教
师
教
案
（2008 ~2009 学年第 2 学期）
课程名称: 内科学
授课题目: 血液系统疾病（巨幼细胞性贫血）
授课对象: 临床医学七年制 2005 级
授课教师: 崔久嵬
职
称: 教
授
吉林大学第一医院
Teaching Plan
Name of Curriculum：Internal Medicine（Hematological Disorders）
Name of the
teacher
CUI Jiuwei
Students
Time
Type of the
Class
Title
Profess
2005 seven-year program Clinical medicine
2009.4.28
the First
Class (45 min）
Topic of the class
Megaloblastic Anemia
Theory class
Teaching methods
Multimedia（powerpoint）
(bilingual education)
1. Grasp the clinical magnifestation and principles for the treatment of megaloblastic
Aim and
requirement
anemia；
2. Be familiar with the pathogenesis and etiology of megaloblastic anemia；
3. Understand the metabolism and function of folic acid and vitamin B12.
Key points：
Teaching key
points and
difficult points
1. Pathogenesis and etiology of megaloblastic anemia;
2. Clinical magnifestation and lab examination of megaloblastic anemia;
3. Diagnosis and differential diagnosis of megaloblastic anemia；
4. Treatment of megaloblastic anemia
Difficult point：
Lab examination of megaloblastic anemia
Textbook and
Reference
Textbook：WANG Ji-yao. "Internal Medicine", First Edition (8-year teaching program)
People's Health Publishing House, 2005.
Reference：1．YE Ren-gao, LU Zai-ying. "Internal Medicine", Sixth Edition, People's
Health Publishing House. 2004.
2．Thomas E. Andreoli, "Cecil Essentials of Medicine"． Seventh
Edition (the English version of a photocopy), Peking University Medical
Press. 2008.01.
Teaching Content
Brief introduction:
Go over the last class content of Iron Deficiency Anemia (IDA). IDA is microcytic anemia, and
we will introduce a macrocytic anemia in this class.
1. The definition of megaloblastic anemia
Key: Disorders caused by impaired DNA synthesis.
Introduce the incidence, the features of morphology: macrocytic.
Time assignment
2 minutes
Ask
questions.
the
3minutes
(Stress
point)
the
Compare the pictures of the morphology of red blood cells between the normal situation,
microcytic and macrocytic anemia on the slides.
2. Metabolism and function of folic acid and vitamin B12
Introduce the source, absorption, storage and excretion of folic acid and 6 minutes
vitamin B12 in the body briefly.
Key
Show the pictures of the whole progress of folic acid and vitamin B12 metabolism, and
introduce what could cause the deficiency of folic acid and vitamin B12, and what will occur when
there is deficiency of folic acid and vitamin B12 by introducing the function of them. That is,
introduce the etiology and pathogenesis briefly in this session, and make it easy for the students to
understand the following content.
3. Etiology and pathogenesis
5 minutes
a. the etiology of folic acid deficiency
i. Dietary deficiency; ii. Decreased absorption; iii. Increasd
requirement.
b. the etiology of Vitamin B12 deficiency
i. Dietary deficiency; ii. Decreased absorption; iii. Increasd
requirement; iv. Deficiency of intrinsic factor.
c. When there is deficiency of folic acid or vitamin B12, cell division is
sluggish, but cytoplastic development progresses normally, so
megaloblastive cells tend to be large, with an increased ratio of RNA
to DNA.
Through the introduction in session 2, the students can understand the etiology and
pathogenesis of deficiency of folic acid and vitamin B12 easily. So I can ask the students to
analysis the etiology and pathogenesis of deficiency of folic acid and vitamin B12, then I do the
summarization.
4. Clinical features
a. Symptoms and signs of anemia
b. Symptoms and signs of gastrointestinal system
c. Symptoms and signs of neurological system
5 minutes
(key point)
Show the picture of the specific feature of megaloblastic anemia： beefy-red tongue.
5. Lab examination
a. Peripheral blood: macrocytic anemia, the neutrophils show
5minutes
hypersegmented nuclei (with six or more lobes).
b. Bone marrow: erythroblasts are large
Show the morphology of cells on the slides, and compare with that in the normal person.
c. Chemistry tests
Serum and red blood cell folate and/or B12 are usually very low.
Indirect bilirubin increases lightly.
6. Diagnosis and differential diagnosis
6minutes
a. Diagnosis
According to the history, clinical features, blood and bone marrow （key points）
features, the diagnosis can be made.
Tell the students about the process of diagnosis by introducing a case with megaloblastic
anemia.
b. Differential Diagnosis
Make differential diagnosis between disease with megaloblative cells,
such as acute erythroleukemia, MDS
7. Treatment
a. The most important management is to find and treat the underlying 5minutes
(key point)
causes.
b.Replacement of folic acid and /or vitamin B12.
i. Folic acid deficiency:
folic acid, 5-10 mg/d, t.i.d.
ii. B12 deficiency:
100ug, i.m., daily, until the CBC becomes normal.
In patients with pernicious anemia, therapy must continue for lifelong.
c. Response of treatment
The count of reticulocyte will increase within 4-6 days, reach the
peak at d10 after replacement of folate and vitamin B12.
8. Prevention
9. Summarization
1minute
10. Case discussion
Go over the process of diagnosis by introducing a case with megaloblastic anemia.
2minutes
3minutes
11.Question & answer
2minutes
Homework
1. What are the main causes of megaloblastic anemia?
2. How to diagnosis of megaloblastic anemia？
3.How to treat the megaloblastic anemia？
Terminoglogy
Megaloblastic anemia(巨幼细胞性贫血)； Folate（folic acid, 叶酸）；Cobalamin (vitamin B12, 维生
素 B12)；Pepsin（胃蛋白酶）
；Transcobalamin I
III (R binders，转钴蛋白)；Proximal duodenum（十
二指肠近端）
；pancreatic（胰腺的）
；Intrinsic factor（内因子）
；Parietal cell（壁细胞）
；Distal ileum(回
肠 远 端 ) ； Methymalonyl-coenzyme
(CoA)
mutase （ 甲 基 丙 二 酰 辅 酶
A
变 位
酶 ；） Homocysteine-methionine methyltransferase （ 同 型 半 胱 氨 酸 - 蛋 氨 酸 甲 基 转 移 酶 ）；
Tetrahydrofolate （ 四 氢 叶酸 ）； Deoxyuridine （ 脱 氧 尿 嘧啶 ）； Deoxythymidine （ 脱 氧胸 腺嘧
啶）
； Pernicious anemia（恶性贫血）； Pallor（苍白）； Jaundice （黄疸）；Bilirubin （胆红素）；
Lactate dehydrogenase （ 乳 酸 脱 氢 酶 ）； Intramedullary （ 髓 内 的 ）； Neurological （ 神 经
的）
； Demyelination （脱髓鞘）
1. Because the key words involved in this class have been given to the
students in last class, the students can better grasp the content of
Summarization
bilingual education of this class.
after class
2. The emotions of the students and the classroom atmosphere are
mobilized by applying the Powerpoint, paying attention to interaction
with students, and discussing the proper cases. Therefore, the students
can take the initiative to participate in teaching activities, and achieve a
very good teaching result.
Problems and suggestions
The students didn’t grasp the relevance of the basic knowledge that
they have learned before very well, such as the DAN synthesis of
biochemical knowledge. So it still needed to explain some basic
knowledge in the class. In order to allow students to better understand the
lesson, we should have to review the relevant knowledge during their
internship.