors on the human state and health. 2. Increasing of adaptation processes and health promotion by means of: adequate nutrition, regulation of school adjustment, physical fitness, work satisfaction. 3. Promotion of healthy life style and education. 4. Prevention programs against non-communicable diseases with social importance.

EXPECTATION RESULTS

The students must have the following knowledge and abilities after the education:

-Theoretical knowledge and practical ability in the field of the hygienic science and prevention measures against the negative effects of different environmental factors (air- ,water- soil pollution; food contamination et al.) and working conditions;

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- Theoretical knowledge and practical ability in the field of healthy nutrition for different population groups and prevention measures against non-communicable diseases with social importance ( cardio-vascular diseases, diabetes mellitus, overweight and obesity, osteoporosis, cancer et al.); - Promotion of healthy life style and education .

CURRICULUM

Academic hours by years and Examination Academic hours semesters Science Practical Semester Total Lectures ІV V VІ VІІ VІІІ ІХ Х exercises

Hygiene and VI 120 60 60 2/2 2/2 ecological medicine

PROGRAMME OF THE LECTURE COURSE III. course, V.semester

Academic № Theme Date hours

1. Introduction to environmental health and hygiene. organization and structure of environmental health service. 2h.

2. Hygienic requirements to water supply. Water pollution. 2h.

Drinking water quality - health requirements. 3. Drinking Influence of the water chemical content on the health. 2h.

4. Water purification and disinfection. 2h.

5. Atmosphere. Air composition 2h.

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6. Air pollution. Health effects of air pollution and prevention. 2h.

7. Hygienic characteristic of physical factors of the atmosphere 2h.

8. Climate and weather. Diseases dependent on meteorological factors. Acclimatization. 2h.

9. Hygiene of the soil. Disposal of wastes. 2h.

Hygienic characteristics of living conditions in the areas. 10. H Urbanization. Hygienic characteristics of the housing conditions. 2h.

Hygienic characteristics of noise “pollution” in built-up 11. H areas. 2h.

12. Personal hygiene. Principles of healthful life style. 2h.

13. Hospital hygiene. Common hygienic requirements to hospitals. 2h.

Hygienic requirements to hospitals /clinics/ with high 14. epidemiological risk. Prevention of hospital infections. Characteristics of the medical work. 2h.

Ionizing radiation. Main principles of protection. 15. 2h.

TOTAL: 30 h.

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PROGRAMME OF THE LECTURE COURSE

ІІІ course, VІ semester

№ Тheme Academic Date hours

1. Hygiene of nutrition –introduction. Principles of healthy

nutrition. 2 h. .

Nutrients (proteins, fats and carbohydrate) .Physiological 2. N importance, sources and needs. 2 h.

Nutrients (vitamins and minerals). Physiological 3. N importance, sources and needs. 2 h.

Foods of animal and vegetable origin. 4. F 2 h.

5. 2h. Food processing and preservation.

6. 2 h. Food-borne diseases-classification and prevention.

7. 2 h. Nutrition of different population’s groups. .

8. 2 h. Nutritional prevention of some non-communicable diseases with social importance

9. Occupational hygiene - introduction . 2 h.

10. Physiology of work. Fatigue - prevention measures. 2 h.

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11. Occupational physical factors and prevention measures. 2 h.

Toxicology. Risk assessment. Chemical damages and 12. T 2h. prevention measures.

13. 2 h. School hygiene - basic activities. Physical growth and development of children.

14. 2 h. Physiological bases of school education. Physical training and inurement.

15. 2 h. Hygienic requirements to arrangement of kindergartens and school.

TOTAL: 30 h.

PROGRAMME OF THE PRACTICAL EXERCISES

ІІІ course, V semester

№ Тheme Academic Date hours State Healthy Control - organization, structure, public 1. health protection activities. Regional Health Inspection (RHI). 2h.

Methods for hygienic investigation of water supplies and 2. drinking water. Analysis of drinking water parameters with indicative significance (organoleptic indices, hardness of water) 2h.

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3. Hygienic monitoring of drinking waters. Chemical analysis of the drinking water. 2h.

4. Microbiological analysis of the drinking water. Purification and disinfection of the water. 2h.

Hygienic investigation of pumping (purifying) station for 5. drinking water (visitation of station). 2h.

6. Methods for air pollution analysis. Determination of CO2, 2h. CO, SO2.

Methods for air pollution analysis. Determination of NO 7. 2, lead aerosols, dusts. 2h.

Current methods for monitoring of the air pollution 8. (visitation of station for monitoring of air pollution). 2h.

Methods for hygienic investigation and evaluation of the 9. microclimate factors – air temperature, air humidity, air velocity and IR radiation. 2h.

Methods for complex microclimate evaluation. 10. 2h.

11. Hygienic evaluation of the heating, lightning and ventilation in housing, public, including hospital buildings. 2h. Hygienic investigation of hospitals. Community Hygiene colloquium. 12. Test examination and written examination on 2 questions from conspectus of Community Hygiene 2h.

Hygienic requirements to special hospitals (clinics) with 13. high epidemiological risk. Prevention of the inter-hospital infections. 2h.

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Hygienic investigation of sports center (swimming pool) – 14. visitation of swimming pool. 2h.

Main principles of ionizing radiation safety. Radiation 15. protection. 2h.

TOTAL: 30 h.

PROGRAMME OF THE PRACTICAL EXERCISES

ІІІ course, VІ semester

№ Тheme Academic Date hours Assessment of personal nutrition. Methods for 1. determination of daily energy expenditure, normal body 2 h. weight, body mass index and personal nutritional requirements).

2. Methods for assessment of dietary intake. Making and 2h. evaluation a diet per person from determinate population group.

3. Hygienic investigation of food products. Hygienic 2 h. investigation of meat.

4. Hygienic investigation of milk, baby foods and canned 2 h. foods.

5. Prevention of the food-borne diseases – control and 2 h. preventive measures.

6. Hygienic requirements of eating places. 2 h.

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7. Hygienic investigation of eating places (eating place 2h. visitation).

Nutrition Hygiene colloquium. 8. Test examination and written examination on 2 questions 2h. from conspectus of Nutrition Hygiene

9. Physiological and psychophysical methods for 2h. assessment of the efficiency and fatigue

10. Noise and vibration – hygienic assessment and 2 h. measurement.

11. Hygienic investigation of industrial enterprise (industrial 2 h. enterprise visitation).

12. Hygienic-toxicological evaluation of chemicals. 2 h. Hygienic control in the use of pesticides.

Methods for control and evaluation of health status and 13. 2 h. physical development of children and adolescents

Hygienic investigation of kindergartens (kindergarten 14. visitation). 2h.

15. Hygienic investigation of schools of general education 2h. and educative workshops (school visitation).

TOTAL: 30 h.

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LECTURES –THESES

III. course, V. semester

LECTURE № 1 -2 hours:

INTRODUCTION TO ENVIRONMENTAL HEALTH AND HYGIENE. ORGANIZATION AND STRUCTURE OF ENVIRONMENTAL HEALTH SERVICE

1. Hygiene and Medical Ecology – introduction 2. Main tasks. 3. Main branches of hygiene. 4. Methods of hygiene. 5. Environmental health service in Bulgaria-basic functions and activities.

LECTURE №2 -2 hours:

HYGIENIC REQUIREMENTS TO WATER SUPPLY. WATER POLLUTION.

1. Necessities of water . 2. World water resources . 3. Water supply sources – advantages and disadvantages 3.1.Rain water (atmospheric water) 3.2 Surface water 3.3. Ground water 4. Distribution of water. 5.Water pollution . 6. Water-related diseases.

LECTURE №3 -2 hours:

DRINKING WATER QUALITY- HEALTH REQUIREMENTS. INFLUENCE OF THE WATER CHEMICAL CONTENT ON THE HEALTH.

1. Chemical indices. 2. Microbiological indices. 3. Radiological indices. 4. Influence of the water chemical content on the health.

LECTURE №4 -2 hours:

WATER PURIFICATION AND DISINFECTION

1. Water purification

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1.1 Storage with coagulation, flocculation and sedimentation (by the rapid sand filters). 1.2. Filtration- slow and rapid sand filters –advantages and disadvantages of these filters. 1.3. Special treatment ( water quality improvement ) 2. Disinfection. 2.1. Chemical methods for disinfection- chlorination, ozonation 2.2. Physical methods for disinfection - ultraviolet irradiation, ultrasound 2.3. Household disinfection of water - boiling, chlorine tablets et al.

LECTURE №5 -2 hours:

ATMOSPHERE. AIR COMPOSITION

1. Atmosphere- definition, zones of atmosphere. 2. Air composition-natural gas content 2.1. Oxygen - health effects in conditions of oxygen deficiency or in condition of oxygen pressure increase 2.2. Nitrogen 2.3. Carbon dioxide (CO2)- health effects 2.4. Others gases – argon, neon, radon et al.

LECTURE №6 -2 hours:

AIR POLLUTION. HEALTH EFFECTS OF AIR POLLUTION AND PREVENTION

1. Air pollution – definition 2. Sources of air pollution: 2.1. Natural pollutans 2.2. Pollutans in consequence of human activity 3. Effects of air pollution 3.1. Health effects 3.2. Social and economic effects 4.Prevention measures against air pollution

LECTURE № 7 -2 hours:

HYGIENIC CHARACTERISTIC OF PHYSICAL FACTORS OF THE ATMOSPHERE

1. Meteorological factors:

1.1 Atmospheric pressure – diseases as a result in increased or decreased atmospheric pressure. 1.2. Air temperature 1.3. Humidity 1.4. Air velocity 1.5.Air –ionization

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2. Factors, coming from the cosmos: 2.1.Sun radiation –health effects 2.2. Electromagnetic radiation 3.Effect of the physical factors of atmosphere on the man’s organism.

LECTURE № 8 -2 hours:

CLIMATE AND WEATHER. DISEASES DEPENDENT ON METEOROLOGIC FACTORS. ACCLIMATIZATION

1. Climate- definition 2. Weather – classification 3. Diseases dependent on sharp changes of meteorological factors: 4. Acclimatization

LECTURE № 9 -2 hours:

HYGIENE OF THE SOIL. DISPOSAL OF WASTES

1. Soil structure and characteristics 2. Chemical content and soil pollution 3. Microorganisms and protozoa in the soil. 4. Disposal of wastes: 4.1. Solid wastes -methods of disposal 4.2. Liquid wastes-methods of disposal

LECTURE № 10 -2 hours:

HYGIENIC CHARACTERISTICS OF LIVING CONDITIONS IN THE AREAS. URBANIZATION. HYGIENIC CHARACTERISTICS OF THE HOUSING CONDITIONS

1.Planning, building in the areas 2.Assessment of the living conditions 3. Improvement of the living conditions. 4. Urbanization – advantages and disadvantages 5. Hygienic characteristics of the housing conditions 6. Health effects connected to hygienic conditions of the houses, or so called sick building syndrome

LECTURE № 11 -2 hours:

HYGIENIC CHARACTERISTICS OF THE NOISE “POLLUTON” IN BUILT-UP AREAS

1.Noise-definition 2. Sources of noise 3. Health effects of noise exposure 4. Prevention measures and control of noise in the cities

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LECTURE № 12 -2 hours:

PERSONAL HYGIENE. PRINCIPLES OF HEALTHFUL LIFE STYLE

1.Introduction to personal hygiene 2. Principles of healthful life style 3. Skin hygiene 4.Tooth hygiene 5.Hygienic characteristics of washing means 6.Hygienic characteristics of dress materials and shoes

LECTURE № 13 -2 hours:

HOSPITAL HYGIENE.COMMON HYGIENIC REQUIREMENTS TO HOSPITALS.

1.Systems of hospital building – decentralized, centralized , mixed system

2.Hygienic characteristics of clinics and medical centres - common hygienic requirements.

3.Hygienic requirements to the operation block.

LECTURE № 14 -2 hours:

HYGIENIC REQUIREMENTS TO HOSPITALS (CLINICS) WITH HIGH EPIDEMIOLOGICAL RISK. PREVENTION OF HOSPITAL INFECTIONS. CHARACTERISTICS OF THE MEDICAL WORK

1. Hygienic requirements to the special hospitals with high epidemiological risk: 1.1. Hospital for infectious diseases 1.2.Hospital for treatment of tuberculosis 1.3.Children’s hospital: 1.4.Psychiatric hospital 1.5.Hospital (clinic) for delivery and gynaecological diseases 2. Inter-hospital infections – definition 2.1. Prevention of the hospital infections: non-specific and specific prevention 3. Characteristics of the medical work

LECTURE № 15 -2 hours:

IONIZING RADIATION.MAIN PRINCIPLES OF PROTECTION

1. Ionizing radiation-definition 1.1. Natural sources of ionizing radiation 1.2. Man-made sources of ionizing radiation 1.3. Types of radiation 1.4. Radiation units 2.Biological effects of radiation 3. Main principles of protection of external exposure and closed devices 4. Main principles of protection of open sources of radiation 5. Other recommendations for protection against ionizing radiation

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LECTURES –THESES

III. course, VI. semester

LECTURE № 1 -2 hours:

HYGIENE OF NUTRITION –INTRODUCTION.PRINCIPLES OF HEALTHY NUTRITION

1. Hygiene of nutrition- definition. 2. Nutrient requirements and healthy eating. 3. Principles of healthy nutrition 4. Medical nutrition 5. Current nutrition status in Europe

LECTURE № 2 -2 hours:

NUTRIENTS (PROTEINS, FATS AND CARBOHYDRATES) - PHYSIOLOGICAL IMPORTANCE, SOURCES AND NEEDS

1. Nutrients – classification. 2. Proteins – functions, sources, protein requirements. 3. Fats – classification, sources, functions, requirements. 4. Carbohydrates - classification, function, sources, requirements

LECTURE № 3 -2 hours:

NUTRIENTS (VITAMINS AND MINERALS) –PHYSIOLOGICAL IMPORTANCE, SOURCES AND NEEDS

1. Vitamins –physiological importance 1.1. Fat soluble vitamins- functions, sources, daily requirements, deficiency and toxicity as a result of excess intake 1.2. Water soluble vitamins- functions, sources, daily requirements, deficiency. 2. Minerals – classification. 2.1. Macroelements / calcium, magnesium et al./ –sources, daily needs. 2.2. Trace elements / iodine, fluorine, zinc, copper et al./ - sources, daily needs.

LECTURE № 4 -2 hours:

FOODS OF ANIMAL AND VEGETABLE ORIGIN

1.Classification of foods by origin and by nutritive value. 2. Foods of animal origin- physiological importance 3. Foods of vegetable origin- physiological importance 4. Beverages – classification.

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LECTURE № 5 -2 hours:

FOOD PROCESSING AND PRESERVATION

1. Food processing – definition, techniques. 1.1.Canning- advantages and disadvantages. 1.2.Freezing -advantages and disadvantages. 1.3.Drying and extrusion- advantages and disadvantages. 2. Hygienic evaluation of the techniques for food preservation.

LECTURE № 6 -2 hours:

FOOD-BORNE DISEASES - CLASSIFICATION AND PREVENTION

1. Food-borne diseases- definition. 2. Food-borne diseases - classification . 2.1. Food-borne diseases as a result of biological food contamination 2.2. . Food-borne diseases as a result of chemical food contamination 2.3. Diseases in result of super sensitiveness. 2.4. Diseases in result of irregularly nutrition 3. Prevention measures against food-borne diseases.

LECTURE № 7 -2 hours:

NUTRITION OF DIFFERENT POPULATION’S GROUPS

1. Nutrition of pregnant women 2. Nutrition of the lactating woman 3. Nutrition of children and schoolchildren 4. Nutrition of old people

LECTURE № 8 -2 hours:

NUTRITIONAL PREVENTION OF SOME DISEASES WITH SOCIAL IMPORTANCE.

1. Recommendations for preventing diabetes 2. Recommendations for preventing excess weight gain and obesity 3. Recommendations for preventing cardiovascular diseases 4. Recommendations for preventing cancer 5. Recommendations for preventing dental diseases 6. Recommendations for preventing osteoporosis

LECTURE № 9 -2 hours:

OCCUPATIONAL HYGIENE - INTRODUCTION

1. Occupational hygiene- definition.

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2. Basic principles of the occupational hygiene investigation. 3. Brief historical view of the industrial development and its influence on the working conditions and work 4. Relationship between working conditions and health effects.

LECTURE № 10 -2 hours:

PHYSIOLOGY OF WORK. FATIGUE – PREVENTION MEASURES.

1. Work physiology- definition ,main tasks. 2. Work ability – definition. 3. Fatigue – definition, classification of fatigue. 4. Fatigue - prevention measures.

LECTURE № 11 -2 hours:

OCCUPATIONAL PHYSICAL FACTORS AND PREVENTION MEASURES.

1.Sound (noise) 1.1.Effects of noise on humans 1.2. Noise control 2.Vibrations 2.1. Health effects of vibration 2.2. Control of vibration 3. Non- ionizing radiation 3.1. Ultraviolet radiation – health effects 3.2. Infrared radiation– health effects 3.3. Radiofrequency radiation-sources, health effects. 3.4 Extremely low frequency radiation and static fields -sources, health effects. 3.5.Lasers - sources, health effects, control measures. 4. Unfavourable microclimate. 4.1. Work in hot environments- health effects. 4.2. Health effects of exposure to extremes of cold. 5. Dust in the working environment - sources, health effects, prevention.

LECTURE № 12 - 2 hours:

TOXICOLOGY. RISK ASSESSMENT. CHEMICAL DAMAGES AND PREVENTION MEASURES 1. Toxicology – definition. 2. Hazards, risks and risk assessment. 3. Toxic effects of hazardous substances. 4. Chemical hazards 4.1. Cadmium 4.2. Chromium 4.3. Mercury 4.4. Benzene 4.5. Asbestos and other fibers 4.6. Prevention measures.

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LECTURE № 13 - 2 hours:

SCHOOL HYGIENE - BASIC ACTIVITIES. PHYSICAL GROWTH AND DEVELOPMENT OF CHILDREN

1. School hygiene – basic activities 2.Physical growth and development of children 2.1. Growth and development periods of children 2.2. Preschool years 2.3. Early school years 2.4. Adolescence- early adolescence, middle adolescence, late adolescence. 3. Disorders of pubertal development

LECTURE № 14 - 2 hours:

PHYSIOLOGICAL BASES OF SCHOOL EDUCATION. PHYSICAL TRAINING AND INUREMENT

1.Physiological bases of school education 1.2.The rational daily regiment 2. Physical training- medical control on physical education. 3. Physical inurement -basic principles.

LECTURE № 15 - 2 hours:

HYGIENIC REQUIREMENTS TO ARRANGEMENT OF KINDERGARTENS AND SCHOOLS

1.Crèches and kindergartens - main hygienic requirements in construction of kindergartens. 2.Schools of general education- main hygienic requirements 3.Hygienic requirements to labour and professional training

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PRACTICAL EXERCISES – THESES

III. course, V. semester

PRACTICAL EXERCISE № 1 - 2 hours:

State Healthy Control - organization, structure, public health protection activities. Regional Health Inspection (RHI).

1. Introduction to Hygiene and ecological Medicine – definition, aim, main tasks, branches of hygiene, methods of hygiene. 2. State Healthy Control – organization and structure. 3. State Healthy Control - public health protection activities. 4. Regional Health Inspection (RHI)- structure and basic activities.

PRACTICAL EXERCISE № 2 - 2 hours:

Methods for hygienic investigation of water supplies and drinking water. Analysis of drinking water parameters with indicative significance (organoleptic indices, hardness of water)

1. Preliminary and current health control of water supplies and drinking water. 2. Laboratory analysis of drinking water. 3. Water sampling for chemical and microbiological analysis. 4. Organoleptic /aesthetic/ analysis of drinking water. 5. Analysis of other drinking water parameters with indicative significance –water hardness.

PRACTICAL EXERCISE № 3 - 2 hours:

Hygienic monitoring of drinking waters. Chemical analysis of the drinking water.

1. Monitoring of drinking water. 2. Chemical analysis of the drinking water. 2.1. Determination of pH 2.2.Oxidizability of water 2.3.Determination of ammonia 2.4.Determination of nitrite and nitrate 2.5. Determination of chloride 2.6. Determination of sulphate

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PRACTICAL EXERCISE № 4 - 2 hours:

Microbiological analysis of the drinking water. Purification and disinfection of the water. 1. Microbiological analysis of the drinking water. 1.1. Methods for determination of coliform organisms in drinking water - 1.2. Determination of Enterococcus in drinking water 1.3. Determination of Clostridium perfringens 1.4. Determination of Pseudomonas aeruginosa 1.5. Determination of Colony count 2. Purification and disinfection of the water. 2.1.Experimental coagulation 2.2. Chemical methods for disinfection 2.3. Physical methods for disinfection. 2.4. Purification of water on a small scale - physical, chemical, mechanical methods.

PRACTICAL EXERCISE № 5 - 2 hours:

Hygienic investigation of pumping (purifying) station for drinking water (visitation of station).

PRACTICAL EXERCISE № 6 - 2 hours:

Methods for air pollution analysis. Determination of CO2, CO, SO2.

1. Air pollution: Definition; - Natural pollutants; - Pollutants from human activity; 2. Determination of concentration of gaseous and aerosol pollutant- - principles of the methods. 3. Methods for collecting samples: - absorbing and absorbing medium; - grab sampling; 4. Analysis methods. 5. Results calculation. 6. Determination of CARBON DIOXIDE. 7. Direct colorimetric method for CARBON MONOOXIDE determination. 8. SULFUR DIOXIDE – determination.

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PRACTICAL EXERCISE №7 - 2 hours:

Methods for air pollution analysis. Determination of NO2, lead aerosols, dusts.

1. Determination of NO2. 2. Determination of lead aerosols. 3. Determination of dust: - Air sampling for dust analysis; - Methods for dust analysis;

PRACTICAL EXERCISE №8 - 2 hours:

Current methods for monitoring of the air pollution (visitation of station for monitoring of air pollution).

1. National system for air monitoring

PRACTICAL EXERCISE № 9 - 2 hours:

Methods for hygienic investigation and evaluation of the microclimate factors – air temperature, air humidity, air velocity and IR radiation.

1. Microclimate – definition. 2. Methods for hygienic investigation and evaluation of the air temperature. 3. Methods for hygienic investigation and evaluation of the air humidity 4. Methods for hygienic investigation and evaluation of the air velocity. 5. Methods for hygienic investigation and evaluation of the IR radiation 6. Discussion on the results from measurement of microclimate factors.

PRACTICAL EXERCISE № 10 - 2 hours:

Methods for complex microclimate evaluation.

I. Thermal comfort. Thermal balance/imbalance – factors. II. Methods for complex microclimate evaluation: 1. Subjective methods: a) Questionnaire method for determination a subjective thermal sensation according to the 7-bale scale of Bedford; b) Effective Temperature (ET) index; c) Corrected Effective Temperature (CET) index; d) Fanger’s comfort criteria for Predication of Thermal Comfort. 2. Objective methods: a) Physical methods:  Resulting Temperature (RT)  Wet Bulb Globe Temperature (WBGT) index b) Physiological methods:  Pulse frequency  Blood pressure level  Vegetative Index of Kerdo

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 Average skin temperature  Average body temperature  Heat content of the body  Evaporative heat loss c) Integral methods – Heat Stress indices III. Discussion on the results from complex microclimate investigation.

PRACTICAL EXERCISE № 11 - 2 hours:

Hygienic evaluation of the heating, lightning and ventilation in housing, public, including hospital buildings. Hygienic investigation of hospitals.

1. Hygienic evaluation of heating - hygienic requirements. 2. Hygienic evaluation of lightning- the requirements of good lighting: - natural lighting: measurement of daylight; - artificial lighting: the Lighting system; methods of artificial illumination, lighting standard; 3. Evaluation of the effectiveness of the natural ventilation. - Volume of adequate ventilation; - The actual volume of ventilation; - Ventilation rate ; 4. Mechanical ventilation. 5. Hygienic evaluation of the ventilation in housing, public, including hospital buildings.

PRACTICAL EXERCISE № 12 - 2 hours:

Community Hygiene colloquium. Test examination and written examination on 2 questions from conspectus of Community Hygiene

PRACTICAL EXERCISE № 13 - 2 hours:

Hygienic requirements to special hospitals (clinics) with high epidemiological risk. Prevention of the inter-hospital infections.

1. Hygienic requirements to special hospitals (clinics) with high epidemiological risk. 2. Hospital-acquired (nosocomial) infections – definition. 3. Prevention of nosocomial infection – principles. 4. Discussion on the role of the physician in the prevention and control of hospital-acquired infections.

PRACTICAL EXERCISE № 14 - 2 hours:

Hygienic investigation of sports center (swimming pool) – visitation of swimming pool.

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PRACTICAL EXERCISE № 15 - 2 hours:

Main principles of ionizing radiation safety. Radiation protection.

1. Radiation protection and safety conditions. 2. Ionizing radiation - main principles of protection. 3. Decontamination (deactivation). Ways and means for decontamination. 4. Introduction to the activity of the State Radiation Control Department at Regional Health Inspection, Plovdiv - visitation.

PRACTICAL EXERCISES – THESES

III. course, VI. semester

PRACTICAL EXERCISE № 1 - 2 hours:

Assessment of personal nutrition. Methods for determination of daily energy expenditure, normal body weight, body mass index and personal nutritional requirements.

1. Role of the diet and nutrition in the prevention of chronic diseases /noncommunicable diseases (NCD)/. 2. Assessment of personal nutrition. Methods for determination of daily energy expenditure: a) Determination of basal metabolic rate (BMR) b) Determination of physical activity level (PAL) c) Determination of total energy expenditure (TEE). 3. Determination of normal body weight and body mass index (BMI). 4. Determination of personal nutritional requirements; population nutrient intake goals. 5. Discussion on the individual results.

PRACTICAL EXERCISE № 2 - 2 hours:

Assessment of nutritional status. Dietary assessment methods

1.Assessment of nutritional status – methods. 2. Dietary assessment methods: a) methods to assess dietary intake at household level: - food accounts, - inventories, and - household recall. b) methods to assess dietary intake at individual level: - food records, -24-hours recall, and - food frequency questionnaires.

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3. Making and evaluation a diet per person from determinate population group. 4. Discussion on the individual results. 5. Determination of personal nutritional requirements; population nutrient intake goals.

PRACTICAL EXERCISE № 3 - 2 hours:

Hygienic investigation of food products. Hygienic investigation of meat.

1. Complex of biological indicators of nutritive value. 2. Complex of fitness for consumption of harmless. 3. Complex of commercial indicators. 4. Stages of the healthy monitoring: - Introduction; - Taking samples: common, medium and double samples; - Conclusion; 5. Hygienic evaluation of meat: - Taking of meat sample; - Organoleptic analysis of meat; - Chemical and biochemical meat tests: - Meat bouillon reaction whit copper sulfate; - Biochemical test for peroxidase; - Reaction for ammonia; - Microbiological analyses - Parasitological investigation

PRACTICAL EXERCISE № 4 - 2 hours:

HYGIENIC EVALUATION OF MILK, BABY FOOD AND CANNED FOOD

1. Taking of the milk sample. 2. Organoleptic analysis of milk. 3. Chemical and biochemical tests: - Milk density determination; - Milk acidity determination; - Pasteurization of milk -test; - Test for sodium bicarbonate; 4. Hygienic evaluation of baby food 5. Hygienic evaluation of canned food

PRACTICAL EXERCISE № 5 - 2 hours:

Prevention of the food-borne diseases – control and preventive measures

1. Food-borne diseases – definition, classification. 2. Duties of the medical specialist (physician of generally practice) in the case of outbreak of food-borne disease. 3. Discussion on the cases of food-borne diseases. 4. Food-borne diseases – control and preventive measures.

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PRACTICAL EXERCISE № 6 - 2 hours:

Hygienic investigation of eating places- healthy control 1. Location and transport – requirement. 2. Varied premises: - Storehouses for all kinds of products, refrigerators; - Preparation’s rooms for a variety of food; - Kitchen block and kitchen offices – warm kitchen, cold kitchen; - Washing room for kitchen’s dishes and for table’s dishes; - Administrative and residential premises; - Dinning hall- equipment and hygienic condition; 3. Food- transport, storage, entry controls – quality, organoleptic quality, temperature, storage. 4. Prepared dishes - culinary hygiene, adequate technological processing of culinary production. 5. Operation of maintenance – washing, cleaning and sterilization of food preparation areas. 6. Requirements for working in the food sectors.

PRACTICAL EXERCISE № 7 - 2 hours:

Hygienic investigation of eating places (eating place visitation).

PRACTICAL EXERCISE № 8 - 2 hours:

Nutrition Hygiene colloquium (written form) – test+2 questions from conspectus for nutrition hygiene colloquium

PRACTICAL EXERCISE № 9 - 2 hours:

Physiological and psychophysical methods for assessment of the efficiency and fatigue

1. Tests for evaluation of attention- Anffimov and Schultze tests. 2. Determination of volume, accuracy and speed of the revised information. 3. Tremometriya 4. Study of fatigue of the optic analyzer 5. Measurement of the latent period of senso-motor reaction (chronorefleksometriya).

PRACTICAL EXERCISE № 10 - 2 hours:

Noise and vibration – hygienic assessment and measurement. 1. Noise – definition and determination. 1.1.Measurement of noise 1.2. Personal Hearing Protection 1.3.Audiometric testing

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1.4. Audiometric testing 2. Occupational vibration 2.1.Measuring vibration - whole-body vibration measurement and hand–arm vibration measurement. 2.2.Control of vibration.

PRACTICAL EXERCISE № 11 - 2 hours:

Hygienic investigation of industrial enterprise (industrial enterprise visitation).

PRACTICAL EXERCISE № 12 - 2 hours:

Hygienic-toxicological evaluation of chemicals. Hygienic control in the use of pesticides. 1. Pesticides – definition, classification. 2. Pesticide toxicity, pesticide exposure – hazard. 3. Hygiene control in the use of pesticides. Preventing pesticide exposure, protective clothing and personal safety. 4. Medical tests for the effects of organophosphorous and carbamate pesticide exposure.

PRACTICAL EXERCISE № 13 - 2 hours:

Childhood and adolescent hygiene.Methods for investigation and assessment of growth and development in children and adolescents .Medical check-up

1. Investigation of the anthropometric indicators: - Morphological - height, weight, circumferences of head and chest, widths, lengths of the body; - Functional - mobility of the chest’s muscles; 2. The indicators of physical capacity. 3. Medical examination / somatoskopiya /: - Anamnesis; - Status of the skin and the mucous membranes; - Status of the lymph node; - Status of the thyroid gland; - Status of the respiratory and cardiovascular system; - Status of sense receptors : visual, auditory and etc. - Status of the locomotor system- scoliosis, kifoza, lo rdosis, flat-back; 4. Pubertal growth - Sexual Maturity Rating. 5. Evaluation of physical development ( method for the assessment).

PRACTICAL EXERCISE № 14 - 2 hours:

Hygienic investigation of kindergartens (kindergarten visitation).

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PRACTICAL EXERCISE № 15 - 2 hours:

Hygienic investigation of schools of general education and educative workshops (school visitation).

SOURCES OF SELF-DEPENDENT TRAINING

1 Hygiene and Ecology - Lecture guide for medical students – edited by assoc. Prof. Dr. P. Gatseva, Plovdiv, 2009, ISBN 978-954-9549-35-5 2 Hygiene and Ecology- Handbook for practical exercises – edited by assoc. Prof. Dr. P. Gatseva, Medical Publ. House VAP -Plovdiv, 2011 ISBN 978-954-8326-47-6

CONSPECTUS FOR THE SEMESTER THEORETICAL EXAMINATION OF HYGIENE AND ECOLOGICAL MEDICINE FOR MEDICAL STUDENTS

1. Introduction to environmental health and hygiene. Organization and structure of environmental health service. 2. Hygienic requirements to water supply. Water pollution. 3. Drinking water quality - health requirements. Influence of the water chemical content on the health. 4. Water purification and disinfection 5. Atmosphere. Air composition. 6. Air pollution. Health effects of air pollution and prevention. 7. Hygienic characteristic of physical factors of the atmosphere. 8. Climate and weather. Diseases dependent on meteorologic factors. Acclimatization. 9. Hygiene of the soil. Disposal of wastes. 10. Hygienic characteristics of living conditions in the areas. Urbanization. Hygienic characteristics of the housing conditions. 11. Hygienic characteristics of noise “pollution” in built-up areas. 12. Personal hygiene. Principles of healthful life style.

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13. Hospital hygiene. Common hygienic requirements to hospitals. 14. Hygienic requirements to hospitals /clinics/ with high epidemiological risk. Prevention of hospital infections. Characteristics of the medical work. 15. Ionizing radiation. Main principles of protection. 16. Hygiene of nutrition –introduction 17. Nutrients (proteins, fats and carbohydrate) -physiological importance, sources and needs. 18. Nutrients (vitamins and minerals) –physiological importance, sources and needs. 19. Foods of animal and vegetable origin. 20. Food processing and preservation. 21. Food-borne diseases-classification and prevention. 22. Nutrition of different population’s groups. 23. Nutritional prevention of some diseases with social importance. 24. Occupational hygiene -introduction. 25. Physiology of work. Fatigue. 26. Occupational physical factors and prevention measures – noise and vibration. 27. Occupational physical factors and prevention measures – non-ionizing radiation (ultraviolet radiation, infrared radiation, radiofrequency radiation, extremely low frequency radiation and static fields, lasers). 28. Occupational physical factors and prevention measures – unfavourable microclimate. 29. Toxicology - risk assessment. Toxic effects of hazardous substances. 30. Chemical damages (cadmium, chromium, mercury et al.) and prevention measures. 31. School hygiene - basic activities. Physical growth and development of children. 32. Physiological bases of school education. Physical training and inurement. 33. Hygienic requirements to arrangement of kindergartens and school.

CONSPECTUS FOR THE SEMESTER PRACTICAL EXAMINATION IN HYGIENE AND ECOLOGICAL MEDICINE FOR MEDICAL STUDENTS

1.Methods for hygienic investigation of water supplies and drinking water. 2.Indices for organoleptic and physical evaluation of the water. - - 3.Chemical analysis of the drinking water – NH3, NO2 , NO3 , pH, oxidation, chloride, sulfates.

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4.Microbiological analysis of the drinking water. Purification of the water on a large and small scale (experimental coagulation). 5.Disinfection of the water – chlorination, superchlorination, ozonation. 6.Air pollutants. Air sampling for gases and vapors. Monitoring of air pollution.

7.Methods for air pollution analysis. Determination of CO and CO2, SO2 and NO2. 8.Methods for air pollution analysis. Determination of lead aerosols and dust. 9.Methods for hygienic investigation and evaluation of main physical factors of the air – air temperature and air humidity, the velocity of the air and IR radiation. 10.Methods for complex microclimate evaluation – physical methods (Kata thermometry, WBGT index) and subjective methods (Effective Temperature index, Corrected Effective Temperature index). 11.Methods for complex microclimate evaluation – physiological methods. 12.Hygienic evaluation of the heating, lightning and ventilation in housing. 13.Assessment of personal nutrition. Methods for determination of daily energy expenditure /determination of basal metabolic rate (BMR), physical activity level (PAL), total energy expenditure (TEE)/. Determination of normal body weight and body mass index (BMI). 14.Methods for a dietary nutrient intake assessment: methods to assess dietary intake at household level (food accounts, inventories, and household recall) and at individual level (records, 24-hours recall, and food frequency questionnaires). 15.Food-borne diseases – control and preventive measures. Duties of medical specialist (physician of generally practice) in the case of outbreak of food-borne disease. 16.Healthy food control – stages. 17. Hygienic evaluation of meat. Taking of the meat samples. Laboratory tests. 18. Hygienic evaluation of milk. Taking of the milk samples. Laboratory tests. 19. Hygienic evaluation of baby foods, and canned foods. 20. Hygienic investigation of eating places - kitchen block and kitchen offices, storage and refrigerators, preparatory, hot kitchen, cold kitchen, dishwasher, administrative and residential premises, equipment and hygienic conditions. Culinary hygiene, adequate technological processing of culinary production. Requirements for working in the food sectors. 21. Pesticides – definition, classification. Pesticide toxicity, pesticide exposure – hazard. 22. Hygiene control in the use of pesticides. Preventing pesticide exposure, protective clothing and personal safety. Tests for the effects of organophosphorous and carbamate pesticide exposure. 23. Physiological and psychophysical methods for assessment of the efficiency and fatigue.

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24. Hygienic assessment and measurement of noise and vibrations. 25. Methods for investigation and assessment of growth and development of children and adolescents.

CONSPECTUS FOR THE STATE EXAMINATION OF HYGIENE AND ECOLOGICAL MEDICINE FOR MEDICAL STUDENTS

1. Hygiene and ecology – aim, main tasks, branches of hygiene, methods of hygiene. 2. Hygienic requirements to water supply. Water pollution. Water –related diseases. 3. Drinking water quality - health requirements. Influence of the water chemical content on the health. 4. Water purification and disinfection. 5. Atmosphere. Air composition. 6. Air pollution. Health effects of air pollution and prevention measures. 7. Hygienic characteristic of physical factors of the atmosphere. 8. Climate and weather. Diseases dependent on meteorologic factors. Acclimatization. 9. Hygiene of the soil. Disposal of wastes. 10. Hygienic characteristics of living conditions in the areas. Urbanization. Hygienic characteristics of the housing conditions. 11. Hygienic characteristics of noise “pollution” in built-up areas. 12. Personal hygiene. Principles of healthful life style. 13. Hospital hygiene. Common hygienic requirements to hospitals. 14. Hygienic requirements to hospitals /clinics/ with high epidemiological risk. Prevention of hospital infections. Characteristics of the medical work. 15. Ionizing radiation. Main principles of protection. 16. Hygiene of nutrition –introduction 17. Nutrients (proteins, fats and carbohydrate) -physiological importance, sources and needs. 18. Nutrients (vitamins and minerals) –physiological importance, sources and needs. 19. Foods of animal and vegetable origin. 20. Food processing and preservation. 21. Food-borne diseases-classification and prevention.

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22. Nutrition of different population’s groups. 23. Nutritional prevention of some diseases with social importance. 24. Occupational hygiene -introduction. 25. Physiology of work. Fatigue. 26. Occupational physical factors and prevention measures – noise and vibration. 27. Occupational physical factors and prevention measures – non-ionizing radiation (ultraviolet radiation, infrared radiation, radiofrequency radiation, extremely low frequency radiation and static fields, lasers). 28. Occupational physical factors and prevention measures – unfavourable microclimate. 29. Toxicology - risk assessment. Toxic effects of hazardous substances. 30. Chemical damages (cadmium, chromium, mercury et al.) and prevention measures. 31. School hygiene - basic activities. Physical growth and development of children. 32. Physiological bases of school education. Physical training and inurement. 33. Hygienic requirements to arrangement of kindergartens and school.

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MEDICAL UNIVERCITY PLOVDIV MEDICINE DEPARTMENT

PROGRAMME

FOR BASICS IN INTERNAL MEDICINE

ACCEPTED IN CLINICAL COUNCIL IN 20.06.2012г.

ACCEPTED IN FACULTATIVE COUNCIL IN...... , 2012г.

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MEDICAL UNIVERCITY PLOVDIV MEDICINE DEPARTMENT DEPARTMENT OF BASICS IN INTERNAL MEDICINE

Name of subject: „Basics in Internal Medicine”

Kind of subject according EDA: Facultative

Degree of science: Master/M/

Forms in teaching: Lectures, practical trainings, self-training.

Course of teaching: Terms 2, 1 year

Horarium: 60 h lectures, 180 h practical training

Technical devices use in the educational process : Multimedia, audiovisual devices, tables, etc.

Control and Assessment:1. During terms: test, writing exam, oral examination. 2. Final exam : Test, practical exam, writing exam, oral exam.

Form of the final score: The final score is form in the end of 2-nd term after final exam.

How is formed the final score: test, writing exam, practical exam,Latin terminology, oral exam.

Term exam: Yes / test, writing exam, practical exam,Latin terminology, oral exam /.

Professional practice exam: No/

Leading Professors: Three Professors with academic rank in the Department of “Basics in Internal Medicine”

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Department: Basics in Internal Medicine

ANOTATION : Basic principles of physical examination. Diagnostic process. Semiotics of Internal diseases. Clinical picture, methods of physical examination, anamnesis, laboratory investigations, differential diagnosis of respiratory, cardiovascular, GIT, nephrological , haematological , endocrine and musculoskeletal diseases. Complications and prognosis.

MAIN OBJECTIVES: To learn and apply the basic principles of the physical examination of the internal organs. The students should perform a complete exam including taking history, internal organs check, posing diagnosis, determining the prognosis of a certain disease

OBLIGATORY COMPETENCE:

1. Theoretical : getting adequate knowledge, referring to:

- taking history and basic methods of physical examination - physical and instrumental exam of respiratory system - respiratory diseases - anamnesis and physical examination of cardiovascular system - ECG – normal interpretation and rhythm and conductive disturbances - Echocardiography, arterial pulse examination - Cardiovascular diseases - Anamnesis, physical and instrumental examination of GIT - Gastrointestinal diseases - Physical examination of kidneys and main renal diseases - Haematological diseases – anaemiae and leucoses - Endocrine and metabolic diseases - Physical examination of musculoskeletal system: rheumatoid arthritis, osteoarthritis, connective tissue diseases.

2. Practical:

- Taking history of a patient

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- Physical examination of lungs - Physical examination of heart - Physical exam of abdomen and abdominal organs - Physical exam of joint diseases - Reading of normal and pathologic ECG - Analysis of laboratory results in internal diseases.

EDUCATIONAL PLAN – III year of medicine, English speaking students:

Forms of educational Horarium/hours/ Credits events Weeekly V term. VI term. Total Lectures 2 30 30 60 Practicals 6 90 90 180

Total 8 120 120 240

PROGRAMME OF LECTURES

III COURSE , V TERM

№ TEMA HOURS DATES

1. Anamnesis. Inspection. Palpation./ general principles/ 2h.

2. Percussion. Auscultation – basic principles 2h.

3. Anamnesis of patients with respiratory diseases. Inspection of chest 2h.

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Palpation, percussion and auscultation of lungs 4. 2h.

Lungs auscultation: 5. 2h.

6. Pulmonary instrumental and functional investigations. Bronchitis 2h.

Pneumonias. Bronchial asthma. Pulmonary emphysema. 7. Pulmonary carcinoma 2h.

Bronchiectasis. Pulmonary abscessus. Pleuritides 8. 2h

Cardiovascular diseases. Anamnesis of a cardiac patient. 9. Inspection and palpation of cardiac apex. Percussion of 2h heart borders

ОБЩО: 30 H.

PROGRAMME LECTURES

ІІІ COURSE, VІ TERM

№ Т Е М А ЧАСОВЕ Д А Т А

1. Auscultation of heart. Heart sounds, rhythm, murmurs

2 h. .

2. Organic and functional murmurs. Pericardial friction rub 2 h. Rhythm and conductive disturbances 3. 2 h.

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4. Echocardiography. Examination of arterial and venous 2 h. pulse.

Rheumatic fever. Valvular diseases 5. 2h.

Arterial hypertension. Myocarditis an d cardiomyopathies. 6. 2 h. Pericarditis

ОБЩО: 30 H.

PROGRAMME PRACTICAL TRAINING

ІІІ COURSE, V TERM

№ TEMA HOURS DATES

Acquaintance of the students to the Clinic. Taking history 1. of a patient 3h.

Anamnesis vitae, anamnesis familiae. 2. 3h.

3. TAKING OF HISTORY AT THE PATIENT’S COUCH 3h.

GENERAL ASESMENT OF THE PATIENT. POSITION 4. IN THE BED. GAIT. MENTAL ASESMENT. 3h.

EXAMINATION OF SKIN AND ADNEXES. 5. CHANGES IN THE COLOR OF THEN SKIN: ANEMIA, JAUNDICE, CYANOSIS. SKIN RASHES. EXAMINATION OF NAILS, HAIR ETC. 3h.

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EXAMINATION OF HEAD AND NECK: SIZE AND 6. SHAPE. LYMPH NODES PALPATION. EXAMINATION OF THE THYROID GLAND. EXAMINATION OF 3h. ARTERIES AND VEINS ON THE NECK.

INSPECTION AND PALPATION OF CHEST. STATIC 7. AND DYNAMIC INSPECTION. PATHOLOGIC SHAPES OF CHEST. PALPATION OF VOCAL 3h. FREMITUS – INTERPRETATION.

PERCUSION OF THE CHEST. TECHNIQUE OF 8. PERCUSION. BASIC SOUNDS. 3h.

PERCUSSION OF LUNGS. DETECTION OF KROENIG 9. SPACES. COMPARATIVE PERCUSSION. DETECTION OF RESPIRATORY EXPANSION. 3h

LUNGS PERCUSSION. PATHOLOGIC SOUNDS AND 10. ANALYSIS. 3h

INSPECTION, PALPATION AND PERCUSSION OF 11. LUNGS – REVISION. EXAMINATION OF A PATIENT. 3h

AUSCULTATION OF LUNGS. BASIC BREATHING 12. SOUNDS. VESICULAR AND BRONCHIAL BREATHING. 3h

AUSCULTATION OF LUNGS. PATHOLOGIC 13. VESICULAR AND PATHOLOGIC BRONCHIAL BREATHING. 3h

AUSCULTATION OF LUNGS. ADDITIVE SOUNDS: 14. RONCHI, CLASSIFICATION, CRACKLES/ RALES/. 3h

PLEURAL FRICTION RUB. PLEURAL PUNCTURE: 15. TECHNIQUE AND ANALYSIS 3h

/ BODY TEMPERATURE. FEVER. SPECIFIC 16. TEMPERATURE CURVES. 3h

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RESPIRATORY DISEASES. ACUTE, CHRONIC 17. BRONCHITIS, PULMONARY EMPHYSEMA, BRONCHIAL ASTHMA. 3h

PHYSICAL EXAM OF PATIENTS WITH 18. PNEUMONIAS PHYSICAL EXAM OF PATIENTS WITH PLEURITIS. 3h

PHYSICAL EXAMINATION OF RESPIRATORY 19. SYSTEM – EXAM 3h

20. ANAMNESIS OF A CARDIAC PATIENT. INSP;ECTION AND PALPATION OF PRECORDIUM: 3h APEX, AORTIC, PULMONARY ZONES, NECK, EPIGASTRIUM PERCUSSION OF HEART BORDERS: RELATIVE 21. AND ABSOLUTE. 3h

PERCUSSION OF HEART. PATHOLOGIC CHANGES. 22.

AUSCULTATION OF HEART. MECHANISM OF 23. FORMATION OF HEART SOUNDS. MAIN ZONES OF AUSCULTATION. 3h

AUSCULTATION OF HEART. CHANGES IN HEART 24. SOUNDS: ACCENTUATION, WEAKENING, SPLITTING, ADDITIVE HEART SOUNDS. GALLOP 3h RHYTHM. AUSCULTATION OF HEART. HEART 25. MURMURS.CLASSIFICATION. EXTRACARDIAL MURMURS: PERICARDIAL FRICTION RUB. 3h

CLINICAL INTERPRETRATION OF HEART 26. MURMURS. 3h

ARTERIAL PULSE EXAMINATION. QUALITIES OF 27. ARTERIAL PULSE. 3h

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TAKING OF BLOOD PRESSURE: MAIN RULES. 28. ARTERIAL HYPERTENSION. 3h

PERCUSSION AND AUSCULTATION OF HEART – 29. REVISION. 3h

PHYSICAL EXAMINATION OF PATIENTS WITH 30. VALVULAR DISEASES: MITRAL STENOSIS AND REGURGITATION, AORTIC STENOSIS AND 3h REGURGITATION.

ОБЩО: 90 H.

PROGRAMME PRACTICAL TRAINING

ІІІ COURSE, VI TERM

№ TEMA HOURS DATES

1. NORMAL ECG: ANALYSIS. 3h ECHOCARDIOGRAPHY.

2. RHYTHM AND CONDUCTION DISTURBANCES. 3h CLINICAL MANIFESTATIONS. ECG IMAGES.

EXAMINATION OF A PATIENT WITH CAD: 3. ANGINA PECTORIS AND MYOCARDIAL 3h INFARCTION.

4. PHYSICAL EXAMINATION OF PATIENTS WITH 3h HEART FAILURE.

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5. PHYSICAL EXAMINATION OF PATIENTS WITH 3h MYOCARDITIS AND PERICARDITIS.

6. PHYSICAL EXAMINATION OF CARDIOVASCULAR 3h SYSTEM. EXAM

7. . 3 h PHYSICAL EXAM OF ABDOMEN. SUPERFICIAL AND DEEP PALPATION. PALPATIKON OF ABDOMENAL ORGANS. DETECTIOIN OF ASCITES.

8. PHYSICAL EXAM OF GIT. OESOPHAGEAL 3h. DISEASES. MAIN SYMPTOMS OF GASTROINTESTINAL DISEASES. 9. PHYSICAL EXAMINATION OF LIVER AND GALL 3h BLADDER. MECHANISMS OF JAUNDICE. PALPATION AND PERCUSSION OF LIVER. AUSCULTATION OF LIVE:R: PERIHEPATIC FRICTION RUB.

10. LABORATORY, FUNCTIONAL AND 3h INSTRUMENTAL EXAM OF LIVER AND BILE DUCTS.

11. PHYSICAL EXAM OF PATIOENTS WITH ULCER 3h DISEASE. CHRONIC ULCERATIVE HEMORRHAGIC COLITIS.

12. PHYSICAL EXAM OF PATIENTS WITH CHRONIC 3h HEPATITIS, LIVER CIRRHOSIS, CHOLELITHIASIS. CLINICAL MANIFESTATIONS, INVESTIGATIONS, COMPLICATIONS.

13. PHYSICAL EXAM OF SPLEEN. SPLENOMEGALY. 3h

14. PHYSICAL EXAM OF PANCREAS. FUNCTIONAL 3h AND INSTRUMENTAL INVESTIGATIONS. CHRONIC PANCREATITIS. CARCINOMA OF PANCREAS. 15. PHYSICAL EXAMINATION OF KIDNEYS: 3h INSPECTION, PALPATION, SUCCUSIO RENALIS.

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16. FUNCTIONAL INVESTIGATION OF KIDNEYS. 3h RADIOGRAPHIC INVESTIGATIONS. ABDOMENAL ECHOGRAPHY.

17. PHYSIKCAL EXAMINATIONS OF PATIENTS WITH 3h GLOMERULONEPHRITIS, NEPHROTIC SYNDROME, PYELONEPHRITIS, NEPHROLITHIASIS. 18. PHYSICAL EXAM OF PATIENTS WITH RENAL 3h FAILURE.: ACUTE AND CHRONIC.

19. PHYSICAL EXAMINATION OF PATIENTS WITH 3h ANEMIA: IRON DEFICIENT, MEGALOBLASTIC, HEMOLYTIC.

20. PHYSICAL EXAMINATION OF PATIENTS WITH 3h LEUCOSIS AND LYMPHOMAS

21. PHYSICAL EXAMINATION OF PATIENTS WITH 3h HEMORRHAGIC DIATHESIS: THROMBOCYTOPENIA, HEMOPHYLIA AND CAPILLAROTOXICOSIS.

22. PHYSICAL AND FUNCTIONAL EXAM OF 3h ENDOCRINE GLANDS.

23. PHYSICAL EXAMINATION OF PATIENTS WITH 3h HYPERTHYROIDISM, MYXOEDEMA, CUSHING AND ADDISON DISEASES.

24. / PHYSICAL EXAMINATION OF PATIENTS WITH 3h DIABETES MELITUS.

25. PHYSICAL EXAMINATION OF 3h MUSCULOSKELETAL SYSTEM. BASIC SYMPTOMS.

26. PHYSICAL EXAMINATION OF PATIENTS WITH 3h RA, OA , AS, SLE.

27. PERFORMING OF COMPLETE STATUS PRAESENS. 3h

28. RESPIRATORY DISEASES – REVISION 3h

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29. CARDIOVASCULAR DISEASES – REVISION 3h

30. GASTROINTESTINAL AND RENAL DISEASES – 3h REVISION.

ОБЩО: 90 H.

Lecture-Tesis

PROGRAMME FOR THE LECTURES IN BASICS OF INTERNALMEDICINE

Lecture N1: Anamnesis. Inspection. Palpation./ general principles/ / 2hours/ Anotation: 1. Basic principles in taking the history of a patient. Plan for taking anamnesis:a/ Passport data b/ anamnesis morbi c/ anamnesis vitae d/ anamnesis familiae e/ social history f/ bad habits Physical examination – methods a/ inspection b/ palpation

Lecture N2: Percussion. Auscultation – basic principles / 2hours/ Anotation: 1. Types of percussion Analysis of the percutory sounds Auscultation – types of auscultation / direct and indirect/.

Lecture N3: Anamnesis of patients with respiratory diseases. Inspection of chest / 2hours/ Anotation: 1. Basic symptoms and syndromes: cough, dyspnoea, sputum, haemoptoe etc. Inspection of chest: pathologic chest shapes, static and dynamic inspectiion. Frequency, type and rhythm of breathing.

Lecture N4: Palpation, percussion and auscultation of lungs /2hours/ Anotation: 1. Palpation of chest:a/ painful zones b/ vocal fremitus

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Percussion of the chest: a/ lung apexes / Kroenig spaces/ b/ comparative percussion c/ determination of lung bases and respiratory expansion. Lung auscultation: a/ vesicular breathing b/ bronchial breathing

Lecture N5: Lungs auscultation: /2hours/ Anotation: 1. Additive breathing sounds: a/ ronchi b/ crackles c/ pleural friction rub Detection of bronchophony

Lecture N6: Pulmonary instrumental and functional investigations. Bronchitis /2hours/ Anotation: 1. Functional investigation of respiratory system Radiographic investigations Invasive methods of investigation Bronchitis. Definition. Classification: a/ acute bronchitis b/ chronic bronchitis

Lecture N7: Pneumonias. Bronchial asthma. Pulmonary emphysema. Pulmonary carcinoma /2hours/ Anotation: 1. Pneumoniae: a/ bacterial – lobar pneumonia and bronchopneumonia b/viral Bronchial asthma. Classification Pulmonary emphysema: clinical picture, complications Lung carcinoma – clinical forms.

Lecture N8 Bronchiectasis. Pulmonary abscessus. Pleuritides /2hours/ Anotation: 1. Bronchiectasis: congenital and acquired Pulmonary abscessus: clinical forms, complications Pleuritides: a/ dry/ fibrinous/ b/ exudative c/ adhesive

Lecture N9: Cardiovascular diseases. Anamnesis of a cardiac patient. Inspection and palpation of cardiac apex. Percussion of heart borders /2hours/ Anotation: 1. Anamnesis – basic symptoms Inspection of precordium: deformities, pathologic pulsations Palpation of precordium – apex cordis, pulmonary, aortic zones, fremissement cattaire Percusion of heart borders: a/ relative b/ absolute

Lecture N10 Auscultation of heart. Heart sounds, rhythm, murmurs /2hours/ Anotation: 1. Mechanism of formation of heart sounds a/ normal findings b/ pathologic sounds Heart murmurs. Principles of formation. Classification: a/cardial / organic, functional/ b/ extracardial

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Lecture N11 Organic and functional murmurs. Pericardial friction rub /2hours/ Anotation: 1. Organic murmurs: systolic, diaastolic, continuous Functional murmurs Extracardial murmurs: pericardial friction rub, pleuropericardial rub, venous hums

Lecture N12: Rhythm and conductive disturbances /2hours/ Anotation: 1. Rhythm disturbances clinical picture and ECG images a/ sinus tachycardia and bradicardia b/ extrasystoles, c/ atrial flutter and fibrillatioin d/ ventricular tachycardia an d fibrilation Conductive disturbances: a/ AV block b/ Bundle branche blocks

Lecture N13 Echocardiography. Examination of arterial and venous pulse. /2hours/ Anotation: 1. Echocardiography Arterial pulse qualities Taking of arterial and venous blood pressure.

Lecture N14 Rheumatic fever. Valvular diseases /2hours/ Anotation: 1. Rheumatic fever definition, aetiology, pathogenesis, clinical picture, complications Valvular diseases: clinical manifestations, complications, prolgnosis

Lecture N15 Arterial hypertension. Myocarditis an d cardiomyopathies. Pericarditis /2hours/ Anotation: 1. Arterial hypertension definition, classification, stages, complications Myocarditis. Cardiomyopathies dilatative, hypertrophic, restrictive Pericarditis: dry, exudative, adhesive

PROGRAMME OF PRACTICAL TRAININGS IN BASICS OF INTERNALMEDICINE

Practical N1/3hours/ Acquaintance of the students to the Clinic. Taking history of a patient

Practical N2 /3hours/ Anamnesis vitae, anamnesis familiae.

Practical N3/3hours/

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TAKING OF HISTORY AT THE PATIENT’S COUCH

PRACTICAL N4/3HOURS/ GENERAL ASESMENT OF THE PATIENT. POSITION IN THE BED. GAIT. MENTAL ASESMENT.

PRACTICAL N5 /3HOURS/ EXAMINATION OF SKIN AND ADNEXES. CHANGES IN THE COLOR OF THEN SKIN: ANEMIA, JAUNDICE, CYANOSIS. SKIN RASHES. EXAMINATION OF NAILS, HAIR ETC.

PRACTICAL N 6 /3HOURS/ EXAMINATION OF HEAD AND NECK: SIZE AND SHAPE. LYMPH NODES PALPATION. EXAMINATION OF THE THYROID GLAND. EXAMINATION OF ARTERIES AND VEINS ON THE NECK.

PRACTICAL N7 /3HOURS/ INSPECTION AND PALPATION OF CHEST. STATIC AND DYNAMIC INSPECTION. PATHOLOGIC SHAPES OF CHEST. PALPATION OF VOCAL FREMITUS – INTERPRETATION.

PRACTICAL N8 /3HOURS/ PERCUSION OF THE CHEST. TECHNIQUE OF PERCUSION. BASIC SOUNDS.

PRACTICAL N9 /3HOURS/ PERCUSSION OF LUNGS. DETECTION OF KROENIG SPACES. COMPARATIVE PERCUSSION. DETECTION OF RESPIRATORY EXPANSION.

PRACTICAL N10 / 3HOURS/ LUNGS PERCUSSION. PATHOLOGIC SOUNDS AND ANALYSIS.

PRACTICAL N11 /3HOURS/ INSPECTION, PALPATION AND PERCUSSION OF LUNGS – REVISION. EXAMINATION OF A PATIENT.

PRACTICAL N12 / 3 HOURS/ AUSCULTATION OF LUNGS. BASIC BREATHING SOUNDS. VESICULAR AND BRONCHIAL BREATHING.

PRACTICAL N13 /3HOURS/ AUSCULTATION OF LUNGS. PATHOLOGIC VESICULAR AND PATHOLOGIC BRONCHIAL BREATHING.

PRACTICAL N14 / 3HOURS/ AUSCULTATION OF LUNGS. ADDITIVE SOUNDS: RONCHI, CLASSIFICATION, CRACKLES/ RALES/.

PRACTICAL N15 /3HOURS/

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PLEURAL FRICTION RUB. PLEURAL PUNCTURE: TECHNIQUE AND ANALYSIS.

PRACTICAL N16 /3HOURS/ BODY TEMPERATURE. FEVER. SPECIFIC TEMPERATURE CURVES.

PRACTICAL N17 /3HOURS/ RESPIRATORY DISEASES. ACUTE, CHRONIC BRONCHITIS, PULMONARY EMPHYSEMA, BRONCHIAL ASTHMA.

PRACTICAL N18 /3HOURS/ PHYSICAL EXAM OF PATIENTS WITH PNEUMONIAS PHYSICAL EXAM OF PATIENTS WITH PLEURITIS.

PRACTICAL N19 / 3HOURS/ PHYSICAL EXAMINATION OF RESPIRATORY SYSTEM – COLOQIUM

PRACTICAL N20 / 3HOURS/ ANAMNESIS OF A CARDIAC PATIENT. INSP;ECTION AND PALPATION OF PRECORDIUM: APEX, AORTIC, PULMONARY ZONES, NECK, EPIGASTRIUM

PRACTICAL N21 / 3HOURS/ PERCUSSION OF HEART BORDERS: RELATIVE AND ABSOLUTE.

PRACTICAL N22 /3HOURS/ PERCUSSION OF HEART. PATHOLOGIC CHANGES.

PRACTICAL N23 /3HOURS/ AUSCULTATION OF HEART. MECHANISM OF FORMATION OF HEART SOUNDS. MAIN ZONES OF AUSCULTATION.

PRACTICAL N24 /3HOURS/ AUSCULTATION OF HEART. CHANGES IN HEART SOUNDS: ACCENTUATION, WEAKENING, SPLITTING, ADDITIVE HEART SOUNDS. GALLOP RHYTHM.

PRACTICAL N25 /3HOURS/ AUSCULTATION OF HEART. HEART MURMURS.CLASSIFICATION. EXTRACARDIAL MURMURS: PERICARDIAL FRICTION RUB.

PRACTICAL N26 /3HOURS/ CLINICAL INTERPRETRATION OF HEART MURMURS.

PRACTICAL N27 / 3HOURS/ ARTERIAL PULSE EXAMINATION. QUALITIES OF ARTERIAL PULSE.

PRACTICAL N28 /3HOLURS/

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TAKING OF BLOOD PRESSURE: MAIN RULES. ARTERIAL HYPERTENSION.

PRACTICAL N29 /3HOURS/ PERCUSSION AND AUSCULTATION OF HEART – REVISION.

SOURSE OF INFORMATION

1. Davidson's Principles and Practice of Medicine 2. Hutchison's Clinical Methods. 3. Harrison's Principles of Internal Medicine

C O N S P E C T

BASICS OF INTERNAL MEDICINE

1Anamnesis Structure. 2.General assessment of patient: mental status, skin and mucosa changes, nails, hair, lymph nodes, temperature, temperature curves Examination of head, eyes and neck Examination of respiratory system – inspection and palpation of chest. Percussion of lungs. Auscultation of lungs – normal breath sounds. Added sounds – ronchi Added sounds – crackles /crepitations/ and pleural friction rub Acute and chronic bronchitis Bronchial asthma Pulmonary emphysema Pneumonia – lobar pneumonia Bronchopneumonia Bronchiectasis Lung abscess ang gangrene. Lung carcinoma. Early diagnosis Pleuritis. Dry and exudative. Adhesive pleuritis History / anamnesis / in cardiovascular diseases  Inspection and palpation of precordium Percussion of heart borders: relative and absolute. Auscultation. Heart sounds. Heart murmurs. Mechanisms of formation. Classification

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Organic heart murmurs Functional / innoncent/ heart murmurs Pericardial friction rub. Extracardial murmurs Examination of the peripheral arteries. Arterial pulse. Sphygmogram Examination of venous pulse. Phlebogram Normal ECG  Rhythm and conduction disturbances  Rheumatic fever. Rheumocarditis / etiology, pathogenesis, clinical picture Mitral valve stenosis Mitral valve insufficiency / regurgitation/ Aortic stenosis Aortic regurgitation Infective endocarditis Myocarditis. Cardiomyopathies Idiopathic Arterial hypertension. Symptomatic arterial hypertension. Ischemic heart disease. Classification. Angina pectoris Myocardial infarction Pericarditis Acute heart failure Clinical equivalents.  Chronic heart failure Rheumatoid arthritis Osteoarthritis Systemic lupus erythematosus Functional exam of kidneys Acute renal failure Chronic renal failure Acute glomerulonephritis Chronic glomerulonephritis. Nephrotic syndrome Acute and chronic pyelonephritis Nephrolithiasis Renal tuberculosis Renal tumors Major symptoms of gastrointestinal system Inspection and palpation of abdomen – superficial and deep Acute and chronic gastritis Ulcer disease. Complications Stomach carcinoma Chronic ulcerative colitis Physical examination of liver

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Examination of the gall bladder and the bile ducts Chronic hepatitis Liver cirrhosis Cholelithiasis. Cholecystitis Tumors of liver and bile ducts Acute hepatic failure. Hepatic coma Physical examination of spleen Physical examination of pancreas Chronic pancreatitis Carcinoma of pancreas Iron defficiency anemia Megaloblastic anemia Hemolytic anemias Hypo and aplastic anemia Agranulocytosis Acute/ blastic/ leukoses Chronic myeloleukosis Chronic lympholeukosis Thrombocytopenia Hemophylia Capillarotoxicosis. Schonlein- Hennoch disease. Thyrotoxicosis. Graves' disease. Myxoedema Acromegaly Incipid diabetes Hypopituitarism Hypercorticism. Cushing disease. Hypocorticism. Adison's disease. Hypoparathyroidism. Hyperparathyroidism Diabetes mellitus. Etiology, pathogenesis, clinical picture Diabetes mellitus. Complications: hypo and hyperglycemic coma  Gout. Uric acid crystal induced arthritis

PRACTICAL EXAM

1.Thyroid gland palpation Percussion of lung apex. Detection of Kronig space Comparative pulmonary percussion

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Detecting of respiratory expansion Lung auscultation Inspection and palpation of precordium Percussion of heart borders Auscultation of heart – sounds and murmurs Arterial pulse examination Renal palpation. Pasternacki symptom Palpation of liver Palpation of spleen Palpation of pancreas Examination of joints and vertebral column.

QUESTIONS FOR SELF -TRAINING TEMA 1 Anamnesis. Inspection. Palpation./ general principles/ 1.Which are the physical methods of exam? 2. Which are the parts of anamnesis? TEMA 2 Percussion. Auscultation – basic principles 1.Which are the main percussion tones? TEMA 3 Anamnesis of patients with respiratory diseases. Inspection of chest 1.Which are the main symptoms in patient with respiratory disease? 2. Can you point several types of thorax? TEMA 4 Palpation, percussion and auscultation of lungs 1.How will you describe the percussion tone in Pulmonary emphysema? 2.Can you describe the auscultation phenomenon in Pneumonia cruposa? TEMA 5 Lungs auscultation: 1.How will you define crackles and pleural friction? 2.Can you point several disease where you can find crackles?

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TEMA 6

Pulmonary instrumental and functional investigations. Bronchitis

1.Describe the anamnesis of patient with Acute Bronchitis. 2.Describe the findings from the physical examination of patient with Chronic Bronchitis.

TEMA 7

Pneumonias. Bronchial asthma. Pulmonary emphysema. Pulmonary carcinoma

1.Describe the symptoms of Pneumonia. 2.What kind of percussion tone you can find in Pulmonary emphysema?

TEMA 8

Bronchiectasis. Pulmonary abscessus. Pleuritis

1.Can you describe the finding from the physical exam on the line of Pleuritis exudativa. 2.Can you point the main symptoms of Bronchiectatic disease.

TEMA 9

Cardiovascular diseases. Anamnesis of a cardiac patient. Inspection and palpation of cardiac apex. Percussion of heart borders

1.Can you point several symptoms of cardiac diseases. 2.Where you can find the cardiac apex in Left Heart Failure.

TEMA 10

Auscultation of heart. Heart sounds, rhythm, murmurs

1.Which are the main heart sounds? 2.How is formed T1 heart sound?

TEMA 11

Organic and functional murmurs. Pericardial friction rub

1.Can you point several disease in which you can hear friction rub? 2.Can you point several causes for organic murmurs.

TEMA 12

Rhythm and conductive disturbances

1.What is Fibrilacio atriorum?

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2.How will you describe ventricle premature complex?

TEMA 13

Echocardiography. Examination of arterial and venous pulse.

1.What is pulse deficiency ? 2.Which are the places for examination of arterial pulse?

TEMA 14

Rheumatic fever. Valvular diseases

1.Describe the anamnesis of a patient with Rheumatic fever. 2.Which are the main symptoms of Rheumatic fever ?

TEMA 15

Arterial hypertension. Myocarditis an d cardiomyopathies. Pericarditis

1.Can you point the risk factors for Arterial hypertension? 2.Can you describe the auscultation findings in patient with Myocarditis?

TESTS FOR SELF-TRAINING

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MEDICAL UNIVERSITY PLOVDIV

TEACHING CURRICULUM

Department: Ist department of Internal diseases, Section cardiology

Discipline: Internal diseases

Module: Cardiology

Type of discipline: Compulsory

Level of education: Master

Form of education: Lectures, practical training, self preparation

Horarium: 105 hours

Duration: 1 semester

Head of English teaching course: Assoc-prof. Mariya Tokmakova, MD, PhD

Teaching curriculum

Horarium (hours) Credits Form of teaching Per week Per semester Per year Lectures 2 30 30 Practical training 5 75 75 9.9 Total 7 105 105

Annotation: The cardiology module is designed to familiarize the studentst with the basic methods for evaluation, investigation and management of patients with cardiovascular

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problems – present, past and family history, clinical examination, instrumental and laboratory testing, treatment principles. The student will gain experience in the diagnosis and treatment of patients with cardiac conditions and appropriate selection of cardiac diagnostic testing.

Educational purpose and goals:  Improving history taking and cardiac physical examination techniques  Learning basic EKG and arrhythmia interpretation  Learning diagnostic and management skills of patients with common cardiac disorders  Learning the treatment principles of cardiovascular disease and basic representatives of drugs classes used in cardiology

Teaching methods: Lectures, practical training at the patient’s bed, seminars, self-preparation  Faculty supervision of student taking and presenting the history, physical examination and initial diagnosis of in hospital patients with cardiovascular disease selected in accordance with the curriculum plan. Discussion of instrumental and laboratory tests, proposition of treatment and differential diagnosis.  Self-study of assigned readings.  Self-study with faculty review of EKG interpretation.  Presenting information about assigned cardiology topics.

Teaching materials:  Multimedia presentations  Educational films  Audio demonstrations of cardiac murmurs  Practical cases with discussion  Demonstration of functional tests in cardiology  Live clinical cases

Methods for evaluating progress of education:  Entry tests on a weekly bases  Oral discussions

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 Colloquium on selected topics in cardiology

Final semester evaluation of the work of the student:  End of semester summary mark for the practical training given from the assistant- professor based on active participation, regular theoretical self-preparation, marks from the semester colloquiums.

End of semester exam in cardiology and final assessment of knowledge:  Test  Practical exam  Written theoretical exam

Expected results:  Learning and understanding the definitions, etiology, epidemiology, pathogenesis, classifications, clinical manifestation, instrumental and laboratory investigation and treatment strategies of cardiac diseases  Learning and improving history taking and cardiac physical examination techniques and presenting of clinical cases  Understanding and interpreting ECG and other instrumental tests indications and results  Understanding and interpreting laboratory tests indications and results  Building up a diagnosis and differential diagnosis  Decision-making for a proper and motivated treatment strategy

List of lectures in Cardiology

1. Chronic heart failure – classification, haemodynamics, treatment – 2h

2. Acute heart failure – 1h. Cardiogenic shock – 1h.

3. Rhythm and conduction disturbances – 2h.

4. Pulmonary thromboembolism – 1h. Chronic cor pulmonale – 1h.

5. Rheumatic heart disease – 1h. Infective endocarditis – 1h.

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6. Mitral valve disease – 2h.

7. Aortic valve disease – 2h.

8. CAD – classification, etiology, risk factors – 1h. Antiischaemic drugs – 1h.

9. Stable angina – 1h. Unstable angina – 1h.

10. Acute myocardial infarction – etiology, pathogenesis, risk factors, clinical characteristics – 2h.

11. Acute myocardial infarction – complications, differential diagnosis, treatment – 2h.

12. Atherosclerosis – primary and secondary prevention – 2h.

13. Arterial hypertension – 2h.

14. Diseases of the myocardium – myocarditis – 1h. Cardiomyopathies – 1h.

15. Congenital valvular disease – 1h. Diseases of the pericardium – 1h.

List of themes for practical training in cardiology

1. Methods for cardiac investigation – 3 hours

 Introduction to the structure of cardiac ward – ICU, clinic, non-invasive and invasive labs

 Evaluation of a patient with cardiovascular disease – algorithm

 Basic clinical symptoms and syndromes

 Algorithm of reporting a patient’s clinical case

 Functional tests in cardiology – ECG, echocardiography, exercise testing – ergometer and treadmill, 24 hour Holter ECG and blood pressure monitoring, rentgenography, isotopic testing, angiography

2. Chronic Heart Failure – 2 hours 190

 Chemodynamics

 Classification

 Clinical characteristics

 Presentation of a clinical case or cases

3. Chronic Heart Failure – 3 hours

 Basic principles of treatment

 Non-pharmacological treatment – diet, change of lifestyle, physical rehabilitation

 Pharmacological – groups of drugs, mechanism of action, basic representatives, indications and contraindications, drug interactions, overdosing

4. Acute HF – cardiac asthma, acute pulmonary edema, cardiogenic shock – 2 hours

 Chemodynamics

 Classification

 Clinical characteristics

 Treatment

 Presentation of a clinical case or cases

5. Arrhythmias – supraventricular – 3 hours

 Classification

 ECG characteristics and interpretation of different arrhythmia

 Clinical cases

6. Arrhythmias – ventricular – 2 hours

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 Classification

 ECG characteristics and interpretation of different arrhythmia

 Clinical cases

7. Conduction disturbances – 3 hours

 Classification

 ECG characteristics and interpretation of different arrhythmia

 Clinical cases

8. Treatment of arrhythmias – 2 hours

 Classification of antiarrhythmic drugs

 Representatives

 Indication and contraindication

 Overdosing and proarrhythmia

 Indications for temporary or permanent electrocardiostimulation

9. Colloquium – HF, arrhythmias – 3 hours

10. Chronic cor pulmonale – 2 hours

 Pathophysiology

 Clinical characteristics

 Treatment

 Presentation of a clinical case

11. Rheumatic heart disease – 3 hours

 Discussion on etiology and pathogenesis of the disease

 Clinical characteristics

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 Diagnostic criteria and differential diagnosis

 Treatment

12. Infective endocarditis – 2 hours

 Discussion on etiology and pathogenesis of the disease

 Clinical characteristics

 Diagnostic criteria and differential diagnosis

 Treatment and complications

13. Mitral stenosis – 3 hours

 Haemodynamics

 Auscultotary findings

 Clinical characteristics

 Indication for surgery and prophylactics for IE

 Clinical case

14. Mitral regurgitation – 2 hours

 Haemodynamics

 Auscultotary findings

 Clinical characteristics

 Indication for surgery and prophylactics for IE

 Clinical case

15. Aortic stenosis – 3 hours

 Haemodynamics

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 Auscultotary findings

 Clinical characteristics

 Indication for surgery and prophylactics for IE

 Clinical case

16. Aortic regurgitation – 2 hours

 Haemodynamics

 Auscultotary findings

 Clinical characteristics

 Indication for surgery and prophylactics for IE

 Clinical case

17. Colloquium – valvular heart diseases – 3 hours

18. CAD – classification, etiology, risk factors – 2 hours

 Definition

 Classification

 Etiology and risk factors

 Clinical case

19. Antiishemic drugs – 3 hours

 Classification

 Representatives

 Indication and contraindication

 Overdosing

20. Stable angina – 2 hours

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 Classification

 Clinical characteristics

 Assessment of risk and functional evaluation

 Treatment strategy

 Clinical cases

21. Unstable angina – 3 hours

 Classification

 Clinical characteristics

 Evaluation of risk and treatment strategies

 Biomarkers

 Clinical cases

22. Myocardial infarction – pathogenesis, clinical manifestation, diagnosis – 2 hours

 Pathogenesis

 Clinics

 Diagnostic criteria

 Biomarkers

23. Myocardial infarction – complications, differential diagnosis – 3 hours

 Complications

 Clinical cases

 Differential diagnosis

24. Treatment – 2 hours

 Strategies – invasive vs non-invasive

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 Secondary prevention

 Rehabilitation

 Clinical cases

25. Colloquium – CAD – 3 hours

26. Arterial hypertension – etiology, pathogenesis, clinical manifestation – 2 hours

 Etiology

 Pathogenesis

 Staging and grading

 Hypertensive crysis

27. Arterial hypertension – treatment – 3 hours

 Classification of antihypertensive drugs

 Representatives

 Indication and contraindication

 Clinical cases

28. Myocardites – 2 hours

 Classification

 Clinical characteristics

 Complications and prognosis

 Treatment

29. Cardiomyopathies – 3 hours

 Classification

 Clinical characteristics

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 Complications and prognosis

 Treatment

30. Pericardial diseases – 2 hours

 Classification

 Clinical characteristics

 Complications and prognosis

 Treatment

List of topics for theoretical written exam in Cardiology

1. Congestive heart failure – hemodynamics, classification, treatment. 2. Acute heart failure – cardiac astma, acute pulmonary edema, cardiogenic shock. 3. Supraventricular arrhythmias – classification, etiology, ECG and clinical characteristics, treatment 4. Ventricular arrhythmias - classification, etiology, ECG and clinical characteristics, treatment 5. Conduction disturbances - classification, etiology, ECG and clinical characteristics, treatment 6. Rheumatic heart disease. 7. Acute pulmonary embolism. 8. Chronic Cor pulmonale. 9. Infective endocarditis. 10. Mitral valvular heart disease. 11. Aortic valvular heart disease. 12. Diseases of the myocardium. Myocarditis. 13. Diseases of the myocardium. Cardiomyopathies. 14. CAD – classification, etiology, risk factors.

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15. Stable angina – classification, etiology, pathogenesis, clinical characteristics, diagnosis and treatment. 16. Unstable angina - classification, etiology, pathogenesis, clinical characteristics, diagnosis and treatment. 17. Acute myocardial infarction – etiology, pathogenesis, risk factors, clinical presentation, biomarkers. 18. Acute myocardial infarction – complications, differential diagnosis, treatment. 19. Arterial hypertension - classification, etiology, pathogenesis, clinical characteristics, diagnosis and treatment. 20. Pericarditis - classification, etiology, pathogenesis, clinical characteristics, diagnosis and treatment.

Recommended literature 1. Harrison’s principles of internal medicine.

2. Hurst’s the Hart.

3. Диагноза и терапия на вътрешните болести – І част, под редакцията на проф. Ат.Джурджев

4. Актуални аспекти на обща медицинска практика, под редакцията на доц. Д. Толева

01.09.2012 Prepared by:

Plovdiv /Asoc.prof. M.Tokmakova, MD, PhD/

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MEDICAL UNIVERCITY PLOVDIV MEDICINE DEPARTMENT

PROGRAMME

FOR RHEUMATOLOGY

ACCEPTED IN CLINICAL COUNCIL IN 20.06.2012г.

ACCEPTED IN FACULTATIVE COUNCIL IN...... , 2012г.

199

MEDICAL UNIVERCITY PLOVDIV MEDICINE DEPARTMENT DEPARTMENT OF BASICS IN INTERNAL MEDICINE RHEUMATOLOGY CLINIC

Name of subject: „Rheumatology”

Kind of subject according EDA: Facultative

Degree of science: Master/M/

Forms in teaching: Lectures, practical trainings, self-training.

Course of teaching: Terms 1

Horarium: 10 h lectures, 20 h practical training

Technical devices use in the educational process : Multimedia, audiovisual devices, tables, etc.

Control and Assessment:1. During terms: test, oral examination. 2. Final exam : it is part from the exam of Internal Medicine

Form of the final score: The final score is form after final exam of Internal Medicine.

How is formed the final score: test, writing exam, practical exam,Latin terminology, oral exam.

Term exam: No

Professional practice exam: No/

Leading Professors: Three Professors with academic rank in the Department of “Basics in Internal Medicine” Rheumatology Clinic

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Department: Basics in Internal Medicine

ANOTATION : Basic principles of rheumatologic examination. Examination of joints, muscles and bones. Diagnostic process. Semiotics of rheumatic diseases. Clinical picture, methods of physical examination, anamnesis, laboratory investigations of musculoskeletal diseases. Complications and prognosis.

MAIN OBJECTIVES: To learn and apply the basic principles of the physical examination of the rheumatic patients.. The students should perform a complete exam including taking of history, internal organs check, posing diagnosis, determining the prognosis of a certain disease.Students should be orientated of the modern treatment of the main inflammatory and degenerative rheumatic diseases.

OBLIGATORY COMPETENCE:

1. Theoretical : getting adequate knowledge, referring to: - taking history and basic methods of physical examination - Physical examination of musculoskeletal system: rheumatoid arthritis, osteoarthritis, connective tissue diseases. - Etiology,pathogenesis, clinical criteria of the main rheumatic diseases. - Main therapeutic agents: NSAIDs, DMARDs , biologic agents - Knowledge in inflammatory joint diseases: RA, AS, PsA etc. - Knowledge in connective tissue diseases: SLE, SS, vasculitides. - Knowledge in metabolic joint diseases: gout - Knowledge in degenerative diseases: osteoarthritis.

2. Practical: - Taking history of a rheumatic patient - Physical exam of joints and muscles

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- Physical exam of vertebral column. - Reading of normal and pathologic radiographs - Analysis of laboratory results in rheumatic diseases.

EDUCATIONAL PLAN – IV year

Forms of educational Horarium/hours/ Credits events Weekly VII term Total Lectures 2 10 10 Practical training 4 20 20

Total 6 30 30

PROGRAMME OF LECTURES

IV COURSE , VII TERM

№ TEMA HOURS DATES

1. Rheumatoid arthritis 2h.

2. Systemic lupus erythematosus / SLE/ 2h.

3. Seronegative spondyloarthropathies 2h.

Crystal induced arthritis. Gout 4. 2h.

5. Osteoarthritis 2h.

ОБЩО: 10 H.

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PROGRAMME PRACTICAL TRAINING

ІІІ COURSE, V TERM

№ TEMA HOURS DATES

Semiotics in rheumatic patients. Taking history of a 1. rheumatic patient. Physical examination of musculoskeletal system. Interpretation of main arthritis 2h. syndromes.

Drug therapy of rheumatic patients: 2.

2h.

3. Rheumatoid arthritis: complete physical exam. Clinical manifestations 2h.

Rheumatoid arthritis – treatment 4. 2h

Seronegative spondyloarthropathies. Physical examination 5. of patients with AS. Specific radiographic changes Management and physical therapy. 2h.

Reactive arthritis. Reiter’s syndrome: definition, etiology, 6. pathogenesis, clinical picture and therapy. Psoriatic arthritis: clinical picture, management. 2h.

Systemic lupus erythematosus. Diagnostic criteria. Clinical 7. manifestations. Therapeutic strategies. 2h.

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Dermato/polymyositis: etiology, pathogenesis, clinical 8. picture, investigations and management. 2h.

9. Gout. Clinical picture and investigations. Management of acute and chronic gout. Osteoarthritis: clinical picture and 2h. management.

EXAM on rheumatic diseases. 10. 2h

ОБЩО: 20 H.

Lecture-Tesis

PROGRAMME FOR LECTURES IN RHEUMATOLOGY

Lecture N1 Rheumatoid arthritis /2hours/ Anotation: 1. Definition, etiology, pathogenesis, clinical picture 2. Diagnostic criteria ACR 1987 3.Radiographic, immunologic ivestigations, arthrocentesis, 4. Treatment: a/ conventional b/ DMARDs c/ biologic agents d/ synovectomy 5. Prognosis.

Lecture N2 Systemic lupus erythematosus / SLE/ /2hours/ Anotation: 1. Definition, aetiology, immunology 2. Diagnostic criteria. Clinical picture. 3. Laboratory and specific immunologic investigations 4. Treatment: conventional and pulse therapy. 5. Prophylaxis and prognosis.

Lecture N3 Seronegative spondyloarthropathies

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/2hours/ Anotation: 1. Main characteristics. Clasification 2. AS: definition, etiology, pathogenesis / HLA B27/, clinical manifestations 3. Physical examination of vertebral column of a patient with AS 4. Therapy of AS 5. Presentation of patients with Reiter’s syndrome and psoriatic arthritis.

Lecture N4 Crystal induced arthritis. Gout /2hours/ Anotation: 1. Definition, aetiology, pathogenesis 2. Clinical presentation: a/ acute , b/ chronic gout 3. Complications: nephropathy, renal failure, CAD 4. Laboratory investigations, synovial analysis 5. Treatment 6. Prognosis

Lecture N5 Osteoarthritis /2hours/ Anotation: 1. Definition, aetiology, pathogenesis 2. Clinical picture: peripheral joints and axial skeleton involvement 3. Radiographic and echographic changes 4. Treatment: conservative , arthroplasty 5. Prognosis

PROGRAMME FOR PRACTICAL TRAININGS IN RHEUMATOLOGY

Practical N1/2hours/ Semiotics in rheumatic patients. Taking history of a rheumatic patient. Physical examination of musculoskeletal system. Interpretation of main arthritis syndromes.

Practical N2 /2hours/ Drug therapy of rheumatic patients: a/ NSAIDs b/ DMARDs c/ corticosteroids d/ biologic agents

Practical N3/ 2hours/ Rheumatoid arthritis: complete physical exam. Clinical manifestations

Practical N4 /2hours/ Rheumatoid arthritis – treatment

Practical N5 /2hours/ Seronegative spondyloarthropathies. Physical examination of patients with AS. Specific radiographic changes Management and physical therapy.

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Practical N6 /2hours/ Reactive arthritis. Reiter’s syndrome: definition, etiology, pathogenesis, clinical picture and therapy. Psoriatic arthritis: clinical picture, management.

Practical N7 /2hours/ Systemic lupus erythematosus. Diagnostic criteria. Clinical manifestations. Therapeutic strategies.

Practical N8 /2hours/ Dermato/polymyositis: etiology, pathogenesis, clinical picture, investigations and management. SS: definition, immunopathogenesis, clinical picture, treatment. Vasculitides: classification, main clinical and immunologic features.

Practical N9 /2hours/ Gout. Clinical picture and investigations. Management of acute and chronic gout. Osteoarthritis: clinical picture and management.

Practical N10 /2hours/ EXAM on rheumatic diseases.

SOURSE OF INFORMATION

1. Davidson's Principles and Practice of Medicine 2. Hutchison's Clinical Methods. 3. Harrison's Principles of Internal Medicine

CONSPECT RHEUMATOLOGY

1. Rheumatoid arthritis – aetiology, pathogenesis, clinical picture, management 2. SLE – clinical picture. Therapy 3. Ankylosing spondylitis – clinical picture, investigations, therapy 4. Reiter’s syndrome – clinical picture, investigations, therapy 5. Psoriatic arthritis – clinical picture, radiographic changes. Therapy 6. Gout – clinical picture, investigations. Therapy 7. Osteoarthritis – clinical manifestations. Therapy

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QUESTIONS FOR SELF -TRAINING TEMA 1 Rheumatoid arthritis 1.Which are the criteria for diagnosis RA? 2. Can you point several drugs for treatment of RA ? TEMA 2 Systemic lupus erythematosus / SLE/ 1.Which antibodies you can find in the serum of patient with SLE? TEMA 3 Seronegative spondyloarthropathies 1.Which are the main symptoms in patient with AS? 2. Can you point several symptoms of Reiter disease? TEMA 4 Crystal induced arthritis. Gout 1.How will you describe the anamnesa in patient with gouty arthritis? 2.How will you treat the gouty attack? TEMA 5 Osteoarthritis 1.Which joints are the most common place for OA? 2.What kind of complains dose the patient with OA have?

TESTS FOR SELF-TRAINING

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PATHOLOGY AND CYTOPATHOLOGY

Training Course: Year 3 and 4 Semesters of study: V - General Pathology, VI and VII - Clinical Pathology Exam: after semester V - General Pathology after VII semester - Clinical Pathology Workload of the auditorium sessions: 210 hours Lecturer: associate professor

Auditorium Hour workload Type of auditorium Credits weekly V sем. VІ sем. VІІ sем. Total Lectures 2 30 30 30 90 Practicals 2 60 30 30 120 13,2 Total hours 4 hours 90 h 60 h 60 h 210 h

SUMMARY: intracellular accumulation of lipids, proteins and pigments; adaptative processes accumulation of fibrinoid, hyaline, amyloid, calcium salts and sodium urat in the intercellular matrix, necrosis, disturbances in blood circulation, inflammation, immunity pathology, tumors. Pathology of the cardiovascular system, respiratory pathology, pathology of the haematopoietic system, pathology of the digestive system. Pathology of the urinary system, reproductive system pathology, endocrine pathology, pathology of the nervous system, musculoskeletal pathology, infectious diseases. PURPOSE OF COURSE: Study of basic pathological processes and structural changes in each nosoological units. Acquisition of detailed morphological knowledge of all sections of the clinical pathology which allow construction of high medical knowledge. OBJECTIVES OF THE COURSE: Acquisition of detailed morphological knowledge of the basic pathological processes in all sections of clinical pathology. Learning in detail the theoretical basis of emergence, growth and development of tumors. Use the terminology of precancerous, benign and malignant tumors. Use the principles of making biopsy, completing forms and learn skills for objective correlation with the clinical findings. Development of high medical knowledge. Teaching methods: lectures, seminars, workshops. TECHNICAL TOOLS AND EQUIPMENT FOR THE PURPOSE IN TEACHING: microscopes, permanent microscopic slides, gross preparations, audiovisual equipment, exercise books. MONITORING AND EVALUATION: Current control - oral examination, tests sections, colloquia, final test on macroscopic and microscopic preparations preceding the semester exams. Final test - entry microscopic test, entry written test, written examination, oral examination (interview). METHODS OF CONTROL OF KNOWLEDGE: tests in all sections. REQUIRED SKILLS: Theoretical knowledge - acquiring and discussions:  general pathological processes: inflammation, degeneration, disturbances in blood circulation, adaptativni processes.  tumor pathology - etiology, pathogenesis, classification of neoplastic diseases.  etiology, pathogenesis and morphological changes in individual nosological units of all organs and Учебна програма за специалност “Медицина” 208 systems.  formulating and organizing the clinical and pathological - anatomical diagnosis, pathogenetic basis and according to WHO requirements. Ability to:  Work with a light microscope.  correctly making materials for cytological examination and biopsy.  introduction to how to fix the materials according to the pathological processes and organ localization.  correctly and completely fill slips for cytological examination and biopsy.  acquiring knowledge of the organization, operation and capabilities of the pathology department.  to read and interpret appropriate patho-anatomical responses.

COURSE PROGRAMME (V semester) LECTURE № 1 - 2:00: Introduction to Pathology. CELL PATHOLOGY. Reversible cell damage (cell edema accumulation of proteins and carbohydrates). LECTURE № 2-2 hours: DISORDERS OF lipid metabolism. TESAURISMOSES. LECTURE № 3-2 hours: DISORDERS OF exchanges of pigments. LECTURE № 4-2 hours: Pathology of connective tissue. Disturbances in the amount of collagen and elestin. Accumulation of inorganic substances. Deposition of fibrinoid. Hialinosis. Amyloidosis. LECTURE № 5-2 hours. Cell death. ADAPTIVE PROCESSES Apoptosis and necrosis. Atrophy, hypertrophy and hyperplasia, metaplasia, dysplasia. LECTURE № 6 - 2:00: disturbances in blood circulation. Arterial hyperemia. Venous plethora. Bleeding and hemorrhage. Plasmorrhagia. LECTURE № 7 - 2:00: disturbances in blood circulation. Rheological disturbances. Thrombosis. Disseminated intravascular coagulation (DIC syndrome). LECTURE № 8 - 2:00: disturbances in blood circulation. Embolism. Shock. Lymph circulation disorders. Changes in the amount of fluid. LECTURE № 9-2 hours: inflammation. Definition. Etiology. Phases. Morphogenesis and pathogenesis of inflammation. Exudative inflammation. LECTURE № 10 - 2:00: productive inflammation. Morphological characteristics of diffuse interstitial and granulomatous inflammation productive. LECTURE № 11 - 2:00: REGENERATION. PATHOLOGY OF IMMUNITY. LECTURE № 12 - 2:00: Tumors. Definition and nature of tumor growth. Carcinogenesis. Biological manifestations of benign and malignant tumors. Terminology. LECTURE № 13 - 2:00: Tumors. Cell Biology. Morphological characteristics. Diagnostics. LECTURE № 14 - 2:00: Tumors. Classification. Tumors of epithelial origin. LECTURE № 15 - 2:00: Tumors. Soft tissue tumors. Pigmented tumors. Teratoma.

PROGRAM OF PRACTICALS (V semester) EXERCISE № 1-2 hours: Scope, objectives and methods of pathology. Biopsy method: indications, types (intraoperative frozen section, excision, puncture, operational, punching (punch) biopsy, Pap smears) – technology, fixation and processing. Use and limitations. EXERCISE № 2-2 hours: review of normal histology: brain, liver, lung, spleen, lymph node, kidney, heart, skin and colon.

Учебна програма за специалност “Медицина” 209

EXERCISE № 3-2 hours: Basics of morphological techniques. A. Morphological examination of cells and tissues. Methods for taking and fixation of the material. Making samples for microscopic examination. 2. Demonstration of an autopsy. EXERCISE № 4-2 hours: Acute reversible cell damage: cell swelling, accumulation of carbohydrates and proteins. I. Histological samples: Balloon degeneration of hepatocytes (Hepatitis viralis). Protein accumulation in the epithelium of the renal tubules - H-E. II. Macroscopic samples: Diabetic glomerulosclerosis. EXERCISE № 5-2 hours: Accumulation of lipids. Accumulation of exogenous pigments. I. Histological samples: Steatotic liver - fat accumulation in hepatocytes - H-E. Steatosic liver - Sudan III. Coal dust in lungs. II. Macroscopic samples: Fatty degeneration of the liver. "Tiger" heart. Lipomatosis of the heart. Lipomatosis of the pancreas. Coal dust in lungs. Tattoos. EXERCISE № 6-2 hours: Dissection A. Autopsy technique. 2. Description of the sectional findings: size, shape, color and texture. 3. Demonstration of an autopsy. EXERCISE № 7-2 hours: Intracellular accumulation. Accumulation of endogenous pigments. I. Histological samples: Haemosiderosis in lungs (brown induration of lungs) - H-E. Haemosiderosis in lungs – PERLS reaction Jaundice in liver - H-E. Jaundice in kidney - H-E. Naevus - H-E. II. Macroscopic samples: Livers in Cooley’s anemia. Cholangiohepatitis - jaundice. Pancreas - haemosiderosis. Pancreas & thyroid & liver with metastatic melanoma. EXERCISE № 8-2 hours: Injuries of the intercellular matrix. Accumulation of fibrinoid and hyaline. I. Histological samples: Rheumatic valve- H-E, toluidine blue. Corpus albicans in ovary - H-E. Arteriolosclerotic nephrosclerosis - HE. Benign hypertension (brain) - N-E. II. Macroscopic samples Rheumatic heart disease: mitral stenosis. Arterioloscrerotic nephrosclerosis. Glazed spleen. Pinpoint hemorrhages in the brain. EXERCISE № 9-2 hours: Intercellular matrix. Accumulation of amyloid, calcium salts and sodium ureic acids. I. Histological samples: Amyloidosis in kidney - CONGO RED. Amyloidosis in spleen - sago - H-E. Amyloidosis in liver - H-E. Calcification of aorta - H-E. Ureic acid tophi - H-E. II. Macroscopic samples of Amyloidosis: spleen - sago and lardaceous; kidney - a big white kidney. Amyloid sclerosis of kidney. Atherosclerosis of the aorta with calcification. Uric acid infarction of the kidney. EXERCISE № 10 - 2:00: Cell death: apoptosis and necrosis I. Histological samples: Necrosis in spleen (anemic infarction of spleen) - N-E. Necrosis in brain (anemic infarction of brain) - H-E. Steatonecrosis in pancreas (necrotic pancreatitis ) - H-E. Caseous necrosis in lymph nodes in tuberculosis (TBC in lymph nodes) - H-E. II. Macroscopic samples - Anemic infarction of the spleen. Anemic infarction of the kidney. Anemic infarction of the brain. Brain pseudocyst. Lymph node with tuberculosis. Gangrene of the toe. Acute necrotizing pancreatitis. EXERCISE № 11 - 2:00: Compensatory-adaptive processes: atrophy, hypertrophy, hyperplasia, metaplasia, dysplasia. I. Histological samples: Hypertrophy of myocardium- HE. Hyperplasia of uterine mucosa - HE. Hyperplasia ofe prostate - H-E. Atrophy of liver- H-E. Atrophy of myocardium - H-E. II. Macroscopic samplens: Tongue in acromegaly. Dilatation of the left ventricle in chronic myocarditis. Hypertensive heart. Hypertrophy of the prostate with bladder stones. Atrophy of the myocardium. Internal hydrocephalus. EXERCISE № 12 - 2:00: review of macro - and microscopic samples from all degenerative processes, cell death, compensatory-adaptive processes (exercises № 4-12). EXERCISE № 13 - 2:00: Test and Seminar: Acute and chronic reversible cell damage. Abnormal deposits in the intercellular matrix. Cell death. Compensatory-adaptive processes. Учебна програма за специалност “Медицина” 210

EXERCISE № 14 - 2:00: Disturbances of blood flow: hyperemia, edema, and hemorrhage. I. Histological samples: Cyanotic liver - HE. Nutmeg liver - H-E. Pin point hemorrhages in braini - H- E. Oedema of skin - H-E. Oedema in lungs - H-E. II. Macroscopic samples Nutmeg liver. Cardiac liver fibrosis. Bleeding in the brain. 4. Brown induration of lung. EXERCISE № 15 - 2:00: Circulatory disorders: ischemia, thrombosis, embolism, heart attack. I. Histological preparations: Mixed thrombus - H-E. Anemic infarction of kidney - H-E. Hemorrhagic infarction of the lungs- H-E. Fat embolism in lungs - Sudan III. II. Macroscopic samples: Recent myocardial infarction. Anemic infarction of kidney. Infarct of the spleen. Ischemic infarction of the brain. Thrombus in aorta. Round thrombus in the left ventricle. Pulmonary thromboembolism. Hemorrhagic infarction of the lung. Mesenteric thrombosis. EXERCISE № 16 - 2:00: Colloquium: Cellular damage and circulatory disorders (test and a written answer). EXERCISE № 17 - 2:00: Inflammation: Basic morphological changes. Mediators of inflammation. Classification. Types of exudative inflammation. I. Histological samples: Fibrinous pericarditis - H-E. Purulent leptomeningitis - H-E. Phlegmonous appendicitis - H-E. Acute absceding myocarditis - H-E. II. Macroscopic samples fibrinous pericarditis. "Armoured" heart. Purulent leptomeningitis. Phlegmonous appendicitis. EXERCISE № 18 - 2:00: Productive inflammation. I. Histological samples: Granulation tissue - H-E. Nasal polyp - H-E. "foreign body" type granuloma e - H-E. Hydatid cyst - H-E. Giant cell epulis - H-E. II. Macroscopic samples Hydatid cyst of the spleen. Hydatid cyst in liver. Trichinella. Nasal polyp. EXERCISE № 19 - 2 hours: granulomatous inflammation. I. Histological preparations: Necrosis caseosa lymponodi (Lymphadenitis tuberculosa caseosa). Mesaortitis luetica - H-E. Gumi luetici - H-E. Actinomycosis - H-E. II. Macroscopic swamples Cavity of the lung. Miliary tuberculosis of the lung. Tuberculous leptomeningitis. Lymph node tuberculosis. Tuberculosis of the kidney. Luetic aneurysm of the aorta. EXERCISE № 20 - 2:00: review of macro - and microscopic samples on circulatory disorder and inflammatory processes (exercises № 14 - № 19). EXERCISE № 21 - 2:00: Regeneration. Pathology of immunity. I. Histological samples: Regeneration of bone marrow - H-E. Granulation - H-E. Scarring of myocardium - H-E; Van Gieson. Hashimoto diseases. Rheumatoid arthritis. Nodosal polyarterritis - toluidine blue. II. Macroscopic samples: Regeneration of bone marrow. Heart- postinfartion scarring, chronic aneurysm with superimposed thrombus. Lymphomatous goiter (Hashimoto). Rheumatoid arthritis. EXERCISE № 22 - 2:00: TEST AND SEMINAR: Inflammation and immune pathology. EXERCISE № 23 - 2:00: Tumors. Benign and malignant tumors of the surface epithelium. I. Histological samples: Papiloma in oral cavity. Basal cell carcinoma . Squamos cell carcinoma. Urothelial carcinoma. II. Macroscopic samples: basal cell carcinoma. Lung cancer. Bladder cancer. Breast cancer. Cancer of the cervix. EXERCISE № 24 - 2:00: Benign and malignant tumors of glandular epithelium. I. Histological preparations: Pleomorhic adenoma of parotis (tumor "mixtus"). Gastric adenocarcinoma. ‘Gelatinous’ adenocarcinoma. II. Macroscopic preparations fibroadenoma of the breast. Breast cancer. Stomach Cancer: ulcerative, excavative types. Cancer of the colon. Endometrial cancer. EXERCISE № 25 - 2:00: Tumors. Benign and malignant soft tissue tumors. I. Histological samples: Lipoma - H-E. Cavernous haemangioma of liver - H-E. Capillary haemangioma of skin - H-E. Leiomyoma in uterus - H-E, Van Gieson. Leiomyosarcoma - H-E. II. Macroscopic samples: 1. Lipomas. 2. Hibernoma. 3. Cavernous haemangioma of the liver. 4. Adrenal adenoma. 5. Uterine leiomyomas. Учебна програма за специалност “Медицина” 211

EXERCISE № 26 - 2:00: Pigment tumors. Teratoma. Review of macro - and microscopic samples - (Exercise № 25 - № 26). I. Histological samples: Naevus. Melanoma malignum. Mature teratoma II. Macroscopic samples: Malignant melanoma - skin. Metastases from malignant melanoma in the liver, brai, etc. Mature teratoma (dermoid cyst) of the ovary. EXERCISE № 27 - 2:00: Quiz on Tumours. EXERCISE № 28 - 2 hours: Final test on macroscopic and microscopic samples from general pathology. EXERCISE № 29 - 2:00: Final test - retry. EXERCISE № 30-2 hours: Dissection.

PROGRAM COURSE (VI semester) LECTURE № 1-2 hours: Pathology of the Cardiovascular System. Atherosclerosis. LECTURE № 2-2 hours: A: Pathology of the Cardiovascular System. Hypertension. Ischemic heart disease. Chronic pulmonary heart. LECTURE № 3-2 hours: Pathology of the Cardiovascular System Rheumatism. Infectious and non infectious endocarditis. LECTURE № 4-2 hours: Pathology of the Cardiovascular System Myocarditis. Cardiomyopathies. Pericarditis. Congenital heart defects. LECTURE № 5-2 hours: Connective tissue disease Systemic lupus. Rheumatoid arthritis. Systemic vasculitis. LECTURE № 6-2 hours: PATHOLOGY OF THE RESPIRATORY SYSTEM Diseases of the nose, paranasal sinuses, pharynx and larynx. Bronchitis. Bronchiectatic disease. LECTURE № 7-2 hours: PATHOLOGY OF THE RESPIRATORY SYSTEM Pneumonia. Abscess and gangrene of the lung. Allergic diseases of the lung. LECTURE № 8-2 hours: Pathology of HEMOPOETIC SYSTEM Anemia. Erithremia. Thrombocytopenias. Agranulocytosis. Acute and chronic leukemia. LECTURE № 9-2 hours: Pathology of HEMOPOETIC SYSTEM Multiple myeloma. Malignant lymphomas. LECTURE № 10 - 2:00: Pathology of the Digestive System Pathology of the oral cavity and esophagus. LECTURE № 11 - 2:00: Pathology of the Digestive System Pathology of the stomach and duodenum. LECTURE № 12 - 2:00: Pathology of the Digestive System Enteritis and enterocolitis. Appendicitis. Mesenteric thrombosis. Colonic tumors. Bowel obstruction. LECTURE № 13 - 2:00: PATHOLOGY OF LIVER. Hepatitis LECTURE № 14 - 2:00: PATHOLOGY OF LIVER Liver cirrhosis. Liver Cancer. LECTURE № 15 - 2:00: Pathology of the bile ducts and pancreas.

PROGRAM OF PRACTICAL EXERCISES (VI semester) EXERCISE № 1-2 hours: Dissection. Sectional technique organs in the chest. Samples of pulmonary thromboembolism and air embolism. EXERCISE № 2-2 hours: Diseases of the cardiovascular system: aterosclerosis, hypertension. I. Histological samples: Atherosclerosis of aortae - HE, Sudan III. Benign hypertension in brain. Arteriolosclerotic nephrosclerosis. Pin point haemorrhages in brain. II. Macroscopic samples: 1. Arteriosclerotic nephrosclerosis . 2. Hypertensive heart. 3. Arteriolosclerotic nephrosclerosis. 4. Obturative thrombus in the abdominal aorta. 5. Pinpoint bleeding in the brain white.6. Large hematoma in the cerebral hemisphere. 7.’ White softening’ of brain. 8. Pseudocyst of the brain.

Учебна програма за специалност “Медицина” 212

EXERCISE № 3 - 2:00: Diseases of the cardiovascular system. Myocardial infarction. Miokardiofibrosis. Cardiomyopathies. I. Histological samples: Hypertrophy of myocardium. Recent myocardial nfarction. Scarring of myocardium- H-E, Van Gieson. Anemic infarction of brain. II. Macroscopic samples: 1. Recent myocardial infarction. 2. Hypertrophy of the left ventricle. 3. Hypertrophy and dilatation of the left ventricle. 4. White softening of brain. 5. Coronary artery bypass. EXERCISE № 4 - 2:00: Diseases of the cardiovascular system. Endocarditis. Myocarditis. Pericarditis. Systemic connective tissue diseases. I. Histological preparations: 1. Endocarditis fibrosa. 2. Myocarditis rheumatica. 3. Pericarditis fibrinosa. 4. Polyarteriitis nodosa - H-E. II. Macroscopic preparations: 1. Fibrinous pericarditis. 2. Fibrotic mitral valve endocarditis. 3. Stenosis and mitral insufficiency with round left atrial thrombus. 4. Ulcero-polypotic endocarditis. 5. Kidney – nodosal poliarteriitis. EXERCISE № 5-2 hours: Dissection. Sectional technique. Description of changes in the organs in the abdominal cavity. Measurement of free fluid in the abdominal cavity. EXERCISE № 6-2 hours: Colloquium: "Cardiovascular System". EXERCISE № 7-2 hours: Diseases of the respiratory system. Inflammatory diseases of the lung and pleura. Emphysema. Pleurisy. I. Histological preparations: Acute and chronic bronchitis. Emfhysema. II. Macroscopic samples: 1. Chronic bronhitis.2. Pulmonary emphysema. 3. Pleural fibrosis. EXERCISE № 8-2 hours: Diseases of the respiratory system. Pneumonia. I. Histological preparations: Bronchopneumonia acuta abscedens. Bronchopneumonia acuta mycotica. Pneumonia crouposa. Interstitial pneumonia. II. Macroscopic samples: 1. Absceding pneumonia.2.Pneumonia in the stage of gray hepatisation. EXERCISE № 9-2 hours: Diseases of the respiratory system. Pneumoconiosis. Neoplasms. I. Histological samples: Silicosis pulmonis (nodular form). Squamos carcinoma of the lung. Undifferentiated, small cell carcinoma of the lungs. Bronhioloalveolary cancer. II. Macroscopic samples: 1. Carbon duct in lungs.2. Silicosis of the lung. 3. Lung cancer. EXERCISE № 10 - 2:00: Workshop: "Respiratory System". EXERCISE № 11 - 2:00: Diseases of the haematopoietic system. Anemia. Leukemia. Diseases of the lymph nodes. Lymphomas. I. Histological samples: 1. Regeneration of bone marrow - H-E. 2. Chronic lympholeucemic infiltrates in liver- H-E. 3. Myeloleucemic infiltrates in liver - H-E. 4. Hodgkin’s disease - HE. 5. Non Hodgkin’s lymphoma - H-E. 6. Plasmocytoma - H-E II. Macroscopic samples. . 1. Chronic lympholeucemic infiltrates in liver 2. Myeloleucemic infiltrates in liver. EXERCISE № 12 - 2:00: Diseases of the oral cavity. I. Histological samples: 1. Leucoplakia - H-E. 2. Giant cell epulis - H-E. 3. Adamantinoma - H-E. 4. Pleomorphic adenoma of parotid - H-E. 5. Chronic tonsillitis - H-E. II. Macroscopic samples Pleomorphic adenoma of salivary gland – mixed tumor. EXERCISE № 13 - 2:00: Diseases of the gastrointestinal tract: stomach, small and large intestines. Ulcer of stomach and duodenum. Complications. Benign and malignant tumors of the stomach. Chronic ulcers, hemorrhagic colitis (CUHK). Tumors of the intestines. I. Histological samples: 1. Gastritis chr. atrophicans - H-E. 2. Ulcus chronicum ventriculi exacerbata - N. F. 3. Gastric adenocarcinoma - H-E. 4. Duodenal ulcer - H-E. 5. Appendicitis phlegmonosa - H-E. II. Macroscopic samples: 1. Hypertrophic gastritis. 2. Acute ulcers of the stomach. 3. Chronic gastric ulcer perforation. 4. Chronic ulcers of the stomach and duodenum 5. Gastric cancer - polypoid, ulcerated, scirrhous. 6. Phlegmonous appendicitis. 7. Diverticulum of the esophagus.

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EXERCISE № 14 - 2:00: Diseases of the liver, gallbladder and pancreas. Acute toxic liver dystrophy. Acute and chronic hepatitis. Liver cirrhosis. Diseases of the gallbladder and bile ducts. Acute pancreatitis and pancreatic cancer. I. Histological samples: 1. Acute toxic necrosis of liver - H-E. 2.Micronodular cirrhosis - H-E. 3. Chronic cholecystitis - H-E. 4. Steatonecrosis pancreatis (pancreatitis ac. necroticans) - N-E. II. Macroscopic samples: 1. Micronodular cirrhosis of liver 2. Cholelithiasis. 3. Gangrenous cholecystitis. 4. Acute pancreatic necrosis. EXERCISE № 15 - 2:00: SEMINAR: "Pathology of forming and digestive system."

PROGRAM COURSE (VII semester) LECTURE № 1-2 hours: Pathology of the urinary system Anatomy and physiology of urinary system. Primary glomerulopathies. LECTURE № 2-2 hours: Pathology of the urinary system Tubulo-interstitial disease. LECTURE № 3-2 hours: Pathology of the urinary system Acute and chronic renal failure. Nephrosclerotic kidney. Nephrolithiasis. Pathology of the bladder. LECTURE № 4-2 hours: Pathology of the female reproductive system Diseases of the vagina, cervix and uterine body. LECTURE № 5-2 hours: Pathology of the female reproductive system Ovarian tumors. Pathology of pregnancy. Diseases of the breast. LECTURE № 6-2 hours: Pathology of the male reproductive system LECTURE № 7-2 hours: PATHOLOGY of the endocrine system Diseases of the pituitary and adrenal. LECTURE № 8-2 hours: PATHOLOGY of the endocrine system Diseases of thyroid and endocrine pancreas. LECTURE № 9-2 hours: PATHOLOGY OF THE NERVOUS SYSTEM Inflammatory diseases of the nervous system. LECTURE № 10 - 2:00: PATHOLOGY OF THE NERVOUS SYSTEM Tumors of nevroepitelnata tissue of nerve sheaths, the meninges and their kindred fabrics. LECTURE № 11 - 2:00: Pathology of bones and joints. Osteoporosis. Osteomalacia. Metabolic and inflammatory bone diseases. Arthritis. Arthrosis. LECTURE № 12 - 2:00: INFECTIOUS DISEASES.Sepsis. AIDS. LECTURE № 13 - 2:00: INFECTIOUS DISEASES. TB LECTURE № 14 - 2:00: INFECTIOUS DISEASES. Lues LECTURE № 15 - 2:00: PRINCIPLES OF CONSTRUCTION AND COMPARISON OF CLINICAL AND PATHOLOGICAL DIAGNOSIS.

PROGRAM OF PRACTICALS (VII semester) EXERCISE № 1-2 hours: Dissection. A. Preparation of autopsy protocol. 2. Principles of pathological diagnosis. 3. Categories: main disease, comorbidities and background. 4. Preparation of pathological epicrisis. 5. Demonstration of an autopsy. EXERCISE № 2-2 hours: Test and Seminar - digestive system. EXERCISE № 3-2 hours: Glomerulonephritis. Definition, etiology and pathogenesis. Classification. Morphological changes in the basic types of glomerulonephritis. I. Histological samples: 1. Crescentic glomerulonephritis (subacute). 2. Mesangiocapillary glomerulonephritis. 3. Glomerulonephritic nephrosclerosis. II. Macroscopic samples: acute glomerulonephritis. Subacute glomerulonephritis. Nephrosclerosis. Minimal change disease. Учебна програма за специалност “Медицина” 214

EXERCISE № 4-2 hours: Pyelonephritis. Nephrosclerotic kidney. Tumors of the kidneys and bladder. I. Histological samples: Acute pyelonephritis (absceding). Chronic pyelonephritis. Carcinoma of kidney. Bladder cancer. II. Macroscopic samples: 1. Nephrosclerotic kidney. 2. Diabetic glomerulosclerosis. 3. Amyloid nephrosclerosis and a big white kidney. 4. Calculi in pyonephrosis. 5. Carcinoma of the kidney. 6. Wilm's tumor. 7. Polycystic kidney. 8. Bilateral hydronephrosis. EXERCISE № 5-2 hours: Pathology of pregnancy. Diseases of the female reproductive system. A. Benign and malignant tumors of the cervix and uterine body. 2. Abortion, glandular hyperplasia of the endometrium. I. Histological samples: Abortion - H-E. Mola hydatidosa - H-E. Chorionepithelioma (choriocarcinoma). CA planocellularae coli uteri - H-E. Adenocarcinoma corporis uteri - H-E. II. Macroscopic samples: 1. Uterus with fetus. 2. Abortion. 3. Ectopic pregnancy. 4. Hydatidiform mole. 5. Choriocarcinoma. 6. Uterine polyp. 7. Uterus with fibroids. 8. Polyp of the cervix. 9. Endometrial carcinoma. 10. Sarcoma of the uterus. EXERCISE № 6-2 hours: Tumors of the ovary. Diseases of the breast. I. Histological samples: 1. Papillary cystadenoma of ovary - H-E. 2. Mucinous cystadenocarcinoma of ovary. 3. Dysplasia of breast - H-E. 4. Fibroadenoma of breast - H-E. 5. Ductal carcinoma (invasive) - H-E. 6. Scirrhous carcinoma of breast - H-E. II. Macroscopic samples: Breast cancer. Fibroadenoma of the breast. Cystadenoma of the ovary. Krukenberg’s metastases in the ovaries. EXERCISE № 7-2 hours: Diseases of the male reproductive system. Prostatic hyperplasia. Tumors of the testis. I. Histological samples: Hyperplasia of prostate. Adenocarcinoma of prostate. Seminoma testis. Teratoma. II. Macroscopic samples: hypertrophy of the prostate. Prostate cancer. Seminoma of the testis. Mature teratoma - (ovary). EXERCISE № 8-2 hours: Colloquium: "Excretory and reproductive system." EXERCISE № 9-2 hours: Diseases of the endocrine system. Diseases of the thyroid gland. Diabetes. I. Histological samples: Struma colloides - H-E. Struma basedowiana (Struma toxica). Thyreoiditis chronica (struma lymphomatosa - Hashimoto) - H-E. Glomerulosclerosis diabetica - H-E. Adenoma gl. hypophyseae (eosinophilic). II. Macroscopic samples Nodular colloid goiter. Graves' goiter. Acromegaly - language. Pituitary adenoma. Diabetic glomerulosclerosis. Adrenal adenoma. EXERCISE № 10 - 2:00: Inflammatory diseases of the nervous system. I. Histological samples: Leptomeningitis purulenta - H-E. Polioencephalitis acuta - H-E. Poliomyelitis anterior acuta - H-E. Leptomeningitis tuberculosa - H-E. II. Macroscopic samples: Purulent leptomeningitis. T.B.Leptomeningitis. Internal hydrocephalus. EXERCISE № 11 - 2:00: Tumors of the central nervous system, the sheaths of peripheral nerves and soft tissues. I. Histological samples: Astrocytoma. Glioblastoma multiforme. Schwanoma (neurinoma). Meningioma. II. Macroscopic samples: 1. Glioma of the brain. 2. Glioblastoma multiforme. 3. Neurinoma of n. statoacusticus. 4. Meningioma. EXERCISE № 12 - 2:00: Infectious diseases. Tuberculosis. Lues. Sepsis. I. Histological samples: Milliary tuberculosis. Caseous necrosis in lymph nodes. Gummi luetici. Cytomegalovirus nephritis. II. Macroscopic samples: 1. Tuberculosis of t kidney. 2. Cavity in lung. 3. Acinus tuberculosis. 4. Lymph node-caseous necrosis. 5. Luetic mesaortitis (aneurysm). EXERCISE № 13 - 2:00: Review of final test samples. EXERCISE № 14 - 2:00: Final test on museum and microscopic preparations of Clinical Pathology. EXERCISE № 15 - 2:00: Final test - retry. Sectional occupation: Comparison of clinicopathological diagnosis. Clinicopatological conferences. Учебна програма за специалност “Медицина” 215

Syllabus of general pathology

1. Subject, tasks and methods of pathology. 2. Health and disease. Main categories in pathology (etiology, pathogenesis, Morphogenesis, sanogenesis, tanatogenesis). 3. Death: Clinical and biological. Signs of biological death. 4. Cell injury.Definition. Categories of cellular injury. Causal factors. Pathogenetic and morphogenetic mechanisms. 5. Cellular injury. Types of degeneration. Acute reversible cellular damage (cellular swelling). Hydropic degeneration. 6. Abnormal accumulation of substances in the cell. Mechanisms. Accumulation of protein (hyaline-drop degeneration, Lewy and Mallory bodies; Russel bodies) and carbohydrates. Methods of proof. 7. Disorders of the metabolism of lipids. Types of adipose degeneration. Accumulation of cholesterol and cholesterol esters. Methods of proof. Total obesity. Lipomatosis. Cachexia. 8. Lysosomal diseases (tesaurismoses) - features. Lipidoses (Gaucher disease, Niemann-Pick disease, Tay-Sacks, disease, Hand-Schuller-Christian) and glycogenoses. 9. Disturbances in the metabolism of the pigments. Classification. Accumulation of exogenous pigments. 10. Accumulations of iron-containing pigments (hemoglobinogenic). 11. Accumulation of iron-free hemoglobinogenic pigments. Jaundice. 12. Disturbances in the metabolism and accumulation of proteinogenic (tyrosine, tryptophan) and lipidogenic native pigments. 13. Abnormal accumulation of substances in the extracellular matrix Mucoid edema. Fibrinoid. Hialinosis - types. Accumulation of fibrillary substances in the interstitium: scarring, fibrosis (sclerosis) and cirrhosis. 14. Amyloidosis. Common physical and chemical characteristics. Classification. Types according to their composition. Methods of proof. 15. Types of amyloidosis depending on cause and spread of the process. Organ deposits. Diagnosis. 16. Disturbances in the metabolism of calcium and copper. Abnormal accumulation of salts of the uric acid. 17. Cell death. Necrobiosis. Necrosis: definition, types (coagulation and kaseous; liquefactive), nuclear and cytoplasmic morphological changes. 18. Clinical and anatomical forms of necrosis (infarction, gangrene, decubitus, sequesters, mutilation, steatonecrosis, fibrinoid necrosis, ‘noma’). Evolution and complications. 19. Apoptosis. Definition, differences between apoptosis and necrosis. Role of apoptosis. 20. Hemodynamic disorders: an overview, local and general hemodynamic disorders. Changes in the amount of blood. Arterial hyperemia. 21. Venous plethora (congestion). Acute and chronic left heart failure - morphological changes. 22. Venous plethora. Acute and chronic right heart failure - morphological changes. Local venous plethora. 23. Ischemia: definition, types, complications. 24. Bleeding and bleedingdisorders. Plasmoraghia. Terminology, mechanisms, outcome. 25. Rheological disorders: prestasis, stasis, ‘sludge’-phenomenon. 26. Thrombosis. Order and Morphogenesis. Structure of thrombi. Difference between the thrombus and post-mortem blood clot. 27. Thrombosis. Types of blood clots, complications and evolution. Disseminated intravascular coagulopathy (DIC syndrome).

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28. Embolism. Definition. Types of embolism by the way of their distribution: venous and arterial, orthograde, retrograde and paradoxical embolism. 29. Pulmonary thromboembolism: cause, proof, complications and outcomes. 30. Types of embolism, according to the substrate: air, gas, fat, amnial, bacterial, parasitic, tumor cell. Comparison between embolism and metastasis. 31. Infarction. Definition. Types. Morphological characteristics of anemic infarction. 32. Infarction. Definition. Types. Morphogenesis of hemorrhagic infarctions. Types of hemorrhagic infarctions. 33. Shock. Definition, pathogenetic types and organ morphological changes. 34. Disorders of lymph circulation: terminology and complications. Quantitative changes of tissue fluid. Oedema: definition, types. Pulmonary and cerebral edema. Dehydration. 35. Inflammation. Definition. Terminology. Main features. Etiologic factors. 36. Inflammation. Phases of inflammatory reaction. Pathogenesis and morphogenesis of inflammation. Plasma and cellular mediators. 37. Morphogenesis of acute ( exudative ) inflammation.Hemodynamic changes in microcirculation. Leukocyte migration and phagocytosis. 38. Cell types in the outbreak of acute and chronic inflammation. 39. Exudative inflammation. Morphology, complications and outcomes. 40. Productive inflammation: forms and morphological characteristics of diffuse productive inflammation. 41. Nonspecific and specific productive – ‘granulomatous’ inflammation. Morphology of foreign body granuloma, tubercle, luetic ‘gumma’, granulomas in leprosy and sarcoidosis, cat- scratch disease, toxoplasmosis, rhinoscleroma. 42. Pathology of immunity. Hypersensitivity reactions. Anaphylactic cytotoxic type immune reactions (first and second type reactions). 43. Pathology of immunity. Hypersensitivity reactions. Immune complexes reactions. Delayed type hypersensitivity (third and fourth type reactions). 44. Pathology of immunity - types. Autoimmune diseases. Congenital syndromes and acquired immune deficiency. 45. Adaptivey processes: hypertrophy and hyperplasia, atrophy - definition, types, morphological characteristics. 46. Metaplasia - definition, types, morphological characteristics, complications. 47. Regeneration. Restitution and substitution. Factors affecting recovery processes. Wound healing. Regeneration of bone tissue. 48. Tumors: definition, incidence and prevalence. Biology of tumor growth ( irreversibility, relative autonomy, tumor impact on the whole body). 49. Tumors: Terminology. Classification. Tumor structure. 50. Etiology of tumors. Chemical, physical, genetic and viral carcinogenesis. Role of growth factors. 51. Morphogenesis of tumors. Monocentric and multicentric theories for their emergence. Proliferating and non-proliferating tumor fractions. Biological basis of invasion of malignant tumors. Metastasis. 52. Morphological characteristics of tumors. Differences between benign and malignant tumors. Tissue and cellular atypia. 53. Precancerous. Dysplasia. Carcinoma in situ. 54. Metastasis of tumors. 55. Degree of differentiation and staging in the development of tumors. TNM-system. 56. Structure and shape of tumors - macroscopic and microscopic characteristics. Role of immunohistochemistry for the diagnosis of tumors. 57. Benign tumors of epithelial origin. 58. Malignant tumors of epithelial origin. 59. Benign soft tissue tumors. Учебна програма за специалност “Медицина” 217

60. Malignant soft tissue tumors. 61.Tumors of the central nervous system - general features, classification, basic representatives. 62. Tumors of the nerve sheath. Tumors of the meninges. 63. Tumors and tumor-like entities of melanocytes. Teratomas.

SYLLABUS FOR EXAMINATION OF CLINICAL PATHOLOGY

1. Atherosclerosis. Risk factors. Pathogenesis and Morphogenesis. 2. Atherosclerosis. Stages. Organ damage. 3. Hypertension: types, etiology and pathogenesis. 4. Morphogenesis of vascular lesions in benign and malignant hypertension, organ damage. 5. Pulmonary hypertension - primary and secondary. Acute and chronic pulmonary heart. 6. Ischemic heart disease. Morphogenesis, classification, forms of angina. Sudden cardiac death. 7. Myocardial infarction. Risk factors. Species. Evolution and complications. 8. Systemic connective tissue disease - a common feature. Rheumatism: definition, etiology and pathogenesis, major events. 9. Rheumatic heart disease. Rheumatic endocarditis, morphological stagies. Rheumatic myocarditis and pericarditis. 10. Rheumatic valvular defects: morphological characteristics, hemodynamic disorders and organ complications. 11. Infective endocarditis - acute and subacute: etiology, pathogenesis, morphology and complications. 12. Non-infectious endocarditis: Libman-Sachs endocarditis, mitral valve prolapse, degenerative calcification of aortic valve endocarditis, marantic type. Cardiomyopathy: dilated, hypertrophic and restrictive. 13. Myocarditis - infectious and noninfectious. 14. Diseases of the pericardium: pericarditis and pericardial effusion. 15. Congenital heart defects: septal defects and inter - ventricular septa, persistent ductus Botali, coarctation of the aorta Congenital transposition of the trunk vessels. 16. Systemic lupus erythematodes: definition, etiology and pathogenesis, morphological amendments. 17. Rheumatoid arthritis: definition, pathogenesis, Morphogenesis of articular lesions skin and vascular changes, clinical course. 18. Systemic sclerosis. Dermatomyositis. Polymyositis. Sjogren syndrome. 19. Vasculitis. Temporal arteritis. Arteritis Takayasu. Polyarteritis nodosa. 20. Local vasculitis: infectious arteritis, Raynaud (trombangiitis obliterans) syndrome. . 21. Aneurysms. Dissection of the aorta. Varices, phlebotrombosis and thrombophlebitis. 22. Inflammatory diseases and tumors of the nose and paranasal sinuses. Tumors of larynx. 23. Inflammatory diseases of the trachea and bronchi: acute tracheitis, bronchitis and bronchiolitis. Chronic bronchitis. Bronchiectasis. 24. Pneumonia: definition and overview. Lobar pneumonia: definition etiology, Morphogenesis, morphological stages, complications and outcomes. 25. Focal pneumonia: definition, etiology, pathogenesis, morphological features. Interstitial, and chronic viral pneumonia. 26. Abscess and gangrene of the lung. Atelectasis. 27. Chronic obstructive pulmonary disease. Pulmonary emphysema: a definition Classification, complications. 28. Bronchial asthma. Idiopathic pulmonary haemosiderosis. 29. Pneumoconiosis - an overview. Silicosis: forms and complications. 30. Lung cancer: incidence and prevalence, etiology, Morphogenesis, morphology. Metastasis. Complications. 31. Pleurisy and tumors of the pleura. Учебна програма за специалност “Медицина” 218

32. Inflammatory diseases of the oral cavity. Stomatitis, glossitis and angina: Complications of streptococcal infections. 33. Diseases of teeth and soft tissue apparatus: caries, pulpitis, periodontitis, radicular cyst, periodontal disease. 34. Tumors of the jaw bone and tumor-like processes of the soft tissues of oral cavity. Epulis. 35. Sialoadenitis and tumors of salivary glands. 36. Diseases of the esophagus:-hiatus hernia, diverticula, esophagitis, gastroesophageal reflux, Barrett's esophagus. 37. Tumors of the esophagus. 38. Acute and chronic gastritis. Etiology, Morphogenesis, clinical and morphological forms complications. 39. Acute and chronic ulcers of the stomach and duodenum. Definition etiology, pathogenesis and Morphogenesis. Morphological picture. 40. Chronic ulcers of the stomach and duodenum. Complications. 41. Benign tumors of the stomach - epithelial and mesenchymal. Early cancer stomach - morphology. 42. Malignant tumors of the stomach. Etiology, pathogenesis, classification,morphological characteristics, metastasis. 43. Inflammatory bowel disease: acute and chronic enteritis. Acute and chronic non-specific colitis. Ulcerative colitis. Crohn’s disease. 44. Benign and malignant tumors of the colon. 45. Bowel obstruction. Peritonitis. 46. Acute appendicitis - morphology and complications. Tumors of the appendix. 47. Acute viral hepatitis: etiology, pathogenesis, morphological and biological features of hepatitis A, B and C. 48. Chronic hepatitis: etiology, classification, clinical and morphological forms of evolution. 49. Toxic hepatitis. Acute toxic degeneration of the liver. 50. Liver cirrhosis: definition, etiology, classification. Morphogenesis. 51. Liver cirrhosis: basic morphological types. Complications. 52. Cholecystitis: etiology, types, morphological characteristics, complications. Cholelithiasis. 53. Tumors of the liver, bile duct and gallbladder. 54. Inflammatory diseases and tumors of the exocrine pancreas. 55. Anemia: definition, etiology, classification. Acute and chronic posthemorrhagic anemia. 56. Pernicious, foil acid, and iron deficiency anemia. Aplastic anemia. Idiopatic thrombocytopenia. 57. Myelogenous malignancies. Acute myelogenous leukosis (leukemia). Chronic myelogenous leukosis. 58. Hyperplastic and inflammatory processes in the lymph nodes: chronic nonspecific and granulomatous lymphadenitis. 59. Malignancy of lymphoid tissue. Acute lymphoblastic leukemia / lymphoma. Chronic lymphocytic leukemia (small lymphocytic lymphoma). 60. Myeloma disease. Solitary myeloma (plasmacytoma). 61. General characteristics and classification approach for Non-Hodgkin's malignant lymphomas. 62. Hodgkin’s disease: etiology and pathogenesis, classification, prognosis. 63. Primary glomerulopathy (glomerulonephritis). Pathogenesis and Morphogenesis. Diagnostic approach. 64. Glomerulonephritis occurring with nephritic syndrome: diffuse endocapillary proliferative glomerulonephritis. Rapidly progressive (‘crescentic’) glomerulonephritis. Goodpasture pulmonary-renal syndrome. 65. Glomerulonephritis occurring with nephrotic syndrome: minimal disease changes, focal segmental glomerulosclerosis, mesangiocapillary glomerulonephritis. 66. Glomerulonephritis occurring with nephrotic syndrome: IgA-nephropathy and Membranous nephropathy. Diffuse sclerosing glomerulonephritis. 67. Acute and chronic pyelonephritis: etiology, pathogenesis, morphology, complications. Учебна програма за специалност “Медицина” 219

68. Acute renal failure. Ischemic and nephrotoxic acute tubular necrosis. 69. Nephrolithiasis. Etiology. Types of concretion. Complications. Polycystic kidney. 70. Nephrosclerosis: classification approach macroscopic characteristic. Morphology chronic renal failure. 71. Tumors of the kidney and bladder. 72. Diseases of the cervix. Precancerous conditions (CPC). Carcinoma in situ. Microinvasive, invasive squamous and adeno-carcinoma. Morphological diagnosis. Prognosis. 73. Chronic endometritis, endometriosis, endometrial hyperplasia, etiology, morphology. 74. Benign and malignant tumors of the uterine body. 75. Ovarian tumors: classification, key representatives biological characteristics. Metastatic ovarian tumors. 76. Abortion and ectopic pregnancy: cause, morphology, complications. 77. Molar pregnancy and choriocarcinoma. Postnatal sepsis. 78. Inflammatory and fibrotic cystic changes of the breast. 79. Benign and malignant breast tumors: morphology and staging. 80. Tumors of the testis and epididymis. 81. Hyperplasia and tumors of the prostate gland. Complications. 82. Tumors of the anterior pituitary. Hyperpituitarism: Acromegaly. Gigantism. Cushing disease. Hypopituitarism: dwarfism. Sheehan syndrome Adiposo-genital dystrophy. Diabetes insipidus. Craniopharingeoma. 83. Hyperplastic thyroid disease. Hyper-and hypothyroidism. 84. Hashimoto: etiology, pathogenesis, morphological characteristics. 85. Tumors of the thyroid gland. 86. Diseases of parathyroid glands. Hyper-and hypoparathyroidism. 87. Diseases of the adrenal gland: chronic and acute adrenal failure. Adrenal tumors. 88. Diabetes mellitus. Tumors of the endocrine pancreas. 89. Serous viral meningitis. Viral polioentcephalitis. Demyelinating encephalomyelitis and neuropathy. 90. Bacterial meningitis and meningoencephalitis: epidemic cerebrospinal meningitis, purulent non-meningococcal leptomeningitis, tuberculous meningitis and menigoencephalitis. 91. Astroglial tumors - types. Glioblastoma multiforme. Morphological and biological characteristic. 92. Tumors of ependimal glia and plexus chorioideus. Medulloblastoma. Morphological and biological characteristic. 93. Tumors of the meninges and shwan cells. Types. Morphological and biological characteristic. 94. Hydrocephaly: definition, etiology, pathogenesis, classification. 95. Tuberculosis: general characteristics and classification. Primary tuberculosis. 96. Hematogenic tuberculosis. Secondary tuberculosis. Types. Complications. 97. Acquired syphilis: epidemiology, etiology, pathogenesis. Primary, secondary and tertiary lues. Neurolues. Congenital syphilis. 98. Sepsis. 99. AIDS. 100. Principles of construction and comparison of clinical and pathological diagnosis: diagnostic categories

BIBLIOGRAPHY: 1. "General Pathology". Volume 1, edited by Professor Grigor Velev, Publishing group "Knowledge" Ltd., 1999 2. "Clinical Pathology". Volume 2, edited by Professor Grigor Velev, publishing "Knowledge" Ltd., 2002 3. "Atlas of histopathology," Prof. Hristo Milenkov Dr. Ivanka Peeva, 1995 Учебна програма за специалност “Медицина” 220

4. "Guide to practical exercises in pathological anatomy" edited by Prof. Alexander Georgiev publisher "Medicine and Physical", 1993 5. Workbook "Practicals in general pathology" edited by Prof. Benjamin Anavi, Department of General and Clinical Pathology, Medical University Plovdiv, 2011 6. Workbook with training CD "Practicals in clinical pathology" edited by Prof. Benjamin Anavi, Department of General and Clinical Pathology, Medical University Plovdiv, 2011

Accepted by the Departmental Board Meeting № 7 / dated 8.09.2010

List of preparations for the final microscopic test of General Pathology Medics III course

1. Liver steatosis 2. Liver steatosis - Sudan III 3. Coal dust in lungs 4. Haemosiderosis in lungs - H.E. 5. Haemosiderosis in lungs- Perls 6. Jaundice (liver) 7. Jaundice (kidney) 8. Common mole 9. Mucoid degeneration of cuspid valves – Toluidine Blue 10. Corpus albicans ovarii 11. Hyalinosis of small arterioles in kidney 12. Arterial hypertension (brain) 13. Amyloidosis (kidney) - H.E. 14. Amyloidosis (kidney) - Congo rot 15. Amyloidosis (spleen) 16. Ureic acid tophy 17. Coagulative necrosis in spleen (Infarctus ischaemicus lienis) 18. Liquefactive necrosis in brain (Infarctus ischaemicus cerebri) 19. Steatonecrosis pancreatis 20. Hypertrophy of myocardium 21. Hyperplasia of mucosal endometrial glands 22. Hyperplasia of prostatic glands 23. Bown atrophy of liver 24. Cyanotic liver 25. Nutmeg liver 26. Punctual hemorrhages in brain 27. Edema in skin 28. Lung edema 29. Mixed thrombus 30. Anemic infarction in kidney 31. Haemorrhagic infarction in lungs 32. Fibrinous pericarditis 33. Purulent leptomeningitis

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34. Phlegmonous appendicitis 35. Absceding myocarditis 36. Granulation tissue 37. Nasal Polyp 38. Foreign body granuloma 39. Echinococcus hepatis (Hydatid cyst) 40. Lymphadenitis tuberculosa 41. Mesaortitis luetica 42. Actinomycosis 43. Scarring in myocardium (Cicatrix myocardii) 44. Struma lymphomatosa (Hashimoto thyreoiditis) 45. Papilloma in oral cavity 46. Basal cell carcinoma 47. Squamous cell carcinoma 48. Transitional cell carcinoma 49. Pleomorphic adenoma of parotid gland 50. Adenocarcinoma in stomach 51. Lipoma 52. Haemangioma cavernosum (liver) 53. Haemangioma capillarae (skin) 54. Leiomyoma uteri 55. Leiomyosarcoma 56. Mature (adult) teratoma

Description of macroscopic preparations for the final test of General Pathology –Medical students III year

1. Fatty degeneration of liver. Part of the liver with a smooth, shiny and taut fibrous capsule. The cut surface is homogeneous with orange-yellow color - diffuse fatty degeneration (steatosis) of the liver. 2. Antracosis of lung. Lungs with a characteristic mosaic appearance. Under the visceral pleura is seen through the gray to black in color pigment - coal dust accumulated in the form of stripes and spots. Such are the changes in the peribronchial lymph nodes visible on lung chilus. 3. Arteriolosclerotic nephrosclerosis. Kidney show relatively symmetrical changes - slightly reduced size and increased consistency. The surface is uniformly finely granular. In view of the cut surface it is evident that the parenchyma is mainly at the expense of the chilus. Fat in the chilus is increased. The finding reflects changes in the kidney in benign hypertension. 4. ‘Glazed’ spleen. The surface of the spleen shows a thick uneven with gray-white color, hyaline-like material deposited on capsular surface and covering the organ as a glaze. The cut surface is unchanged. 5. Pinpoint hemorrhages in the white brain matter. In shear surface of the cerebral hemispheres in the white brain matter showing scattered red-brown spots, the size of which ranges from 1-2 mm to 5 mm in diameter. 5. Sago spleen. Part of the spleen, the organ diagnosis is based on the presence of smooth and stretched capsule. In shear surface showing small-sized simple (sago) spots with whitish color merging together and forming focal deposition in the lymph follicles (white pulp) of amyloid. Surrounding red pulp is homogeneous with gray-yellowish color.

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7. Amyloid nephrosis (large white kidney). Presented is a highly enlarged kidney with a waxy texture and a whitish color. Its surface is completely smooth. Crossover cortex is strongly enhanced by the boundary between it and the pyramids is relatively deleted. Pyelo-calyx system is unchanged. 8. Ischemic infarction of spleen. Part of the spleen, suggested by the existence of a smooth and extended capsule, below is seen the trabecular structure of parenchyma. Subcapsularly, there is an area measuring 4 / 3 cm, with triangular shape whose apex is directed to chilus, slightly prominating with deleted structure and whitish-yellow color (coagulation necrosis). That area is separated from the surrounding tissue by brown-red band (hyperemic-haemorrhagic area). 9. Ischemic infarction of kidney. In renal shear surface in the lower pole, showing whitish-yellow areas with irregular shape, well delimited from the surrounding intact tissue by brown-red band (hyperemic-haemorrhagic area), slightly prominating. 10. Ischemic infarction of the brain. Part of the brain, a cut surface that appears gray area of liquefaction with a size 2 / 2 cm finely cystical structure transition into the surrounding tissue. Cerebral vessels visible under leptomeninges are haemorrhagic. Visible scars and swelling namozachen – massively depressed folds with shallow grooves between them. 11. Brain with pseudocyst. Cross-section through the hemisphere of the brain hemisphere. In the right hemisphere, a unicameral pseudo cystic formation is evident (cavity without epithelial lining) with yellowish smooth walls, with a size about 4 / 3 cm The rest of the brain tissue has an increased volume (swollen). Apparent is dislocation of the medial line towards the left hemisphere. 12. Lymph node in tuberculosis. Highly enlarged lymph node - 4,5 / 3 cm, with smooth, taut fibrous capsule. The cut surface is variegated, lobular, with irregular dry yellowish areas of caseous necrosis. 13. Gangrenous toe. Preparation of the left foot. The skin of the thumb showing necrotic changes. Rear surface of the skin is dark brown in color without well-defined line of demarcation. 14. Acute necrotizing pancreatitis. Highly enlarged pancreas - size 18/10/4 cm thick with texture and pale color. The external and cut surfaces are highlighted - different shape and size fields soaked with blood turns orange-yellow necrotic fields and such, looking like ‘chalky spray’ - steatonecrosis. 15. Hypertrophy of the left ventricle. Presented is the left ventricle of the enlarged heart. Valvular apparatus is intact. Myocardium is thick- over 15 mm and the cavity is dilated (eccentric hypertrophy). Shown are massive endocardial papillary muscles and trabeculae. 16. Prostatic hyperplasia with calculi of urinary bladder. Preparation of bladder prostate, the latter is strongly enlarged. External shear and its surfaces are rough, nodular. Initial part of the urethra is very narrow. The bladder is a mucous rough terrain due to thickening of the muscle fibers in its wall. In the cavity of the bladder is a concretion the size of olive, brown in color. 17. Hydrocephaly. Cut through both hemispheres. Both lateral ventricles are severely dilated, forming a cavity among the brain tissue with total 12 / 8.5 cm, with smooth inner surface. Adjacent white brain matter is atrophic. The brain pons is preserved. It is internal hydrocephaly. 18. Nut-meg liver. Part of the liver highly variegated cut surface due to the presence of numerous dark brown-red small and large spots, which merge in places surrounded by grayish yellow fields. The changes are diffuse and are the result of chronic venous stasis.

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19. Brain hemorrhage. Section of brain, with a clearly visible distinct, rounded, brownish-red area in the white brain matter demarcated from the surrounding tissue - hematoma. 20. Brown induration with haemorrhagic infarcts of the lung. The lungs were increased in size, sealed. Its shear surface is showing well-delimited areas airless triangular-shaped, dark red-brown, slightly protruding. Environmental lung tissue is brown with a rusty hue - brown induration. Visceral pleura is smooth and evenly stretched, fireplace, dim the sections above infarctions. 21. Obturating thrombus in abdominal aorta. Abdominal aortic bifurcation with both iliyaca arteries is presented. a large thrombus obstructing the lumen with pale color - "riding" thrombus. In view of the upper part of the preparation, over the thrombotic mass, the aorta intima is covered with complicated atherosclerotic plaques. 22. Round thrombus in left atrium. Preparation of the heart, including incoming tract of the left ventricle, mitral valve and left ventricle. Valves layers are thickened, gray-white, with an uneven surface, deformed, shortened and fused with each other - a combined heart defect - stenosis and insufficiency, predominantly stenosis. Left ventricle is significantly enlarged with hypertrophic myocardium and endocardium is thickened and whitish. In the lumen is seen a large circular thrombus. The left ventricle is small (atrophy by inactivity) and appears as an appendage of the atrium. 23. Fibrinous pericarditis ("Armoured" heart). Preparation of the heart with a significantly enlarged size ("buffalo" heart). In epicardium, grayish- whitish deposits appear with a thickness of 2-3 mm. covering the entire heart. 24. Pneumonia crouposa. Guide to diagnosis is lung organ chilus, which is visible at the rear of the preparation. The cut surface shows that both lobes are evenly diffuse greyish with fine granular structure. Density creates an impression that the edges between the two cut surfaces are very well defined (stage of gray ‘hepatization’). Fine whitish coating of fibrin in visceral pleura is seen. 25. Purulent leptomeningitis. Head brain with polished edge - the folds are broad and flat and gyri between them were shallow. Blood vessels are dilated and haemorrhagic. By convexity there is a heavy white purulent exudate, located subarachnoidal, filling gyri and spreading on the folds. Pia mater is thickened and opaque. 26. Phlegmonosal appendicitis. Appendix with thickened, swollen wall. Serosa is uneven, covered with dirty grayish bloom. Lining is the same color. 27. Echinococcus of the liver (Hydatid cyst). Organ diagnosis is made in view of the rear surface of the preparation, where a partially removed Glisson’s capsule shows the hepatic parenchyma. There is a large cystic formation measuring 9.5 / 5.5 cm, distinct from the surrounding tissue by fibrous capsule. Inside, thin cystic structure with a milky color soft and friable - chitin membrane of Hydatid cyst. 28. Postinfarction chronic heart aneurysm with mural thrombosis. Enlarged heart with an open left ventricle. Subepicardially, excessive fat is seen. Its wall is slightly thickened, hypertrophic, and the cavity is dilated. In the area of the apex, the heart myocardium is whitish, sealed and significantly taper - chronic aneurysm. In endocardium in this area there is mural lobular gray-brown mass with whitish stripes - thrombus. 29. Lung cancer. Lungs with signs of anthracosis. Top shows a large tumor formation - 7,5 / 6 cm, whitish, poorly demarcated, with a central fission of tissue originating from the wall of the main broncus - mostly exophytic bronhogenic cancer. 30. Gastric cancer - ulcerative form. Material from the stomach with smooth mucosa because of atrophic changes. In the field of small curvature, a rounded tumor formation is seen with sunken central part and raised, not better contouring soft edges. The bottom is colorful - showing necrotic areas, hemorrhage, inflammatory deposits. Учебна програма за специалност “Медицина” 224

31. Colon cancer. Part of the colon with available exophytic, nodular, tumor formation, increasing broad-based, measuring 3.5 / 3,5 cm, with central ulceration. The bottom was unequal, with a whitish color, and the raised edges with the color of environmental mucosa. 32. Lipomas. Split encapsulated tumor formation with a total size 7/6/4, 5 cm. The cut surface is homogeneous, yellow, because tumor grew mature fat. 33. Cavernous haemangioma of liver. Organ diagnosis is made by the presence of smooth fibrous capsule and preserved nodular array. In the middle of the preparation is clearly visible distinct bluish-black area with a spongy structure - a cavernous haemangioma. Neighboring liver tissue shows signs of fatty degeneration. 34. Uterine leiomyomas. Complex of vagina, cervix and uterine body. Uterus is very enlarged. It starts about 10 large cm. tumor formation, relatively well-delimited, off-white, with nodular cut surface. 35. Metastases from malignant melanoma in the liver. Material from liver, cut surface on which are visible numerous large rounded foci with dark brown to black, sharply contrasting with preserved liver parenchyma - metastatic malignant melanoma. 36. Mature teratoma of the ovary. Enlarged and deformed ovary. Unicameral cystic formation with traces of ‘porridge- like’ content, , brownish in color about 1 cm in diam. lesion on its wall with a rough surface and well-formed teeth - cystic teratoma.

Description of macroscopic preparations for the final test in clinical pathology - IV year medical students

1. Arteriolosclerotic nephrosclerosis. The kidneys are slightly reduced in size and diffusely thickened texture. The surface is uniformly as "grain" sizes are 1-2 mm which correspond to hypertrophic (regenerative) nephrons. Renal cortex tapered. Fat in the chilus is secondarily grown. The finding reflects changes in the kidney in benign hypertension. 2. Hypertensive heart. Open is the left chamber of the enlarged heart with an intact aortic valve. Myocardium is hypertrophic (thickness at the base of the flap is over 15 mm). Papillary muscles are massive, rounded and with prominant trabeculae in the cavity. Outlet tract (distance between heart and aortic valve peak) is extended. The cavity of the left ventricle is reduced - concentric hypertrophy. It is about working pathological hypertrophy in arterial hypertension. 3. Atherosclerosis of the aorta. Abdominal aortic bifurcation with a iliyaca arteries. The intima is a colorful and grossly unequal because of outbreaks and prominent yellowish thick whitish areas that narrow and deform lumens. calcium deposits (calcinosis degenerative) and erosion of the surface is seen. Distally, there is mural thrombotic deposition (uneven dark brownish-red mass above bifurcation). 4. Recent myocardial infarction. The cut surface of the myocardium of the posterior wall of the left ventricle. Visible extensive area of irregular shape, deleted fascicular structure and clay-yellow (coagulation necrosis), with distinct peripheral dark red stripe (hyperemic-haemorrhagic area). The latter is around the transmural infarction. 5. Postrheumatic fibrous endocarditis of mitral valve (combined heart defect) . Preparation of the heart, including incoming tract of the left ventricle, mitral valve and left ventricle. Valves layers are thickened, gray-white, with an uneven surface, deformed, shortened and fused with each other.-combined heart disease - stenosis and insufficiency, predominantly stenosis. Left

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ventricle is significantly enlarged with hypertrophic myocardium and endocardium thickened and whitish in color. 6. Ulcero-polypotic endocarditis. Outgoing tract of the left ventricle. One of the sails of the aortic valve with ulceration and another with thrombotic deposits that have polypoidal appearance. Left ventricle is thickened, the cavity is dilated. Papillary muscles were thickened, with marked structure. 7. Fibrinous pericarditis. Significantly enlarged heart size - "buffalo" heart (cor bovinum). The visceral pericardial sheet (epicardium) shows grayish-whitish, sometimes ‘velvet’-like coating with a thickness of 2-3 mm, covering the whole heart . 8.Bulosal emphysema of the lungs. Lung increased in volume, but reduces its weight. Thin bodies with transparent walls, filled with air (bullae) are seen in the upper and lower lobe. The background ispale gray-pink to gray-white parenchyma showing abundant deposits of anthracotic pigment, imparting a characteristic mosaic variegation on the surface. Combination of atrophy (pseudohypertrophy) and exogenous pigmentation. 9. Absceding pneumonia. Lung, covered with smooth, slightly dim, intense visceral pleura, showing numerous airless areas with dense grayish color and texture - lobular pneumonia. Their size varies from millimeters to several centimeters. In many places nearby inflammatory foci merge - confluent pneumonia. These changes are detected also sub-pleurally. 10. Silicosis of the lung. The lungs are increased in volume, solid. Visceral pleura is tense and below shows deposition of anthracotic pigment. The cut surface is diffusely airless, compact, grayish, covered with small whitish nodules or fields the size of ‘millet’ grains. 11. Lung cancer. Lung, in which chilus a nodular tumor formation is seenwith a size about 10 cm emanating from a wall of the bronchus and sprouting into the surrounding lung tissue. The tumor infiltrates the visceral pleura. 12. Diverticulitis of the esophagus. Preparation of the esophagus, the upper half of which shows saccular extension of its wall, with communicating lumens – pulsating diverticulitis. 13. Acute ulcers of the stomach. Stomach with smooth, atrophic, mucosa. Shown are several shallow ulcers with a round shape, sizes from 1 mm to 2 cm, with slightly raised edges and a smooth hollow bottom with black color. 14. Chronic gastric ulcer with perforation. In the small gastric curvature seen ulcerative defect with irregular oval, raised, solid and well- contouring edges. In depth defect is funnel shaped and ends with perforatsionno opening. Well seen lining overhang on one side and stapaloobraznostta by the other. 15. Gastric cancer. Part of the stomach wall which is engaged by exophytic tumor with rounded shape, gray-whitish in color and shaped with a central ulcerative defect. Its edges are rounded, succulent, wavy raised and vaguely defined. Neighboring mucosa is flat, the folds are not seen- atrophic gastritis. 16. Micronodular liver cirrhosis. Preparation of liver. Its fibrous capsule is slightly thickened with a dull color. The outer surface is uneven, dotted with identical knots. The cut surface showed normal liver lobular pattern. Diffusely scattered nodules with a size of lentil to a pea stand out above the hepatic parenchyma. Among them there are dents of connective tissue that separate them. 17. Cholelithiasis. Dilatated gallbladder wall with a tapered polished mucous. A single rounded concretion with a brownish color and uneven surface is presented in its lumen.

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18. Non-Hodgkin's malignant lymphoma. Fragment of the trachea and part of ascending aorta with her trunk out of vessels. The two bodies are prorastnati the periphery of highly enriched, and sivkavobeleznikavi srastnali packages in lymph nodes with uniform structure. 19. Porphyry spleen (disease Hodgkin). Highly enlarged spleen with a longitudinal length about 18 cm, dark brown in color. Subkapsularno and cut her face are visible off-white nodular structures (tumor infiltration) with sizes of up to lentil beans, imparting a characteristic diversity of the body. 20. Sclerosing glomerulonephritis. The two kidneys are symmetrically reduced in size. Their fibrous capsule is fixed to the underlying tissue. The surface is granular, homogeneous. The color is grayish and the consistency with increased density. Crossover cortex is atrophic. Fat has grown secondarily In in the chilus. Kidney of the "final stages" - output from various types of glomerulonephritis. 21. Calculosal chronic pyelonephritis. Both kidneys were cut along the outer edge and open. The outer surface is uneven with small retention cysts and extensive shallow depressions with grayish-brown bottom. The cut surface is dominated by theexpansion and deformation of pyelon and calices. At places, the atrophic process is particularly strong and parenchyma remained as a thin strip - significant hydronephrosis. 22. Polycystic kidney. Strongly and equally enlarged kidneys with longitudinal length about 20 cm Their color is white, the capsule is tense. The surface is very uneven because of numerous thin-walled cystic formations in size from 1 to 3-4 cm, filled with clear contents. There is severe atrophy of renal parenchyma. 23. Carcinoma of the kidney. Preparation of kidney, in which upper pole large spherical tumor is visible, well distinct from the renal parenchyma by pseudocapsule. The tumor appears to infiltrate the fibrous capsule of the kidney. The cut surface has a cystic appearance, colorful – yellow-gray with bleeding. 24. Prostatic hypertrophy. Preparation of bladder prostate significantly larger at the expense of its three parts. Both side press the narrow urethra, , preventing leakage of urine. The prostate is nodular firm. The bladder has a thickened wall and mucosal rough appearance due to pathological hypertrophy of the muscles. 25. Bladder cancer. Open bladder filled with papillary-polypotic formation of broad-based, infiltrating bladder wall. The surface of the tumor is uneven, covered with short, thick and brittle papillae. 26. Seminoma of the testis. Germ-cell tumor presented in the form of nodular mass, poorly demarcated from the testis which has increased in size. The color of the tumor is gray-white, the surface is smooth, homogeneous. 27. Tubal abortion. Fallopian tubes significantly dilated and strongly thickened wall. in the middle part a rupture is seen soaked with bloody matter. Separately presented is the embryo, length about 1.5 cm, wrapped in a sac. 28. Molar pregnancy. Contents of the pregnant uterus without embryo. Uterine cavity is filled by a mass resembling a semi-dry grapes - bubbles with sizes and lentil seeds, brownish in color, captured in thin stalk. These

are the chorionic villi undergoing hydropic degeneration. 29. Carcinoma of the cervix. Preparation of the uterus with cervix. The latter is fully covered and distorted by nodular, gray-white tumor formation with unclear boundaries. In the cut sections infiltrative growth is seen- whitish tumor strands, sprouting in myometrium and cervix. In almost all cases histologyl shows squamous cell carcinoma.

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30. Carcinoma of the endometrium. Uterus with the adnexa. The front third of the uterine body shows exophytic tumor mass with papillae, gray-whitish in color, with fields of bleeding and necrosis originating from the endometrium and spreading to the fundus and cervix. Histologically, the most common type is that

of adenocarcinoma. 31. Krukenberg metastases in the ovaries. Bilateral cystic ovarian metastases from primary tumors of the digestive system (stomach, colon), breast and others. The ovaries are highly increased in size, deformed, with a smooth, nodular surface.

Dense consistency and gray-white color. 32. Breast cancer. Among the fatty tissue of non-lactating mammary gland is found a thick, nodular formation with irregular contours, apparently infiltrating the surrounding tissue (skin and fat). The cut surface is white, slightly depressed and finely granular. The surrounding skin resembles ‘orange peel’. Histologically, the most common types are ductal or lobular carcinoma. 33. Tongue in acromegaly. Increased levels of growth hormone in adults, most commonly due to pituitary adenoma, lead to viscero-megaly. The tongue is enlarged significantly above the norm. Furthermore, hypertrophic

taste papillae are seen, making the surface uneven and rough. 34. Nodosal goitre. Significantly increased in volume thyroid gland. Presented are hyperplastic nodules of different size, each separated with whitish connective tissue strands. The color and consistency of units vary depending on the secondary change. They can be: - Cystic – light-brown filled with jelly-like colloid; - Dark brown to black in hemorrhages; - Whitish and very dense in cartilage and bone degenerative metaplasia and calcinosis. 35. Diabetic glomerulosclerosis. The kidneys are reddish brown in color and slightly enlarged, unlike vascular nephrosclerosis. The cortex is finely granular and its border with the pyramids does not appear well. 36. Glioma. Presented is a section of large hemispheres. The cut surface shows solid tumor formation measuring 4.5 to 6 cm, slightly outstanding from the surrounding normal tissue, gray in color, dense, non- infiltrating. The two hemispheres are asymmetric. 37. Meningioma. Preparation, including the brain and brain dura. Derived from the latter, round, encapsulated, well- delimited tumor with gray-yellowish color is seen. In the cortex, the area adjacent to the tumor shows deep depression - atrophy of pressure. 38. Neurinom of n.statoacusticus. Preparation of brain-oriented from the basal surface. In the left Ponto-cerebellar angle is clearly visible distinct tumor with a slightly uneven surface, gray-pink. The tumor pushes and distorts brain hemisphere and the pons. 39. Tuberculous leptomeningit. Preparation of brain-oriented from the base. The soft meninges in the area of the brain and the bridge feet are swollen, turbid, with yellowish granular fibrinous exudate. 40. Fibrocavernous tuberculosis of the lung. Part of the upper lobe of the lung. From the lung chilus are seen large cavities (caverns) with fibrotic walls and uneven inner surface. Lower cavern is drained by a large bumper (round hole). In lymph nodes, which are slightly enlarged, yellow-gray fields are visible of caseos necrosis and anthracotic pigment. The amendments represent one of the forms (phases) of secondary pulmonary tuberculosis. 41. Tuberculosis of the kidney. The cut surface of the kidney with several broken pyramids which parenchyma is replaced by white- yellow fragile substance (caseous necrosis). The process started in the outer medulla and is ahead in the direction of the papillae, two of which are with ulcerative changes. It is a type of extra- Учебна програма за специалност “Медицина” 228

pulmonary tuberculosis with hematogenous localization.

42. Luetic aneurysm of the aorta. The preparation shows the output tract of the left ventricle and the ascending part of aorta. Just above the aortic valve, the aorta is enlarged and saccular- saccular aneurysm. Intima is uneven, with many different yellowish plaques - the picture looks like bark. Pathological process has damaged the cuspids of the aortic valve - insufficiency has developed. The cavity of the left ventricle is significantly enlarged and its walls are thickened - eccentric hypertrophy.

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CLINICAL IMMUNOLOGY

Course of education: 4th course Semesters of education: VIIIth semester Exam: After VIII semester Total: 36 hours Examinator: Prof. Marianna Murdjeva, MD, PhD

Plan of education

Horarium Type of studies Credits Weekly VІІІ sem. Total Lecture 9х2 18 18 Practical exercises 9х2 18 18 1,5 Total 36 hours 36 hours

ANNOTATION: The clinical immunology is a study discipline with an interdisciplinary character. The students are acquainted with the mechanisms of innate and acquired immunity; with the changes of immune status parameters and their clinical meaning; congenital and acquired immunodeficiency conditions and diseases; hypersensitivity reactions; autoimmune reactions and diseases; tumor immunology; transplant immunology; reproduction violations; infectious immunology.

AIM OF DISCIPLINE: The aim of education in clinical immunology is to prepare medical doctors, competent to make a diagnosis, provide treatment and prophylaxis of immunopathological conditions and diseases.

TASKS OF THE DISCIPLINE:

1. Students are introduced to the discipline clinical immunology; the role between other disciplines is underlined; the meaning to general medicine as well. 2. Acquaintance with the most important aspects of immune response and its changes, leading to diseases. 3. Mastering of principles, main point and clinical meaning of immunological tests for diagnosis. 4. Learning of indications for immunomodulation therapy, drug monitoring, monitoring of activity of immune disease.

METHODS OF EDUCATION: lectures, practical exercises, seminars, circle groups

TECHNICAL EQUIPMENT APPLIED IN EDUCATION: multimedia, microscopes, slide show, immunological appliances.

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CONTROL AND EVALUATION:  Continuous control – oral examining, tests, seminars;  Final control – entrance test, written exam, oral exam

METHODS FOR CONTROL OF KNOWLEDGE: tests, clinical cases, oral examination OBLIGATORY COMPETENCES:  Тheoretical knowledge of students – to know:  mechanisms of humoral and cell immune response – in health and disease  innate and acquired immunodeficiency conditions and diseases  mechanisms of hypersensitivity reactions  mechanisms of autoimmunity and autoimmune diseases  immnunity against tumors  different reactions of transplant rejection  immune violations in cases of reproductive failure  development of immunopathological reactions in cases of infections  different immunomodulative drug therapy  indications for immunological examination

 Practical skills of the students:  Performance, and interpretation of skin tests  Interpretation of the test results for detection of immune status in vivo and in vitro.

LECTURE PROGRAM LECTURE №1 - 2 hours: Clinical immunology. Innate immunity. The subject and tasks of clinical immunology. Short historical overview and parts of clinical immunology. Innate immunity – definition and mechanisms. Mechanical barriers – skin, mucous membranes, normal flora. Cell factors of innate immunity. Phagocytosis – stages, clinical meaning, methods for detection of phagocyte activity and its violations. Antibody-dependent cell-mediated cytotoxicity. Humoral factors of innate immunity – complement, lysozyme, interferons, acute-phase proteins. Clinical meaning and methods for detection. Toll-like receptors and ligands. Inflammation – defense and pathological reaction.

LECTURE №2 - 2 hours: Adopted immunity. Immune system. Development of immune response. The immune system – a base of immune response. Anatomy and structure: immune organs (central and peripheral); cells (populations, subsets, markers and functions); molecules (of the cell interaction and antibodies); HLA genes and products. Stages of immune response. Types and forms of immune response, depending on the antigen (development of immune

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response against extracellular and intracellular antigens). Dynamics of immune response - primary and secondary. Immune memory. Regulation of immune response.

LECTURE № 3 - 2 hours: Immunodeficiency conditions and diseases. AIDS Innate immunodeficiencies of phagocytic system. Innate immunodeficiencies of complement system. Angioedema hereditaria. Innate immunodeficiencies of humoral immunity. Innate immunodeficiencies of cell-mediate immune response. Combined immunodeficiencies. AIDS.

LECTURE № 4 - 2 hours: Allergy. Allergens – definition, types. Classification of allergic reactions. Anaphylactic and atopic reactions and diseases. Immunological methods for diagnosis. Principles of therapy. Cytotoxic allergic reactions and diseases. Hemolytic disease of newborn. Immuno-complex allergic reactions and diseases. Infectious allergy.

ЛЕКЦИЯ №5 - 2 hours: Autoimmune reactions and diseases. Immunological tolerance. Mechanisms of interruption. Organ-specific autoimmune diseases – basic immunological characteristics and manifestations. Organ-nonspecific autoimmune diseases – immunological characteristics and manifestation of systemic lupus erythematodes, rheumatoid arthritis, systemic sclerosis, dermatomyositis/polymyositis, systemic vasculitis. Th1/Th2 immune response in pathogenesis of autoimmune diseases. Diagnosis and treatment of autoimmune diseases. Immunological tests in organ-nonspecific autoimmune diseases. Antinuclear, anti-cardiolipin antibodies, rheuma factor. Immunological tests in organ-specific autoimmune diseases. Antimitochondrial, anticytoplasmic, antithyroid antibodies. Principles of immunomodulative treatment in autoimmune diseases.

LECTURE №6 - 2 hours: Tumor immunology. Mechanisms of induction of tumour growth. Immune response against tumor. Immnunological diagnosis in lymphoprolypherative diseases. Tumor markers. Slipping out of tumor growth from immune response.

LECTURE №7 - 2 hours: Transplantation immunity. Reproductive immunity. Tissue compatibility. HLA system – genes and gene products. Immune response after transplantation. Rejection reactions – accelerated, hyperacute, chronic. Immnunological mechanisms. Immunological tracing of transplanted patients. Immunomodulative therapy in transplanted patients. Immunological mechanisms in reproduction. Immunological paradox of pregnancy. The meaning of HLA-G. Reproductive irregularity – abortion, sterility. Types of immunological examinations. Directions to immunotherapy.

LECTURE №8 - 2 hours: Infectious immunity. Role in case of bacterial, mycotic and viral infections. Special features of immune response in bacterial infections. Immunity in viral infections. Immune response in mycotic infection. Immune response in parasitic infections.

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LECTURE №9 - 2 hours: Immunological prophylaxis and immunotherapy. Active and passive immunoprophylaxis. Vaccines and sera. Contemporary directions in immunotherapy. Immunomodulators – natural and artificial. Immunostimulators – types and indications. Immunosuppresive resourses – types and application.

PROGRAM FOR PRACTICALS

EXERCISE №1 – 2 hours: Laboratory methods for examination of humoral immune response. DEMONSTRATION OF: Agglutination reactions – agglutination type Widal; latex agglutination; hemagglutination; passive hemagglutination and hemagglutination inhibition. Precipitation and immunodiffusion techniques – single radial immunodiffusion and Ouchterlony immunodouble diffusion. Nephelometry for measuring the quantity of different classes of immunoglobulins and complement. ASO reaction and its interpretations. Complement fixation test (CFT). Immunofluorescence assays – direct (IFA) and indirect (IIFA) for autoantibodies – types of fluorescence. ELISA (enzyme – linked immunosorbent assay) – principle, variants, instruments for reading. PRACTICAL TASKS: Reading: agglutination type Widal reaction, Waaler-Rose, ASO, passive hemagglutination, hemagglutination inhibition, CFT. Interpretation of results. Reading IFA and ELISA. Performing and reading latex agglutination test. EXERCISE №2 – 2 hours: Laboratory methods for examination of cellular immune response. DEMONSTRATION OF: Phagocytosis – phagocytic index (FI) and phagocytic number (FN). NBT (nitroblue-tetrazolium) test. Immunophenotyping of T, B and NK cells with FACS (fluorescence – activated cell sorter), using flow cytometric technique – principle. PRACTICAL TASKS: Reading: NBT test, FI and FN. Interpretation of the FACScan results of a patient with AIDS. EXERCISE №3 – 2 hours: Immune status and monitoring. Molecular diagnosis in clinical immunology. DEMONSTRATION OF: Different patterns of immune status. Minimal panel for identification of lymphocyte subsets, using flow cytometry. Interpretation of histograms. PRACTICAL TASKS: Counting white blood cells (leucocytes) in differential cell count preparation from peripheral blood, stained by Romanovski-Giemsa. Determination of FI and FN in a smear from peripheral blood plus staphylococcal suspension, stained by Romanovski- Giemsa. Reading NBT test (peripheral blood smear, stained with neutral-red). Analysis of CD3+, CD4+, CD8+, CD19+ and CD56+ subsets after flow cytometry. Discussion on clinical cases in immunodeficiency disorders.

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EXERCISE №4 – 2 hours: Immunologic methods in allergy. Test on practicals 1,2,3. DEMONSTRATION OF: Bioproducts for in vivo diagnosis of hypersensitivity. ELISA devices for in vitro diagnosis of allergic diseases. PRACTICAL TASKS: Performing Mantoux (tuberculin skin) test on guinea pig. Presentation and discussion on clinical cases in allergic diseases. EXERCISE №5 – 2 hours: Immune tests for detection of autoantibodies in organ non-specific autoimmune diseases. DEMONSTRATION OF: Algorythm for immunological examination of autoantibodies in antibody-mediated autoimmune diseases of the connective tissue. Indirect immunofluorescent test for establishing of ANA, using HEp2 and McCoy-Plovdiv cell lines as substrates. Types of fluorescence. ELISA test, used for detection of autoantibodies in systemic autoimmune diseases (anti-ds DNA, anti-Sm, anti-CCP, anti-CL, anti-beta 2 GP1). Waaler-Rose reaction. PRACTICAL TASKS: Reading different types of fluorescence on cell line substrates. Interpreting the results for ANA. Reading and interpretation of Waaler-Rose reaction and ELISA in patients with Systemic lupus erythematosus (anti-ds DNA, anti-Sm), Rheumatiod arthritis (anti-CCP, RF) and Antiphospholipid syndrome (anti-CL, anti-beta 2 GP1). Presentation and discussion on clinical cases. EXERCISE №6 – 2 hours: Immune tests for detection of autoantibodies in organ- specific autoimmune diseases. DEMONSTRATION OF: The most common autoantibodies in some organ-specific autoimmune diseases (tables). ELISA tests for TAT and MAT. IIFA for detection of AMA (on rat’s kidney and McCoy-Plovdiv cell line) and ASMA (on rat’s stomach). ELISA for detection of organ-specific autoantibodies: anti-GBM, anti-LKM1, anti-thyroglobulin and anti-TPO. PRACTICAL TASKS: Reading IIFA for AMA and ASMA. Describing the type of fluorescence for AMA on cell line substrate. Reading ELISA for anti-LKM1 and anti- thyroglobulin antibodies, using a plate, patient’s report form and record of proceedings. Interpretation of results. Presentation and discussion on clinical cases. EXERCISE №7 – 2 hours: Immunological diagnosis of tumors. DEMONSTRATION OF: Chest radiography and immunoscintigraphy scan of a patient with carcinoma of the colon. Immunohistochemistry of biopsy specimen (thyroid gland). Flow cytometry of T, B and NK cells from a patient with lymphoproliferative disease. Monitoring of hormones, linked with some tumors. Detecting monoclonal immunoglobulins – M protein in Multiple myeloma and Bence-Jones protein in urine, using immunoelectrophoresis. Humoral immune response to tumors (anti-EBV antibodies in Burkitt’s lymphoma). PRACTICAL TASKS: Discussion on clinical cases.

Study programme Medicine specialty 234

EXERCISE №8 – 2 hours: Examination of tissue and blood-borne histocompatibility. Transplantation immunology. Test on practicals 4, 5, 6, 7. DEMONSTRATION OF FIGURES AND TABLES ON: 1. Serological detection of HLA – incompatibility A/ Lymphocytotoxicity test B/ Flow cytometry 2. Mixed lymphocyte culture 3. Molecular methods – PCR, RF LP (Restriction fragment length polymorphism) PRACTICAL TASKS: Discussion on clinical cases. EXERCISE №9 – 2 hours: Seminar. Test on practicals 1-8

SYNOPSIS

1. Clinical Immunology. Subject and parts – general characteristics. Basic humoral and cellular mechanisms for development of defense and immunopathological reactions. 2. Innate immunity. Comparison with adaptive immunity. Factors of innate immunity – mechanical barriers, cellular and humoral factors. Clinical significance of innate immunity mechanisms. The inflammation as a defense and pathological process. 3. Adaptive immunity and immune response. Immune system – the basis of immune response. Anatomy and structure of the immune system – immune organs (primary and secondary), immune cells (populations, markers and function), molecules (cytokines and antibodies), HLA genes and their products. 4. Development of immune response. Stages of the immune response. Types and forms of the immune response according to the antigen (immune response against intracellular and extracellular antigens). Dynamics of the immune response – primary and secondary immune response. Immune memory. Regulation of immune response. 5. Infectious immunology. Immune response in bacterial, viral, mycotic infections. 6. Immune deficiencies. Definition and origin.Immunological characteritics of primary and secondary immune deficiencies. Syndromes and diseases. 7. Allergy. Terms. Types of alleregens. Types of allergic reactions – characteristics, mechanism of tissue damage, diseases and syndormes – examples. 8. Autoimmune reactions and diseases. Terms. Immune tolerance – definition, underlying mechanisms and immune processes for its maintenance. Causes and mechanisms for development of autoimmunity. Types of autoimmune diseases – organ-specific and non-organ specific. Immunological characteristics. 9. Tumor immunology.Tumor antigens. Immunological mechanisms against tumors. Immunological diagnosis of the tumor diseases. Anti-tumor immune prophylaxis and immune therapy – basic approaches.

Study programme Medicine specialty 235

10. Transplantation immunity. The role of MHC molecules in transplantation.Post- transplantational immune response – types of reactions and mechanisms; graft versus host disease. Pre- and posttransplantational immune monitoring.Haemotransfusion reactions. 11. Reproductive immunology. 12. Immunological methods for testing innate and adaptive humoral factors – tests for complement and other serum proteins (agglutination, precipitation, complement- fixation and labeled immune reactions) – principles, clinical application and interpretation. 13. Immunological methods for testing innate and adaptive cellular factors – tests for phagocytosis and immune phenotyping – principles, clinical application and interpretation.Immune status and monitoring – examples in various immune disorders. 14. Immune modulation – terms and parts. Immune stimulation – specific and nonspecific immune prophylaxis and therapy. Examples and application.

LITERATURE:  Obligate: 1. Lecture course, Prof. Marianna Murdjeva, MD, PhD 2. Roitt`s Essential Immunology, Peter J. Delves, 12th edition, 2011  Advisable: 1. Immunology for medical students, Roderick Narin and Matthew Helbert, 2002

AUTOR OF THE PROGRAMME: Department of Microbiology and Immunology MU – Plovdiv

Study programme Medicine specialty 236

MEDICAL UNIVERSITY- PLOVDIV FACULTY OF MEDICINE

PROGRAMME SCHEDULE IN CLINICAL LABORATORY

for obtaining an education and qualification degree “Master” and professional qualification „Physician”

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CLINICAL LABORATORY

Education course: III course Speciality: Medicine Semester of education: VI semester Examination: after VI semester Workload of the auditorium sessions: 60 hours Lecturer: Habilitated professor and Assistant professor from Dept. Clinical Laboratory

ACADEMIC CURRICULUM Workload of the auditorium sessions Classes Credits weekly V sem. VІ sem. Total Lectures 2 30 30 - Practical exercises 2 30 30 3,1 Total 60 60 4 hours - hours hours

GOAL OF THE DISCIPLINE: To organize and implement optimum education in clinical laboratory to provide medical students preparation of the discipline for a complete, successful and effective work in the medical profession.

TASKS OF THE DISCIPLINE:  Implementation and observing the requirements for preanalytical preparation of the patient and biological material, providing results with high reliability. To know and eliminate errors in preanalytical stage and the possible interference (pharmaceutical, diagnostic and therapeutic procedures) on the results of clinical laboratory analysis.  Creating skills to fully use the capacity of clinical laboratory diagnostics for correct choice of parameters, taking into account the economic aspects of laboratory activities.  Creating a critical attitude towards the individual analytical methods, knowing their advantages and disadvantages.  Creating skills for correct and complete interpretation of the results of clinical laboratory analysis, knowledge of their diagnostic reliability, the correlation between parameters in different diseases, allowing the selection of the most informative combination of indicators.  Learning of close practical skills to perform basic clinical laboratory activities (analysis of urine, microscope smears of peripheral blood, bone marrow, CSF, etc.) which are important for future independent practice. Learning the rules for using tests for express diagnostics. Acquiring skills for solving clinical laboratory tasks after learning the reference range and the correlation between parameters.

TEACHING METHODS: Lectures, practical exercises.  Each exercise begins with a test on previous material  The exercises are held after student's preliminary preparation of announced theme.  The exercises are conducted mainly through dialogue between assistant and students.  Each exercise ends with a solution of appropriate clinical and laboratory tasks, relevant to the material.

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TECHNICAL TOOLS AND EQUIPMENT APPLYING IN TEACHING: Multimedia, computers, microscopes and collections of smears, tables, diagrams, charts, albums, prints of the analyzers, displaying the available modern equipment, specialized library; CD animation to illustrate the principles and methods, documented quality control data.

CONTROL AND EVALUATION:  Current control: The students fill in test on material from previous exercise and lecture and solve problems of the current theme. Tests and tasks are made by individual assistants for various topics and discussed by the Departmental Board. Evaluations of tests, tasks and current testing form assessment for the semester.  Examination: Exam with a test. The test is passive with 20 questions taken from the material of lectures and exercises. By 60 % correct answers to test the student is allowed a theoretical examination. The theoretical exam is written on two questions from the questionnaire of clinical laboratory for the entire group of students. Written examination questions are drawn from one of the students examined. The time for submission of written material on these themes is two hours.

TEST METHODS FOR KNOWLEDGE:  Test from previous exercise and lectures  Solving practical problems associated with interpretation of laboratory constellations  Answering questions related to material from the new exercise  Practical application of acquired theoretical knowledge:  completing the form for clinical laboratory analysis  choice of laboratory parameters  choice of proper type closed system (tube)  microscopy of blood smears

REQUIRED SKILLS: theoretical knowledge and practical skills of the student: 1. The result in clinical laboratory. 1. Be aware of the theoretical basis and practical application of the term “reference range”. Be able to use the reference intervals for interpretation of results. 2. To assimilate main groups of of clinical laboratory parameters. To properly select, order the necessary analysis and fill in the request forms. 3. To know the main types of request forms. To be able to fill in the required information for the patient. 4. To be aware of the possible sources of preanalytical and postanalytical errors in clinical laboratory analysis and the measures to limit them. 5. To know the basic and special requirements for preparing the patient for clinical laboratory testing and be able to apply them in practice. 6. To know the interference from medical procedures and drugs on clinical laboratory results and to apply in practice the measurements for control of this effect. 7. To know and apply the basic rules and requirements, to observe basic procedures and avoid sources of errors in taking of biological material for analysis. 8. To know the requirements for storage and transport of biological material, different types of closed systems for biological material. Selection of the proper tubes for analysis.

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9. To be aware of the principles and rules of internal quality control and external quality assessment. To be able to interpret data from control charts. 10. Have theoretical knowledge and practical skills for dealing with dry tests for qualitative and semi-quantitative analysis of urine. 11. Know the principles of rational ordering of clinical laboratory tests in diagnosis and monitoring of treatment and be able to apply them in practice.

2. Electrolytes and trace elements in blood serum. 1. Know the basic macro- and micronutrients, their biological meaning, metabolism, regultion, indications for analysis. To properly select parameters for assessment of water electrolyte balance. 2. Know the reference ranges of main oligoelements. To properly interpret the results.

3.Haematological parameters. 1. Know haematological parameters, the rules for taking of biological material, indications for analysis for analysis and the reference ranges. To properly interpret the results. 2. Know the maturation lines and being able to recognize microscopically normal cell distribution in bone marrow. 3. Know the main parameters of leukocyte, erythrocyte and platelet line in peripheral blood and their reference intervals, indications for analysis, clinical meaning. Be able to interpret the results. 4. To know the morphological characteristics of leukocytes and be able to make a DBC. To know the morphological characteristics of red blood cells and be able to distinguish microscopically normal from abnormal cell.

4. Red blood cell line abnormalities. 1. To know and be able to select clinical laboratory parameters in red blood cell line disorders: iron deficiency, posthemorrhagic, pernicious and hemolytic anemia. 2. To know the reference ranges of these parameters and to properly interpret the results. 3. To know and be able to recognize the microscopic characteristics of red blood cell line on peripheral blood smear and bone marrow in different types of anemia. 4. To know the laboratory constellations and be able to make differential diagnosis of anemias.

5. White blood cell line abnormalities. 1. To know and be able to select clinical laboratory parameters in white blood cell line disorders: agranulocytosis, leukemoid reaction, acute and chronic leukemia, plasmocytoma. 2. To know the reference ranges of these parameters and to properly interpret the results. 3. To know and be able to recognize the microscopic characteristics of blast cells on peripheral blood smear and bone marrow in acute blast leukemia. 4. To know the laboratory constellations and be able to make differential diagnosis of leukemias.

6. Haemostasis. 1. To know the key stages of coagulation, coagulation plasma factors and inhibitors, laboratory tests and reference intervals. Be able to make interpretation of the results.

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2. To know factors and inhibitors of fibrinolysis. To properly order the necessary tests and make interpretation of the results. 3. To know the main clinical laboratory tests for monitoring therapy with direct and indirect anticoagulants and to determine the therapeutic range. 4. To know and be able to order laboratory tests in DIC syndrome, thrombophilia, hemorrhagic diathesis. 5. To know the informative value and clinical significance of screening tests and to analyze the type and phase of haemostatic disorders by using the received results.

7. Disorders of carbohydrate metabolism. 1. To know basic, extended and specialized analysis of disorders of carbohydrate metabolism in patients with diabetes mellitus. To properly choose laboratory tests according to diagnostic, prognostic and therapeutic need. 2. To know the opportunities of the “fasting glucose” assessment in impaired carbohydrate metabolism, preparation of the patient, to know and avoid interfering factors on the results, reference intervals and interpretation of the results. 3. To know clinical significance of glucose load tests, to order and perform these tests, to properly interpret the results. 4. To know glycated proteins as parameters of therapeutic evaluation in diabetes. Being able to correctly select the optimal parameter for monitoring hyperglycemia for a prior period of time in different types of diabetes.

8. Serum proteins. 1. To know separation methods of serum proteins (electrophoresis and immunoelectrophoresis), their informative value, performance, advantages and disadvantages. Be able to distinguish normal from abnormal results. 2. To know the changes in protein fractions obtained by electrophoresis, basic terminology and interpretation. Be able to match them with the main groups of disorders. To know the acute phase proteins (positive and negative reactants), their biological and clinical significance. To properly select laboratory parameters for inflammatory and neoplastic diseases. 3. To know the meaning of hyperimmunoglobulinemia, polyclonal gammopathy, be able to distinguish polyclonal and monoclonal gammopathy on electrophoresis. 4. To know immunoglobulins, their structure, biological significance, classification, dynamics, synthesis, indications for analysis, reference ranges. Be able to specify groups of diseases in which to order and properly interpret the results.

9. Enzymes. 1. To know the main cellular and secretory enzymes. Be able to make constellations of laboratory parameters and interpret increased blood levels according cell and organ pathology. 2. To know organ and subcellular localization of enzymes (ASAT, ALAT, AP, LDH. HBDH, Amylase, GGT, Cholinesterase, indications for analysis, required biological material, reference ranges. Be able to evaluate results of their analysis in cardiovascular, liver and malignant diseases.

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10. Bile pigments 1. To know the bile pigments in blood and urine, their pathobiochemistry, indications for analysis, reference ranges. To be able to make differential diagnosis between hemolytic, mechanical and parenchimal icterus by the results obtained. 2. Be able to interpret the results of bile pigments analysis in main liver and nonliver diseases.

11. Non-protein nitrogen containing fractions. 1. To know the informative value of urea, creatinine and uric acid. To be able to make proper selection and interpretation of these laboratory parameters in renal diseases. 2. To know the advantages and the way to aviod their disadvantages by examination of renal function.

12. Lipid parameters. 1. To know the requirements for analysis of lipid parameters, risk levels and sources of errors. To be able to distinguish the main types hyperlipidemia using laboratory results.

PROGRAMME OF LECTURE COURSE IN CLINICAL LABORATORY

LECTURE №1 – 2 hours: The analysis and the result in clinical laboratory. Clinical laboratory parameters. 1. The clinical laboratory in the field of medical sciences. Subject and tasks. 2. Analytical reliability of the methods in the clinical laboratory. 3. Reference ranges – populational and individual. 4. Diagnostic reliability of clinical laboratory parameters. Requirements and criteria for diagnostic reliability of clinical laboratory parameters in different diseases.

LECTURE №2 – 2 hours: The clinical laboratory result and its reliability. 1. Reliability of clinical laboratory results. 2. Basic groups of factors affecting the clinical laboratory results. Mechanism of action. 3. The clinical laboratory investigations in the diagnostic process.

LECTURE №3 – 2 hours: Clinical laboratory parameters for evaluation of water-electrolyte exchange. 1. Body water and its distribution in the human body. 2. Osmolality and osmolarity. Methods of investigation. Reference ranges. Result interpretation. 3. Water-electrolyte balance disturbance and its evaluation. 4. Sodium and chloride. Analytical methods, indication of investigation, interferences, reference ranges, result interpretation. 5. Potassium. Analytical methods, indication of investigation, interferences, reference ranges, result interpretation.

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LECTURE №4 – 2 hours: Clinical laboratory parameters’ evaluation of the results of hormonal analysis. 1. Hormonal distribution and analysis. Biological meaning – classification of hormones, interactions and correlations. 2. Pituitary and adrenal (suprarenal) glands hormones’ – methods of analysis, indications for investigation, patient preparation. 3. Valuation of laboratory data and correlations in pituitary and adrenal glands disorders. 4. Thyroid hormones. Methods of analysis, indications for investigation, patient preparation. 5. Valuation of laboratory data and correlations in thyroid gland disorders. 6. Hormones of reproductive system – evaluation of the results of the laboratory analysis.

LECTURE №5 – 2 hours: Clinical laboratory evaluation of the tumor markers investigation. 1. Definition and classification of the tumor markers. 2. Laboratory methods of analysis. 3. The “perfect” tumor marker. 4. The significance of tumor marker investigation in the follow-up and treatment of malignant diseases.

LECTURE №6 – 2 hours: Steps and approaches for choice of clinical laboratory parameters and their interpretation in red blood cell disorders. 1. Basic and extended laboratory tests. 2. Specialized laboratory tests. 3. Assessment of clinical laboratory results in different types of anemia.

LECTURE №7 – 2 hours: Steps and approaches for choice of clinical laboratory parameters and them consideration in white blood cell disorders. 1. Basic, extended and specialized laboratory tests. 2. Flow cytometry – immunophenotyping of cells in leukemias and lymphomas. 3. LECTURE №8 – 2 hours: Choice of laboratory parameters for evaluation of hemostasis disturbances. 1. Basic, extended and specialized laboratory tests parameters for evaluation of hemostasis disturbances. 2. Choice of clinical laboratory parameters and them consideration in bleeding tendency (hemorrhagic diatheses). 3. Selection of clinical laboratory parameters and their consideration in disorders leading to thrombosis. 4. Selection of clinical laboratory parameters in disseminated intravascular coagulation.

LECTURE №9 – 2 hours: Clinical laboratory evaluation of carbohydrate metabolism. 1. Blood sugar (glucose). Concentration in the blood. Regulation. 2. Pathobiochemical changes in diabetes mellitus disturbed carbohydrate metabolism: - pathobiochemistry of hyperglycemia and glucosuria - pathobiochemistry of changes of the lipid fractions

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- pathobiochemistry of ketoacidosis - pathobiochemistry of changes ketoacidosis in changes of acid-alkaline and electrolyte equilibrium - pathobiochemistry of glycated proteins and microalbuminuria.

LECTURE №10 – 2 hours: Clinical laboratory parameters evaluation of carbohydrate metabolism disturbance. 1. Selection of clinical laboratory parameters in reveiling and follow-up of disturbance in patients with diabetes mellitus: - basic laboratory tests - extended laboratory tests - specialized laboratory tests 2. Control of diabetes mellitus patient’s treatment – glycated hemoglobin. 3. Screening for microalbuminuria in patients with diabetes mellitus.

LECTURE №11 – 2 hours: Clinical laboratory evaluation of porphyrins and bile pigments in the blood. 1. Laboratory parameter for demonstration of destroyed hem synthesis – principle of methods, indications for investigation, specimen, reference values, results’ interpretation. 2. Bilirubin in the serum - pathobiochemistry, principle of the quantity measurement, indications for investigation, results’ interpretation. 3. Bile pigments in the serum and urine. Hyperbilirubinemia from different reasons. Correlation with other laboratory parameters.

LECTURE №12 – 2 hours: Clinical laboratory evaluation of serum proteins. 1. Changes in protein fractions – basic terminology and its interpretation. 2. Construction of appropriate strategy for clinical laboratory tests ordering for serum proteins evaluation. 3. Monoclonal and polyclonal hypergammaglobulinemia. 4. Selection of clinical laboratory parameters and their consideration in inflammatory and neoplastic diseases.

LECTURE №13 – 2 hours: Choice and evaluation of clinical laboratory parameters in liver and bile diseases. 1. Basic pathobiochemical changes in liver diseases. 2. Special features of clinical laboratory diagnosis of destroyed liver function. 3. Basic, extended and specialized laboratory tests parameters. 4. Evaluation of the laboratory results from bile pigments, enzymes, serum proteins in the different groups of liver diseases. 5. Prognostic laboratory tests and parameters showing hepatocellular carcinoma development.

LECTURE №14 – 2 hours: Choice and evaluation of clinical laboratory parameters in heart (myocardial) diseases. 1. Clinical laboratory risk factors in ischemic myocardial diseases (IMD) 2. Early and late laboratory parameters for myocardial ischemia.

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3. Clinical laboratory changes in IMD (stabile angina pectoris, unstable angina pectoris, nontransmural myocardial infarction (MI), transmural MI, reinfarction). 4. Future perspectives for clinical laboratory diagnosis.

LECTURE №15 – 2 hours: Steps and approaches for clinical laboratory parameters in renal diseases. 1. Evaluation of changes in values of рН, Osmolality and 24-hours diuresis in the course of renal diseases diagnostics. 2. Evaluation of proteinuria – glomerular and tubular. Sequences of procedures in explanation of proteinuria. 3. Evaluation of hematuria. Sequences of procedures in its explanation. 4. Kidney functional tests and result interpretation.

THE PRACTICAL EXERCISES PROGRAMME

EXERCISE №1- 2 hours: The result in the clinical laboratory. 1. Organization and management of the laboratory clinical activity (process). Getting familiar with Lab structure (departments, laboratories) and with the working process. Getting familiar with the main groups of clinical laboratory parameters. Ordering the clinical laboratory tests: fill in the request forms (individually, not in groups). Main kinds of request forms. Obligatory data (lab cod, clinic, first name and family name, ages, gender, diagnose, doctor’s name, nurse’s name, date and time). Types of the obtained results. Methods in the clinic laboratory: basic methods and analyzers in the Cytology clinic laboratory and clinical chemistry. Internal and external quality assessment of the laboratory results. Discussion of the data from control charts. 2. Reliability of the clinical laboratory results. Errors affecting the clinical laboratory result – preanalytical, analytical and post analytical. 3. Reasons, which may influence the clinical laboratory results during the pre analytical stage. Basic rules and requirements. Venous or capillary blood is more appropriate for investigation. 4. Main procedures and sources of errors in the process of biological specimen collection and sending it to the clinical laboratory for analyses. Closed system for biological material collection. 5. Demonstration of different changes of the biologic material that influence on the laboratory results (hemolysis, clots, lipemia, etc).

EXERCISE №2 – 2hours: Urine. General characteristics and chemical tests. 1. Filling in test from previous study material. 2. Rules and requirements for urine collection– random urine and diuresis. 3. Urine - general characteristics, reference ranges, results interpretation. 4. Chemical analysis - pH, glucose, protein, ketone bodies, bilirubin, urobilinogen, blood – quality and quantity analysis. 5. Presentation of samples of different color and transparency. 6. Getting to know the rules of processing and storage of express urine tests.

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EXERCISE №3 – 2hours: Evaluation of the laboratory results of Minerals and Trace Elements in human serum. 1. Filling in test from previous study material. 2. Inorganic Phosphorus, Calcium, Magnesium - total and ionized: laboratory methods, indications for investigation, reference ranges, results interpretation. 3. Serum Iron and Iron Binding Capacity. Laboratory methods, interferences, indications for investigation, reference ranges, results interpretation.

EXERCISE №4 – 2hours: Evaluation of the laboratory results of hematological parameters. 1. Filling in test from previous study material. 2. Hematological parameters - reference ranges. 3. Cell composition of the bone marrow. Microscopic investigation of normal bone marrow smears. 4. Bone marrow and venous blood evaluation in red blood cells disorders. Types of anemia: posthemorrhagic, Iron deficient, pernicious, aemolytic. Anemia’s laboratory characterization. Microscopy.

EXERCISE №5 – 2 hours: Evaluation of the laboratory results of hematological parameters (continuation). 1. Filling in test from previous study material. 2. Microscopic observation of bone marrow and venous blood smears in different diseases (continuation). 3. Solving clinical laboratory diagnostic tasks.

EXERCISE №6 – 2 hours: Microscopic observation of bone marrow and venous blood smears. 1. Filling in test from previous study material. 2. Bone marrow and venous blood evaluation in white blood cells disorders – agranulocytosis, leukemoid reaction, acute and chronic leukemias, plasmocytoma, etc. Microscopic observation. 3. Solving clinical laboratory diagnostic tasks.

EXERCISE №7 – 2 hours: Microscopic observation of bone marrow and venous blood smears (continuation).

EXERCISE №8 – 2 hours: Clinical laboratory evaluation of hemostasis. 1. Filling in test from previous study material – exercise and lecture. 2. The hemostasis as an integrated functional system. The action of vessels’ wall, platelets and blood plasma in the hemostasis. 3. Coagulation. Key phases in the process of coagulation. 4. Plasma factors of coagulation and them inhibitors– necessity and opportunity for investigation. 5. Fibrinolysis – factors and them inhibitors - necessity and opportunity for investigation.

EXERCISE №9 – 2 hours: Clinical laboratory evaluation of hemostasis 1. Filling in test from previous study material.

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2. Clinical laboratory parameters for evaluation of hemostasis – test principles, sources of errors, patient preparation, specimen, indications for investigation. 3. Screening tests for evaluation of hemostasis. Results interpretation 4. Tests for investigation of activity and concentration of individual plasma factors of coagulation and fibrinolysis. Results interpretation. 5. Specialized analysis for evaluation of hemostasis. 6. Control of anticoagulant therapy. 7. Solving clinical laboratory diagnostic tasks.

EXERCISE №10 – 2 hours: Clinical laboratory parameters for evaluation disturbance of carbohydrate metabolism. 1. Filling in test from previous study material – exercise and lecture. 2. Glucose in the blood – definition, interferences, indications for investigation, reference ranges, results interpretation. 3. Tests with overload – two hour postprandial test and oral glucose tolerance test - indications for investigation, reference ranges. 4. Evaluation of gliycemia for preceded period of time - test principles (demonstration), sources of errors, patient preparation, specimen, reference ranges, indications for investigation. 5. Solving clinical laboratory diagnostic tasks.

EXERCISE №11 – 2 hours: Clinical laboratory parameters for evaluation of serum proteins. 1. Filling in test from previous study material – exercise and lecture. 2. Total serum protein: test principles - demonstration, sources of errors, drug interference in laboratory testing, patient preparation, specimen, reference ranges, indications for investigation, results interpretation. 3. Methods for protein fractioning – types, test principles, disadvantages and advantages. 4. Demonstration of electrophoretical fractioning of the proteins in different diseases and discussion.

EXERCISE №12 – 2 hours: Clinical laboratory parameters for evaluation of serum proteins. 1. Individual proteins – biological characteristics. Results interpretation. 2. Immunoglobulins – quantity measurement, methods, specimen, reference ranges, indications for investigation, results interpretation in patients with disturbed immunoglobulin synthesis. 3. Demonstration of cases and finding of different types of myeloma multiplex and other diseases with hyperimmunoglobulinemia. 4. Solving clinical laboratory diagnostic tasks.

EXERCISE №13 – 2 hours: Clinical laboratory parameters for evaluation of enzyme activity in body fluids. 1. Filling in test from previous study material. 2. Enzymes in the serum. Mechanisms of hyperenzymemia. Advantages and disadvantages of enzyme analysis. 3. Cell and secretory enzymes in the serum - test principles, sources of errors, reference ranges, indications for investigation, results interpretation.

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4. Solving clinical laboratory diagnostic tasks.

EXERCISE №14 – 2 hours: Clinical laboratory parameters for evaluation of nonprotein nitrogen containing substances 1. Filling in test from previous study material – exercise and lecture. 2. Urea – principle of analytical methods, sources of errors, drug interference in laboratory testing, patient preparation, specimen, reference ranges, indications for investigation, results interpretation. 3. Creatine and creatinine - principle of analytical methods, sources of errors, drug interference in laboratory testing, patient preparation, specimen, reference ranges, indications for investigation, results interpretation. 4. Uric acid and ammonia - principle of analytical methods, sources of errors, drug interference in laboratory testing, patient preparation, specimen, reference ranges, indications for investigation, results interpretation. 5. Solving clinical laboratory diagnostic tasks.

EXERCISE №15 – 2 hours: Clinical laboratory evaluation of lipid parameters and lipopro- teins. 1. Filling in test form previous study material. 2. Pathobiochemistry of lipid metabolism – changes in the lipid fractions. 3. Basic clinical laboratory parameters for evaluation of lipid metabolism - principle of analytical methods, sources of errors, drug interference in laboratory testing, patient preparation, specimen, reference ranges, indications for investigation, results interpretation, recommended ranges. 4. Steps and approaches in the choice of clinical laboratory parameters in cases of disturbed lipid transportation. Evaluation of hyperlipidemias types. 5. Solving clinical laboratory diagnostic tasks.

SYLLABUS CLINICAL LABORATORY EXAMINATION

1. Analytical reliability of clinical laboratory methods – criteria. Reference ranges – populational constructed (definition, reference groups, reference status, reference condition, choice of statistical method, performance, disadvantages) individual (performance, advantages). 2. Diagnostic reliability of clinical laboratory parameters – criteria. Requirements to the criteria of diagnostic reliability of clinical laboratory tests in different group of diseases. 3. Permanent, long-term and short-term acting factors on the biological variation of the results – examples. 4. Influence of medical procedures and medicines on the clinical laboratory results (chemical and pharmacological interferences). Instructions for control of medicinal effects on the clinical laboratory investigations. 5. Specimen collection for clinical laboratory investigation – basic rules and requirements. Venous and capillary blood for analysis? Closed system for biological samples collection – advantages for the clinic, advantages for the laboratory.

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6. Venous blood collection clinical laboratory investigation – basic procedures and sources of errors. 7. Storage of the biological samples for analysis and transportation to the laboratory – requirements and sources of errors. Criteria for rejection of the specimen for laboratory analysis. 8. Urine for clinical laboratory investigation – basic rules and requirements for urine collection, storage and transportation to the laboratory. Sources of errors. Cerebrospinal fluid, body fluid punktats and stool - basic rules and requirements for urine collection, storage and transportation to the laboratory. Sources of errors. 9. The laboratory investigation in the course of the diagnostic process. 10. Body water and its distribution in the human body. Osmolality and osmolarity - methods of investigation, reference ranges, result interpretation. 11. Water-electrolyte balance disturbance. Clinical laboratory parameters for evaluation of water-electrolyte balance. 12. Sodium and chloride – common data for the parameters, indications for investigation, principles of the analytical methods, reference ranges, result interpretation. 13. Potassium - common data for the parameter, indications for investigation, principles of the analytical methods, reference ranges, result interpretation. 14. Total and ionized calcium, total and ionized magnesium - common data for the parameters, indications for investigation, principles of the analytical methods, reference ranges, result interpretation. 15. Inorganic phosphate - common data for the parameter, indications for investigation, principles of the analytical methods, reference ranges, result interpretation. 16. Serum Iron and Iron Binding Capacity - common data for the parameters, indications for investigation, principles of the analytical methods, reference ranges, result interpretation. 17. Diabetes mellitus – metabolism disturbance of: glycolysis, gluconeogenesis, glycogenolysis and glycogen synthesis, ketogenesis, ketonuria, glucosuria, osmotic diuresis, polyuria. 18. Glucose in the blood - common data for the parameters, indications for investigation, principles of the analytical methods, reference, borderline and pathological ranges, result interpretation. 19. Glucose in the blood - tests with overload: two hour postprandial test and oral glucose tolerance test (GTT) - indications for investigation and contraindications, implementation of the tests, source of errors, reference ranges, results interpretation. 20. Evaluation of gliycemia for preceded period of time: glycated proteins - glycated hemoglobin HbA1; HbA1c and fructosamine: common data for the parameters, indications for investigation, patient preparation, specimen, reference ranges, informative content and results interpretation. 21. Selection of clinical laboratory tests in detecting and tracking disturbance of carbohydrate metabolism in patients with diabetes mellitus - basic, extended and specialized laboratory tests (glycated proteins, microalbuminuria) and their discussion. 22. Total protein - common data for the parameters, principles of the analytical methods and interferences, indications for investigation, patient preparation, reference ranges, result interpretation. 23. Major protein fractions – electrophoreses: indications for investigation, result interpretation, informational value.

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24. Individual proteins – proteins of the acute phase – types, analytical methods for investigation, indications for investigation, patient preparation, reference ranges, results interpretation. 25. Immunoglobulins in the serum – common data for the parameters, classification, dynamic in prenatal and early postnatal period, methods of investigation, results’ interpretation. 26. Selection of clinical laboratory tests and their discussion in inflammatory and neoplastic diseases: white blood cells, differential count, hemoglobin, red blood cells, proteins of acute phase, ESR, proteinograma, specific laboratory parameters. 27. Urea - common data for the parameter, principles of the analytical methods, source of errors, indications for investigation, patient preparation, reference ranges, result’s interpretation. 28. Creatinine - common data for the parameter, principles of the analytical methods, source of errors and interference, indications for investigation, patient preparation, specimen, reference ranges, result’s interpretation. 29. Uric acid - common data for the parameter, principles of the analytical methods, source of errors and interference, indications for investigation, patient preparation, specimen, reference ranges, result’s interpretation. 30. Selection of clinical laboratory tests in renal diseases. Evaluation of the results of a study of nonproten nitrogen containing substances – advantages and disadvantages. 31. Transaminases in serum – general information, principles of analytical methods, sources of errors, indications for analysis, biological material, reference ranges, interpretation of results. 32. Alkaline and acid phosphatase in serum - general information, principles of analytical methods, sources of errors, indications for analysis, biological material, reference ranges, interpretation of results. 33. Lactate dehydrogenase and creatine phosphokinase in serum - general information, principles of analytical methods, sources of errors, indications for analysis, biological material, reference ranges, interpretation of results. 34. Amylase, gamma-glutamyltransferase and cholinesterase - general information, principles of analytical methods, sources of errors, indications for analysis, biological material, reference ranges, interpretation of results. 35. Choice and evaluation of clinical laboratory parameters in myocardial diseases. 36. Cholesterol in serum and its fractions - general information, analytical methods, interferences, risk limits, interpretation of results. 37. Triglycerides in serum general information, analytical methods, interferences, risk limits, interpretation of results. 38. Serum bilirubin and fractions – metabolism, methods, interferences, reference ranges, interpretation of results. 39. Choice and evaluation of clinical laboratory parameters in hepatic and bile diseases. 40. Hemostasis as a complex functional system – phases and factors. 41. Blood coagulation and fibrinolysis – factors and inhibitors. 42. Clinical laboratory parameters for evaluation of haemostasis. 43. Choice and discussion of laboratory parameters in hemorrhagic diathesis. 44. Choice and discussion of laboratory parameters in thrombophilia. 45. Choice and discussion of laboratory parameters in DIC syndrome.

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46. Choice and assessment of clinical laboratory parameters in renal diseases – basic, extended and specialized analysis. 47. Evaluation of changes in the values of pH, osmolality 24-hour diuresis in the course of diagnosis of renal diseases. Evaluation and procedures for clarifying of hematuria. 48. Choice of clinical laboratory parameters in renal diseases – sequence of procedures for clarifying and assessment of proteinuria – mainly glomerular and mainly tubular proteinuria. Mechanism of appearance, diagnostic significance. 49. Tumor markers. Markers of the first and second choice. 50. Choice and assessment of clinical laboratory parameters in iron deficiency anemias. 51. Choice and assessment of clinical laboratory parameters in megloblastic anemias. 52. Choice and assessment of clinical laboratory parameters in hemolytic anemias. 53. Choice and assessment of clinical laboratory parameters in white blood cell line disorders. Cytochemical and immunophenotype characteristics of leucocytes in acute leukemia. 54. Choice and assessment of clinical laboratory parameters in white blood cell line disorders. Cytochemical and immunophenotype characteristics of leukocytes in chronic leukemias (lymphocytic and granulocytic). 55. Hormones of thyroid gland. Evaluation of laboratory data and correlations in thyroid diseases.

RECOMMENDED READING: 1. Henry's Clinical Diagnosis and Management by laboratory methods, 21st ed., edited by Richard Mcpherson and Matthew Pincus 2. Extended theses of lectures and exercises.

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MEDICAL UNIVERSITY OF PLOVDIV

FACULTY OF MEDICINE

PROGRAMME

NEUROLOGY

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MEDICAL UNIVERSITY OF PLOVDIV FACULTY OF MEDICINE

Name of course: Neurology

Type of course according to the Unified Governmental Regulations: Compulsary

Educational level: Magister (Master)

Teaching methods: Lectures, exercises, self-study.

Length of training: Two semesters

Hours: 30 hours of lectures, 30 hours of practical training exercises

Auxillary teaching aids: Multimedia presentations, discussions, demonstration of patient-based cases, abnormal findings of EMG, EEG, Doppler sonography, CT, MRI and angiography approaches

Assessment forms: Continuous assessment during the semesters, 1 colloquium per semester, entrance exam test on general neurology, written exam on clinical neurology and practical exam

Rating: The average rating is based on colloquiums passed during the semesters; the written and theoretical exams (after a successful entrance test with a threshold of 65% correct answers).

Note: If there is some incertainty about the final rating, additional questions can be asked in relation to the items from the written exam or lapses from the practical exam.

Semestrial exam: Entrance tests, written and practical exam.

Leading lecturer: Senior qualified lecturer from the Department of Neurology

Department: Neurology

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АNNOTATION

The main aim of the clinical discipline of Neurology is theoretical and practical training of future physicians for the comprehensive care of the neurological patient, including the ability to assess the need for specialized consultative neurological help or emergency hospitalization of the patient in a hospital for active treatment. The teaching courses of Neurology are as follows: General Neurology which includes: - taking the case history and examining the patient; - investigation and identification of the symptoms and syndromes of the impairment of the central nervous system (CNS) and peripheral nervous system (PNS); - the possibilities of making a topical diagnosis by clinical, laboratory, neurophysiological and neuroimaging approaches. Clinical Neurology. Contemporary and challenging neurological diseases: Cerebrovascular, inflammatory, degenerative, demyelinating, movement disorders, epilepsy, headache and other paroxysmal conditions, the pathological disorders of ANS, the tumor and traumatic injuries of CNS, dementias are examined by an accepted algorithm: etiology, pathology, pathogenesis, classifications, clinical features, diagnosis and differential diagnosis, treatment, prognosis and prevention.

THE MAIN GOALS OF THE TEACHING PROGRAMME

Gaining knowledge and skills in applying contemporary approaches and means for the diagnosis, treatment and prevention. - theoretical knowledge about the anatomy and physiology of the nervous system, symptoms and syndromes of the nervous system impairment, criteria for topical diagnostics of the injuries of CNS, PNS and ANS; - gaining practical skills in taking a neurological case history and working with a reflex hammer; - neurological examination with identification of pathological reflexes, sensory and motor disturbances, coordination syndromes and higher cortical dysfunctions - establishing a topical diagnosis; - establishing a clinical diagnosis;

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- specialized examination of CNS and PNS (EEG, EMG, Doppler sonography, EP), neuroimaging (CT, MRI, cerebral angiography), laboratory (blood, cerebrospinal fluid examination) approaches; - identification of abnormal laboratory, electrophysiological and nauroimaging findings; - choosing the adequate therapeutic approach under emergency conditions.

EXPECTED RESULTS

After the completion of the course, student should have knowledge and skills as follows: - to take a detailed neurological case history - to know the main symptoms and syndromes of the CNS and PNS injuries - to posses practical skills for the diagnostics of the general cerebral and focal neurological symptoms - the ability to make a topical diagnosis - to be aware of the etiology, pathogenesis, clinical features and diagnostic procedures of neurological diseases - to know the clinical approaches, laboratory findings and neuroimaging features of different neurological conditions and the main indications for hospitalization - to know the main principles of treatment under emergency conditions - to know the primary and secondary means of prevention of the main neurological diseases; to know and recommend related diet regimens and physiotherapy when needed

TEACHING SCHEDULE

Exams Hours Hours Course Semester Total Lectures Exercises ІV V VІ VІІ VІІІ ІХ Х

Neurology VIІ и VІІІ 60 30 30 1/1 1/1

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LECTURES PROGRAMME

ІVth year , VІІth semester

№ TITLE HOURS DATE

1. Short history of neurology Reflex activity and its clinical significance 2 h

2. Somatic sensation. Sensory disorders: clinical significance 2 h

3. Syndromes of sensory disorders. Pain. 2 h

4. Motor system and motor activity. Pyramidal system. Muscle tone 2 h

5. Extrapyramidal system and its disorders. Main extrapyramidal syndromes 2 h

6. Cerebellum and coordination of movements. Clinical significance of their disorders. Gait and posture 2 h.

7. Autonomic nervous system and autonomic disorders 2 h

8. General neurological syndromes: syndromes of meningeal irritation, alterations of 2 h consciousness, syndromes of elevated intracranial pressure 9. Localization of cerebral functions. Topical diagnosis of brain diseases 2h

10. Localization of cerebral functions. Topical diagnosis of individual spinal nerve lesions, root lesions, plexus lesions 2 h

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11. Localization of cerebral functions. Topical diagnosis of syndromes of spinal cord and brainstem lesions 2 h

12. Localization of cerebral functions. Higher cortical functions and their disorders 2 h

13. Localization of cerebral functions. Syndromes of lesions of the cerebral lobes 2 h

14. Neuroradiology and magnetic resonance imaging (MRI) 2 h

15. Clinical neurophysiology. Electroencephalography (EEG). Electromyography (EMG) 2 h

TOTAL: 30 h.

LECTURES PROGRAMME

ІVth year, VІIIth semester

№ ТITLE HOURS DATE

1. Diseases of the peripheral nervous system – Bell’s palsy, Trigeminal neuralgia. Herpes zoster 2 h .

2. Polineurites and polyneuropathies. Guillain-Barre syndrome. Cervical and lumbar radiculopathies 2 h

3. Meningites. Neurosyphilis 2 h

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4. Ist part 2 h Encephalomyelites

5. 2nd part 2 h Encephalomyelites. Encephalopathies.

6. 1st part 2 h Cerebrovascular diseases. 7. 2nd part 2 h. Cerebrovascular diseases.

Acute stroke treatment 8. 2 h.

Degenerative diseases. Dystrophinopathies 9. 2 h

10. 2 h Epilepsy

11. 2 h Neuroses. Psychosomatic disorders

12. 2 h. Headache

13. 2 h Brain tumors

14. 2 ч. Traumatic injuries of nervous system

15. 2 ч. Emergencies in neurological practice.

TOTAL: 30 h.

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PROGRAMME OF EXERCISES

ІVth year, VIIth semester

№ ТITLE HOURS DATE

1. Introduction. Short history of neurology 2 h Neurological case history

2. Normal reflexes 2h

3. Pathological reflexes. Clinical significance 2 h.

4. Somatic sensation. Anatomy and physiology. Examination methods 2 h

5. Sensory syndromes - clinical significance 2 h

6. Meningeal syndrome. Symptoms of meningeal irritation. 2 h Cerebrospinal fluid examination. CSF syndromes

7. Motor system and motor activity. Pyramidal system. Muscle tone and muscle strength. 2 h Syndromes of disordered motor function 8. Motor system and motor activity. Extrapyramidal system and its disorders 2 h

9. Motor system and motor activity. Coordination of movements. Anatomy and physiology. 2 h Clinical significance of their disorders

10. Cranial nerves I-VII.. Anatomy and physiology. Examination methods. Symptomatology 2 h

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11. Cranial nerves VIII- XII. Anatomy and physiology. Examination methods. Symptomatology. 2 h Bulbar palsy. Pseudobulbar palsy

12. Spinal nerves. Spinal cord syndromes. Brainstem syndromes 2 h

13. Internal capsule syndrome. Syndromes of lesion of the cerebral cortex 2 h

14. Neurophysiological methods of examination of the nervous system 2 h

15. Topical diagnosis 2 h

TOTAL : 30 h

PROGRAMME OF EXERCISES

ІVth year, VІIIth semester

№ Т ITLE HOURS DATE

1. Meningites. Diagnosis. Differential diagnosis. Treatment 2 h

2. Colloquium 2 h General neurology

4. Peripheral nervous system disorders. Polyneurites. 2 h Polyradiculoneurites. Herpes zoster. Tabes dorsalis

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5. Encephalomyelites. Diagnosis. Differential diagnosis. 2 h Treatment

6. Encephalopathies. Diagnosis. Differential diagnosis. 2 h Treatment

7. Haemorrhagic stroke. Diagnosis. Differential diagnosis. 2 h Rehabilitation

8. Subarachnoid haemorrhage. Diagnosis. Differential 2 h diagnosis. Treatment. Rehabilitation.

9. Ischaemic stroke. Diagnosis. Differential diagnosis. 2 h Treatment. Rehabilitation.

10. Brain tumors. Spinal cord tumors. Diagnosis. Treatment 2 h

11. Traumatic injuries of the nervous system. 2 h

12. Degenerative diseases. Distrophinopathies. Diagnosis. 2 h Treatment

13. Epilepsy. Status epilepticus. Diagnosis. Differential 2 h diagnosis. Modern treatment

14. Neurological syndromes of some internal diseases – 2 h funicular myelosis, colagenoses, polymyosites, SLE, etc.

15. Headache. Neuroses 2 h

TOTAL: 30 h.

261

LECTURES

Lecture № 1 – 2 hours

SHORT HISTORY OF NEUROLOGY. REFLEX ACTIVITY AND ITS CLINICAL SIGNIFICANCE 1. Definitions 2. Classifications (types of reflexes) 3. Examination of reflexes 4. Reflex abnormalities 4.1. Quantitative abnormalities 4.2. Qualitative changes of the reflexes (pathological reflexes) 5. Clinical significance 6. Dependence of reflex changes upon site of the lesion

Lecture № 2 – 2 hours

SOMATIC SENSATION. SENSORY DISORDERS:CLINICAL SIGNIFICANCE

1. Definition 2. Functiuonal anatomy of sensation 3. Sensory system examination 3.1. Examination of primary sensory modalities 3.2. Examination of complex sensations 3.3. Application of tests 4. Common signs of disordered general sensation

Lecture № 3 – 2 hours

SYNDROMES OF SENSORY DISORDERS. PAIN

1. Syndromes of peripheral nerve lesion 2. Sensory syndromes of spinal nerve roots 3. Sensory syndrome of the spinal cord 4. Sensory syndromes due to lesions of the brainstem 5. Sensory syndromes due to lesion of the thalamus 6. Sensory syndromes due to lesions of the sensory cortex 7. Psychogenic sensory disturbances 8. Pain

Lecture № 4 – 2 hours

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THE MOTOR SYSTEM AND MOTOR ACTIVITY. PYRAMIDAL SYSTEM. MUSCLE TONE

1. Pyramidal (corticospinal) system 2. Anatomy and physiology of the motor act 3. Terminology and definitions. 4. Examination of the motor system 4.1. Muscle volume 4.2. Muscle strength 5. Syndromes of disordered motor function 5.1. Syndrome of lower motor neuron lesion 5.2. Upper motor neuron syndrome 5.3. Specific syndromes according to the location of lesion along the upper (pyramidal tract) and lower motor neuron 6. Muscle tone. Syndromes of disordered muscle tone

Lecture № 5 – 2 hours

THE EXTRAPYRAMIDAL SYSTEM AND ITS DISORDERS. MAIN EXTRAPYRAMIDAL SYNDROMES

1. General considerations 2. Anatomy and physiology of the extrapyramidal system 3. Clinical-pathological correlation in lesions of the basal ganglia 4. Examination of the extrapyramidal system 5. Involuntary movements 5.1. Tremor 5.2. Chorea 5.3. Hemibalism 5.4. Athetosis 5.5. Dystonia 5.6. Myoclonus 5.7. Tics 6. Main extrapyramidal syndromes 6.1. Parkinsonian syndrome 6.2. Choreic syndrome

Lecture № 6 – 2 hours

THE CEREBELLUM AND COORDINATION OF MOVEMENTS. CLINICAL SIGNIFICANCE OF THEIR DISORDERS. GATE AND POSTURE

1. General considerations 2. Anatomy and physiology of coordination 3. Anatomy of the cerebellum 4. Physiology and pathophysiology of the cerebellum 5. Main signs of cerebellar dysfunction 6. Clinical examination of coordination

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7. Cerebellar syndromes 7.1. Cerebellar syndrome of midline lesions 7.2. Syndrome of cerebellar hemispheric lesion 7.3. Syndrome of pancerebellar disorders 8. Syndromes of disturbed coordination 9. Gait and posture

Lecture № 7 –2 hours

AUTONOMIC NERVOUS SYSTEM AND AUTONOMIS DISORDERS

1. General considerations 2. Anatomophysiology of ANS 3. Tests and abnormalities of the autonomic nervous system 4. Autonomic innervation of the pupils and its disorders 5. Anatomy of of bladder function and its disturbances 6. Clinical syndromes of disordered autonomic function 7. Clinical hypothalamic syndromes

Lecture № 8 – 2 hours

GENERAL NEUROLOGICAL SYNDROMES: SYNDROMES OF MENINGEAL IRRITATION, ALTERATIONS OF CONSCIOUSNESS, SYNDROMES OF ELEVATED INTRACRANIAL PRESSURE

1. General considerations 2. Syndrome of meningeal irritation 3. Syndrome of cerebrospinal fluid changes 3.1.Bacterial meningitis 3.2.Tuberculous meningitis 3.3.Viral meningitis 3.4.Subarachnoid haemorrhage 3.5.Meningism 4. Non-obligatory involvement of cranial nerves of brain tissue 5. Non-obligatory syndrome of psychic changes 6. Clinical features in infants 7. Consciousness. Alterations of consciousness. Brain death 7.1.Definition 7.2.Coma

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Lecture № 9 – 2 hours LOCALIZATION OF CEREBRAL FUNCTIONS. TOPICAL DIAGNOSIS OF BRAIN DISEASES

1. Localization problem 2. Lateralization of cerebral functions 3. Brodmann’s fields 4. Brain syndromes

Lecture №10 – 2 hours LOCALIZATION OF CEREBRAL FUNCTIONS. TOPICAL DIAGNOSIS OF INDIVIDUAL SPINAL NERVE LESIONS, ROOT LESIONS AND PLEXUS LESIONS

1. General considerations 2. Anatomy of the peripheral nervous system 3. Clinical syndromes of spinal nerves and root lesions 4. Clinical syndromes of the plexus lesions 5. Clinical syndromes of individual peripheral spinal nerve lesion

Lecture № 11 – 2 hours LOCALIZATION OF CEREBRAL FUNCTIONS. TOPICAL DIAGNOSIS OF SYNDROMES OF SPINAL CORD AND BRAINSTEM LESIONS

1. Functional anatomy 2. The spinal cord 2.1. Syndrome of spinal ganglion 2.2. Syndrome of posterior roots 2.3. Syndrome of posterior tracts 2.4.Syndrome of posterior horn 2.5.Syndrome of the gray matter 2.6.Syndrome of combine damage of posterior funiculi and corticospinal tracts 2.7.Syndrome of anterior horn 2.8.Syndrome of combined anterior horns and pyramidal tracts damage 2.9.Syndrome of corticospinal tracts 2.10. Syndrome of combined involvement of posterior funiculi, spinocerebellar pathways, and possibly pyramidal tracts 2.11. Syndrome of hemisection of the spinal cord 2.12. Syndrome of complete transection of the spinal cord 2.13. Syndromes of lesions at different levels of the spinal cord 3. Brainstem 3.1 Focal brainstem syndromes – general considerations

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3.2 Syndromes of medulla oblongata lesions 3.3 Syndromes of pons lesions 3.4 Syndromes of midbrain lesions.

Lecture №12 – 2 hours

LOCALIZATION OF CEREBRAL FUNCTIONS. HIGHER CORTICAL FUNCTIONS AND THEIR DISORDERS

1. Definitions and neurological terms, associated with higher cortical functions and their disorders 2. Agnosia 3. Apraxia 4. Language, speech and aphasia.

Lecture № 13 – 2 hours LOCALIZATION OF CEREBRAL FUNCTIONS. SYNDROMES OF LESIONS OF THE CEREBRAL LOBES

1. Functional anatomy of the cerebral lobes and cerebral cortex 2. Functional organization of the cortex 3. Syndromes of the cerebral lobes – general considerations 4. Frontal lobe 5. Parietal lobe 6. Temporal lobe 7. Occipital lobe 8. Subcortical syndromes of the cerebral hemisphere

Lecture № 14 – 2 hours

NEURORADIOLOGY AND MAGNETIC RESONANCE IMAGING

1. Neuroradiology 1.1.Plain radiology 1.2.Computed tomography 1.3.Invasive investigations 1.4.Myelography 1.5.Cerebral angiography 2. Magnetic resonance imaging (MRI)

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Lecture № 15 – 2 hours

CLINICAL ELECTROPHYSIOLOGY

1. Electroencephalography (EEG) 1.1. Neurophysiological bases of EEG 1.2. Normal EEG 1.3. EEG abnormalities 2. Electromyography (EMG) and nerve conduction studies 2.1. Nerve conduction studies 2.2. Electroduagnostic syndromes 3. Indications for electroduagnostic investigation 4. Evoked potential study

Lecture № 1 – 2 hours

DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. BELL’S PALSY. TRIGEMINAL NEURALGIA. HERPES ZOSTER

1. Plexus and root lesions 2. Bell’s palsy 2.1. Etiology and pathology 2.2. Clinical features 2.3. Treatment and prognosis 3. Trigeminal neuralgia 3.1. Etiology 3.2. Clinical features 3.3. Complications 3.4. Treatment 4. Herpes zoster

Lecture № 2 – 2 hours

POLYNEURITES AND POLYNEUROPATHIES. GUILLAIN-BARRE SYNDROME. CERVICAL AND LUMBAR RADICULOPATHIES.

1. Polyneurites 2. Polyneuropathies 2.1. Patterns of injury 2.2. Classification 2.3. Syndrome of polyneuropathy 3. Guillain-Barre syndrome 3.1. Definition 3.2. Etiology 3.3. Clinical features 3.4. Complications 3.5. Diagnosis and differential diagnosis 3.6. Treatment an prognosis

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4. Diabetic polyneuropathy 5. Alcocholic polyneuropathy 6. Cervical and lumbar radiculopathies

Lecture № 3 – 2 hours

MENINGITES. NEUROSYPHILIS

1. Bacterial meningitis 1.1. Etiology. Pathogenesis 1.2. Classification 1.3. Clinical features 1.4. Diagnostic procedures 1.5. Treatment 2. Tuberculous meningitis 2.1. Definition. Risk factors 2.2. Clinical features 2.3. Complications 2.4. Diagnosis 2.5. Treatment 3. Viral meningitis 3.1. Definition. Risk factors 3.2. Clinical features 3.3. Diagnosis and treatment 4. Syphylis. Neurological complications

Lecture № 4 – 2 hours

Ist part. ENCEPHALOMYELITES. Herpes Simplex Virus Encephalitis. AIDS encephalitis. Creutzfeld-Jakob Disease. Subacute Sclerosing Panencephalitis. Lyme Disease

1. Herpes simplex virus encephalitis. 1.1.Etiology and pathology 1.2.Clinical features 1.3.Diagnosis and treatment 2. AIDS encephalitis 2.1.Etiology and pathology 2.2.Clinical features 2.3.Diagnosis and treatment 3. Creutzfeld-Jakob Disease. 3.1.Etiology and pathology 3.2.Clinical features 3.3.Diagnosis and treatment 4. Subacute Sclerosing Panencephalitis. 5. Lyme Disease

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Lecture № 5 – 2 hours

2nd part. ENCEPHALOMYELITES. Multiple sclerosis

1. Etiology and epidemiology 2. Pathology and pathogenesis 3. Clinical features 4. Diagnosis and differential diagnosis 5. Treatment 6. Prognosis

Lecture № 6 – 2 hours

1st part. CEREBROVASCULAR DISEASES

1. Haemorrhagic stroke 1.1. Definition 1.2. Etiology 1.3. Pathogenesis 1.4. Classification 2. Subarachnoid haemmorrage 2.1. Clinical features 2.2. Diagnosis and differential diagnosis 3. Intracerebral haemmorrage 3.1. Clinical features 3.2. Diagnosis and differential diagnosis

Lecture №7 – 2 hours

2nd part. CEREBROVASCULAR DISEASES

1. Ischaemic stroke 1.1 Definition 1.2 Etiology. Cerebrovascular risk factors 1.3 Pathogenesis 1.4 Classification 2. Transient ischaemic attacks 3. Ischaemic stroke. Minor stroke. Lacunar infarcts 3.1. Clinical features 3.2. Diagnostic procedures 3.3. Differential diagnosis

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Lecture №8 – 2 hours

ACUTE STROKE TREATMENT

1. Treatment of acute ischaemic stroke 2. Treatment of subarachnoid haemmorrage 3. Treatment of intracerebral haemorrhage 4. Stroke prevention 5. Stroke prognosis

Lecture №9 – 2 hours

DEGENERATIVE DISEASES. DISTROPHYNOPATHIES

1. Alzheimer’s disease. Pick’s disease 2. Parkinson’s disease 3. Myasthenia gravis 4. Amyotrophic lateral sclerosis 5. Hereditary motor and sensory polyneuropathy (Charcot-Marrie-Tooth disease). Spinal muscular atrophy. 6. Dystrophinopathies 7. Myotonic dystrophy

Lecture №10 – 2 hours

EPILEPSY

1. Definition 2. Etiology. Epidemiology 3. Classification of epileptic seizures 4. Guidelines for evaluation after the first seizure 5. Clinical features 6. Diagnosis 7. Principles of antiepileptic drug therapy 8. Status epilepticus 9. Psychosocial and psychiatric issues 10. Practical advice for the epileptic patient

Lecture №11 – 2 hours

THE NEUROSES AND PERSONALITY DISORDERS

1. Neuroses 1.1. Incidence 1.2. Classifications

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2. Anxiety neurosis and panic attacks 3. Phobic neurosis 4. Obsessive-compulsive neurosis 5. Hysteria (Briquet Disease, Somatization disorder). 5.1. Special hysterical syndromes 5.2. Principles in treatment of hysteria 6. Hypohondriasis

Lecture №12 – 2 hours

HEADACHE

1. Definition 2. Approach to the patient with headache 3. Acute headache 4. Chronic headache 5. Primary headaches 5.1. Tension-type headache 5.2. Migraine headache 5.3. Cluster headache 5.4. Exertional headaches 6. Secondary headaches

Lecture №13 – 2 hours

BRAIN TUMORS

Lecture №14 – 2 hours

TRAUMATIC INJURIES OF THE NERVOUS SYSTEM

Lecture №15 – 2 hours

EMERGENCIES IN NEUROLOGICAL PRACTICE

1. Nonepileptic paroxysmal conditions 2. Sleep and its disorders 3. Examination methods

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PRACTICAL EXERCISES

VIIth semester

Exercise № 1 – 2 hours

Introduction. Short history of neurology. Neurological case history

Exercise № 2 – 2 hours Examination of normal reflexes

 Gaining practical skills in working with reflex hammer  Examination of deep tendon reflexes  Examination of superficial reflexes  Examination of patient with normal reflexes

Exercise № 3– 2 hours Pathological reflexes

 Gaining practical skills in examination of pathological reflexes  Examination of patient with pathological reflexes  Identification of reflex abnormalities  Determination of the clinical significance of reflex changes

Exercise № 4 – 2 hours Somatic sensation. Anatomy and physiology. Examination methods

 Gaining practical skills in examination of primary sensory modalities  Gaining practical skills in examination of complex sensations  Application of tests  Examination of patient with positive sensory signs  Examination of patient with negative sensory signs

Exercise № 5 – 2 hours Sensory syndromes. Clinical significance

 Gaining practical skills in examination of patient with syndrome of peripheral nerve lesion  Gaining practical skills in examination of patient with syndrome of spinal nerve root  Gaining practical skills in examination of patient with syndrome of spinal cord  Gaining practical skills in examination of patient with syndrome of brainstem, thalamus, sensory cortex and psychogenic sensory disturbances

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Exercise № 6 – 2 hours Meningeal syndrome. Symptoms of meningeal irritation. Cerebrospinal fluid examination. CSF syndromes

 Gaining practical skills in examination of patient with meningeal syndrome  Application of tests  Examination of patient with meningeal syndrome

Exercise № 7 – 2 hours Motor system and motor activity. Pyramidal system. Muscle tone and muscle strength. Syndromes of disordered motor function

 Gaining practical skills in examination of muscle volume and muscle strength  Assessment of muscle tone  Application of tests for examination of latent hemiparesis  Examination of patient with upper motor neuron lesion  Examination of patient with lower motor neuron lesion

Exercise № 8 – 2 hours Motor system and motor activity.Extrapyramidal system and its disorders

 Examination of patient with Parkisonian syndrome or other extrapyramidal syndromes  Application of tests

Exercise № 9 – 2 hours Motor system and motor activity. Coordination of movements. Anatomy and physiology. Clinical significance of their disorders

 Gaining practical skills in examination of coordination  Application of tests for detection of static ataxia  Application of tests for detection of locomotor ataxia  Application of tests for detection of dynamic ataxia  Examination of patient with cerebellar syndrome or other syndromes of disturbed coordination

Exercise № 10 – 2 hours Cranial nerves I-VII.. Anatomy and physiology. Examination methods. Symptomatology.

 Gaining practical skills in examination of cranial nerves I-VI  Application of tests for main clinical signs and syndromes  Examination of patient with cranial nerve disorder

Exercise № 11 – 2 hours Cranial nerves VIII- XII. Anatomy and physiology. Examination methods. Symptomatology. Bulbar palsy. Pseudobulbar palsy

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 Gaining practical skills in examination of cranial nerves VII-XII  Application of tests for main clinical signs and syndromes  Examination of patient with bulbar palsy  Examination of patient with pseudobulbar palsy

Exercise № 12 – 2 hours Spinal nerves. Spinal cord syndromes. Brainstem syndromes

 Gaining practical skills in examination of patient with spinal cord syndromes  Gaining practical skills in examination of patient with brainstem syndromes  Application of tests for main clinical signs and syndromes  Examination of patient with spinal cord or brainstem syndrome

Exercise № 13 – 2 hours Internal capsule syndrome. Syndromes of lesion of the cerebral cortex

 Gaining practical skills in examination of patient with internal capsule syndrome  Application of tests for main clinical signs and syndromes  Examination of patient with internal capsule syndrome or syndrome of lesion of the cerebral cortex

Exercise № 14 – 2 hours Neurophysiological methods of examination of the nervous system

 Indications for electrodiagnostic investigation  Electroencephalography  Electromyography  Evoked potentials study

Exercise № 15 – 2 hours Topical diagnosis. Complete neurological examination

 Complete neurological examination  Examination of patient with focal neurological signs

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PRACTICAL EXERCISES

VIIIth semester

Exercise № 1 – 2 hours Meningites. Diagnosis. Differential diagnosis. Treatment

 Examination of patient with meningeal irritation

Exercise № 2– 2 hours Colloquium General neurology

Exercise № 3 – 2 hours Peripheral nervous system disorders. Radiculites. Bell’s palsy. Trigeminal neuralgia

 Examination of patient with Bell’s palsy and trigeminal neuralgia

Exercise № 4 – 2 hours Peripheral nervous system disorders. Polyneurites. Polyradiculoneurites. Herpes zoster. Tabes dorsalis

 Examination of patient with polyneuropathy

Exercise № 5 – 2 hours Encephalomyelites. Diagnosis. Differential diagnosis. Treatment

 Examination of patient with multiple sclerosis

Exercise № 6 – 2 hours Encephalopathies. Diagnosis. Differential diagnosis. Treatment

 Examination of patient with encephalopathy

Exercise № 7 – 2 hours Haemorrhagic stroke. Diagnosis. Differential diagnosis. Rehabillitation

 Examination of patient with haemorrghagic stroke

Exercise № 8 – 2 hours Subarachnoid haemorrhage. Diagnosis. Differential diagnosis. Treatment. Rahbilitation.

 Examination of patient with subarachnoid haemorrghage

275

Exercise № 9 – 2 hours Ischaemic stroke. Diagnosis. Differential diagnosis. Treatment. Rahbilitation.

 Examination of patient with ischaemic stroke

Exercise № 10 – 2 hours – in Neurosurgery Brain tumors. Spinal cord tumors. Diagnosis. Treatment

Exercise № 11 – 2 hours – in Neurosurgery Traumatic injuries of the nervous system.

Exercise № 12 – 2 hours Degenerative diseases. Distrophinopathies. Diagnosis. Treatment

 Examination of patient with Parkinson’s disease, Alzheimer’s disease

Exercise № 13 – 2 hours Epilepsy. Status epilepticus. Diagnosis. Differential diagnosis. Modern treatment

 Examination of patient with epilepsy

Exercise № 14 – 2 hours Neurological syndromes in some internal diseases – funicular myelosis, colagenoses, polymyosites, SLE, etc

 Examination of patient with different neurological syndromes

Exercise № 15 – 2 hours  Examination of patient with headache or patient with neurosis

WRITTEN EXAM CLINICAL NEUROLOGY SYLLABUS

1. Diseases of the peripheral nervous system . Cervical and Lumbar Radiculopathies. 2. Diseases of the peripheral nervous system. Facial Neuropathy (Bell’s palsy) 3. Diseases of the peripheral nervous system. Trigeminal Neuralgia. Herpes zoster. 4. Popyneurites and polyneuropathies. Guillain-Barre Syndrome (Acute Inflammatory Demyelinating Polyradiculoneuropathy). Diabetic Neuropathy. Alchohol Neuropathy 5. Meningites. Acute Pyogenic (Bacterial) Meningites. Subacute and Chronic Meningites.

276

6. Meningites. Acute aseptic meningites. 7. Meningites. Tuberculous Meningoencephalitis 8. Meningites. Neurosyphilis. 9. Encephalomyelites. Herpes Simplex Virus Encephalitis. AIDS encephalitis 10. Encephalomyelites. Creutzfeld-Jakob Disease. Subacute Sclerosing Panencephalitis. Lyme Disease (Neuroborreliosis). 11. Encephalomyelites. Multiple sclerosis 12. Myelites. Acute Transverse Myelitis. Demyelinative myelitis. Cervical Myelopathy. 13. Cerebrovascular disease. Ischaemic stroke. Transient ischemic attaks 14. Cerebrovascular disease. Haemorrhagic stroke. Subarachnoid haemorrhage 15. Cerebrovascular disease. Haemorrhagic stroke. Primary intracerebral haematoma 16. Acute stroke treatment 17. Degenerative diseases. Alzheimer’s disease. Pick’s disease 18. Degenerative diseases. Parkinson’s disease 19. Degenerative diseases. Hepatolenticular Degeneration. Huntington’s Chorea 20. Degenerative diseases. Friedreich’s Ataxia 21. Myasthenia gravis 22. Amyotrophic lateral sclerosis 23. Hereditary motor and sensory polyneuropathy (Charcot-Marrie-Tooth disease). Spinal muscular atrophy. 24. X-linked Dystrophinopathies. Facio-scapulo-humeral Muscular Dystrophy. Limb- gurdle Muscular Dystrophies. Myotonic Dystrophy 25. Brain Tumors. Classification. Clinical features. 26. Tumors of the spinal cord. Clinical features. 27. Cerebral Concussion. Sequelae of Head Injury. 28. Subdural Hematoma. Epidural Hematoma 29. Traumatic Injuries of Spinal Cord 30. Neuroses. Hysteria 31. Headache. Migraine. 32. Headache. Tension-type Headache. Cluster Headache

277

RECCOMENDED READING

1. General Neurology. Popova, M. Pleven, 2002

2. Basic Neurology .Gilroy, J. McGraw-Hill. 2000

3. Color atlas of neurology. Rohkamm R. Thieme, 2004

4. Clinical Neurology. Aminoff MJ, Greenberg DA, Simon RP. Lange

Medical Books/ McGraw-Hill

5. Adams&Victor’s Principles of Neurolgy. 9th edition

278

MEDICAL UNIVERSITY - PLOVDIV

PROGRAMME OF LECTURES & PRACTICAL CLASSES

Discipline: PEDIATRIC SURGERY Speciality: MEDICINE Course and Semesters of education: ІV course-8th semester (ІІ stream) и V course-9th semester (І stream) Exam: after 9th semester Hours of auditorium classes: 24 hours (8 hours lectures and 16 hours practical classes) Lecturers: Associate Professor Penka Steffanova, M.D., Ph.D. Associate Professor Alexander Yonkov, M.D., Ph.D. Associate Professor Evgenii Moshekov, M.D., Ph.D.

PLAN OF EDUCATION Form of Hours of auditorium classes Credits classes Week 8th 9th Total semester semester Lectures 2 8 8 16 Practical 4 16 16 32 classes Total 6 24 24 48

ANNOTATION: Pediatric surgery is an independent surgical discipline. The education in Pediatric surgery includes studing of the most often diseases in infancy and childhood like congenital anomalies of oesophagus and diaphragm, congenital hypertrophic pyloric stenosis, congenital anomaliees of small and large bowels, acute abdomen in children, acute inflamatory diseases, congenital anomalies of the abdominal wall, major tumors in infancy and childhood.

OBJECT OF DISCIPLINE: Theoretical and practical mastering of knowledges in the main pediatric surgical diseases and their treatment.

TASKS OF DISCIPLINE:  Get acquaintance with the most often diseases in Pediatric surgery: etiology, pathogenesis, pathology, clinical presentation.

279  Mastering of the diagnostic methods of examination in different nosologic units and their practical application.  Get acquaintance and mastering of principals of treatment of pediatric surgical diseases.

METHODS OF EDUCATION:  Practical classes at patient’s bed, manipulation room, dressing room, operation hall.  Lecture course

TECHNICAL MEANS USED IN EDUCATION: tables, schemes, graphics and pictures, operational atlases, X- rays, photos and diapositives, films.

CONTROL AND EVALUATION: - Current control – oral examination, colloquiums in sections; - Final control - written exam, discussion with the examiner.

METHODS FOR КNOLEDGECONTROL: - tests

OBLIGATORY COMPETITIONS: 1. Theoretical knowledge: - Presentation of esophageal atresia and pyloric stenosis, methods for diagnosis and principles in operative treatment. - Most common nosological entities leading to acute abdomen. - Presentation and X-ray characteristics of pneumothorax and pyothorax - Recognition of the meaning of prenatal diagnosis in newborn anomalies. - Recognition of the features in transportation of children with congenital anomalies. - Recognition of the terms for operative treatment of congenital anomalies.

2. Practical skills: - Placement of nasogastric tube - Performing of diaphanoscopy - Performing of rectal exam 280 - Performing of thoracentesis - Ablation of the foreskin - Realization of preoperative preparation in prehospital dehydratation and intoxication.

PROGRAMME OF THE LECTURE COURSE IN PEDIATRIC SURGERY LECTURE N1 – 2 hours. HISTORY OF PEDIATRIC SURGERY. DISEASES OF ESOPHAGUS AND STOMACH. 1. Pediatric surgery as a detached surgical discipline. 2. Anatomophisiological features in children’s age and their importance for surgical pathology 3. History of Pediatric surgery 4. History of Pediatric surgery in Bulgaria 5. Relations of Pediatric surgery with other medical branches 6. Esophageal atresia 7. Congenital pyloric stenosis

LECTURE N 2 – 2 hours. ACUTE ABDOMEN IN CHILDREN – ACUTE APPENDICITIS, INTUSSUSCEPTION, INCARCERATED INGUINAL HERNIA. 1. Acute appendicitis in children 2. Intussusception 3. Incarcerated inguinal hernia in children

LECTURE N 3 – 2 hours. ANORECTAL MALFORMATIONS. 1. Forms of anorectal malformations. 2. Presentation and diagnosis. 3. Principles and stages of non operative and operative treatment. Algorythm of conduct.

LECTURE N 4 – 2 hours. MOST COMMON CONGENITAL ANOMALIES IN CHILDHOOD. 1. Congenital diaphragmatic hernia. 2. Classification of congenital intestinal atresia, presentation, diagnosis and treatment. 3. Meconium ileus. 4. Gastrointestinal duplications.

281 PROGRAM OF OF PRACTICAL CLASSES IN PEDIATRIC SURGERY

PRACTICAL CLASS N1 – 2 hours. CONGENITAL DISEASES OF ESOPHAGUS AND DIAPHRAGM. 1. Esophageal atresia. 2. Congenital tracheoesophageal fistula 3. Congenital esophageal stenosis 4. Esophageal deverticulums 5. Chalasia of the cardia 6. Achalasia of the cardia

PRACTICAL CLASS N2 – 2 hours. CONGENITAL DISEASES OF THE ABDOMINAL WALL. 1. Omphalocele – presentation, diagnosis, differential diagnosis, treatment. 2. Gastroschisis– presentation, diagnosis, treatment. 3. Hernias– presentation, diagnosis, treatment. 4. Urinary bladder extrophy– presentation, diagnosis, treatment.

PRACTICAL CLASS N 3 – 2 hours. CONGENITAL DISEASES OF THE STOMACH AND GERD. 1. Congenital hypertrophic pyloric stenosis. 2. Gastroesophageal reflux– presentation, diagnosis, conservative and operative treatment.

PRACTICAL CLASS N4 – 2hours. CONGENITAL DISEASES OF THE SMALL INTESTINE. 1. Congenital diseases of the duodenal segment with symptoms of complete and incomplete bowel obstruction. 2. Congenital disease – atresias and stenoses of the small intestine. 3. Surgical complications of Meckel’s diverticulum. 4. Meconium ileus.

PRACTICAL CLASS N5 – 2 hours. CONGENITAL DISEASES OF THE LARGE INTESTINE. 1. Congenital disease – atresias and stenoses of the large intestine. 2. Hirshsprung’s disease 3. Anorectal anomalies.

282 PRACTICAL CLASS N6 – 2 hours. ACUTE ABDOMEN IN CHILDHOOD – ACUTE APPENDICITIS, INTUSSUSCEPTION, INCARCERATED INGUINAL HERNIA. 1. Definition. Criteria. 2. Classification of the diseases in “Acute abdomen” group. 3. Features of acute abdomen in childhood 4. Presentation. 5. Laboratory studies of acute abdomen. 6. Imaging studies of acute abdomen. 7. Disguises of acute abdomen. 8. Treatment – non operative and operative.

PRACTICAL CLASS N7 – 2 hours. ACUTE INFLAMMATORY DISEASES IN CHILDHOOD – NECTROTIC PHLEGMON, ANAEROBIC INFECTION, EMPYEMA, ACUTE OSTEOMYELITIS. 1. Definition 2. Agents – characteristics 3. Presentation – syndrome characteristics. 4. Methods of treatment 5. Features of acute haematogenous osteomyelitis in childhood – principles of early diagnosis, most common mistakes, X-ray, principles of treatment.

PRACTICAL CLASS N8 – 2hours. TUMORS IN CHILDHOOD. 1. Wilms’s tumor. 2. Neuroblastoma. 3. Rhabdomyosarcoma.

SYNOPSIS - PEDIATRIC SURGERY 1. Esophageal atresia 2. Congenital diaphragmatic hernia 3. Hypertrophic pyloric stenosis 4. Congenital impassability of the duodenum 5. Congenital impassability of the small intestine 6. Hirschsprung’s disease 7. Anorectal malformations 8. Intussusception 9. Meckel’s diverticulum and its complications 10. Acute appendicitis in childhood 283 11. Bacterial destructive lung disease 12. Acute osteomyelitis in childhood 13. Congenital anomalies of the abdominal wall

LITERATURE: 1. Ръководство по хирургия с атлас, том ХІІІ-Детска хирургия, под редакцията на проф. О. Бранков, Академично издателство „Проф. М. Дринов”, София, 2011 г. 2. Учебник по Детска хирургия, под редакцията на проф. Ив. Иванчев, Медицина и физкултура, София 1988г. 3. Учебник по Детска хирургия, под редакцията на проф. д-р Д. Арнаудов, Медицина и физкултура, София ,1978г. 4. Internet – Pediatric surgery, 6th edition, Jay Grosfeld et all, Mosby, 2006. 5. Internet – Pediatric surgery, P. Puri, M. Hollwarth ed. Springer, 2006.

284 Medical University of Plovdiv Department of Ophthalmology

CURRICULUM

Ophthalmology

Приета от Катедрен съвет на 4.06.2012г.

Утвърдена от Факултетен съвет на ……………. 2012г.

285

Medical University of Plovdiv Faculty of medecine

Discipline: Ophthalmology

Type of discipline Mandatory

Degree of training Master

Teachingmethods: lectures,seminars,practice

Duration of training: 1 semester

Horraruim: 30h lectures, 45h practical classes

TECHNICAL TOOLS AND EQUIPMENT FOR THE PURPOSE IN TEACHING: well - equipped classrooms, examination rooms, audiovisual equipment, multimedia discussions, demonstration of examination techniques, diagnostics and treatment.

MONITORING AND EVALUATION: Current control - weekly test, oral interview, review test.

FINAL EVALUATION: test, written examination, oral examination.

ASPECTS OF FINAL MARKS FORMATION: Participation in the weekly tests, results from the final test

Semestrial examination Yes /preliminary test, written and oral interview/.

Professional practice examination: No

Principal lecturer Professor or Associated professor from the department of Ophthalmology.

DEPARTMENT: 286

Ophthalmology

ANNOTATION: History and the subject of ophthalmology. Anatomy of the visual organ. Key features of the visual organ. Light perception. Color vision. Central and peripheral vision. Refraction of the eye and its anomalies. Diseases of the orbit and eyelids. Diseases of the lacrimal apparatus and conjunctiva. Diseases of the cornea and sclera. Diseases of the uvea. Diseases of the lens. Glaucoma. Diseases of the retina. Paediatric ophthalmology. Eye movement disorders. Eye injuries. Ocular manifestations of general diseases. Emergency in ophthalmology. Blindness and its problems.

PURPOSE OF COURSE: 1. Knowledge of anatomy and physiology of the visual organ. 2. Systematic approach to examination of the eye and ists adnexa. 3. Understanding and free use of terminology in ophthalmology. 4. Quality theoretical and practical training in ophthalmology. 5. Knowledge of ocular pathology. 6. Excellent knowledge of emergencies in ophthalmology and principles of first aid.

OBJECTIVES OF THE COURSE: Master the necessary theoretical and practical skills in ophthalmology. Detection of refractive errors, physiology and pathology of the eyeball. Obtaining the necessary practical skills.

REQUIRED SKILLS: Theoretical knowledge: A. Anatomy of the visual organ. 2. Key features of the visual organ. 3. Light perception. Color vision. 4. Central and peripheral vision. 5. Refraction of the eye and its anomalies. 6. Diseases of the orbit and eyelids. 7. Diseases of the lacrimal apparatus and conjunctiva. 8. Diseases of the cornea and sclera. 9. Diseases of the uvea. 10. Diseases of the lens. 11. Glaucoma. 12. Diseases of the retina. 13. Paediatric ophthalmology. 14. Eye motility disorders. 15. Eye injuries. 16. Ocular signs in general diseases. 17. Emergency in ophthalmology. 18. Blindness and its problems.

Practical skills:

A. Exposure of the conjunctiva 287

2. Expression of tear sac 3. Canal and nasal test 4. Fluorescein staining test 5. Examination of corneal sensitivity 6. Biomicroscopy 7. Retroillumination 8. Indirect ophthalmoscopy (principle and performance) 9. Examination of color vision 10. Examination of visual acuity, perception and projection of light 11. Confrontation method for examination of visual field 12. Measurement of intraocular pressure by palpation 13. Recognizing types of corrective lenses 14. Eye drops instillation 15. Eye ointments application 16. Pathcing and Dressings 17. Lavage of the conjunctiva 18. Tonometry - Maklakov, Goldman and Shiotts / principles and performance / 19. Examination of pupil reactions

CURRICULUM

Hours in the years and Exams Hours semesters Discipline Practical Semester Total Lectures. ІV V VІ VІІ VІІІ ІХ Х Classes.

Ophthalmology VІІ(VІІІ) 75 30 45 75 (75)

NOTE: Students are divided into two streams for VII and VIII semester for each stream are entitled to 4.0 credits.

LECTURE COURSE 4 ears, VІІ (VІІІ) semester

№ Topic Hours Date

1. HISTORY OF OPHTHALMOLOGY. СOLOR VISION AND LIGHT PERCEPTION 2 h

288

2. ANATOMY OF THE EYEBALL, CENTRAL AND 2 h PERIPHERAL VISION.

3. REFRACTION OF THE EYE, ACCOMMODATION, ANOMALIES OF REFRACTION 2 h

4. DISEASES OF THE LACHRYMAL APPARATUS AND CONJUNCTIVA, “DRY EYE” SYNDROME. 2 h

5. DISEASES OF THE ORBITA AND EYELIDS 2 h

6. DISEASES OF THE CORNEA AND SCLERA 2 h

7. KERATOCONJUNCTIVITIS: ADENOVIRUS, 2 h PHLYCTENULOUS AND VERNAL, TRACHOMA, PTERYGIUM, PINGUECULA. 8. DISEASES OF THE UVEAL TRACT 2 h

9. DISEASES OF THE LENS. 2 h

10. GLAUCOMA. 2 h

11. DISEASES OF THE RETINA AND OPTIC NERVE. 2 h

12. OCULAR TRAUMAS 2 h

13. OCULAR SYMPTOMS IN SYSTEMIC DISEASE 2 h

14. OCULAR MOTILITY PROBLEMS, CHILD’S VISION 2 h

289

15. BLINDNESS – CAUSES AND PREVENTION. EMERGENCY IN OPHTHALMOLOGY 2 h

Total: 30 h

PRACTICE COURSE 4 ears, VІІ (VІІІ) semester

№ Topic Hours Date

1. ANATOMY OF THE EYEBALL. SYSTEMIC EXAMINATION OF PATIENTS WITH OCULAR DISEASE. FOCAL ILLUMINATION, 3 h EXAMINATION OF THE CONJUNCTIVA.

2. PATHOLOGY OF COLOR VISION AND LIGHT PERCEPTION, PERIPHERAL VISION 3 h

3. CENTRAL VISION. REFRACTION AND ANOMALIES OF REFRACTION. VISUAL ACUITY. 3 h

4. TRANS ILLUMINATION, OPHTHALMOSCOPY, SKIASCOPY 3 h

5. DISEASES OF THE ORBIT AND EYELIDS 3 h

6. DISEASES OF THE LACHRYMAL APPARATUS AND CONJUNCTIVA 3 h

7. DISEASES OF THE CORNEA 3 h

8. DISEASES OF THE UVEA 3 h

290

9. TEST EXAMINATION – REVIEW 3 h

10. DISEASES OF THE LENS 3 h

11. GLAUCOMA – DIAGNOSTICS, PERIMETRY, TREATMENT, PREVENTION 3 h

12. DISEASES OF THE RETINA. RETINOPATHY OF PREMATURITY. RETINAL VASCULAR DISEASE. RETINAL DETACHMENT. MACULAR 3 h DEGENERATION. RETINAL TUMORS. PATHOLOGY OF THE OPTIC NERVE

13. TRAUMAS AND OCULAR URGENCY 3 h

14. DISTURBANCE OF OCULAR MOTILITY. VISION IN CHILDHOOD 3 h

15. INTRODUCTION. BLINDNESS 3 h

Total: 45 h.

PROGRAM COURSE OF OPHTHALMOLOGY FOR MEDICAL

LECTURE 1 - 2 HOURS

SUBJECT AND HISTORY OF OPHTHALMOLOGY. LIGHT PERCEPTION. COLOR VISION 1.Definition and subject of ophthalmology. 2.Meaning of ophthalmology. 3.Features of ophthalmology - High demand for ophthalmic care - Complex character - Close liaison with other medical specialties 4. History of ophthalmology 291

- Prehistoric times - Ancient civilizations: Assyria and Babylonia, Ancient Egypt, Judaic culture, Ancient Indian culture; Ancient Chinese culture, ancient cultures in America. - Classical civilizations: Greece, Alexandria, Rome. - Ages: Byzantium, the Arab Ophthalmology; European ophthalmology ... - Renaissance and later eras - Bulgarian ophthalmology 5.Development of ophthalmological - Phylogenesis - Ontogenesis 6.Basic functions of the visual organ. - Light perception - Color vision - The form vision - Depth perception and stereoscopic vision 7. Essentials of vision - Definition of light: theory, photometric units - Conversion of light energy into nerve impulses 8.Light perception - Definition: absolute sensitivity, descriminative sensitivity - Adaptation: to light and dark, methods for examination of adaptation - Disturbances in adaptation (hemeralopia): symptomatic, functional. 9. Colour perception. - Definition - Spectral colors - Characreristics of color: Hue, luminance, saturation - Basic colors: red, green, blue - Additional colors - Complimentary colors - Theories of color vision - Methods for examination of color vision

LECTURE 2 - 2 HOURS

ANATOMY OF THE EYEBALL. CENTRAL AND PERIPHERAL VISION.

І. Anatomy the eyeball. 1. Anatomy of orbit - Composition of the orbit - Features of the walls of the orbit - Major openings in the orbit - Contents of the orbit - Changes in the position of the eyeball 2. Anatomy of the eyelids. 3. Anatomy of the conjunctiva. 4. Anatomy of the cornea 5.Anatomy of the uvea 292

- Iris - Ciliary body - Choroid 6. Anatomy of the lens. 7. Anatomy and histology of the retina.

ІІ.Central and peripheral vision. 1.Central vision: Visual acuity, visual angle. - Visual charts: Snellen, Monoyer, examination of visual acuity. 2. Peripheral vision. - Definition - Visual field - Importance of the visual field for clinical practice - Historical development of methods for analysis of visual field - Methods for subjective field of vision: a control (confrontation method of Donders, campimetry, perimetry - kinetic, static - Objective methods for testing the visual field.

LECTURE 3 – 2 HOURS REFRACTION OF THE HUMAN EYE. ACCOMMODATION. REFRACTIVE ERRORS 1. Similarirties between human eye and photocamera 2. Physical optics. Physical refraction. Physiological optics 3. The human eye as an optical system 4. Clinical refraction - Emmetropia - Myopia - Hyperopia 5. Causes for ammetropias: theories, types of ammetropia 6. Static and dynamic clinical refraction - far point of view in different clinical refractions 7. Accommodation - definition - near point of view - mechanism of accommodation - field of accommodation - range of accommodation 8. Presbyopia 9. Pathology of accommodation: paralysis and spasm of accommodation 10. Astigmatism - simplex astigmatism - compound astigmatism 11. Methods for refraction testing - subjective methods - objective methods 12. Correction of refractive errors 13. Myopia – clinical presentation 14. Hyperopia – clinical presentation

293

LECTURE 4 – 2 HOURS

DISEASES OF LACRIMAL APPARATUS AND CONJUNCTIVA. “DRY EYE” I. Diseases of the lacrimal apparatus 1. Significance and composition of the tear film. Types of tear secretion 2. Anatomy of lacrimal apparatus: lacrimal gland and lacrimal drainage system 3. Diseases of the lacrimal gland - Acute dacryoadenitis 4. Diseases of lacrimal drainage system - Congenital and acquired changes of lacrimal puncta - Canaliculitis - Acute dacryocystitis II. Diseases of the conjunctiva 1. Freqiency and significance of conjunctival diseases 2. Function of the conjunctiva 3. Morbid changes in the conjunctiva: hyperemia – conjunctival and ciliary, chemosis, foliculae, papilae, phlyctena, discharge – catarrhal, purulent, fibrinous 4. Inflammatory diseases of the conjunctiva /conjunctivitis/. - Classification: acute, subaccute, chronic conjunctivitis; catarrhal, purulent, membranous and pseudomembranous conjunctivitis; allergic conjunctivitis; conjunctival-corneal damage in different skin diseases; other conjunctivitides - Acute catarrhal conjunctivitis: aetiology, clinics, treatment - Purulent conjunctivitis /gonorrhoic/ - Membranous /dyphtheric/ and pseudomembranous conjunctivitis - Chronic conjunctivitis

LECTURE 5 - 2 HOURS

DISEASES OF THE ORBIT AND EYELIDS

I. Diseases of the orbit. 2. Congenital diseases of the orbit. - Craniodysostoses - meningocoele and encephalocoele 3. Vascular diseases of the orbit. - Oedema of the orbit - Bleeding and hematoma of the orbit - Intermittent exophthalmus (proptosis) - Pulsating proptosis

4.Inflamation of the orbit. - Anterior and posterior osteoperiostitis of the orbit - Orbital cellulitis - Thrombophlebitis of the orbit 294

- Orbital phlegmona - Panophthalmitis - Tenonitis: serous and purulent 5.Parasitic diseases of the orbit. - Trichinosis - Echinococcosis 6. Endocrine orbitopathy - Thyroid associated orbitopathy (TAO) - Endocrine ophthalmopathy 7.Tumours of the orbit - Benign: dermoid cyst, holesteatoma, angioma, - Malignant: sarcoma, carcinoma, glioma, meningioma lymphoma . II. Diseases of the eyelids. 2. Function of the eyelids. 3. Diseases of the eyelids - Congenital anomalies - Diseases of the eyelid skin: noninflammatory and inflammatory - Diseases of eyelashes - Static and dynamic disorder of the eyelids: entropium, ektropium, blepharospasm, lagoftalm, ptosis of eyelids - Eyelid tumors: benign and malignant.

LECTURE 6 – 2 HOURS DISEASES OF THE FIBROUS EYE COAT: CORNEA AND SCLERA I. Diseases of the cornea - Function of cornea - Methods for corneal investigation - Pathological changes in cornea: opacities – infiltration, cicatrix, degeneration; vascularisation: superficial, deep 1. Changes in corneal shape and size 2. Inflammatory corneal diseases - Superficial nonpurulent keratitides - Superficial purulent keratitides - Deep /stromal/ keratitides - Trophyc keratitides 3. Treatment and consequences of keratitides II. Diseases of the sclera - Episcleritis - Anterior scleritis - Posterior scleritis

LECTURE 7 – 2 HOURS

KERATOCONJUNCTIVITES: ADENOVIRAL, PHLYCTENULOUS AND VIRAL. TRACHOMA. PTERYGIUM. PINGUECULA. 295

1. Differential diagnosis between conjunctivitis and keratitis.

2. Phlyctenulous keratoconjunctivitis - etiology - clinical signs - treatment

3. Vernal keratoconjunctivitis - etiology - clinical signs - treatment

4. Trachoma - distribution - etiology - clinical signs - differential diagnosis - complications - treatment

5. Degenerative diseases of the conjunctiva - pinguecula - pterygium.

LECTURE 8 - 2 HOURS

DISEASES OF THE UVEAL TRACT

І. UVEITIS. 1. Etiology and histopathology of uveitis. - exogenous agents - endogenous agents: acute and chronic infectious, non-infectious, focal infectious, immunoallergic, endocrine and genetic mechanisms. 2. Classification of Uveitis - according to etiology: infectious – exogenous and endogenous, non-infectious - according to duration: acute, subacute and chronic - according to exudation: serous, fibrinous, purulent and hemorrhagic - according to histopathology: granulomatous and nongranulomatous - according to anatomical localization: Anterior uveitis, Intermediate uveitis, Posterior uveitis and Panuveitis 3. Anterior uveitis - subjective symptoms - objective symptoms - exogenous anterior uveitis - endogenous anterior uveitis: acute infectious diseases, chronic infectious diseases, focal infectious, metabolic diseases, rheumatological diseases - therapy of acute anterior uveitis: topical and systemic. 296

4. Intermediate uveitis. 5. Posterior uveitis (chorioretinitis) - subjective symptoms - objective symptoms - clinical types: diffuse, multifocal, focal, central, peripheral, juxtapapillary - complications - therapy 6. Panuveitis - Tuberculosis - Syphilis - Toxoplasmosis - Sarcoidosis - Uveitis in non-infectious multi-system diseases - Ocular involvement in AIDS - Sympathetic ophthalmia - Acute purulent uveitis ІІ. Uveitic tumours.

LECTURE 9 – 2 HOURS DISEASES OF THE LENS

1. Function of the lens. 2. Methods for examination. 3. Diseases, connected with changes in lens’location.  ectopia lentis  luxation and subluxation of the lens 4. Diseases, connected with changes in lens transparency  acquired cataract: age-related, traumatic, pathologic, complicated, radiation-induced  management of the acquired cataract: medical and surgical  congenital cataract: types, clinical features, management.

LECTURE 10 – 2 HOURS GLAUCOMA

I. NATURE OF GLAUCOMA. DEFINITION. II. PHYSIOLOGY OF THE AQUEOUS HUMOR. III. INTRAOCULAR PRESSURE. METHODS FOR MEASUREMENT. IV. ETHIOPATHOGENESIS. V. CLASSIFICATION OF THE GLAUCOMAS:  primary glaucoma: angle-closure glaucomas, open-angle glaucomas, combined mechanism glaucoma  secondary glaucoma  congenital glaucoma 1. Primary angle-closure glaucoma - pathogenesis: relative papillary block, narrowing anterior chamber angle, plateau iris, vitreo-lenticular block - clinical features

297

- differential doagnosis 2. Open-angle glaucomas - types: primary, pseudoexfoliative, pigmentary A. Primary open-angle glaucoma - pathogenesis: dystrophic changes in different parts of the aqueous drainage system, combined with partial block of the anterior chamber angle by the iris’ root or goniosynechiae. - clinical features - differential diagnosis B. Pseudoexfoliative open-angle glaucoma. C. Pigmentary open-angle glaucoma. 3. Combined forms of glaucoma. VI. COMMON FEATURES AMONG THE PRIMARY GLAUCOMAS. VII. DIFFERENCES IN THE CLINICAL COURSE OF THE THREE TYPES OF GLAUCOMA VIII. MANAGEMENT - medical - surgical - laser

LECTURE 11– 2 HOURS DISEASES OF THE RETINA AND OPTIC NERVE 1. Retinal functions. 2. Diagnostic methods. 3. Classification of\retinal diseases. - Retinal vascular diseases - Retinal inflammation diseases - Retinal degenerative diseases - Phakomatoses - Retinal changes in blood diseases - Retinal detachment - Retinal tumours - Traumatic retinal diseases - Congenital retinal diseases - Perinatal injuries 4. Symptoms of retinal diseases - subjective symptoms - objective symptoms 5. Retinal vascular diseases. - haemodynamic disturbances in retinal vessels: acute retinal artery occlusion, acute retinal vein occlusion 298

- retinal changes in systemic vascular diseases: Hypertensive retinopathy, Kidney retinopathy, Retinopathy of prematurity, Diabetic retinopathy. 6. Inflammatory retinal vascular disease. 7. Retinal inflammatory diseases. - primary inflammatory retinal diseases: Central serous chorioretinoathy - secondary inflammatory retinal diseases: metastatic retinit, tuberculosis retinit. 8. Retinal degenerative diseases. - Retinal pigment epithelium degeneration 9. Retinal detachment - Rhegmatogenouse retinal detachment - Exudative retinal detachment - Tumour retinal detachment 10. Retinal tumours – Retinoblastoma.

LECTURE 12 – 2 HOURS OCULAR TRAUMA

1. Frequency and importance of blindness. 2. Types of ocular traumatism: civil, industrial, pediatric, agricultural, military. 3. Classification of ocular traumatism - contusions - injures: penetrating and non-penetrating – with or without foreign body - combustions A. Eyelid trauma: - contusions - injures B. Orbital trauma C. Globe trauma - contusions - injures: non-penetrating and penetrating, with or without foreign bofy - explosive injures D. Combustions - thermal - chemical - radiation a. Managemet og combustions: medical, surgical b. General practitioner duties

LECTURE 13 – 2 HOURS OCULAR MANIFESTATIONS IN GENERAL DISEASES

1. Two-way connection between eye and organism. 2. Importance of the ocular examination in general diseases diagnostics.

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3. Ocular manifestations in acute infectious diseases. 4. Ocular manifestations in chronic infectious diseases. 5. Ocular manifestations in colagenosis. 6. Ocular manifestations in endocrine disorders. 7. Ocular manifestations in metabolic disorders. 8. Ocular manifestations in vascular diseases. 9. Ocular manifestations in hematologic disorders. 10. Ocular manifestations in central nervous system disorders. 11. Ocular manifestations in AIDS.

LECTURE 14 - 2 HOURS

EYE MOTILITY DISORDERS. PROTECTION OF CHILDREN VISION

1. Motility of the eye. - Eye muscle movement - Function of the eye muscles.

2. Binocular vision. - Prerequsites - Types - Retinal correspondence - Methods of examination of bunocular vision. 3.Heteroforia. - Types - Clinical manifestations - Treatment 4. Concomitant squint. - Types - Etiology - Clinical features - Examination methods - Treatment: optical pleoptical, ortoptical, surgical, complex 5.Paralytic squint. - Etiology - Clinical features - Treatment - Differential diagnosis between concomitant and paralytic strabismus

LECTURE 15 – 2 HOURS

COUSES OF BLINDNESS. FIGHTING BLINDNESS. EMERGENCY IN OPHTHALMOLOGY.

I. BLINDNESS. 1. Definition of blindness. 2. Most common causes of blindness. 3. Types of blindness -absolute 300

-practic -work -professional -pedagogical -monolateral and bilateral -reversible and irreversible 4. Problems of blindness -moral and ethic -social 5. Rehabilitaion of the blind.

II. EMERGENCY AID IN OPHTHALMOLOGY. 1. Emergency aid steps given by the general practitioner (GP) in cases of trauma of the eyeball and ocular adnexa. 2. Emergency aid steps given by the GP in cases of burns. 3. Emergency aid steps given by the GP in cases of occlusion of the central retinal artery. 4. Emergency aid steps given by the GP in cases of thrombosis of the central retinal vein. 5. Emergency aid for acute angle closure glaucoma. 6. Emergency aid for acute iridocyclitis.

PRACTICE 1 - 3 HOURS ANATOMY OF THE EYEBALL. SYSTEMIC EXAMINATION OF PATIENTS. FOCAL ILLUMINATION EXAMINATION OF THE CONJUNCTIVA

І. Anatomy of the eyeball 1.Bulbus oculi – form, poles, meridians, equator

ІІ. Systemic examination of patients 1.Visit to the outdoor patients office: methods of examination of the anterior and posterior segments of the eye, visual charts, correction lenses, direct and indirect ophthalmoscopes, perimeter, tonometer, bio-microscope, instruments. 2. Systemic examination of the patient – history of the disease. 3. Examination of the conjunctiva. 4. Focal illumination. 5.Demonstration of patients: diagnosis, differential diagnosis, treatment. 6. Schematic drawing of the eyeball.

III. Focal illumination –

IV. Examination of the conjunctiva.

PRACTICE 2 - 3 HOURS

PATHOLOGY OF LIGHT PERCEPTION AND COLOR PERCEPTION. PERIPHERAL VISION

I. Light perception

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1. Light sensitivity threshold, adaptation. 2. Light perception. 3.Pathology of light perception.

IІ Color vision 1. Characteristics of colors, principle of pseudochromsatism. 2. Examination with the charts of Rabkin. 3. Pathology of color vision.

III. Peripheral vision 1.Anatomical substrate of peripheral vision and limits of the visual field. 2. Examination of peripheral vision, control method of Donders. 4. Diagnosis of visual field anomalies.

PRACTICE 3 - 3 HOURS CENTRAL VISION. REFRACTION AND REFRACYION ANOMALIES. VISUAL ACUITY.

I. Central vision. Visual acuity. 1. Angulus minimum visibille 2. Visual charts of Snellen, Monoye. 3. Examination of visual acuity, formula of Donders. 4. Examination of the visual acuity by the students.

ІІ. Refraction and refraction anomalies. 1.Physical optics. Physical refraction. Physiological optics. 2. The eye as an optic system. 3. Clinical refraction: emetropia, myopia, hypermetropia. 4. Acomodation. 5. Presbyopia. 6. Astigmatismus. 7. Methods of examination of the refraction – subjective, objective. 8. Correction of the anomalies of refraction. 9. Symptoms of myopia. 10. Symptoms of hypermetropia.. 11. Correction lenses. 12. Skiascopy.

PRACTICE 4 - 3 HOURS TRANSILLUMINATION. OPHTHALMOSCOPY. SKIASCOPY.

1.Transillumination – demonstration of the technique. Pathology of the transparent media. 2.Practical exercise in transillumination. 3.Ophthalmoscopy – direct and indirect. Principles of ophthalmoscopy. 4.Practical exercise in direct and indirect ophthalmoscopy. 5.Skiascopy.

PRACTICE 5 - 3 HOURS DISEASES OF THE ORBIT AND EYELIDS..

I.Diseases of the orbit. 1. Congenital diseases of the orbit. 302

2. Circulatory diseases of the orbit. 3. Inflammatory diseases of the orbit.. 4. Parasitic diseases of the orbit. 5. Endocrine diseases with orbital symptoms. орбитни прояви. 6. Malignent and benign tumors of the orbit. II. Diseases of the eyelids. 1. Congenital anomalies of the eyelids. 2. Diseases of the skin of the eyelids: inflammatory, non inflammatory. 3. Diseases of the eyelashes. 4. Static and dynamic anomalies in the lids position: entropion, ectropion, blepharospasmus, lagophthalmus, ptosis of the eyelids. 5. Malignent and benign tumors of the eyelids.

ІІІ. Demonstration of patients.

PRACTICE 6 - 3 HOURS

DISEASES OF THE LACHRYMAL APPARATUS AND THE CONJUNCTIVA.

I.Diseases of the lachrymal apparatus. 1.Acute dacruoadenitis. 2.Congenital and acquired anomalies of the lachrymal puncta. 3.Canaliculitis. 4.Chronic dacryocistitis. 5.Acute dacryocystitis.

II.Diseases of the conjunctiva. 1.Pathologic changes in the conjunctiva: hyperemia- conjunctival and cilliary, edema, follicules, papillas, phlyctenas, secretion – catarrhal, purulent, fibrin. 2.Inflammation of the conjunctiva ( conjunctivitis ) – acute, mild, chronic conjunctivitis, catarrhal, purulent, membranous, pseudo membranous, chlamidial, allergic conjunctivitis, conjunctiva-corneal damage in skin diseases, other conjunctivitis.

ІІІ.Examination of the lachrymal apparatus and conjunctiva: 1.Examination of the lachrymal secretion – Shirmer test. 2.Examination of the lachrymal pathway: - Canalicule test - nasal test - Anel test – demonstration. 3.Evacuation of the contents of the achrymal sac 4.Examination of the conjunctiva. 5.Focal illumination, bio microscopy.

ІV. Demonstration of patients.

PRACTICE 7 - 3 HOURS DISEASES OF THE CORNEA

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1.Pathologic changes in the cornea: opacities – infiltration, cicatrix, degeneration, pathologic vessels: superficial, deep. 2.Changes in the form and dimensions of the cornea. 3.Inflammatory diseases of the cornea: - superficial, non purulent keratitis - superficial purulent keratitis - deep ( parenchimal ) keratitis - trophic keratitis 4.permanent changes after keratitis and their treatment. 5.Examination of the corneal sensitivity. 6.Focal illumination, bio microscopy. 7.Instillation of eye drops and crèmes.

PRACTICE 8 - 3 HOURS

DISEASES OF THE UVEA

1.Normal structure of the iris – examination by focal illumination. 2.Cilliary hyperemia. Differential diagnosis between cilliary and conjunctival hyperemia. 3.Pathologic changes in iridocyclitis – changes of the structure of the iris, precipitates, Tyndall effect, posterior synechiae, opacities. Differential diagnosis between iridocyclitis, conjunctivitis, keratitis and acute closure angle glaucoma. 4.Examination of patients. 5.Treatment of iridocyclitis. 6.Demonstration of patients. 7.Trans illumination.

PRACTICE 9 - 3 HOURS TEST EXAMINATION. REVIEW.

PRACTICE 10 - 3 HOURS

DISEASES OF THE LENS.

1.Trans illumination. 2.Examination of a patient with a cataract in one eye and transparent lens in the other eye by focal illumination, trans illumination and bio microscopy. 3.Examination of an aphakic patient. 4.Correction of aphakia. 5.Demonstration of patients, video film – cataract extraction. 6.Bio microscopy, trams illumination.

PRACTICE 11 - 3 HOURS 304

GLAUCOMA. DIAGNOSTICS, PERIMETRY, TREATMENT, PREVENTION.

1.Examination of the IOP: а.by palpation б.by the tonometer of Maklakov. в.by the tonometer of Schiots and Goldmann. 2.Medical documentation of a glaucoma patient – changes of IOP during daytime, perimeters. 3.Demonstration of patients and differential diagnosis between open angle glaucoma and cataract. 4.Prevention of glaucoma and monitoring of glaucoma patients. . 5.Perimetry. 6.Treatment – medical, surgery, laser operations. 7.Demonstration of patients, video film – surgical treatment of glaucoma.

PRACTICE 12 - 3 HOURS

RETINAL DISEASES. RETINOPATHY OF PREMATURITY. RETINAL VASCULAR DISEASES. RETINAL DETACHMENT. MACULAR DEGENERATION. RETINAL TUMORS. OPTIC NERVE DISEASES.

1.Classification of the retinal diseases. 2.Retinal vascular diseases. 3.Retinal changes in systemic diseases. 4.Retinopathy of prematurity. 5.Retinal detachment. 6.Macular degeneration. 7.Malignant melanoma of the choroid – clinical picture, treatment. 8.Retinoblastoma – clinical picture, treatment. 9.Optic nerve head edema, optic neuritis, retrobulbar neuritis – ophthalmoscopy, clinical picture, treatment. 10.Anterior ischemic optic neuropathy. 11.Trans illumination. 12.Ophthalmoscopy.

PRACTICE 13 - 3 HOURS

TRAUMAS AND URGENCY IN OPHTHALMOLOGY.

1. What do we do when there is a trauma of the eye and the accessory structures of the eye. 2.Foreign bodies in the conjunctiva and the cornea. 3.Demonstration of patients with ocular traumas: blunt trauma, penetrating traumas of the eyeball. 4.First aid in ocular burns – thermal, chemical. 5.First aid in penetrating injuries of the eyeball. 6.First aid in acute closure angle glaucoma, occlusion of the central retinal artery or vein. 7.Demonstration of patients.

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PRACTICE 14 - 3 HOURS

DISTURBANCE OF OCULAR MOTILITY. VISION IN CHILDHOOD.

I.Disturbance of ocular motility. 1.Subjective complaints. 2.Objective findings in concomitant and paralytic strabismus. 3.What should the general practitioner do? ІІ. Congenital anomalies. ІІІ.Demonstration of patients.

PRACTICE 15 - 3 HOURS

INTRODUCTION. BLINDNESS

I.Problems of blindness. 1.Definition of blindness. 2.Most common diseases leading to blindness. 3.Types of blindness. - absolute - practical - connected with work - professional - pedagogic - monocular and binocular - reversible and irreversible. 4.Problems of blindness. - moral and ethical - social 5.Rehabilitation of blind people.

Note: During practice including the anterior and posterior segment of the eye, patients are demonstrated and practical skills developed, depending on the theme of the practice.

RECOMMENDED LITERATURE FOR SELF-PREPARATION

TEXTBOOK AUTHORS Publisher Clinical Ophthalmology Kanski J. Butterworth Heinemann , UK, 1997

Basik and Clinical Science Course Published by the American Academy of Ophthalmilogy, 12 sections

QUESTIONNAIRE FOR THE END EXAM 306

IN OPHTHALMOLOGY MEDICAL STUDENTS

1. Eyeball – general information. Phylogenesis and embryogenesis of the visual system. 2.Anatomy the outer layer of the eyeball / cornea, sclera /. 3.Anatomy the middle layer of the eyeball / uvea /. 4.Anatomy of the retina. 5.Anatomy the visual pathways. 6.Anatomy the eyelids and conjunctiva. 7.Anatomy lacrimal apparatus. 8.Anatomy the orbit. 9.Anatomy of the muscular system of the eye - external muscles of the eye. 10. Light perception. Adaptation. Methods of examination. Disturbances in adaptation. 11.Colour vision. Theories and disturbances. 12.Central vision. Visual acuity. Examination of visual acuity. Visual charts. 13.Peripheral vision. Visual field. Methods for examination. Abnormal changes of vision field – scotomata, anopsias. 14.Binocular vision. Fusion. 15.Diseases the orbit - general data. Types. Inflammatory diseases of the orbit and soft tissues of the orbit. 16.Tumours the orbit. Parasitic diseases. 17.Inflamatory diseases of the skin and subcutaneous tissue of the eyelids. 18.Diseases of the eyelid edges. 19.Tumours the eyelids and conjunctiva. 20. Disturbances of eyelid mobility and position. 21.Inflamatory diseases of the conjunctiva - objective symptoms and subjective complaints. 22. Catarrhal, purulent, membranous and pseudomembranous conjunctivitis. 23.Chronic conjunctivitis. Chlamydial conjunctivitis - paratrahoma and trachoma. 24.Allergic and autoimmune conjunctivitis. Spring catarrh. Lymphatic keratoconjunctivitis. 25.Degenerations the conjunctiva - pinguecula and pterygium. Dry eye syndrome. 26. Superficial non - purulent keratitis. 27. Superficial purulent keratitis. 28. Deep (stromal) keratitis - in congenital lues, tuberculosis keratitis in sclerosing keratitis. 29.Anomalies in size and curvature of the cornea - keratoconus keratoglobus, megalocornea, mikrocornea. 30. Surgical treatment of corneal opacities. Corneal refractive surgery. 31.Diseases of the sclera - episcleritis, scleritis – anterior and posterior. 32.Anterior uveitis / iridocyclitis / - clinical features, complications, differential diagnosis, treatment. 33.Posterior uveitis, chorioretinitis. 34.Inflamatory diseases of the whole uvea - tubercular, syphilitic, Toxoplasma, sarcoidosis. Ocular signs in AIDS. 35.Ophthalmia sympathyca 36.Endophthalmitis. 37.Malignant melanoma of the uvea. 38.Acute occlusion of central retinal artery and its branches. 39.Vein occlusion of the retina. 40. Retinal changes in vascular diseases - atherosclerosis, hypertension and diabetes mellitus. 41.Retinal periphlebitis /Eal’s disease /. Central serous retinopathy. 42. Degenerations of the chorioretina - Shtargard disease, retinitis pigmentosa. 43.Age – related macular degeneration (AMD). 44.Retinal detachment - congenital, primary, secondary. 307

45.Tumours of the retina / retinoblastoma /. 46.Retinopathy of prematurity (ROP). 47. Papilloedema. Inflammation of the optic nerve - papillitis, retrobulbar neuritis. 48. Ischaemic optic neuropaty. Optic atrophy - primary and secondary. 49. Pupil - general data. Normal reactions of the pupil. Abnormal reactions of the pupil. 50.Senile cataract, forms, stages, treatment. Aphakia. 51.Congenital cataracts. 52. Changes of lens’ location - traumatic, congenital. 53.Diseases of the vitreous - general data, pathological changes. 54. Prymary open-angle glaucoma. 55. Ancle closure glaucoma. 56. Congenital glaucoma. Secondary glaucomas. 57.Refraction of the eye. Physical optics. Eye as an optical system. Physical and clinical refraction. Examination of refraction - subjective and objective methods. 58.Accommodation - types, paralysis and accommodative spasm. Presbyopia. 59.Hypermetropia, hyperopia. 60.Nearsightedness, myopia. 61.Astigmatgism. Anisometropy. Eyeglasses - definition of spectacle lenses, magnifying glasses, telescopic spectacles. Contact lenses. 62. Eye motility disorders - general data. Orthophoria and Heterophorias. 63.Concomitant squint. 64. Paralytic squint. 65.Trauma the eyeball and its adnexa - general data. Classification. Injuries to the eye and its adnexa. 66. Non – penetrating injuries to the eyeball. 67. Penetrating injuries of the eyeball and adnexa with or without foreign body. 68. Eye burns - thermal, chemical. Radiation damage of the eyes. 69. Blindness. The most common topical drugs in ophthalmology. 70. Emergency in ophthalmology: traumas, acute glaucoma attack, acute occlusion of retinal arteries and veins.

TESTS FOR MEDICAL STUDENTS

PRACTICE 1 OUTDOOR OFFICE. SYSTEMIC EXAMINATION OF PATIENTS WITH OCULAR DISEASE. FOCAL ILLUMINATION. EXAMINATION OF THE CONJUNCTIVA.

І. Anatomy of the visual analyzer. 1.Contents of the eyeball: cornea, sclera, cilliary body, lens, retina. 2.Uvea: cornea, sclera, iris, lens, optic nerve. ІІ. Systemic examination of patients with ocular disease.Системен ход на изследване на очно болен. 1.Arrange by anatomical principle the structures of the eyeball and its accessory organs ( systemic examination ): - vitreous - anterior chamber - lens - orbit - conjunctiva 308

- ocular fundus - eyelids - cornea - iris - pupil - lachrymal apparatus ІІІ.Focal illumination 1.What do you need in order to perform focal illumination? 2.What is the principle of focal illumination? 3.What segment of the eye do you examine by focal illumination? ІV.Functions of the visual analyzer. 1.Function of the cornea: transmits light, participates in accommodation, insures dark chamber, participates in the production of aqueous humor. 2.Function of the lens: participates in accommodation, preserves the form of the eye, insures a dark chamber, transforms the light stimulus into a nerve impulse. 3.Function of the iris: transmits light, refracts light, preserves the form of the eye, regulates the quantity of light entering the eye. 4.Function of the choroids: transmits light, preserves the form of the eye, produces aqueous humor. 5.Function of the retina: participates in accommodation, produces aqueous humor, preserves the form of the eye, regulates the light beam entering the eye, transforms the light stimulus into a nerve impulse. 6.Function of the sclera: transmits light, participates in accommodation, preserves the form of the eye, produces aqueous humor . 7.Schematic drawing of the eyeball.

PRACTICE 2 PATHOLOGY OF COLOR VISION AND LIGHT PERCEPTION, PERIPHERAL VISION

І.Color vision. 1.Write down the spectral colors. 3.Write down the main characteristics of colors. 4.Избройте видовете цветни аномалии. 5.Write down the methods of examination of color vision and their principles.

ІІ.Light perception. 1.Definition of light perception. 2.Types of adaptation. 3.Methods of examination of adaptation. 4.pathologic changes in adaptation.

PRACTICE 3

CENTRAL VISION. REFRACTION AND ANOMALIES IN REFRACTION. VISUAL ACUITY.

І.Central vision. 1.Definition of central vision. 2.Formula of Donders. 3.What is the visual acuity of a patient counting fingers at 2 m? 309

4.What is the visual acuity of a patient seeing the movement of your hand at 30 cm? 5.Write down: - correct perception and projection of light - correct perception of light and lack of perception and projection of light - ІІ.Perimetry 1.Definition of the visual field. 2.Show the normal limits of the visual field.

SUP ! ! ! N------!------T ! ! ! INF 3.Write down the methods of examination of the visual field. 4.Types of perimetry. 5.Types of perimeters. 6.Which part of the visual field is examined by campimetry? 7.Pathologic changes in the visual field.

PRACTICE 4

TRANSILLUMINATION. OPHTHALMOSCOPY. SKIASCOPY.

І.Methods of examination. 1.Examination of the anterior segment of the eye: focal illumination, transillumination, direct ophthalmoscopy, indirect ophthalmoscopy, skiascopy. 2.Examination of the posterior segment of the eye: mirror image, focal illumination, transillumination, ophthalmoscopy, skiascopy, tonometry. 3.Methods of examination of the refraction of the eye: biomicroscopy, focal illumination, transillumination, skiascopy.

ІІ.Transillumination. 1.How to prepare the patient. 2.What are the required instruments and environment. 3.What is the purpose of the examination.

ІІІ.Ophthalmoscopy. 1.Types. 2.How to prepare the patient. 3.What are the required instruments and environment. 4.What is the purpose of the examination.

ІV.Skiascopy. 1.How to prepare the patient.. 2.What are the required instruments and environment. 310

3.What is the purpose of the examination.

PRACTICE 5 DISEASES OF THE ORBIT AND EYELIDS

І.Diseases of the eyelids. 1.Inflammatory diseases of the skin of the eyelids. 2.Diseases of the rim of the eyelids and the anomalies of the position of cilia. 3.Tumors of the eyelids. 4.Anomalies of the motility and position of the eyelids.

III. Diseases of the orbit: phlegmona orbitae.

PRACTICE 6 DISEASES OF THE LACHRYMAL APPARATUS AND THE CONJUNCTIVA.

І.Lachrymal gland. 1.Anatomy of the lachrymal gland: - position - dimensions - openings of the channels - types of secretion 2.Diseases of the lachrymal gland.

ІІ.Lachrymal pathway. 1.Anatomy of the lachrymal pathway. 2.Diseases of the lachrymal pathway. ІІІ.Diseases of the conjunctiva. 1.Parts of the conjunctiva, depending on the position. 2.Classification of conjunctivitis. 3.Symptoms of conjunctivitis. 4.Differential diagnosis between conjunctival and cilliary hyperemia: diseases, position, color, blood vessels. 5.Tumors of the conjunctiva: malignant, benign.

PRACTICE 7 DISEASES OF THE CORNEA.

1.Main characteristics of the cornea. 2.Horizontal and vertical diameters of the cornea. 3.Methods of examination of the cornea. 4.Changes in the cornea in corneal disease. 5.Differential diagnosis between infiltration of the cornea and corneal cicatrix. 6.Differential diagnosis between deep and superficial blood vessels of the cornea. 7.When do we observe cilliary hyperemia? 311

PRACTICE 8 DISEASES OF THE UVEA.

І.Anterior uveitis ( iridocyclitis ). 1.Etiology. 2.Subjective symptoms. 3.Objective findings in iridocyclitis. 4.Methods of examination in iridocyclitis. 5.Complications of iridocyclitis. 6.Local therapy in iridocyclitis.

PRACTICE 9

REVIEW

І.Methods of examination. 1.Examination of the anterior segment of the eye: focal illumination, transillumination, direct ophthalmoscopy, indirect opthalmoscopy, skiascopy. 2.Examination of the posterior segment of the eye: mirror images, focal illumination, transillumination, ophthalmoscopy, skiascopy, tonometry. 3.Methods of examination of the refraction: biomicroscopy, focal illumination, transillumination, skiascopy.

ІІ.Anatomy of the visual analyzer. 1.Contents of the eyeball: cornea, sclera, cilliary body, lens, retina. 2.Uvea: cornea, sclera, iris, lens, optic nerve.

ІІІ. Function of the visual analyzer. 1.Function of the cornea: transmits light, participates in accommodation, secures a dark chamber, participates in intraocular liquid secretion. 2.Function of the lens: participates in accommodation, secures a dark chamber, transforms the light stimulus into a nerve impulse. 3.Function of the iris: transmits light, refracts light, regulates the quantity of light entering the eye. 4.Function of the choroid: transmits light, secures a dark chamber, participates in the intraocular kiquid secretion. 5.Function of the retina: participates in accommodation, preserves the form of the eye, participates in the intraocular liquid secretion, regulates the quantity of light entering the eye, transforms the light stimulus into a nerve impulse. 6.Function of the sclera: transmits light, participates in accommodation, preserves the form of the eye, participates in the intraocular liquid secretion. 7.Schematic drawing of the eyeball.

Note: Underline the right answer.

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PRACTICE 10

DISEASES OF THE LENS.

1.Anatomy of the lens: form, dimensions, position, refractive power. 2.Functions of the lens. 3.Methods of examination of the lens. 4.Diseases of the lens. 5.Types of cataract. 6.Methods of cataract extraction. 7.Correction of aphakia. .

PRACTICE 11

GLAUCOMA. DIAGNOSIS. TREATMENT. PREVENTION.

1.Methods of examination of the intraocular pressure. 2.Normal limits of intraocular pressure, measured by the method of Maklakov. 3.Types of glaucoma. 4.Methods of examination of glaucoma patients. 5.Pathologic changes in glaucoma. 6.Differential diagnosis between iridocyclitis and acute closure angle glaucoma. :

Iridocyclitis Acute closure angle glaucoma .Pain – irradiation Hyperemia of the eye Cornea Anterior chamber Changes of the iris Pupil - reaction intraocular pressure Ocular fundus First aid

PRACTICE 12

DISEASES OF THE RETINA. RETINOPATHYOF PREMATURITY. RETINAL VASCULAR DISEASES. RETINAL DETACHMENT. MACULAR DEGENERATION. RETINAL TUMORS. DISEASES OF THE OPTIC NERVE.

І. Retinal diseases. 1.Methods of examination of the retina. 2.Subjective symptoms in macular diseases. 3.Objective findings in retinal diseases: inflammatory, vascular diseases, diabetic retinopathy, retinal detachment. 4.Differential diagnosis between rhegmatogenous and tumoral retinal detachment. 313

ІІ.Diseases of the optic nerve. 1.Methods of examination of the optic nerve. 2.Objective findings and functional changes in optic neuritis. 3.Objective findings and functional changes in optic nerve edema. 4.Objective findings and functional changes in anterior ischemic optic neuropathy. 5.Differential diagnosis between primary and secondary atrophy of the optic nerve.

PRACTICE 13

TRAUMAS AND URGENCY IN OPHTHALMOLOGY

1.Non penetrating traumas of the eyeball: erosion, hyphema, cilliary hyperemia, prolapsus iridis, conjunctival hyperemia, epiphora, light hyper sensitivity, corneal foreign body, hemorrhage, subconjunctival hemorrhage, iridodialisis, iridodonesis, hemophthalmus, traumatic cataract, increased IOP, decreased IOP, intraocular foreign body, retinal detachment, decreased visual acuity, pain.

2.Penetrating traumas of the eyeball: erosion, hyphema, cilliary hyperemia, prolapsus iridis, conjunctival hyperemia, epiphora, light hypersensitivity, corneal foreign body, hemorrhage, subconjunctival hemorrhage, iridodialisis, iridodonesis, hemophthalmus, traumatic cataract, increased IOP, decreased IOP, intraocular foreign body, retinal detachment, decreased visual acuity, pain.

3.Blunt traumas of the eyeball: erosion, hyphema, cilliary hyperemia, prolapsus iridis, conjunctival hyperemia, epiphora, light hypersensitivity, corneal foreign body, hemorrhage, subconjunctival hemorrhage, iridodialisis, iridodonesis, hemophthalmus, traumatic cataract, increased IOP, decreased IOP, intraocular foreign body, retinal detachment, decreased visual acuity, pain.

4.First aid given by the general practitioner in penetrating ocular traumas.

5.First aid given by the general practitioner in chemical burns of the eyeball and the ocular accessory structures.

PRACTICE 14

DISTURBANCES OF THE OCULAR MOTILITY. VISION IN CHILDHOOD.

І.Disturbances of the ocular motility. 1.Anatomy of the ocular musculature: types of muscles and their nerve supply. 2.Definition of optophoria. 3.Definition of heterophoria. 4.Definition of concommitent strabismus. 5.Definition of paralytic strabismus. 6.Differential diagnosis of concommitent and paralytic strabismus. 7.Phases in the treatment of concommitent strabismus.

Test N 1 314

1. Lens develops from: a. neural ectoderm b. surface ectoderm c. optic vesicle d. all of the above 2.Corneal thickness is measured by: a. keratometer b. vernier scale c. pachymeter d. none of the above 3.Unilateral aphakia can be treated by: a. contact lens b. intraocular lens implant c. both d. none 4.Angular conjunctivitis is caused by : a. Staphilococcus b. pneumococcus c. virus d. Morax-Axenfeld bacillus 5.The ectatic cicatrix in which iris is incarcerated is called : a. adherent leucoma b. anterior synechia c. prolapse of iris d. anterior staphyloma 6.The optic nerve pierces the sclera: a. anteriorly b. posteriorly c. at the equator d. 4 mm behind the uquator 7. Rubeosis iridis is seen in: a. diabetes b. central retinal vein oclusion c. both d. none 8.Diminished vision in daylinght is seen in : a. central cataract b. peripheral cataract c. zonular cataract d. none of the above 9.Subhyaloid haemorrhage occurs between: a. retina and vitreous b. within vitreous c. behind retina d. none of the above 10.Glaucoma may be secondary to all the following EXCEPT: a.iritis b.dislocation of lens c.hyphaema d.occlusion of short ciliary artery 11.Diabetic retinopathy is characterized by: a. superficial haemoffhage b.perivasculitis c.microaneurysms d.A-V crossing changes 12.Vision is grossly reduced in: 315

a. papillitis b. papilloedema c. pseudopapillitis d. all of the above

Test N 2 1. Retinal develos from: a. surface ectoderm b. mesoderm c. optic vesicle d. embryonic fissure 2. Corneal sensations are reduced in: a. hypopion ulcer b. phlyctenular keratitis c. herpes simplex d. arcus senilis 3.Cylindrical lens are prescribed in: a. presbyopia b. astigmatism c. myopia d. squint 4.Eye should not be bandaged in: a. corneal ulcer b. purulent conjunctivitis c. glaucoma d. retinal detachment 5.Central corneal ulceration may be associated with: a. herpes virus b. bacteria c. fungus d. all of the above 6.Episcleritis and scleritis are common in: a. women b. allergic reaction to endogenous toxin c. associated with collagen d. all of the above 7.Anterior uveitis is seen in association with: a. rheumatoid arthritis b. ankylosing spondylitis c. Reiter’s syndrome d. all of the above 8.Cataacts are found in association with: a. parathyroid deficiency b. myotonic dystrophy c. dinitrophenol toxicity d. all of the above 9.The complications of vitreous bands and membranes are: a. retinal oedema b. retinal hole formation c. retinal detachment d. all of the above 10.Acute congestive glaucoma manifests as: a. cupping of disc b. pinpoint pupil

316

c. hand movements vision d. all of the above 11. Cherry red spot is seen in: a. chorioretinitis b. amaurotic familial idiocy c. central serous retinopathy d. all of the above 12.Enlargement of the blind spot occurs in: a. papilloedema b. papillitis c. retrobulbar neuritis d. glaucoma

317

Test N 2 - Answers

1 – c 2 – c 3 – b 4 – b 5 – d 6 – c 7 – d 8 – d 9 – d 10 – c 11 – b 12 – a

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ORTHOPEDICS AND TRAUMATOLOGY

Education course - 4 Semester-8 Exam-after 8 semester Workload of the lections-90 hours Lector Professor Dr. V.Stavrev

Curriculum

Curriculum Credentials Classes weekly semester 8th sem. totally

Lections 2 30 30 Exercises 4 60 60 4.2 Totally 6 90 hours 90 hours hours

Annotation

A. Objective methods of study of Muscular Skeletal System /MSS/ B. Instrumental methods of study of MSS: 1.Non-invasive methods: metric study of axis and length of extremities, angulometry for motion volume of the joints in the three main projections, image diagnostics in orthopedics and traumatology/classical X-ray, tomography, CT, MRI. 2.Invasive methods of study: joint aspiration, contrast artrography, fistulography, endoscopy /arthroscopy/. C. Actual prophylactic and treatment options in orthopedics and traumatology- conservative and operative.

Purpose of the course : Study of diseases and injuries of MSS, their exploration, diagnosis and treatment. Tasks of the course : Study of investigation methods and their practical applications in orthopedics and traumatology. Introduction of treatment methods-conservative and surgical. Methods of study: Lections. Practical training with patients in the operating room, plaster and manipulation rooms.

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Technical resources used in study: Multimedia, charts, schemes.

Control and evaluation: Current and final: A. Preliminary test. B. Theoretical exam-preliminary done exam tickets with two questions-one from Orthopedics and Trauma.

Control methods :oral exams and tests

Mandatory competitions: theoretical knowledge and practical skills.

-Theoretical knowledge :all nosological units included in Orthopedics and Traumatology schedule . -Practical skills : all practical researches based on practical training course.

Program :detailed for lections and exercises divided by hours: -lections 27 x2 sch.hours -exercises 30 x2 sch.hours

PROGRAM OF LECTURES 2 sch.hours each. 1. Main historical notes. Congenital hip dysplasia. 2. Congenital hip dislocation. Coxa vara. Adolescent epiphysitis. Rickets deformation. 3. Congenital deformations and diseases of upper extremity. 4. Diseases of muscles, tendons and their insertions caused by strain. Humeral periarthritis . 5. Foot deformities. Movie. 6. Birth injuries. 7. Deformations and diseases of the spine. 8. Degenerative joint diseases. 9. Traumatic injuries of MSS-Common characteristic. Contusion. Distortion. Ruptures. 10. Fractures of the shoulder/Scapula and clavicle/ and proximal part of the humerus. 11. Humeral fractures-middle and distal part. 12. Fractures of the forearm-upper and middle part. 13. Distal radius fracture. Fractures of the wrist and fingers. Hand injuries. 14. Luxations .Humeral and elbow luxation . 15. Fractures of the spine. Movie. 16. Traumatic hip dislocation. Vertebral dislocation. Dislocation of the thumb. 17. Pelvic fractures. 18. Hip fractures-upper and middle part. 19. Intraarticular fractures of the leg. 20. Leg fractures. Movie.

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21. Ankle fractures. 22. Bone tumors. 23. Knee injuries. 24. Bone tuberculosis. 25. Aseptic /avascular/ necrosis. 26. Flaccid and spastic palsy. 27. Demonstration movies.

PRACTICAL EXERCISES SCHEDULE

2 sch.hours each.

1. Organisation of orthopedic and trauma aid. Basic treatment methods. 2. Patient study. 3. Common immobilization techniques. Splinters, casts. 4. Kinesytherapy,orthopedic workshop. Polyclinic. 5. Congenital hip dislocation. 6. Coxa vara, valga, knee deformities. Adolescent epiphysitis. 7. Spine deformities. Scoliosis, kyphosis, lordosis. 8. Leg injuries. 9. Foot deformities. 10. MSS diseases caused by strain. 11. Traumatic injuries of MSS-common characteristic. 12. Fractures of the shoulder. Humeral fractures-proximal and middle part. 13. Fractures of the distal humerus, forearm, wrist, fingers. 14. Upper extremity injuries .Diagnosis, first aid. Treatment and complications. 15. Dislocations. 16. Lower extremity injuries. Diagnosis, first aid. Treatment and complications. 17. Pelvic fractures. 18. Proximal hip fractures. 19. Hip fractures-middle and distal part. Supracondylar fractures. 20. Knee fractures. 21. Leg fractures. 22. Ankle fractures. 23. Spine fractures. 24. Congenital diseases. 25. Knee injuries. 26. Degenerative joint diseases. 27.Aseptic necroses. 28. Bone tumors. 29. Rickets deformity. 30. Flaccid and spastic palsy.

Literature: Textbook of the clinic-edited by Proff,Dr.Stavrev,proff.Atanasov

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FORENSIC MEDICINE AND DEONTOLOGY Year of study: 5 Semester: 10th semester Exam: after the 10th semester Total number of lectures: 75 hours Lecturer: A habilitated lecturer from the Department of General and Clinical Pathology and Forensic Medicine.

CURRICULUM Number of Instructional Hours Type Credits Per week ІХ sem. Х sem. Total Lectures 3 45 45 - Seminars 2 30 30 4,3 Total 5 hours - 75 hours 75 hours

ANNOTATION: Basics of legal proceedings in Forensic Medicine. Forensic traumatology. Basics of Forensic Medical Expert Examination of living persons. Forensic Obstetrics and Gynaecology. Expert Examination of simulated diseases and self-injuries. Expert Examination in case of disputable paternity and/or maternity. Forensic Toxicology. Expert Examination of written data. Expert Examination of trace evidence. Medical Ethics and Deontology. THE AIM of the course in Forensic Medicine is to develop capability and skills necessary in graduating medical students, for medicolegal cases in their career practice. LEARNING OBJECTIVES: The main objective is to gain knowledge and practical skills necessary for participation in the functioning of courts. TEACHING METHODS: In its methodological aspect Forensic Medicine uses routine clinical methods of research and training known from other fields of Medicine. Some of the methods are adjusted to the nature and specific characteristics of Forensic Medicine and others are innovative methods described in forensic literature. Experimentation, as a method, is used in the course of study or in the practice. The basic teaching methods are the following:  demonstration of a medicolegal specimen or case  solving practical problems  introduction of the specific problems of the subject of the lecture by means of particular medicolegal cases  work in groups

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 laboratory practice  doing tests and completing sample tasks

EQUIPMENT USED IN THE COURSE OF STUDY: projectors, diagrams, sketches, models, photographs, instructional film, organ specimens, posters related to different medicolegal cases, spectrophotometers, laboratory equipment, histologic specimens, multimedia presentations, instructional computers. CONTROL AND ASSESSMENT  Current control – tests at the end of each seminar. The grade resulting from the current control constitutes one third of the final grade.  Final control – an end-of-semester exam; the grade thereof constitutes one third of the final grade. This exam includes a test, a written exam on a question randomly selected for each student and a discussion. METHODS AND CONTROL: oral exams, written exams, solving a practical problem, - tests. MINIMUM COMPETENCE:  Theoretical competence: basic knowledge of basics of legal proceedings in forensic examination in The Republic of Bulgaria, thorough knowledge of Forensic Traumatology, Tanatology, Toxicology, Deontology.  Practical skills: active participation in crime scene investigation of a dead body; writing a forensic report individually; distinguishing features of death, defining its duration, primary assessing its type and kind, properly reacting to the bodies of Ministry of Interior and approaching them whenever necessary.

SCHEDULE OF LECTURES LECTURE No 1 - 2 hours: Historical aspects of Forensic Medicine. Subject, objectives, methods and content of Forensic Medicine. Basics of legal proceedings in and organization of Forensic Medical Expert Examination – Penal Procedure Code, Criminal Code, Code of Civil Practice. Rights and obligations of the expert. Types of Expert examinations. Subjects of Forensic Medical Expert Examinations. Subjects of Forensic Medical Expert Examination. Responsibility of the experts. LECTURE No 2 - 2 hours: Injuries caused by mechanical factors – general description, classification of injuries. Forensic Medical Expert Examination in blunt force trauma. Soft- tissue traumatic injuries – abrasions, bruises, lacerated wounds. Bone fractures typical of Forensic Medicine. Blunt force trauma of

323 internal organs. Medicolegal aspects of blunt force trauma. Objectives of the Forensic Medical Expert Examination in case of such injuries. LECTURE No 3 – 2 hours: Traffic accidents. Definition, classification, types. Injuries of pedestrians - characteristics of traumatic injuries. Rolling injuries - characteristics of traumatic injuries. Injuries of occupants of the vehicles- characteristics of traumatic injuries. Problems in cases of motor vehicle traumas. Objectives of the Forensic Medical Expert Examination. Medicolegal importance. LECTURE No 4 – 2 hours: Forensic Medical Expert Examination in cases of sharp force trauma and firearm injuries. Stab, incised, puncture and chop wounds. Morphological characteristics. Distant, close, near and contact range gunshots. Morphological characteristics of entry and exit firearm wounds. Additional gunshot factors. Medicolegal importance. Objectives of the Forensic Medical Expert Examination. LECTURE No 5 – 2 hours: Cause and mechanism of death in case of mechanic force injuries. Vital and postmortem injuries. LECTURE No 6 - 2 hours: Mechanical asphyxias – major issues, classification of mechanical asphyxias. Pathophysiology of mechanical asphyxias. Hanging, ligature strangulation and manual strangulation – general and type characteristics, manner of death. Problems. Objectives of the Forensic Medical Expert Examination. LECTURE No 7 - 2 hours: Other types of mechanical asphyxias – drowning, airway obstruction, postural asphyxia, asphyxia due to exhaustion or displacement of environmental oxygen. Problems. Objectives of the Forensic Medical Expert Examination. LECTURE No 8 - 2 hours: Thermal deaths. Cold. Burns. Scalds. Electrical injuries. Lightning stroke. Specific medicolegal issues. LECTURE No 9 - 2 hours: Forensic Toxicology – definition of “poison”, toxicokinetics and toxicodynamics of poisoning, conditions influencing poison reactions, major issues, medicolegal tests to detect drugs or poisons in living persons or dead bodies, toxicological analysis. LECTURE No 10 - 2 hours: Forensic Toxicology – specific issues, poisoning caused by different types of poison. Rare, particular poisonings. LECTURE No 11 - 2 hours: Forensic Medical Expert Examination of dead body – Violent death and Sudden natural death. LECTURE No 12 - 2 hours: Forensic Thanatology. Cause and mechanism of death. Meaning of cellular, clinical (somatic), brain-stem, biological death and suspended animation. Determination of death. Early postmortem changes – changes in the skin, changes in the eye, livor mortis, algor mortis, rigor mortis. Late postmortem changes- putrefaction, adipocere, mummification. Time since death. 324

LECTURE No 13 - 2 hours: Forensic Medical Expert Examination of living people. Bodily injuries according to the Criminal Code of the Republic of Bulgaria. Legal and medical criteria for bodily injury. Short summary of the various medicobiological signs. LECTURE No 14 - 2 hours: Forensic Medical Expert Examination in cases pertaining to sex. Sexual offences and paraphilias – legal criteria according to the Criminal Code of the Republic of Bulgaria. Forensic Medical Expert Examination in case of debauchery. LECTURE No 15 - 2 hours: Forensic Medical Expert Examination in cases of pregnancy, abortion and delivery. Criminal abortion – legal regulation of willful abortion in the Republic of Bulgaria. Criminal liability in cases of criminal abortion. LECTURE No 16 - 2 hours: Infanticide – legal criterion. Forensic Medical Expert Examination of dead body of newborn infant in cases of infanticide. Major issues, particular aspects of cadaver examination. LECTURE No 17 - 2 hours: Disputable paternity or maternity. Blood type test – genetic rules and methods of examination. АВО system – clinical and medicolegal importance. LECTURE No18 - 2 hours: Forensic Medical Expert Examination of trace (material) evidence. Biological materials- blood, sperm, saliva and other materials. DNA typing. LECTURE No 19 - 2 hours: Forensic Medical Expert Examination in cases of forensic anthropology identification. Identification data. LECTURE No 20 - 2 hours: Legal and deontological issues in the medical practice - legitimacy of medical actions. Euthanasia. LECTURE No 21 - 2 hours: Professional negligence (Malpraxis) by medical staff. Classification of Malpraxis. Willful crimes regarding medical activity. LECTURE No 22 - 3 hours: Professional incompetence of medical staff. Medical errors. Fatal accidents (misadventure) in the medical practice. „Calculated risk” cases in the medical practice.

SCHEDULE OF SEMINRAS SEMINAR No 1 – 2 hours: Introduction to Forensic Medicine – general concept of Forensic Medicine. Subjects of Forensic Medical Expert Examinations. Acquainting students with the requirements of the department, the proceedings of the seminars, the current control and the final exams. SEMINAR No 2 – 2 hours: Basics of legal proceedings in Forensic Medicine. Introduction of the normative base concerning Forensic Medical Expert Examinations in the Republic of Bulgaria. Subjects of Forensic Medical Expert Examinations. Types of Forensic Medical Expert Examinations. Experts – rights, 325 obligations, responsibility, right of challenge, forensic problems in the work of medical practitioners. Medicolegal reports. SEMINAR No 3 – 2 hours: Forensic Medical Expert Examination in cases of blunt force trauma. Injuries caused by mechanical factors – general description, classification of injuries. Soft- tissue traumatic injuries – abrasions, bruises, lacerated wounds. Bone fractures typical of Forensic Medicine. Blunt force trauma of internal organs. Medicolegal aspects of blunt force traumas. Objectives of the Forensic Medical Expert Examinations in cases of such injuries. Blunt force trauma of internal organs. Medicolegal aspects of blunt force traumas. Objectives of the Forensic Medical Expert Examination in cases of such injuries. Demonstrations of specimens, photographs, and slides of both dead bodies and living people. SEMINAR No 4 - 2 hours: Forensic Medical Expert Examination in cases of sharp force trauma. Stab, incised, puncture and chop wounds. Morphological characteristics. Demonstrations of specimens, photographs, and slides of both dead bodies and living people. SEMINAR No 5 – 2 hours: Forensic Medical Expert Examination in cases of traumatic injuries due to the traffic accidents. Demonstrations of specimens, photographs, and slides of both dead bodies and living people. SEMINAR No 6 – 2 hours: Forensic Medical Expert Examination in cases of firearm injuries. Distant, close, near and contact range gunshots. Morphological characteristics of entry and exit firearm wounds. Additional gunshot factors. Demonstrations of specimens, photographs, and slides of both dead bodies and living people. SEMINAR No 7 – 2 hours: Forensic Medical Expert Examination in cases of mechanical asphyxias. Types of mechanical asphyxia- hanging, ligature strangulation and manual strangulation – general and type characteristics, manner of death. Problems. Objectives of the Forensic Medical Expert Examination. Other types of mechanical asphyxia - drowning, airway obstruction, postural asphyxia, asphyxia due to exhaustion or displacement of environmental oxygen. Medicolegal autopsy- cadaver demonstration. SEMINAR No 8 - 2 hours: Forensic Medical Expert Examination of a dead body – Medicolegal autopsy- demonstration. SEMINAR No 9 – 2 hours: Forensic Medical Expert Examination of a dead body. Medicolegal autopsy in cases of traumatic injuries, postmortem changes, diagnosis of death. SEMINAR No 10 - 2 hours: Forensic Medical Expert Examination of living people – demonstration.

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SEMINAR No 11 - 2 hours: Forensic Medical Expert Examination of living people – the students work alone under the supervision of the assistant-professor. SEMINAR No 12 – 2 hours: Forensic Medical Expert Examination of living people- the students work alone and afterwards their work is checked and corrected by the assistant-professor. SEMINAR No 13 – 2 hours: Forensic Medical Expert Examination of written data. Documentary evidence. Introduction and preparing a specific Forensic Medical Expert Examination for a particular case. SEMINAR No 14 - 2 hours: Forensic Medical Expert Examination of trace (material) evidence. Examination of blood stains- general, chemical and serological examinations (ABO system). SEMINAR No 15 – 2 hours: Forensic Medical Expert Examination in cases of poisoning. Cases. Practical introduction of the methods of chemical examination of biological materials.

SYNOPSYS OF FORENSIC MEDICINE AND DEONTOLOGY EXAMINATION

1. Definition, subject, methods, content and importance of Forensic Medicine. Forensic Medical Expert Examination – definition, subjects, types. Basics of legal proceedings in Forensic Medicine in the Republic of Bulgaria (Penal Procedure Code and Code of Civil Practice). Organization of Forensic Medicine in the Republic of Bulgaria. 2. Injuries caused by mechanical factors. Comprehensive definition, classification of mechanical force injuries. The algorithm for description of the traumatic injuries. Major issues concerning Forensic Medical Expert Examination. Blunt force trauma – definition, types, mechanism of causation, morphological characteristics of the injuries. 3. Blunt force trauma. Abrasions – definition, mechanism of causation, morphological characteristics, medicolegal importance. Bruises – definition, mechanism of causation, morphological characteristics, medicolegal importance. Lacerations - definition, mechanism of causation, morphological characteristics, medicolegal importance. 4. Blunt force traumas of bones and internal organs. 5. Fall injuries. Falling from great height and own height . 6. Traffic accidents. Motor vehicle trauma – definition, classification, major issues concerning Forensic Medical Expert Examinations. Specific features of Forensic Medical Expert Examinations. 7. Traffic accidents. Injuries of pedestrians - characteristics of traumatic injuries. Rolling injuries - characteristics of traumatic injuries. 327

8. Traffic accidents. Injuries of occupants of the vehicles-characteristics of traumatic injuries 9. Rail trauma - classification, characteristics of the injuries. Major issues concerning Forensic Medical Expert Examination. 10. Sharp force trauma. Sharp and thin objects. Blunt, long and rigid objects. Puncture wounds – morphological characteristics of injuries. Sharp-edged objects. Incised wounds morphological characteristics of injuries. 11. Sharp force trauma. Sharp and flat objects. Stab wounds – morphological characteristics of injuries. Chop wounds - morphological characteristics of injuries. 12. Firearm injuries. Definition. Mechanism of injury. Summary of Forensic Ballistics. Main objectives of forensic examination. Distant-range gunshot. Morphological characteristics of injuries. 13. Firearm injuries. Close-range and near-range gunshots. Morphological characteristics of injuries. Contact-range gunshot. Morphological characteristics of the injuries. 14. Firearm injuries by smooth bore firearm(shotgun) and country made firearm. Characteristics of injuries. Injuries caused by explosions. 15. Vital and postmortem injuries. 16. Cause and mechanism of death in case of mechanical force injuries. 17. Mechanical asphyxia. General information. Vital symptoms of the mechanical asphyxia. Common morphological characteristics in cases of death caused by mechanical asphyxia-postmortem appearances. Classification of mechanical asphyxias. 18. Mechanical asphyxia. Hanging. Ligature strangulation and manual strangulation. 19. Mechanical asphyxia. Drowning. 20. Mechanical asphyxia. Airway obstruction, postural asphyxia, asphyxia due to exhaustion or displacement of environmental oxygen. Autoerotic asphyxia. Major issues of Forensic Medical Expert Examination in cases of mechanical asphyxias. 21. Thermal injuries. Cold. Burns. Scalds. Local and general effects. Carbonization. Major issues concerning Forensic Medical Expert Examination. 22. Electrical injuries. Injuries caused by electrocution. Specific features of electrical injuries. Injuries caused by lightning stroke. Major issues concerning Forensic Medical Expert Examination in cases of electrical injuries and lightning stroke. 23. The impairment of health and death caused by the effect of chemical agents (Forensic Toxicology). General information, concept of poison and 328

poisoning. Toxicodynamics and toxicokinetics. Factors and conditions influencing poison reactions. 24. Forensic estimation in a case of poisoning. Major issues of Forensic Medical Expert Examination in cases of poisoning. Types of the poisons. 25. Corrosive poisoning. Blood poisons. CO-poisoning. Major issues and signs. 26. Medical Drug poisoning. Major issues and signs. Agricultural poisoning. Organophosphorus poisoning. Major issues and signs. 27. Ethanol poisoning. Toxicodynamics and toxicokinetics of the ethyl alcohol. Clinical features of the inebriation. Diagnosis and methods for estimation of the alcohol level of living people. Autopsy features in a case of ethanol poisoning. Methyl poisoning. 28. Drug dependence (addiction and habituation). Major issues. Heroin poisoning. Cocaine poisoning. Cannabis poisoning. Major issues. Investigation of drug abuse deaths. 29. Forensic Medical Expert Examination of living people. Bodily injuries according to the Criminal Code of the Republic of Bulgaria. Legal and medical criteria for bodily injury. Short summary of the various medicobiological signs. Trivial bodily injury - article 130 from Criminal Code. 30. Forensic Medical Expert Examination of living people. Bodily injuries according to the Criminal Code of the Republic of Bulgaria. Medium bodily injury - legal and medical criteria (article 129 from Criminal Code) 31. Forensic Medical Expert Examination of living people. Bodily injuries according to the Criminal Code of the Republic of Bulgaria. Severe bodily injury - legal and medical criteria (article 128 from Criminal Code) 32. Forensic Medical Expert Examination of living people. Forensic Medical Expert Examination in cases pertaining to sex. Sex determination. Establishment of the functions of the genital organs in the male and the female. Establishment of the reproduction inability in the male and the female. 33. Forensic Medical Expert Examination of living people. Sexual offences and paraphilias. Fornication (act for the purpose of arousing or satisfying sexual desire, without copulation - articles 149 and 150 from Criminal Code). Homosexual acts (sexual intercourse or acts of sexual satisfaction with a person of the same sex - article 157 from Criminal Code). Legal criteria and Forensic Medical Expert Examination in case of debauchery. 34. Forensic Medical Expert Examination of living people. Sexual offences and paraphilias. Rape (sexual intercourse with a person of the female sex -

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article 152 from Criminal Code). Legal criteria and Forensic Medical Expert Examination in case of rape. 35. Forensic Medical Expert Examination in case of disputable paternity or maternity. Short summary for different types of examination- genetic and serological methods. DNA typing. 36. АВО- and Rh- systems. Medicolegal aspects. Rules and hazards of blood transfusion. 37. Forensic Medical Expert Examination of living people. Establishment of pregnancy, abortion and delivery. Criminal abortion (article 126 from Criminal Code). Legal regulation of willful abortion in the Republic of Bulgaria. 38. Forensic Medical Expert Examination of living people. Simulated diseases and self – injuries. Child abuse (article 187 from Criminal Code). 39. Forensic Medical Expert Examination of dead body. Forensic Thanatology. Categorization of the death. Determination of death and suspended animation. Dying declaration. 40. Forensic Medical Expert Examination of dead body. Crime scene investigation. The role of the Forensic Pathologist at the crime scene. Forensic autopsy. 41. Forensic Medical Expert Examination of dead body. Time since death- methods and short summary. 42. Forensic Medical Expert Examination of dead body. Reautopsy and exhumation. Examination of unidentified, disfigured, mummified and dismembered dead bodies. 43. Forensic Medical Expert Examination of dead body. Forensic Medical Expert Examination of dead body of newborn infant. Infanticide. (articles 120 и 121 from Criminal Code). Major issues, particular aspects of cadaver examination. 44. Forensic Medical Expert Examination of dead body in cases of sudden natural death. 45. Forensic Medical Expert Examination of dead body. Early postmortem changes –changes in the skin, changes in the eye, livor mortis, algor mortis and rigor mortis. Medicolegal importance. 46. Forensic Medical Expert Examination of dead body. Late postmortem changes - putrefaction, adipocere, mummification. Medicolegal importance. 47. Forensic anthropology identification. 48. Forensic Medical Expert Examination of trace (material) evidence. Definition. Major issues. Seizure and safe-keeping of trace evidences.

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49. Forensic Medical Expert Examination of trace (material) evidence. Blood stains analysis. Sperm stains analysis. Hair analysis. Major issues and methods of examination. Examination of other human biological materials. 50. Medical Law and Ethics. Deontology. Definitions and major issues. 51. Legitimacy of medical actions. Professional qualification of medical staff. Basic rights and obligations of medical staff. Duties of medical practitioners. Consents in medical practice. 52. Compulsory medical measures (articles 89-92 from Criminal Code). 53. Application of medical methods for diagnosis and treatment leading to a temporary change in consciousness. 54. Application of new medical methods for diagnosis and treatment. Human experimentation (Declaration of Helsinki). Transplantation of human organs-rules and procedures. Euthanasia- nature and types. 55. Classification of Malpraxis (Professional Negligence). Negative effects in medical practice. 56. Willful crimes regarding medical activity. Illegal medical practice (article 324 from Criminal Code). No rendering of medical help (article 141 from Criminal Code). Crimes against the people's health and the environment (articles 354 and 355 from Criminal Code). Betrayal of „medical” secrets of another person (article 145 from Criminal Code). Crimes related to „medical” documents (articles 311 and 312 from Criminal Code). 57. Professional incompetence or ignorance of medical staff. (articles 123 and 134 from Criminal Code). 58. Medical errors - definition, nature and types. Fatal accidents (misadventure) in the medical practice. „Calculated risk” cases in the medical practice.

REFERENCES: Compulsory: 1. Lecture course. 2. The essentials of Forensic medicine and Toxicology- Dr K. S. Narayan Reddy, 1999. 3. Handbook of Forensic medicine and Toxicology- V.V. Pillay, 2001. Recommended: 1. Criminal Code of the Republic of Bulgaria (http://legislationline.org)

The program is approved by the Departmental Council

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MEDICAL UNIVERSITY - PLOVDIV FACULTY OF PUBLIC HEALTH

PROGRAMME IN

Epidemiology of infectious diseases and epidemiology of mass noninfectious diseases

Approved by the Departmental Council on 29.06.2012 Confirmed by the Faculty Council on……………., 2012

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MEDICAL UNIVERSITY – PLOVDIV FACULTY OF PUBLIC HEALTH COURSE NAME Epidemiology TYPE OF COURSE ACCORDING TO THE UNIFORM STATE REQUIREMENTS Mandatory LEVEL OF EDUCATION: Master degree /М/ FORM OF EDUCATION: Lecture courses, practical courses, self-training. SEMESTERS OF EDUCATION: 9thand 10th semesters AUDITORIUM CLASSES: 22 hours of lecture courses, 30 hours of practical courses

TECHNICAL EQUIPMENT APPLIED IN THE TRAINING: audiovisual equipment, tools and technical devices for illustration and performance, test books. TRAINING METHODS: lecture courses, practical courses, seminars, individual work with excellent students.

CONTROL AND EVALUATION:  Ongoing evaluation – semesterial tests, oral examinations  Final evaluation –entry test, written and oral examination. Score assessment Participation in seminars, weekly tests, essay preparation and presentation Semester exam: Yes / written and oral examination State Exam Yes Lecturer Full Professor from the Department of Epidemiology Department: Epidemiology and medicine of disastrous events. ANNOTATION The contemporary presentation of epidemiology of infectious diseases and epidemiology of non communicable diseases – as a essential medical science today. Methodology and methods of epidemiology of infectious diseases and their application in the study of massive, socially significant diseases. Causes, conditions and mechanisms of emergence and spread of infectious diseases. Parasitic and socio-ecosystems in the theory of epidemic process. Primary and secondary driving forces of the epidemic process. Elimination and eradication of infectious diseases. Desinfection, desincection, deratisation. Immunoprevention. Epidemiologic characteristics, prevention, surveillance and control of infectious diseases. Epidemiology, prevention and control of nosocomial infections. 333

Epidemiology of mass non communicable diseases and such with infectious etiology - etiologic (bio-and genetic markers) and risk factors. Prevention and Control.

COURSE OBJECTIVES: 1.Teoretical and practical training in the field of epidemiology as a essential medical discipline. 2. Knowledge about the mode of transmition and distribution of infectious diseases and the system of measures for prevention and control them. 3. Knowledge of basic epidemiological characteristics of chronic mass non communicable diseases and their prevention and control. 4. Knowledge of basic epidemiologic characteristics of non communicable diseases with massive infectious etiology and their prevention and control. 5. Skills such as physicians to participate in solving practical problems limiting, reducing economic and social losses, elimination and eradication of infectious diseases.

COURSE TASKS: Mastering: theoretical knowledge about the causes, development and elimination of the epidemic process in various infectious diseases; theoretical knowledge about the driving forces of the epidemic process - the source of infection, mechanisms and factors of transmission of infectious disease susceptibility and immunity of the population, social and natural factors, the main methods for epidemiological studies and practical skills for implementation of some of them, theoretical knowledge and practical skills to apply effective tools and methods to control infectious diseases and effective preventive means of reducing, elimination and eradication of infectious diseases. Theoretical knowledge about the epidemiologic features characteristic of mass non communicable diseases with such infectious etiology.

OBLIGATORY COMPETENCIES: Theoretical knowledge – mastering and analysis of: - Epidemiology as a essential medical science; organization of life on a population level, genotype, phenotype and the environment (social and environmental) risk factors that determine in human infectious and non infectious pathology. - Epidemiology as a science of the epidemic process, the general patterns of occurrence and spreading of infectious diseases in human society, causes, conditions, mechanisms of development, peculiarities of the epidemic process in various infectious diseases. - Methods employed in epidemiologic studies; system for epidemiologic diagnosis. - System for control and measures and preparations - vaccines, serums, chemical means of disinfection, rodencides, etc. Technical means and methods - autoclave, desinfection chamber - evaluation effienciency of prevention and control. - Structure of the epidemiologic surveillance: theoretical, methodological and patterns concerning different classification groups. - To master the methods for identifying risk factors and social significance of the major mass. non-communicable diseases. Practical skills: - To make the epidemiologic history of different infectious diseases. - To conduct an epidemiologic study in epidemic outbreaks of airborne and intestinal infections and to evaluate measures of control performed by the GP. - To prepare a plan for disinfection for gastrointestinal and nosocomial infections. - To prepare a plan for immunizations – obligatory and recommended.

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- To prepare a plan for measures prevent and control the most significant non-communicable diseases prepare.

CURRICULUM Course hours Type of courses І ІІ Credits weekly All semester semester Lecture courses 1 6 16 22 Practical courses 1 15 15 30 3,00 All 2 hours 21 hours 31 hours 52 hours

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PROGRAMME IN Epidemiology of infectious diseases and epidemiology of mass noninfectious diseases FIRST SEMESTER

№ LECTURE COURSES HOURS DATE

Subject, theory and methods of epidemiology of infectious 19.09. 1. diseases and epidemiology of mass non-infectious diseases. 2 2012 Theory of the epidemic process.

Source of infection. Transmission of infectious diseases. 17.10. 2. Susceptible houst. Social factors of epidemic process. Natural 2 2012 factors of epidemic process .

Disease Control, Elimination, Eradication and Extinction of 14.11. 3. infectious diseases. 2 2012

4. Еpidemiology of mass non-infectious diseases 2 12.12. 2012

TOTAL - 8 hours

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SECOND SEMESTER

№ LECTURE COURSES HOURS DATE

Epidemiology of air born infections: Diphtheria, Scarlet fever, 1. Meningococcial infection,Pertussis. 2

Epidemiology of air born infections. Measles, Rubella, Mumps, 2. Varicella. 2

3. Epidemiology of intestinal infections. Salmonelosis, Shigelosis. 2 4. Epidemiology of intestinal infections. Typhus abdomenalis, 2 Brucellosis, Cholera.

Epidemiology of viral hepatitis A, B, C, D, E 5. 2 Epidemiology of HIV/AIDS. 6. 2 Epidemiology of tick borne infections: Congo-Crimean fever, 7. Q – rickettsiosis, Mediterranean Spotted fever, Lyme disease. 2

Epidemiology of Tetanus, Anthrax, Lyssa 8. 2

TOTAL - 16 hours

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FIRST SEMESTER

№ PRACTICAL COURSES HOURS DATE Essence, purposes and tasks to epidemiologic control. Tasks to 1. GP,related with the control and prevention of infection 2 diseases.Meaning of source of infection:sick and career.

Physical and chemical disinfection. 2. 2 Chemical disinfection. 3. 2 Live vectors (vectors) of infectious diseases. Disinfestation. 4. 2 Animals and rodents, sources of infectious diseases. Pest control. 5. 2 Epidemiological surveillance and control of nosocomial 6. infections. 2

Management and control of outbreaks of nosocomial infections. 2 7.

TOTAL - 14 hours

338

SECOND SEMESTER

№ PRACTICAL COURSES HOURS DATE

Immune prophylaxis – aim, kinds of bio products, mode of 1. application. Immunization calendar of RBulgaria. Recommended 2 immunizations.

Epidemiological study. Surveillance and control of viral hepatitis 2. A, B, C. 2

Air born infections – epidemiological research of scarlet fever, 3. diphtheria, meningococcal infection, pertussis. 2

Airborn infections- epidemiological study in epidemic outbreak 4. of measles, varicella, rubella and mumps. 2

Epidemiological study in an epidemic outbreak of intestinal 5. infections /salmonellosis, shigellosis,colienteritis/. 2

Epidemiology of noninfectious chronic diseases-etiologic and 6. risk factors for diabetes. Prevention and control. 2

Epidemiology of noninfectious diseases with infectious etiology- 7. etiologic and risk factors for cancer. 2

Prevention and control of socially significant infectious and 2 8 noninfectious diseases.

TOTAL - 16 hours LECTURE COURSE SYLLABUS

Epidemiology of infectious diseases and mass noninfectious diseases for medical students

Lecture 1 – 2 hours. Subject, theory and methods of epidemiology of infectious diseases and epidemiology of mass non-infectious diseases. Theory of the epidemic process. 1.Definition, the aim, the main tasks of epidemiology of infectious diseases and epidemiology of mass non-infectious diseases. 2.Subject of the epidemiology of infectious diseases. 3.Theory of epidemiology of infectious diseases: theory of epidemic process, epidemiologic aspects of infectious process, epidemiologic aspects of epizootic process, socio – ecosystemic dependency of diseases, molecular-genetic processes in microbial populations. 4.Methods of epidemiology: descriptive-evalutional, observation, experimental, analysis and synthesis, molecular-genetic, molecular-biologic. 339

5.Theory of the epidemic process: definition, draiving forses. Lecture 2 – 2 hours. Source of infection. Transmission of infectious diseases. Susceptible houst. Social factors on epidemic process. Natural factors on epidemic process . 1.Source of infection: definition of source of infection and a reservoir, a animal reservoirs, non animal reservoirs. 2.Transmission of infectious diseases: direct and indirect contact, air born, fecal oral, blood, vector-borne transmission, derma, factors for transmition. Zoonozes: definition, routes of transmission of infectious diseases agents. 3.Susceptible houst. 4.Social factors of epidemic process. Dwelling factors - house, type of urban, country, transportation etc. Labour of factor-features and environment. Human behavior among family members among family members, school, work, different groups etc. Public life-science, art culture, moral, religion, health care etc. 5. Natural factors of epidemic process : geographic-climatic-meteorological and cosmic influences depending the place and time. 6.Non infectious diseases: environmental factors, social factors, life-style related factors, iatrogenic factors. Lecture 3 – 2 hours. Disease Control, Elimination, Eradication and Extinction of infectious diseases. 1. Definitions, development of theory of elimination and eradication. 2. Criteria for elimination and eradication: economic considerations , social and political. 3.The costs and benefits of global eradication programmes. Lecture 4 – 2 hours. Epidemiology of air born infections: Diphtheria, Scarlet fever, Meningococcial infection, Pertussis. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mode of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Prevention, control and vaccination. Lecture 5 – 2 hours. Epidemiology of air born infections. Measles, Rubella, Mumps, Varicella. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease, Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Prevention, control and vaccination. Lecture 6 – 2 hours. Epidemiology of intestinal infections. Salmonelosis, Shigelosis. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Season, Age, Morbidity. Prevention, control and vaccination. Lecture 7 – 2 hours. Epidemiology of intestinal infections. Typhus abdomenalis, Brucellosis, Cholera. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission,

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Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Prevention, control and vaccination. Lectures 8– 2 hours. Epidemiology of viral hepatitis A, B, C,D,E. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Geographic epidemiology. Prevention, control and vaccination. Group of risk. Lecture 9– 2 hours. Epidemiology of HIV/AIDS. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiologic process: Lethality, Seasonal features Age, Morbidity. Geographic epidemiology. Prevention, control and vaccination. Group of risk. Lecture 10– 2 hours. Epidemiology of tick borne infections: Congo-Crimean fever, Q – rickettsiosis, Mediterranean Spotted fever, Lyme disease. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Geographic epidemiology. Prevention, control and vaccination. Group of risk. Lecture 11– 2 hours. Epidemiology of tetanus, anthrax, lyssa. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Geographic epidemiology. Prevention, control and vaccination. Group of risk.

PRACTICAL COURSE SYLLABUS

Epidemiology of infection and non infection diseases for medical students

PRACTICAL №1 – 2 hours. Essence,purposes and tasks to epidemiologic control. GP’s tasks,related with the control and prevention of infection diseases.Evalution of source of infection:sick and carrier. 1.Epidemiologic control-definition,items,tasks and structures,making the control. 2.Organization,structure,items of RHI in Bulgaria. 3.GP’s tasks-registration, notice and report to infection diseases. Normative documents to HealthCare Ministry –notification,Note Book for registration of infectious sicks and Note Book of contacts of sicks.

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4.Evalution of source of infection:sick and carrier. Cariages-definition,spicies,epidemiologic meaning,examples. Discovery source of infection. Prove about careerness-indications,mode to collect samples,storage and transport of materials for laboratory examination.

PRACTICAL №2 – 2 hours. Physical and chemical dеsinfection. 1.Purpose,tasks and meaning of physical and chemical disinfection in epidemiologic control of infection diseases. Definition for dеsinfection,sterilization,aseptic,antiseptic,sanitization etc. 2. Kinds of physical stuffs for dеsinfection-sun warm,UV,ionizing radiation,burning,boiling. 3.Structure and principles of work on dry sterilizer,autoclave and disinfection camera.Plazma sterilizer. Methods of control on physical sterilization. 4.Organization and principles of work in Central hospital sterilization unit.

PRACTICAL №3 – 2 hours. Chemical desinfection. 1.Purpose,tasks and meaning of chemical disinfection in epidemiologic control of infectious diseases. 2. Methods for chemical desinfection. The major factors that influence quality of desinfection. 3.Requirements to chemical desinfectants. Characteristics,advantages and disadvantages ,ways and place of exposition by groups: oxidants.,alchohols,halogens,. hibitane- generies,aldechydes. 4.Quantity and quality control of chemical disinfection.

PRACTICAL №4 – 2 hours. Live vectors of infectious diseases. Desinsection. Epidemiological importance of insects and arthropods as vectors of transmissive infections. Shematic presentation of the circuits of circulation of the etiological agents of plague, tularemia, Crimean hemorrhagic fever, Mediterranean spotted fever and others. Desinsection- definition, epidemiological significance and prevention. Characteristic of the methods of desinsection (biological, mechanical, physical and chemical). Characteristic and application of chemical means of desinsection by groups: chlorooganic, phosphoroorganic, carbamates and pyrethrinoides.

PRACTICAL № 5 – 2 hours. Animals and rodents, sources of infectious diseases. Deratisation. Epidemiological significance of domestic and wild animals(birds, rodents, etc.) as sources of infectious diseases. Shematic presentation of the epidemic processes of certain zoonoses ( Q fever, lyme disease, hemorrhagic fever with renal syndrome, anthrax, salmonellosis, rabies, etc.) Rodent species with epidemiological significance – gray rat, black rat, water rat, forest and field mice. Peculiarities in the biology and ecology of rodents. Deratisation – definition, types ( preventive and control), methods (biological, mechanical, physical and chemical). Characteristic and application of rodenticides by groups: slow and rapid acting.

PRACTICAL № 6 – 2 hours. Epidemiological surveillance and control of nosocomial infections. 1.Definition, short historical development by periods, classification, nosocomial infections by types (exogenous, endogenous, imported, exported). 2.Source, mechanism and factors of transmission, risk groups.

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3. Characteristics of the epidemic process – prevalence, incidence, risk clinics and hospital population, forms of the epidemic process, lethality and mortality rate. Medical, social and economic importance of nosocomial infections. 4. Surveillance of nosocomial infections, definition, organization, conducting a comprehensive, targeted and limited surveillance. Detection, registration, notification and reporting of nosocomial infections.

PRACTICAL № 7 – 2 hours. Management and control of outbreaks of nosocomial infections.

Outbreak and epidemic situation- definition. Predisposition and exposition factors contributed to the outbreak and epidemic situation. Settlement of case studies.

PRACTICAL №8 – 2 hours. Immune prevention – aim, types of bio products, mode of application. Immunization programme of RBulgaria. Recommended immunizations. 1. Epidemiologic significance of the immune prophylaxis for the control of the infectious diseases. Achievements in the elimination and eradication of some diseases. 2. Immunity – definition, aspects of epidemiological immunity. Types of bio products – characteristics and application. 3. Immunization calendar – routine immunizations, schemes of application (age, doses, mode of application). Compatiblity between the vaccines. Contra indications and post immunization complications. 4. Planning, providing, registration and notification of the routine immunization. Obligations of the general practitioners related with the immunizations. Storage and transportation of the bio products.

PRACTICAL №9 – 2 hours. Epidemiological study. Surveillance and control of viral hepatitis A, B, C. 1. Definition, aim and problems of the epidemiological study. Methods, phases and documents for providing the research. Analysis of the data, conclusions and propositions for preventive and epidemic measures. 2. Basic statistical methods for the analysis of the data. Intensive and extensive parameters characterizing the epidemic process. 3. Analysis of epidemiological data to evaluate the effect for prevention and control.

PRACTICAL №10 – 2 hours. Air born infections – epidemiologic servey of scarlet fever, diphtheria, meningococcal infection, pertussis. 1. Characteristics of the epidemic process for scarlet fever, diphtheria, pertussis and meningococcal infection. 2. Epidemiologic study in the focus of infection – epidemiologic history, study on the source and factors of transmission. Determination of the contact persons, needing preventive measures. 3. Evaluation of the provided preventive and epidemic measures.

PRACTICAL №11 – 2 hours. Air born infections- epidemiologic study of epidemic outbreak of measles, varicella, rubella and mumps. 1.Characteristic of the epidemic process of measles,varicella,rubella and mumps. 343

2.Practical implementation of an epidemiologic study in epidemic outbreak- epidemiologic history, study of the source of infection and factors of transmission in epidemic outbreak. Contact subjects to anti-epidemic measures. 3.Conducting anti-epidemic measures.

PRACTICAL №12 – 2 hours. Epidemiological study of epidemic outbreak of intestinal infections /salmonellosis, shigellosis,colienteritis/. 1.Characteristic of the epidemic process of salmonellosis, shigellosis,colienteritis. 2.Practical implementation of an epidemiological study in epidemic outbreak- epidemiological history, study of the source of infection and factors of transmission in epidemic outbreak. Contact subjects to anti-epidemic measures. 3.Conducting anti-epidemic measures.

PRACTICAL №13 – 2 hours. Epidemiology of noninfectious chronic diseases-etiologic and risk factors for diabetes. Prevention and control. 1.Application of basic scientific and practical approaches of classical epidemiology for the characteristics of the most significant noninfectious chronic diseases- diabetes. 2.Prevention and control.

PRACTICAL №14 – 2 hours. Epidemiology of noninfectious diseases with infectious etiology- etiologic and risk factors for cancer. 1. Application of basic scientific and practical approaches of classical epidemiology for the characterization of the most significant noninfectious diseases-cancer. 2. Prevention and control.

PRACTICAL №15 – 2 hours. Prevention and control of socially significant infectious and noninfectious diseases.

SYLLABUS IN epidemiology

1. Subject, theory and methods of epidemiology of infectious diseases. 2. Epidemiology of mass non-infectious diseases. 3. Theory of the epidemic process. 4. Source of infection. 5. Transmission of infectious diseases. 6. Susceptible houst. 7. Social factors on epidemic process. 8. Natural factors on epidemic process. 9. Vaccin prevention. Immunization calendar (programme). 10. Desinfection and sterilization. 11. Desinsection. 12. Devastation. 13. Epidemiology of nosocomial infections. 14. Measures for: sick human, contacts and in environment. 15. Epidemiology of Diphtheria. 16. Epidemiology of Scarlatina. 344

17. Epidemiology of Meningococcial infection. 18. Epidemiology of Pertussis. 19. Epidemiology of Measles. 20. Epidemiology of Rubella. 21. Epidemiology of Chicken pox. 22. Epidemiology of Mumps. 23. Epidemiology of Typhus abdomenalis. 24. Epidemiology of Salmoneloses. 25. Epidemiology of Shigelloses. 26. Epidemiology of Cholera. 27. Epidemiology of Polio. 28.Epidemiology of Hepatitis A. 29.Epidemiology of Hepatitis B and D. 30. Epidemiology of Hepatitis C. 31.Epidemiology of Q – rickettsiosis. 32. Epidemiology of Mediterranean Spotted fever. 33.Epidemiology of Congo-Crimean fever. 34.Epidemiology of Lyme disease. 35.Epidemiology of HIV/AIDS. 36.Epidemiology of Tetanus. 35.Epidemiology of Anthrax.

Recommended literature:

1. Harrison's Principles of Internal Medicine, 17th Edition (Harrison's Principles of Internal Medicine, 2008.

2.CDC and ECDC guidelines, recommendation for surveillance and control diseases.

3. Lectures and practicals documented on paper and digital.

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MEDICAL UNIVERSITY OF PLOVDIV, BULGARIA FACULTY OF MEDICINE

DERMATOLOGY AND VENEREOLOGY

TEACHING PROGRAMME

FOR MEDICAL STUDENTS

Approved by the Department Council on 19 June 2012

Approved by the Faculty Council on …………. 2012

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MEDICAL UNIVERSITY OF PLOVDIV, BULGARIA FACULTY OF MEDICINE

Name of the course: "Dermatology and Venereology"

Type of discipline under the Uniform State Requirements: Required

Level of education: Master / M /

Teaching forms: Lectures, practical lessons, self-study

Duration of training: Two semesters

Teaching hours: 30 hours of lectures and 60 hours of practical lessons

Teaching auxiliaries: Multimedia presentations, discussions, demonstration of skin eruptions and disease agents, practical diagnostic and therapeutic tasks solving, development of prevention programs, monitoring, collection of biopsy specimens, making microscopic preparations and mycological culture tests, perform allergy testing and reporting cutaneous allergic tests.

Forms of assessment: Current assessment, test exams

Formation of the assessment: Mean continuous assessment in each semester.

Aspects for this assessment: Participation in discussions, writing an oral exam results

Semester examination: Yes / placement test, written and oral exam /

State Examination: NA

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Lead Lecturer: Academic rank lecturer at the Department of "Dermatology and Venereology"

Department: Dermatology and Venereology

ANNOTATION

The course "Dermatology and Venereology" allows for the acquisition of knowledge and skills for primary diagnosis, therapy and prevention of the most common dermatological diseases.

MAIN TASKS OF THE CURRICULUM

Acquiring knowledge and skills to implement all the modern forms, methods and tools for primary dermatological diagnosis, therapy and prevention:

1. Taking a history in a patient with skin disease 2. Investigation of skin eruptions: - Physical examination with naked eye - Glass pressure (Vitropresia) - Palpation - Systematic and even scraping the skin lesion surface in squamatous dermatoses 3. Physical examination of a patient with skin disease and description of the dermatological status / description of skin eruption / 4. Testing of dermographism 5. Nikolski’s sign examination 6. Assessment of capillary fragility 7. Skin hypersensitivity tests: - patch test - scarification test - intradermal test - prick test 8. Observation of microscopy preparations and culture to demonstrate a mycological disease 9. Search for scabies mite and microscopy examination 10. Physical examination of a patient with sexually transmitted disease 11. Preparation and examination of microscope slides of gonococci 12. Examination of Treponema pallidum by dark-field microscopy and get knowledge of methods for serologic diagnosis of syphilis 13. Prescriptions of local and systemic therapy in dermatology

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EXPECTED RESULTS

After completion of the dermatology course students should have the following knowledge and skills: 1. To possess skills in taking a history of dermatology diseases in the context of general health status of the patient. 2. To know the main methods for objective examination of skin eruptions. 3. Be able to make a short (non-detailed) description of dermatological status. 4. To know the methods for analysis of dermographism, Nikolski’s sign, clinical symptoms of psoriasis, capillary fragility. 5. To know the characteristics of skin hypersensitivity tests: patch, scarification, intradermal, prick tests. 6. To know the phenomena demonstrated in microscope slides and culture tests to establish a mycologic disease. 7. To know the methods for searching scabies mites and phenomena observed in microscope slides. 8. To know the methods to examine a patient with sexually transmitted disease and be able to make and examine microscope slides for gonococci. 9. To know the demonstration of Treponema pallidum by dark-field microscopy and methods for serologic diagnosis of syphilis. 10. Be able to write prescriptions for the most frequently used drugs for local and systemic therapy in dermatology.

TEACHING SCHEDULE

Exams Hours Hours in years / semesters Subject Pract. Semester Total Lectures VІІ VІІІ ІХ Х lessons

Dermatology and IX 90 30 60 1/2 1/2 Venereology

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LECTURE PROGRAMME

4th year, 8th semester

№ SUBJECT HOURS DATE

Anatomy and physiology of the skin and mucous 1. membranes. Pathological changes of the epidermis. 2 h.

Pyococcal skin infections 2. 2 h.

Viral diseases of the skin. Skin tuberculosis 3. 2 h.

Fungal infections of the skin 4. 2 h.

Erythematous dermatoses. 5. Bullous dermatoses 2 h.

Erythematous-papular-squamatous dermatoses 6. 2 h.

Allergic dermatoses – allergic shock, urticaria, strophulus 7. 2 h.

Total: 14 h.

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LECTURE PROGRAMME

5th year, 9th semester

№ SUBJECT HOURS DATE

Eczema. Dermatitis 1.

2 h. .

Drug-induced dermatoses 2. 2 h.

Autoimmune disease of the connective tissue 3. 2 h.

Aphthosis. Seborrheic diseases 4. 2 h.

Precancerous skin diseases. Binign and malignant skin 5. tumors 2 h.

Syphilis (1) 6. 2 h.

Syphilis (2). Gonorrhea 7. 2 h.

HIV infection – skin and mucous membrane 8. manifestations 2 h.

TOTAL: 16 h.

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PRACTICAL LESSON PROGRAMME 4th year, 8th semester

№ SUBJECT HOURS DATE

1. Skin lesions and eruptions 2 h.

2. Skin lesions and eruptions. Therapy of the skin diseases. Local medicinal forms 2 h.

3. Therapy of the skin diseases. Local medicinal forms 2 h.

4. Preliminary exam - Skin lesions and eruptions; therapy of 2 h. the skin diseases. Pyococcal skin infections 5. Pyococcal skin infections 2 h.

6. Viral diseases of the skin 2 h.

7. Skin tuberculosis 2 h.

8. Fungal infections of the skin 2 h.

9. Candidal infections of the skin 2 h.

10. Fungal infections with cutaneous and systemic manifestations (deep mycoses) 2 h.

11. Cutaneous zoonotic diseases. Preliminary exam – Infectious diseases of the skin 2 h.

12 Erythematous dermatoses 2 h.

13 Autoimmune bullous dermatoses 2 h.

14 Erythematous-papular-squamatous dermatoses 2 h.

15. Allergic dermatoses – urticaria, strophulus 2 h.

Total: 30 h.

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PRACTICAL LESSON PROGRAMME 5th year, 9th semester

№ SUBJECT HOURS DATE

Drug-induced dermatoses. Allergic shock 1. 2 h. Drug-induced dermatoses. Fixed drug eruption 2. 2 h.

3. Eczema. Dermatitis 2 h.

4. Dermatoses due to external (environmental) factors 2 h.

5. Seborrhea and Seborrheic diseases 2 h.

6. Autoimmune disease of the connective tissue. Lupus 2 h. erythematosus 7. Autoimmune disease of the connective tissue. Dermatomyosistis. Scleroderma 2 h.

8. Mixed connective tissue disease. Aphthosis. Preliminary exam – Dermatitis; Connective tissue diseases 2 h.

9. Precancerous skin diseases. Binign skin tumors 2 h.

10. Malignant skin tumors. Epidermal malignant tumors. Paget’s disease. Malignanat melanoma. 2 h.

11. Syphilis (1) 2 h.

12 Syphilis (2) 2 h.

13 Gonorrhea. Non-gonococcal urogenital infections 2 h.

14 HIV infection. Preliminary exam – Skin tumors; Sexually transmitted diseases. 2 h.

15. Practical examination 2 h.

TOTAL: 30 h.

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THEMATIC CURRICULUM OF DERMATOLOGY LECTURES FOR MEDICAL STUDENTS

Topic 1. Anatomy and physiology of the skin and visible mucous membranes. Abnormal changes in the epidermis Annotation. Anatomical, histological and electron microscopy structure of the epidermis. Keratinocytes and other cells in the epidermis. Structure of the dermis - anatomy, histology, electron microscopy pattern - fibrous structures, cellular, basic substance. Hypodermis, anatomical and histological pattern. Structure of the visible mucous membranes. Peculiarities in the structure of the mucous membranes. Physiology of the skin: protective, thermoregulative, secretory, resorptive, excretory function of the skin. Keratogenesis and melanogenesis.

TOPIC 2. Pyococcal skin infections Annotation. Etiology. Classification of pyodermas. Staphylococcal skin infections: characteristics of the causative agents. Staphylococcal diseases of the pilosebaceous follicles, acute and chronic forms. Staphylococcal disease of the sweat glands: eccrine and apocrine, acute and chronic forms. Streptococcal skin infections: characteristics of the causative agents. Clinical forms of strepto coccal skin infections: Impetigo – clinical forms. Intertrigo. Ecthyma. Erysipelas - clinical forms. Necrotizing fasciitis. Mixed and atypical forms of pyodermas. Etiologic diagnosis. Treatment.

TOPIC 3. Viral diseases of the skin. Skin tuberculosis Annotation. Viral diseases of the skin. Classification. Viral diseases of the herpes group: herpes simplex - primary and recurrent forms. Herpes zoster. Complications. Treatment. Diseases caused by human papillomaviruses: common and flat warts, genital warts. Viral diseases of smallpox virus and paravaccinia virus - molluscum contagiosum, tuberculum mulgentium, ectthyma contagiosum. Other viral diseases – hand-foot-and-mouth disease. Tuberculosis of the skin - etiology, pathogenesis. Classification. Primary / localized / forms of TB: lupus vulgaris, colliquative, verrucous, ulcerative forms. Secondary / disseminated / forms: indurative, papulo-necrotic, lichenoid, miliary form. Diagnosis. Treatment.

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TOPIC 4. Fungal infections of the skin. Annotation. Etiology, characteristics of the pathogenic fungi, classification. Classification of the fungal infections of the skin. Superficial epidermal mycoses - pityriasis versicolor. Dermatophytoses: microsporosis, trichophytosis (ringworm), favus - superficial and deep forms. Diagnosis. Treatment. Epidermophytosis. Epidermophyton - clinical forms. Rubrophytosis - forms. Onychomycosis. Treatment. Candidiasis - etiology, risk factors for development. Cutaneous and mucosal forms - diagnosis, treatment. Deep mycoses - actinomycosis.

TOPIC 5. Erythematous dermatoses. Bullous dermatoses. Annotation. Erythema exudativum multiforme - etiopathogenesis, clinical picture. Severe forms. Treatment. Erythema nodosum - etiopathogenesis, clinical forms. Treatment. Pemphigus vulgaris - etiopathogenesis. Clinical forms - vulgaris, vegetans, foliatious, seborrheic. Histology and immunofluorescence criteria. Differential diagnosis. Treatment. Pemphigoid. Etiology and pathogenesis. Clinical forms - bullous pemphigoid, cicatricial pemphigoid. Herpetiform dermatitis - etiopathogenesis, clinical features and forms, immunofluorescence and histological diagnosis. treatment

TOPIC 6. Erythemato-papulo-squamatous dermatoses. Annotation. Psoriasis vulgaris. Etiopathogenesis – hypotheses, trigger factors. Clinical picture - typical and atypical forms. Diagnostic and clinical symptoms. Severe forms of psoriasis. Differential diagnosis. Treatment - systemic, local, climate therapy. Pityriasis rosea. Etiology and pathogenesis. Course, complications. Lichen ruber planus. Etiopathogenesis - hypotheses. Clinical forms, differential diagnosis. Histology. treatment

TOPIC 7. Allergic dermatoses: allergic shock, urticaria, strophulus. Annotation. Classification of allergic reactions by Coombs and Gell: clinical variants related to the above classification. Immediate-type reactions. Allergic shock: etiology, forms, symptoms, laboratory findings and treatment. Urticaria - definition, etiological factors. Classification of urticaria - allergic, non- allergic, physical forms. Treatment. Angioneurotic edema (Quincke's edema) - acquired and hereditary forms. Differential diagnosis. Treatment. Pseudoallergic immediate-type rreactions. Strophulus - etiopathogenesis, clinical forms, treatment.

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TOPIC 8. Eczema. Dermatitis. Annotation. Eczema - definition. Classification: exogenous, endogenous and seborrheic. Etiology, pathogenesis and immunology of eczema. Clinical picture, evolution. Forms of exogenous eczema: allergic, non-allergic, dyshidrotic, microbial. Endogenous eczema: characteristics of atopy, stages of development. Features of seborrhoeic eczema. Diagnosis. Treatment of eczema. Dermatitis - definition. Etiopathogenesis. Dermatitis of mechanical, physical, biological and chemical factors.

TOPIC 9. Drug-induced dermatoses. Annotation. Classification of drug-induced reactions. Immunological characteristics and clinical manifestations of drug-induced dermatitis, allergic shock, urticaria, fixed drug eruption, Layel syndrome, allergic vasculitis, allergic dermatitis. Pseudoallergic drug reactions. Dermatoses with possible drug etiology. Diagnosis of drug allergy - direct and indirect test methods. Treatment.

TOPIC 10. Chronic discoid lupus erythematosus. Clinical and histologic characteristics, atypical forms. Diagnosis and treatment. Systemic lupus erythematosus - cutaneous and mucosal manifestations. Systemic manifestations, organ symptoms. Diagnosis and treatment. Dermatomyositis - etiopathogenesis, immunology. Clinical forms. Diagnosis and differential diagnosis. Treatment. Scleroderma - etiopathogenesis, immunology. Circumscribed scleroderma - clinical forms. Diffuse scleroderma - skin manifestations, organ localization. Diagnosis and differential diagnosis. Treatment. Mixed connective tissue disease.

TOPIC 11. Seborrhea and seborrheic disorders. Aphthosis. Annotation. Seborrhea - definition. Etiopathogenesis - factors. Acne vulgaris - etiopathogenetic factors. Clinical picture - clinical forms. Severe forms of acne, associated forms, exogenously triggered forms. Treatment. Rosacea - etiopathogenesis. Clinical picture - clinical forms. Treatment. Aphthosis. Aphthae vulgares, recurrent aphthae. Behcet's syndrome. Aphthous disease. Etiopathogenesis. Clinical picture. Differential diagnosis. Treatment.

TOPIC 12. Precancerous skin conditions. Benign tumors. Malignant tumors of the skin. Classification of precancerous conditions. Annotation. Precancerous conditions - clinical forms, treatment. Intraepidermal carcinomas. Basal cell carcinoma – trigger factors, clinical forms, treatment. Squamous cell carcinoma - characteristics, metastases. Clinical forms, typical locations, histology, treatment. Malignant melanoma – precancerous conditions, early signs of malignancy. Clinical forms, ways of metastasis, histology, treatment.

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TOPIC 13. Syphilis. acquired syphilis. Annotation. Etiology. Epidemiology. Immunity and allergy. General course. Classification. Primary and secondary syphilis. Tertiary syphilis - mucocutaneous manifestations and organ manifestations.

TOPIC 14. Syphilis. Gonorrhea. Annotation. Syphilis of the nervous system and internal organs. Congenital syphilis - classification. Syphilis of the fetus, infant, early and late childhood. Stigmata of congenital syphilis. Diagnosis of syphilis. Serology of syphilis. Treatment criteria for cure. Follow up. Gonorrhea - etiology, epidemiology. General course. Acute and chronic gonorrhea. Clinical picture of gonorrhea in women and men. Extragenital and metastatic gonorrhea. Gonorrhea in children. Gonococcal complications in women. Complications of gonorrhea in men. Treatment of gonorrhea and its complications.

TOPIC 15. HIV infection. Mucocutaneous manifestations of HIV infection. Annotation. HIV infection: definition, etiopathogenesis, stages. Mucocutaneous manifestations of infectious and noninfectious nature. Treatment of mucocutaneous manifestations.

THEMATIC CURRICULUM OF DERMATOLOGY PRACTICAL LESSONS FOR MEDICAL STUDENTS

Practical lesson No 1. Skin lesions and eruptions – 2 h. 1. Morphological skin changes - Skin lesions and eruptions. Primary and secondary eruptions 2. Classification of the skin lesions: a. macules (spotted skin lesions) b. solid skin lesions c. exudative skin lesions d. skin lesions due to damaged skin integrity e. falling off skin lesions f. skin lesions due to atrophy, hypertrophy and scarring

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Practical lesson No 2. Skin lesions and eruptions – 2 h. 1. Characteristics of mucous membrane lesions – enanthemas 2. Localization of exanthemas and enanthemas, arranging, grouping, confluence, erythroderma 3. Monomorphic and polymorphic rashes. Evolutionary polymorphism

Practical lesson No 3. Local treatment of skin diseases. Topical formulations – 2 h. 1. Basic substances. Basic / simple / topical drugs a. Liquid forms b. Powders c. Liquid oils d. Solid, oily, oil-like substances 2. Prescriptions

Practical lesson No 4. Local treatment of skin diseases. Topical formulations – 2 h. 1. Compound / composite drugs: solutions, lotions, mixtures, liniments, cooling unguents, pastes, creams, jellies, paints, plasters, aerosols, preparations for cleaning. Directions for application 2. Prescriptions

Practical lesson No 5. Pyococcal skin infections – 2 h. 1. Etiologic factors: external, internal 2. Main groups of pyococcal skin infections. General characteristics, features of the clinical picture and course 3. Staphylococcal diseases of the skin a. Staphylococcal diseases of the hair follicle / folliculitis / b. Staphylococcal diseases of the sweat glands c. Staphylococcal diseases of the nails 4. Treatment

Practical lesson No 6. Pyococcal skin infections – 2 h. 1. Streptococcal diseases of the skin: Impetigo, streptococcal intertrigo, erysipelas, ecthyma, other streptococcal diseases of the skin 2. Mixed pyococcal diseases of the skin

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3. Bacterial allergy and piemia skin eruptions 4. Treatment 5. Prevention of pyococcal diseases of the skin

Practical lesson No 7. Viral diseases of the skin – 2h. 1. Viral diseases of the herpes virus group: herpes simplex, herpes zoster 2. Viral diseases of the skin and mucous membranes due to papilloma virus group: common warts, flat warts, genital warts 3. Viral diseases of smallpox virus and paravaccinia virus - molluscum contagiosum, tuberculum mulgentium, ectthyma contagiosum 4. Hand-foot-and-mouth disease 5. Treatment

Practical lesson No 8. Tuberculosis of the skin – 2 h. 1. Etiologic factors 2. Classification a. Primary / localized and disseminated / forms of TB on the skin and mucous membranes b. Secondary tuberculosis of the skin and mucous membranes. Focal tuberculosis. Disseminated tuberculosis. Modern view of disseminated forms of TB 3. Diagnosis and differential diagnosis 4. Treatment and prevention

Practical lesson No 9. Fungal infections of the skin – 2 h 1. Fungal infections of the skin. Classification 2. Dermatophytic infections. Localization: scalp, beard, non-hairy skin, body folds / large and small /, hands, feet 3. Laboratory diagnosis of dermatophytes: a. Microscopic mycological examination - native fungal structures slide preparation b. Culture diagnostics. Demonstration of fungal infection cultures 4. Treatment and prevention

Practical lesson No 10. Candida infections – 2 h.

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1. Etiology, risk factors for development. 2. Mucosal forms of candida infections 3. Cutaneous forms of candida infections 4. Chronic cutaneous and mucosal candidiasis in innate immune deficiency. Candida granuloma 5. Laboratory diagnosis of candida infections: a. Microscopic examination b. Culture diagnostics 6. Treatment and prevention

Practical lesson No 11. Fungal infections with cutaneous and systemic involvement / Deep mycoses – 2 h. 1. Actinomycosis 2. Maduromycosis 3. Diagnosis and differential diagnosis 4. Treatment

Practical lesson No 12. Cutaneous zoonotic diseases – 2 h. 1. Diseases caused by mites: scabies, trombidiasis, ixodiasis, demodicosis. Demonstration of mites 2. Diseases caused by insects 3. Other cutaneous zoonotic diseases 4. Treatment

Practical lesson No 13. Erythematous dermatoses – 2 h. 1. Erythema exudativum multiforme. Clinical forms. Management 2. Erythema nodosum 3. Diagnosis and differential diagnosis 4. Treatment 5. Vasculitis. Clinical forms

Practical lesson No 14. Bullous dermatoses. 1. Pemphigus. Pemphigus vulgaris. Pemphigus foliateous, 2. Pemphigoid. Bullous pemphigoid. Cicatricial pemphigoid.

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3. Herpetiform dermatitis. Linear IgA bullous dermatosis. Bullous dermatosis of childhood. 4. Diagnosis and differential diagnosis 5. Treatment

Practical lesson No 15. Erythemato-papulo-squamatous dermatoses 1. Psoriasis. Clinical forms: Psoriasis vulgaris. Psoriatic arthritis. Pustular psoriasis 2. Lichen ruber planus. Clinical forms 3. Pityriasis rosea 4. Diagnosis and differential diagnosis 5. Treatment

Practical lesson No 16. Allergic dermatoses – 2 h. 1. Urticaria. Acute urticarial. Chronic urticarial. Angioneurotic edema (Quincke's edema) - acquired and hereditary forms. Management. Treatment 2. Hereditary angioedema. Diagnosis and differential diagnosis. Management. Treatment 3. Strophulus. Diagnosis and differential diagnosis. Treatment

Practical lesson No 17. Drug-induced dermatoses – 2 h. 1. Allergic shock. Clinical picture, clinical forms. Management. Treatment 2. Toxic epidermal necrolysis (Layel’s syndrome). Diagnosis and differential diagnosis. Treatment

Practical lesson No 18. Drug-induced dermatoses – 2 h. 1. Fixed drug eruption. Clinical forms. Diagnosis and differential diagnosis. Treatment 2. Other forms of drug eruptions Diagnosis, differential diagnosis and diagnostic problems. Management. Treatment 3. Drug-induced diseases 4. Skin appendages damage

Practical lesson No 19. Eczema. Dermatitis – 2 h. 1. Contact eczema. Acute, subacute, chronic eczema. Clinical forms: allergic, non- allergic, dyshidrotic, microbial. Diagnosis and differential diagnosis

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2. Endogenous eczema (Atopic dermatitis): characteristics of atopy, stages of development. Diagnosis and differential diagnosis 3. Seborrheic eczema (Seborrheic dermatitis). Age-dependent stages of development. Diagnosis and differential diagnosis 4. Treatment. Prescriptions

Practical lesson No 20. Dermatoses due to external (environmental) factors – 2 h. 1. Dermatoses resulting from physical factors a. dermatoses from mechanical damage b. dermatoses from thermal effects c. dermatoses from ionizing effects 2. Photodermatoses 3. Occupational dermatoses 4. Allergy laboratory. Prick test, patch test, intradermal test

Practical lesson No 21. Seborrhea and seborrheic disorders – 2 h. 1. Seborrhea. Seborrheic background. Dry seborrhea. Oily seborrhea 2. Acne. Clinical features. Forms of the disease. Induced acne 3. Rosacea. Clinical variants. Differential diagnosis 4. Perioral dermatitis 5. Treatment. Prescriptions

Practical lesson No 22. Autoimmune disease of the connective tissue. Lupus erythematosus – 2 h. 1. Discoid chronic cutaneous lupus erythematosus 2. Subacute lupus erythematosus 3. Systemic lupus erythematosus 4. Diagnosis and differential diagnosis. 5. Treatment

Practical lesson No 23. Autoimmune disease of the connective tissue. Dermatomyosistis. Scleroderma – 2 h. 1. Scleroderma

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a. Circumscribed scleroderma - clinical forms. Diagnosis and differential diagnosis b. Diffuse scleroderma - skin manifestations, organ localization. Diagnosis and differential diagnosis 2. Dermatomyositis. Clinical forms. Diagnosis and differential diagnosis. Treatment

Practical lesson No 24. Autoimmune disease of the connective tissue. Scleroderma-like conditions. Aphthosis – 2 h. 1. Mixed connective tissue disease. Diagnosis and differential diagnosis. Treatment 2. Scleredema of Buschke 3. Aphthous disease a. Chronic recurrent aphthae b. Bipolar aphthosis c. Behcet's syndrome. Generalized aphthous disease d. Treatment

Practical lesson No 25. Precancerous skin diseases. Binign skin tumors – 2 h. 1. Precancerous skin diseases a. Obligatory precancerous diseases/lesions: xeroderma pigmentosum, actinic cheilitis, chronic X-ray dermatitis b. Facultative precancerous diseases/lesions: actinic keratosis, scars, chronic inflammatory processes 2. Benign tumors a. Nevi: melanocytic nevi, organoid nevi b. Seborrheic keratosis c. Fibroma d. Lipoma e. Hemangioma

Practical lesson No 26. Malignant tumors of the skin – 2 h. 1. Epithelial malignant tumors a. Basal cell carcinoma b. Squamous cell carcinoma

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c. Intraepidermal carcinomas d. Paget’s disease 2. Malignant melanoma 3. Treatment

Practical lesson No 27. Syphilis. Acquired syphilis – 2 h. 1. Etiology 2. Epidemiology 3. Clinical picture. General course stages a. Primary syphilis b. Secondary syphilis c. Tertiary syphilis

Practical lesson No 28. Syphilis – 2 h. 1. Congenital syphilis - classification. a. Early congenital syphilis: in fetus, infant, early childhood (0 – 2 years of age) b. Late congenital syphilis: in children greater than 2 years of age 2. Laboratory diagnosis of syphilis a. Examination of Treponema pallidum by dark-field microscopy b. Non-specific serologic tests. Rapid test c. Specific serologic tests: TPHA, IF d. Interpretation of serologic tests for syphilis 3. Treatment. Treatment criteria for cure. Follow up

Practical lesson No 29. Gonorrhea. Non-gonococcal urogenital infections. Non-infectious urogenital diseases – 2 h. 1. Gonorrhea a. Clinical picture of gonorrhea in men and its complications b. Clinical picture of gonorrhea in women and its complications c. Gonorrhea in children d. Extragenital and metastatic gonorrhea. e. Diagnostics. Examination of microscope slides for gonococci f. Treatment of gonorrhea

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2. Non-gonococcal urogenital infections: bacterial, chlamydial, mycoplasma, viral, trichomonas, mycotic infections 3. Non-infectious urogenital diseases 4. Diagnostics: history, urogenital status, laboratory examinations 5. Treatment of infectious and non-infectious urogenital diseases

Practical lesson No 30. HIV infection – 2 h. 1. Etiology 2. Epidemiology 3. Clinical picture. Mucocutaneous manifestations of HIV infection 4. Diagnostics. Laboratory tests 5. Treatment of mucocutaneous manifestations 6. Prevention

Recommended dermatology references:

1. Braun-Falco, O., G. Plewig, H. Wolff, R. Winkelmann. Dermatology. Berlin, Springer, 1991. 2. Textbook of Dermatology. Ed. A. Rook et al., 7th ed., Oxford, Blackwell, 1992 (4 vol.). 3. Fitzpatrick’s Dermatology in General Medicine, 6th ed., New York, Mac Graw Hill, 2003 (2 vol.). 4. European Dermatology Forum. White book of dermatology. 2nd ed., ABW Wissenschaftsverlag GmbH, 2005. 5. Braun-Falco’s Dermatology. Third Edition. O. Braun-Falco (Editor Emeritus), Burgdorf W.H.C., G. Plewig, H.H Wolf, M. Landthaler (Editors). Springer Medizin Verlag Heidelberg, 2009. 6. Rycroft R.J.G., S.J. Robertson. A Color Handbook of Dermatology. Intl. Edition. Manson Publishing Ltd. London, UK, 2002. 7. Baran R., R.P.R. Dawber, A. Tosti, E. Haneke. A Text Atlas of Nail Disorders. Martin Dunitz. London, UK, 2002.

CONSPECTUS

DERMATOLOGY AND VENEREOLOGY FOR STUDENTS IN MEDICINE

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PRECLINICAL DERMATOLOGY

1. Structure of the skin. Epidermis. 2. Structure of the skin. Dermis and hypodermis 3. Cutaneous appendages 4. Structure of the oral mucosa 5. Physiology of the skin - keratogenesis, melanogenesis, secretion of the sweat and sebaceous glands 6. Physiology of the skin - thermal regulation, protective, sensitive, and immunologic interface 7. Methods of examination of skin diseases 8. Skin lesions 9. Hystopathological changes in the epidermis, dermis and hypodermis 10. Local treatment of the skin diseases 11. Local medication according to mode of action 12. Systemic treatment of the skin diseases 13. Physical therapy of the skin diseases

CLINICAL DERMATOLOGY

1. Staphylococcal infections of the skin follicles 2. Staphylococcal infections of the sweat and sebaceous glands 3. Streptococcal infections. Impetigo 4. Еrysipelas. Ecthyma 5. Cutaneous tuberculosis-etiology and pathogenesis. Primary inoculation tuberculosis 6. Local forms of secondary cutaneous tuberculosis 7. Disseminated forms of secondary cutaneous tuberculosis 8. Pityriasis versicolor 9. Tinea of the feet, hands and nails 10. Tinea of the body and folds 11.Tinea of thescalp and beard. Laboratory diagnosis 12. Yeast infections. Candidoses 13. Deep mycoses. Аctinomycosis 14. Lyme disease 15. Scabies 16. Pediculosis 17. Herpes simplex virus infections 18. Varicella zoster virus infections 19. Human papilloma virus infections. Warts, genital warts (condylomata accuminata) 20. Parapox virus infections. Molluscum contagiosum 21. Dermatoses due to external factors /physical, chemical, biological/ 22. Erythema exudativum multiforme 23. Erythema nodosum 24. Psoriasis vulgaris 25. Pityriasis rosea 26. Lichen planus 27. Pemphigus 28. Dermatitis herpetiformis (Duhring). Pemphigoid 29. Urticaria. Angioneurotic edema (Quincke). Strophulus 30. Contact dermatitis/eczema

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31. Atopic dermatitis 32 Seborrheic dermatitis 33. Drug-induced dermatoses 34. Lupus erythematosus 35. Dermatomyositis 36. Scleroderma – localized and systemic 37. Chronic venous insufficiency 38. Vasculitis. Morbus Schoenlein-Hennoch 39. Pigmentary disorders 40. Genodermatoses 41. Benign skin tumours 42. Precancerous skin conditions 43. Basal cell carcinoma 44. Squamous cell carcinoma 45. Malignant melanoma 46. Hair diseases 47. Nail diseases 48. Diseases of the sebaceous glands /seborrhea, аcne, rosacea, perioral dermatitis/ 49. Аphthosis. Behcet’s syndrome 50. Cheilitis, stomatitis, glossitis

SEXUALLY TRANSMITTED DISEASES

1. Syphilis – еtiology, pathogenesis, general course 2. Primary syphilis 3. Secondary syphilis 4. Tertiary syphilis 5. Neurosyphilis 6. Congenital syphilis 7. Serological diagnosis of syphilis 8. Gonorrhea - etiology, pathogenesis, laboratory diagnosis 9. Gonorrhea in men. Complications. Treatment 10. Gonorrhoea in women. Complications. Treatment 11.Gonorrhea in children. Еxtragenital and disseminated gonorrhea 12. Genital chlamydial infection 13. Non-gonococcal urethritis 14. Balanitis and balanoposthitis 15. Vulvitis and vulvovaginitis 16. Тrichomoniasis 17. Muco-cutaneous manifestations in HIV infection

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MEDICAL UNIVERSITY, MEDICAL FACULTY

NEPHROLOGY

TEACHING PLAN

Exams Hours Discipline Semester Total Lectures Practicals

Nephrology IX, X 70 20 50

PROGRAMME OF THE LECTURE COURSE V-th course, IX and X semester

The students of V-th medical course are divided into 3 parts of equal number of groups which have training in the following disciplines of Internal Medicine and Therapy II part: 1.Nephrology,hemodialysis and transplantation; 2.Gastroenterology; 3.Endocrinology and Metabolic Diseases. Each discipline is studed 10 weeks /70 hours-20 hours lectures and 50 hours practicals/. After the end of this 10- weeks training a rotation of these three parts in the three clinics is carried out.

№ LECTURES HOURS

1. Glomerular diseases. General description of glomerular syndromes- proteinuria, hematuria, nephrotic syndrome, anemia. 2 Acute Post-Streptococcal Glomerulonephritis (PSGN)

2. Minimal Change Glomerulopathy. Focal Segmental Glomerulosclerosis.C1q Nephropathy. 2

3. Membranous Glomerulopathy. Membranoproliferative Glomerulonephritis (Mesangial Capillary Glomerulonephritis). 2

4. IgA Nephropathy. Rapidly Progressive Glomerulonephritis and Crescentic Glomerulonephritis. Immune Complex-Mediated Crescentic Glomerulonephritis. Anti-Glomerular Basement 2 Membrane Glomerulonephritis.

Secondary Glomerular Diseases. Systemic Lupus Erythematosus. 5. 2 Diabetic Nephropathy. 6. 2

7. Tubulointerstitial Diseases. Acute interstitial nephritis. Chronic tubulointerstitial nephritis. Balkan Endemic Nephropathy. 2 Chronic Urate Nephropathy.

Urinary Tract Infection. Acute Uncomplicated Cystitis. Recurrent Cystitis. Acute Pyelonephritis. Chronic Pyelonephritis 8. and Reflux Nephropathy. Urinary Tract Infection, Renal Failure, 2 and Hypertension. Nephrolithiasis. Autosomal Dominant Polycystic Kidney Disease.

Acute Kidney Injury (ARF). Chronic Kidney Disease. 9. 2 10. Management of chronic kidney disease. Staging of Chronic Kidney Disease. Malnutrition. Management of anemia,hypertension,metabolic acidosis. Starting Hemodialysis 2. Vascular accsses.

PROGRAMME OF PRACTICAL EXERCISES IN NEPHROLOGY MEDICAL STUDENTS V-TH COURSE

№ SUBJECT HOURS

1. Functional tests in nephrology.Giving an interpretation of the mainsyndromes:swelling(edema);hematuria;hypertension;ane-emia. Changes in the urine sediment; in the amount of total protein and albumines; in the electrolytes, urea,creatinine,clearance of creatinine.The role of the immune system in glomerular 3h. diseases. Giving an interpretation of ultrasonographic examination of the kidneys and roentgenograms of the kidneys.Renal biopsy-indications and contraindications. Сomparison of the clinical features with the histological finding.

2. Acute glomerulonephritis. Clinical features,physical examination,diagnosis, ultrasound examination of the kidneys, renal biopsy. Complications. Treatment. 2h.

3. Rapidly progressive glomerulonephritis. Classification,pathogenesis, clinical features, histological findings, diagnosis, treatment 3h.

4. Chronic glomerulonephritis. Classification.. Сomparison of the histological findings in the kidneys with the clinical features.. Pathogenetic treatment. Pulse therapy with Methylprednisolon and Cyclophosphamide. Plasmapheresis in combination with 2h. immunosuppressive therapy. Immunoabsorbtion.

5. Minimal change disease. Nephrotic syndrome.Findings on EM. Diagnosis and 3h. treatment with glucocorticosteroids.

6. Membranous glomerulopathy. Clinical features.Histological changes. Treatment - glucocorticosteroids, Cyclophosphamide, Cyclosporine, high doses of immunovenin. 2h.

7. Membranoproliferative (mesangiocapillary) glomerulonephritis. Glinical features of the different types based on immunofluorescence microscopy (deposits of IgG, 3h. IgM,IgA,C3-complement) Тherapeutcal approach to the different types.

8. Membranoproliferative (mesangiocapillary) glomerulonephritis Histological findings – specific changes on light microscopy, immunofluorescence microscopy and 2h. electron microscopy. Pathogenetic and symptomatic treatment.

Focal segmental glomerulonephritis. Clinical features of FGS. IgA 9. glomerulonephritis. Pathogenesis, clinical features, laboratory findings, histological 3h. changes, treatment. 10. Diabetic nephropathy – pathogenesis, pathophsiology and histological 2h. findings. Clinical features, diagnosis. Treatment, prognosis.

11. Secondary glomerular diseases.SLE.Lupus nephritis.Shonlein-Hennoh nephritis.Clinical features and course,immunologic tests, histological changes,t 3h. reatment.

12. Acute interstitial nephritis – etiology,pathogenesis,clinical features, diagnosis, treatment. Chronic interstitial nephritis - causative factors, diagnosis, 2h. treatment.

13. Urinary tract infections – classification, epidemiology, pathogenesis. Acute and chronic pyelonephritis. Urinary tract infections and pregnancy. Diagnosis 3h. and treatment of urinary tract infections.

14. Autosomal-dominant polycystic kidney disease. Balkan endemic nephropathy. 2h.

15. Nephrolithiasis – classification, etiology, pathogenesis. Renal colic - 3h. diagnosis, conservative treatment, extracorporal lithotripsy.

16. Acute kidney injury – classification, etiology, pathogenesis Laboratory 2h. findings,diagnosis. Treatment,prognosis.

17. Chronic kidney disease-stages,etiology,pathogenesis Clinical features.Symptoms and syndromes-anemia,metabolic 3h. acidosis,hypertension,hyperkaliemia,hyperparathyreoidismus.

18. Renal replacement therapy-indications. Vascular accsess. Hemodialysis and peritoneal dialysis. 2h.

19. Plasmapheresis and carboperfusion. Management of some side effects and complications due to hemodialysis and CAPD. 3h.

20. Kidney transplantation-indications. Obligatory tests for the donor and the recipient before proceeding kidney transplantation. Complications. Treatment 2h. of transplanted patients and prognosis.

SYLLABUS IN NEPHROLOGY ENGLISH SPEAKING STUDENTS

1.Glomerular diseases. General description of glomerular syndromes- proteinuria, hematuria, nephrotic syndrome, anemia. 2.Acute Post-Streptococcal Glomerulonephritis (PSGN)- etiology, pathogenesis, clinical features. 3.Acute Post-Streptococcal Glomerulonephritis (PSGN)-laboratory findings, pathology, treatment. 4.Minimal Change Glomerulopathy- epidemiology, pathogenesis, clinical features and natural history. 5. Minimal Change Glomerulopathy- laboratory findings, pathology, treatment. 6.Focal Segmental Glomerulosclerosis -clinical features, laboratory Findings. 7. Membranous Glomerulopathy-pathology, clinical features. 8. Membranous Glomerulopathy- laboratory findings, treatment. 9.Membranoproliferative Glomerulonephritis (Mesangial Capillary Glomerulonephritis)- pathology, clinical features, laboratory findings, treatment. 10.IgA Nephropathy- pathogenesis, pathology, clinical features, treatment. 11.Rapidly Progressive Glomerulonephritis and Crescentic Glomerulonephritis- pathogenesis, pathology, clinical features, treatment. 12.Systemic Lupus Erytematosus. Lupus Nephritis-epidemiology, pathogenesis, classification of Lupus Nephritis, pathology (Immunofluorescence, Electron Microscopy). 13. Systemic Lupus Erytematosus. Lupus Nephritis-clinical manifestations, serologic tests, drug-induced lupus, management of Lupus Nephritis, course and prognosis of Lupus Nephritis. 14.Diabetic nephropathy- pathology of diabetic nephropathy, clinical features, laboratory findings, treatment. (blood pressure control, glucose control, dietary protein restriction). 15.Diabetic nephropathy- microalbuminuria, extrarenal complications in diabetic nephropathy, treatment (blood pressure control, glucose control, dietary protein restriction). 16.Tubulointerstitial Diseases. Acute interstitial nephritis-causative factors, pathology, cilinical manifestations and diagnosis, prognosis and management. 17.Chronic tubulointerstitial nephritis-causes(primary and secondary).Analgesic nephropathy- clinical features,diagnosis and treatment. 18.Balkan Endemic Nephropathy- clinical features, diagnosis and treatment,chronic urate nephropathy. 19.Acute pyelonephritis-etiologic agents, clinical features, diagnosis, treatment. 20.Chronic pyelonephritis-classification, etiology, clinical features, diagnosis, general principles of antimicrobial therapy. 21.Nephrolithiasis- clinical manifestations, kidney stones, treatment.

22.Autosomal Dominant Polycystic Kidney Disease - diagnosis, clinical features, complications, treatment. 23.Acute kidney failure (indury) - definition, classification, clinical manifestations, course, complications,management. 24.Acute tubule necrosis - causes, clinical features, complications, therapy. 25.Chronic kidney disease - definition, risk factors, history, physical examination, clinical manifestations, course. 26.Chronic kidney disease - staging, management of chronic kidney disease: dietary protein restriction; treatment of hypertension, anemia, hyperkalemia, hyperphosphatemia, metabolic acidosis. 27.Hemodialysis - criteria for initiating HD; vascular access. Peritoneal Dialysis. Renal transplantation.

TEXTBOOKS: 1. Evidence-based Nephrology, 1st ed. Donald A. Molony, Jonathan C. Craig – 2009. 2. Oxford Textbook of Clinical Nephrology, 3th -4th Ed. Editors: Davison, Alex M.; Cameron, J. Stewart; Grunfeld, Jean-Pierre; Ponticelli, Claudio; Ritz, Eberhard; Winearls, Christopher G.; Ypersele, Charles van; Oxford University Press. 3. Brenner and Rector’s The Kidney- 9th edition; Barry M. Brenner – 2012. 4. Diseases of the Kidney and urinary tract 9th Ed. Robert W. Schrier – 2013. 5. Lecture course in nephrology.

Author:Ass.Prof. Emil Kumchev, Dr. Stefka Pandeva

Approved of the Department Meeting on: 02.10.2014.

COURSE OF LECTURES IN GASTROENTEROLOGY AND HEPATOTLOGY

Lecture № 1- 2 hours DISEASES OF OESOPHAGUS. DISEASES OF STOMACH. GASTRITIDES Definition of the term gastritis.Classification of gastritides. The Sydney System. Histomorphology of acute and chronic gastritis. Etiology and pathogenesis of gastritides. Clinical signs of gastritides. Clinical forms (according to severity). Chronic gastritis of the corpus (type A). Chronic gastritis of the antrum (type B). Special forms of gastritides. Diagnostics and differential diagnosis of gastritides.

Lecture № 2- 2 hours TREATMENT OF GASTRITIDES Functional examination of stomach. Treatment of gastritides – acute and chronic. Etiological treatment of gastritides. Special features of the treatment of chronic gastritis of the corpus (chronic gastritis type A) and chronic gastritis of the antrum (chronic gastritistype B). Substitutional therapy.

Lecture № 3 - 2 hours ULCER DISEASE Definition of the term ulcer disease and peptic ulcer. Classification of ulcer disease. Etiology of the disease: endogenic and exogenic factors. Pathogenesis: acido-peptic theory – aggressive factors, cellularity and stomach secretion in ulcer disease of the stomach (UDS) and ulcer disease of the duodenum (UDD). Cellular mechanisms of stomach secretion. Pathogenic significance of H. pylori in UDS and UDD. Mucous barrier and recurrent diffusion of H+ conceptions. Protective mechanisms of the stomach mucosa. Clinical picture of the ulcer disease of the stomach and the duodenum. Conservative treatment of the ulcer disease.

Lecture № 4 - 2 hours STOMACH CANCER. EARLY DIAGNOSIS Definition of the term early cancer. Frequency and social significance of the disease. Etiology and pathogenesis. Pathology and classification of stomach cancer. Clinical picture of the early stomach cancer. Endoscopic signs and types of the early stomach cancer. X-ray diagnostics of the early and the advanced stomach cancer. Immuno-diagnostics – tumor markers and their significance. Differential diagnosis. Differential diagnosis between the benignant and malignant stomach ulcer. Prophylaxis. Conservative treatment.

Lecture № 5 - 2 hours ENTEROCOLITIDES Definition of the term acute and chronic enterocolitis. Etiology: predisposition and causative factors. Pathogenesis – significance of prostaglandin’s and leucotriens. Pathological changes. Classification of the chronic non-specific enterocolitides. Clinical features of chronic enterocolitides. Diagnosis. Coprological and microbiological tests. Diagnostic tests. X-ray examination of the small intestine. Treatment of enterocolitides.

Lecture № 6 - 2 hours ULCERATIVE COLITIS Definition of the term ulcerative colitis. Etiology and pathogenesis. Basic theories. Immune factors. Pathologic anatomy. Forms of the disease according to localisation of the process. Clinical signs. Clinical forms. Basic syndromes. Diagnosis and differential diagnosis. Complications: local and general. Treatment. Diet. Salazopyrin and 5-ASA deviates. Corticotropin, corticosteroids, immune suppressers, etc.

Lecture № 7 – 2 hours CHRONIC HEPATITIDES Definition of the term chronic hepatitis. Classifications.Etiology.Viral markers. Pathogenesis. Pathogenesis of the chronic viral hepatitides. Histopathology of chronic hepatitides. Histological forms. Chronic viral hepatitides. Clinical features of chronic hepatitides. Chronic autoimmune hepatitis. Diagnosis and differential diagnosis of chronic hepatitides. Treatment: diet, drug therapy of chronic hepatitides.

Lecture № 8 – 2 hours LIVER CIRRHOSES Definition of the term liver cirrhosis. Classifications. Etiology. Pathogenesis of liver cirrhoses. Macroscopic and histomorphological features. Clinical signs of micro- and macronodular cirrhosis. Laboratory manifestations. Instrumental methods of examination. Treatment of liver cirrhoses. Dietary regimen. Drug therapy. Treatment of the complications.

Lecture № 9 – 2 hours GALLSTONE DISEASE Definition of the term cholelithiasis and choledocholithiasis. Etiology. Pathogenesis of cholesterol and bilirubin cholelithiasis. Clinical signs. Clinical forms. Development and complications of cholelithiasis. Choledocholithiasis. Evolution and complications. Diagnostics of cholelithiasis and choledocholithiasis. Instrumental methods. Treatment of gallstone disease. Dietary regimen. Drug therapy. Endoscopic methods of treatment of chole- and choledocholithiasis.

Lecture № 10 – 2 hours PANCREATITIDES. BILE DUCTS’ AND PANCREATIC CANCER Definition of the term pancreatitis. Marseille’s classification of pancreatitides.Etiology and pathogenesis. Clinical picture. Clinical syndromes. Complications of pancreatitides. Diagnosis and differential diagnosis of pancreatitides. Treatment of chronic pancreatitis: dietary, substitutional and symptomatic. Pancreatic cancer.

PRACTICAL EXERCISES IN GASTROENTEROLOGY AND HEPATOLOGY

Еxercise №1 - 3 hours Examination of a patient with gastrointestinal disease. Basic symptoms in gastroenterology - Examination of a patient, a brief oral exam

Exercise № 2 - 2 hours Examination of the stomach. Acute gastritides - Examination of a patient, a brief oral exam, de-monstration of upper GI endoscopy

Exercise № 3 - 3 hours Chronic gastritides - Examination of a patient, a brief oral exam, demonstration of upper GI endo-scopy

Exercise № 4 - 2 hours Treatment of gastritides - Examination of a patient, prescription of therapy, a brief oral exam, pre-paration of a dietary regimen

Exercise № 5 - 3 hours Ulcer disease of the stomach and the duodenum – clinical signs, complications - Examination of a patient, a brief oral exam, demonstration of upper GI endoscopy

Exercise № 6 - 2 hours Ulcer disease of the stomach and the duodenum – treatment - Examination of a patient, a brief oral exam, prescription of therapy, preparation of a dietary regimen

Exercise № 7 - 3 hours Stomach cancer. Early diagnosis - Examination of a patient, a brief oral exam, demonstration of upper GI endoscopy

Exercise № 8 - 2 hours Functional diseases of the stomach - Examination of a patient, a brief oral exam, preparation of a dietary regimen

Exercise № 9 - 3 hours Enterocolitides - Examination of a patient, a brief oral exam, prescription of therapy, preparation of a dietary regimen

Exercise № 10 - 2 hours Disorders of the small intestine (Celiac disease). Cronn’s disease - Examination of a patient, a brief oral exam, demonstration of lower GI endoscopy

Exercise № 11 - 3 hours Ulcerative colitis - Examination of a patient, a brief oral exam, demonstration of lower GI endoscopy, prescription of therapy, preparation of a dietary regimen

Exercise № 12 - 2 hours Colorectal cancer - Examination of a patient, a brief oral exam, demonstration of lower GI endoscopy

Exercise № 13 - 3 hours Examination of the liver - Examination of a patient, demonstration of abdominal ultrasonography

Exercise № 14 - 2 hours Chronic hepatitides - Examination of a patient, a brief oral exam, prescription of therapy, preparation of a dietary regimen, demonstration of abdominal ultrasonography, or blind needle biopsy, if available

Exercise № 15 - 3 hours Liver cirrhoses – clinical signs, complications - Examination of a patient, a brief oral exam, evacuation of ascites by abdominal paracentesis

Exercise № 16 - 2 hours Liver cirrhoses – treatment. Liver cancer - Examination of a patient, a brief oral exam, prescription of therapy, prepation of a dietary regimen

Exercise № 17 - 3 hours Gallstone disease - Examination of a patient, a brief oral exam, demonstration of abdominal ultrasonography, preparation of a dietary regimen, prescription of therapy

Exercise № 18 - 2 hours Chronic cholecystitis - Examination of a patient, a brief oral exam, demonstration of abdominal ultrasonography

Exercise № 19 - 3 hours Chronic pancreatitides - Examination of a patient, a brief oral exam, preparation of a dietary regimen, prescription of therapy

Exercise № 20 – 2 hours Bile ducts’ and pancreatic cancer - Examination of a patient, a brief oral exam, demonstration of abdominal ultrasonography, or thin needle biopsy, if available

SYLLABUS IN GASTROENTEROLOGY Vth medical course

1. Diseases of the esophagus – achalasia, hiatal hernias, cancer of the esophagus. 2. Gastroesophageal reflux disease / GERD/. Functional /non-ulcer dyspepsia. 3. Gastritides. Acute and special forms. Acute gastritis. 4. Chronic gastritides. 5. Ulcer disease – etiology and pathogenesis. 6. Ulcer disease of the stomach. 7. Ulcer disease of the duodenum. 8. Ulcer disease – treatment. 9. Complications of ulcer disease. 10. Stomach cancer. 11. Enterocolitides. 12. Crohn’s disease. 13. Chronic ulcerative colitis. 14. Irritable bowel syndrome. 15. Diverticular disease of the large bowel. 16. Cancer of the rectum and the large bowel. 17. Chronic hepatitides – classification, etiology and pathogenesis. 18. Chronic hepatitides –clinical signs, diagnosis and treatment. 19. Chronic autoimmune hepatitis. 20. Liver cirrhoses – classification, etiology and pathogenesis. 21. Liver cirrhoses – clinical signs, complications, diagnosis, differential diagnosis. 22. Liver cirrhoses – treatment. 23.Primary biliary cirrhosis. 24. Liver cancer. 25. Gallstone disease – etiology, pathogenesis, clinical signs. 26. Gallstone disease – complications, diagnosis, differential diagnosis, treatment. 27. Cholangitides and cholangiohepatitides. 28. Cancer of the gall bladder and the extrahepatic bile ducts. 29. Hepatic /liver/ encephalopathy. Hepatic coma. 30. Pancreatitides. Chronic pancreatitides. 31. Pancreatic cancer.

TEXTBOOKS:

1. Clinics and Therapy of Internal Diseases – Dimitrakov and Auth., part II p. 289 – 410, Plovdiv, Polygraphia, 1998, ISBN 954-9529-23-1 Chapter „Diseases of the Gastrointestinal Tract, Hepatobiliary System and The Pancreas – Iv. Stanchev” – translated in English by Е. Cholakova 2. “Clinics and Therapy of Internal Diseases – Nephrology, Endocrinology, Gastroenetrology –Dimitrakov and Auth., 2006 3. Oxford Handbook of Gastroenterology and Hepatology, authors Stuart Bloom, George Webster, Daniel Marks; publisher – OXFORD UNIVERSITY PRESS 4. Manual of tests in Gastroenterology; 5. Course of lectures Authors of the Program: Ass. Prof. Vl. Andonov; E. Cholakova

MEDICAL UNIVERSITY - PLOVDIV FACULTY OF MEDICINE

Section ENDOCRINOLOGY AND METABOLIC DISEASES

PROGRAMME IN ENDOCRINOLOGY AND METABOLIC DISEASES

Approved by the Sectional Council on 24.09.2012 г. Confirmed by the Faculty Council on……………., 2012

Учебна програма за специалност “Медицина” 1

MEDICAL UNIVERSITY – PLOVDIV, FACULTY OF MEDICINE Section ENDOCRINOLOGY AND METABOLIC DISEASES

Name of the course: „Endocrinology and metabolic diseases”

Type of course according to the Uniform State Requirements: Mandatory

Level of education: Master degree /М/

Forms of education: Lecture courses, practical courses, self-training.

Semesters of education: 9-th / 10-th semesters

Auditorium classes: 20 hours of thelecture course, 50 hours of the practical course

Technical equipment applied in the training: Practical work with patients с пациенти при леглото на болния (анамнеза, клиничен статус, диагностичен и терапевтичен план, методи на изследване, тълкуване на биохимични, хор- монални, имунологични и пр. тестове и образни изследвания, извеждане на визитация); multimedia presentations – theoretical backgr и клинични случаи; дискусии; решаване на казу- си.

Control and evaluation: Ongoing evaluation – tests, oral examinations, colloquia on different syllabus sections Final evaluation – practical and theoretical examination

Score assessment Participation in practical exercises, tests, colloquia

Semester exam: Yes /test, written and oral examination/

State Exam: Yes (part of the exam in Internal diseases)

Lecturer: Full Professor from the Section of Endocrinology and metabolic diseases (Prof. M.Orbetzova)

Department: 2-nd Department of Internal Diseases

Учебна програма за специалност “Медицина” 2

CURRICULUM Hours Forms of education Per semester Per week ІХ/ Х Lectures 2 20 Practical exercises 5 50 Total 7 hours 70 hours

Programme of the lecture course - Theses

T O P I C № 1. – 2h. Diseases of the hypothalamus and the pituitary gland. Principles of the hormonal diagnosis and the feed-back mechanisms in endocrinology. Hypothalamic syndromes – generalized hypothalamic syndrome. Diseases of the adenohypophysis. Hormonally active and inactive tumors. Prolactinoma and hyperprolactinaemia. Acromegaly and gigantism.

T O P I C № 2. – 2h. Hypopituitarism – definition, causes, forms, pathogenesis, clinical presentation, syndromes, isolat- ed forms – hyposomatotropism, hypogonadism. Panhypopituitarism – Sheehan’s syndrome. Basic principles and types of replacement therapy.

T O P I C № 3. – 2h. Hormones of the neurohypophysis – biosynthesis and release. Diseases of the neurohypophysis. Diabetes insipidus – causes, pathogenesis, clinical presentation, types of diabetes insipidus, differential diagnosis and treatment. Syndrome of inappropriate antidiuretic hormone secretion (SI- ADH).

T O P I C № 4. – 2h. Hormones of the adrenal corex, regulation and biological effect. Hyperfunction of the adrenal cortex. Hyperglucocorticism – ACTH-dependent and independent forms. Cushing’s syndrome – ethiopathogenesis, clinical presentation, diagnosis, differential diagnosis, treatment. Ectopic ACTH syndrome. Cushing’s syndrome (primary hyperglucocorticism) - clinical presentation, diagnosis, differential diagnosis and treatment. Primary hyperaldosteronism (Conn’s syndrome) – ethiopathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment.

T O P I C № 5. – 2h. Congenital adrenal hyperplasia – characteristics, forms. Diseases of the adrenal cortex – primary adrenal insufficiency (Addison’s disease) - causes, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Autoimmune polyglandular syndromes (APS) – autoimmune characteristics, clinical presentation, diagnosis and treatment.

T O P I C № 6. – 2h.

Учебна програма за специалност “Медицина” 3

Biosynthesis and metabolism of catecholamines. Diseases of the adrenal medulla: pheochromocytoma – incidence, pathogenesis, classification, clinical presentation, diagnosis, differential diagnosis and treatment. Multiple endocrine neoplasia (MEN) – types, clinical presentation, diagnosis and treatment .

T O P I C № 7. – 2h. Thyroid diseases. Endemic and sporadic goiter – incidence, etiology, clinical presentation, diagnosis and treatment. Hypothyroidism – types, etiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Acute infectious, subacute, granulomatous, chronic lymphocytic, silent, fibrous thyroiditis - etiology, clinical presentation, diagnosis, differential diagnosis and treatment.

T O P I C № 8. – 2h. Hyperthyroidism and thyrotoxicosis. Graves’ disease - etiology, pathogenesis, clinical presentation, course, clinical forms and complications (ТАО, thyrotoxic crisis), treatment. Toxic adenoma - etiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Toxic multinodular goiter - etiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Carcinoma of the thyroid gland – incidence, etiology, classification, clinical presentation, differential diagnosis and treatment.

T O P I C № 9. – 2h. Parathyroid and diseases of bone and mineral metabolism – regulation of metabolism. Hypopara- thyroidism – types, acute and chronic forms, clinical presentation, diagnosis, differential diagnosis and treatment. Primary hyperparathyroidism - etiology, pathogenesis, pathological morphology, clinical presentation, diagnosis, differential diagnosis and treatment. Osteoporosis.

T O P I C № 10. – 2h. Disorders of the metabolism of carbohydrates and the endocrine pancreas – diabetes mellitus and prediabetes, metabolis syndrome. Diabetes mellitus - etiology, pathobiochemistry, classification, clinical presentation, diagnosis and differential diagnosis. Treatment of diabetes mellitus - education, diet, oral therapy, insulin therapy. Acute complications of diabetes mellitus – diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic coma, hypoglycemia. Late vascular degenerative complications of diabetes mellitus – diabetic microangiopathy (diabetic retinopathy, nephropathy), diabetic macroangiopathy, diabetic neuropathy, diabetic foot.

Programme of practical exercices

PRACTICAL EXERCICE №1 – 2 hours: Introduction to endocrinology. Examining an endocrine patient. Examining the hypothalamus-pituitary system. Principles of hormonal diagnosis. Tumors of the hypothalamic-pituitary system - general data. PRACTICAL EXERCICE №2 – 3 hours: Hypothalamic disorders. Male and female hypogonadism – primary and central forms. Diagnosis guidelines and treatment. PRACTICAL EXERCICE №3 – 2 hours: Acromegaly. Prolactinoma and hyperprolactinaemia. PRACTICAL EXERCICE №4 – 3 hours: Hypopituitarism.. Sheehan’s syndrome. Учебна програма за специалност “Медицина” 4

PRACTICAL EXERCICE №5 – 2 hours: Diabetes insipidus. Diagnosis of water-elecrolyte disorders. PRACTICAL EXERCICE №6 – 3 hours: Hyperglucocorticism – clinical presentation. Prin- ciples of differential diagnosis of the ACTH-dependent and ACTH-independent forms (Dexame- thasone suppression tests). Treatment. PRACTICAL EXERCICE №7 – 2 hours: Endocrine hypertension. Pheochromocytoma. Mineralcorticoid hypertension – Conn’s syndrome. PRACTICAL EXERCICE №8 – 3 hours: Congenital adrenal hyperplasia. Primary adrenal hypocorticism – Addison’s disease. PRACTICAL EXERCICE №9 – 2 hours: Examining the thyroid gland – clinical, functional and morphological examination, imaging. Immune testing. Endemic and sporadic goiter. PRACTICAL EXERCICE №10 – 3 hours: Thyrotoxicosis – clinical presentation. Classifi- cation (Graves’ disease, toxic multinodular goiter, toxic adenoma etc.). Differential diagnosis. Therapy of thyrotoxicosis. PRACTICAL EXERCICE №11 – 2 hours:. Thyroidites - Acute infectious, subacute, granulomatous, chronic lymphocytic, silent, fibrous thyroiditis. Carcinoma of the thyroid gland. Princi- ples of the management and follow-up of the nodular goiter. PRACTICAL EXERCICE №12 – 3 hours: Hypothyroidism – classification, clinical presentation, differential diagnosis, treatment. PRACTICAL EXERCICE №13 – 2 hours: Hypoparathyroidism -- etiology, pathogenesis, pathological morphology, clinical presentation, diagnosis, differential diagnosis and treatment.. PRACTICAL EXERCICE №14 –3 hours: Hyperparathyroidism - etiology, pathogenesis, pathological morphology, clinical presentation, diagnosis, differential diagnosis and treatment. Osteoporosis – characteristics, classification, diagnosis, differential diagnosis. PRACTICAL EXERCICE №15 – 2 hours: Diabetes mellitus – classification, diagnosis, characteristics of the main types. Prediabetes. Metabolic syndrome. PRACTICAL EXERCICE №16 – 3 hours: Diabetes mellitus – acute metabolic complications: hypoglycaemia, diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic coma. PRACTICAL EXERCICE №17 – 2 hours: Diabetes mellitus – late vascular degenerative complications. Micro- and macroangiopathy – prevention, clinical characteristics and therapy. PRACTICAL EXERCICE №18 – 3 hours: Diabetes mellitus – education of the patients. Diet and physical activity as part of the therapy. Oral antidiabetic medications. PRACTICAL EXERCICE №19 – 2 hours: Diabetes mellitus – insulin treatment. Types of insulin preparations. Insulin regimens. PRACTICAL EXERCICE №20 – 3 hours: Autoimmune polyglandular syndromes. Multi- ple endocrine neoplasy. Test (colloquium).

Endocrinology and metabolic diseases for English speaking students – V grade

1. Hypothalamic syndromes, generalized hypothalamic syndrome 2. Pituitary tumours – diagnosis of nonactive pituitary tumours. 3. Hyperprolactinaemia. Prolactinoma - diagnosis, clinical picture, treatment 4. Acromegaly and gigantism - diagnosis, clinical picture, treatment, criteria of remission. 5. Diseases of neurohypophysis. Diabetes insipidus. Учебна програма за специалност “Медицина” 5

6. Thyroid diseases – Goitre (endemic; sporadic) 7. Hypothyreoidismus – definition; classification; diagnosis, clinical picture, treatment. 8. Hyperthyreoidismus - definition; classification; diagnosis, clinical picture, treatment. 9. Thyroid carcinoma. 10. Thyreoidites – classification. Subacute thyroiditis of De Querven. 11. Thyreoidites – classification. Chronic autoimmue thyroiditis of Hashimoto. 12. Hypoparathyreoidismus - definition; classification; diagnosis; clinical picture, treatment. 13. Hyperparathyreoidismus - definition; classification; diagnosis; clinical picture, treatment. 14. Morbus Addisoni – clinical picture; treatment. 15. Cushing’s syndrome – classification; diagnosis; clinical picture; treatment. 16. Hypermineralocorticismus - definition, clinical picture; treatment of Conn adenoma. 17. Pheochromocytoma – diagnosis; differential diagnosis; clinical picture; treatment. 18. Daibetes mellitus – etiology, pathogenesis, types; diagnosis, clinical characteristics. 19. Daibetes mellitus – oral treatment. 20. Daibetes mellitus – insulin treatment. 21. Acute metabolic complications of diabetes – hypoglycaemia, ketoacidosis, nonketotic hyperosmolar coma. 22. Chronic complications of diabetes - microangiopathy (retinopathy; nephropathy). 23. Chronic complications of diabetes - macroangiopathy. 24. Chronic complications of diabetes - diabetic neuropathy; diabetic foot.

Textbooks: 1. Lecture course 2. Greenspan& Baxter. Endocrinology. 3. Alexis Labhart. Clinical Endocrinology. 4. Harrison’s Principles in Internal Medicine

In Bulgarian:  Раздел „Ендокринология” в В “Клиника и терапия на вътрешните болести. Нефрология; гастроентерология; ендокринология”. Ред. Д. Димитраков. Издател- ство Медицински Университет – Пловдив, 2006; ISBN 954-9549-13-5.  Раздел „Ендокринология” В “Актуални аспекти на общата медицинска практика. Том 2”. Ред. Л.Деспотова-Толева. Медицинско издателство „ВАП” Пловдив, 2011; ISBN 978-954-8326-29-2. Тестове за самоподготовка:  Тестове по ендокринология. стр. 179-313 В Тестове по нефрология, гастроенте- рология, ендокринология за студенти по медицина. Ред. проф. Д. Димитраков. Издателство Медицински Университет – Пловдив, 2008; ISBN 978-954-9549-31-7.

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