Documente Academic
Documente Profesional
Documente Cultură
1.
Manoperele clinice
2.
U imunologia
F hemoleucograma, M coagulograma, P angiografia, Q ecografia
cardiaca si Doppler, S examinari vasculare noninvazive , T anatomia
patologica, W teste serologice , X medicina nucleara
4. Comunicarea
4.1Comunica in scris
A Interactioneaza cu pacientul
B Comunica cu familia
4. Comunicarea - cont
4.4 Reactioneaza emotional adecvat / empatic la problemele legate de
agresiune, handicap, socio-economice, culturale, rasiale, convingeri
religioase
4.5 Intelege si aplica adecvat principiile comunicarii eficiente
4.6 Primeste si ofera eficient si constructiv feedback
6.
7. Prescriptiile terapeutice (medicamente, etc)
7.1 Face prescriptii terapeutice corect:
8. Abilitati manageriale
Lucrari
Concept general
Baze stiintifice
Evaluarea pacientului cu
boli reumatice
Clinica
Laborator
Artrocenteza
Imagistica Rx, echo,
CT, RMN, scinti, osteo
Biopsii, histo
Componenta
psihosociala
Dizabilitate, handicap
Tratament
Medicamentoase
antialgice
AINS
Steroizi
MMF de fond
Imunodepresoare, citotoxice
Terapie biologica
Hipouricemiante, colchicina
Antiosteoporotice
Terapii recuperare
Terapii chirurgicale
Boala Takayashu
Vasculite vase medii
Poliarterita nodoasa PAN
Trombangeita obliteranta TAO
Granulomatoza Wegener GW
Sindromul Churg Strauss
Vasculite de vase mici
Crioglobulinemia
Boala Behcet
Policondrita recidivanta
Spondilatropatii
Spondilita anchilozanta SA
Sindromul Reiter si artitele reactive
Manifestari reumatice in nolile enterale
inflamatorii (artrite enterale)
Artrite septice
Boala Lyme
Infectii micobacteriene si fungice oa
Artrite virale
Manifestari reumatice in SIDA
Boala Whipple
RAA
Guta
Artrite microcristaline: calcium
pirofosfat, hidroxiapatita, etc
Endocrine
Hematologice: hemofilia, siclemia
Renale
Artroza
Boala Paget
Osteonecroza
Boli nonarticulare/
abarticulare si
regionale si
generalizate
Neoplasme si tumor-like
Tumori maligne osoase primare /
secundare
Tumori osoase benigne
Manifestari reumatice
paraneoplazice
Lombalgia
Cervicalgia
Reumatism abarticular:
tendinite, bursite,
entezite, epicondilite
Neuropatii de compresie
Fibromialgia
Sindroame dureroase
regionale sau sdr
miofasciale
Distrofia simpatica reflexa
(sindrom dureros regional
complex)
Sarcoidoza
Amiloidoza
Fenomenul Raynaud
Conditii speciale
Copilul
Sarcina
1.
2.
3.
4.
5.
6.
7.
1948
annus mirabilis
Durere
Le mort nest rien, la douleur oui Andre Malraux
Impotent funcional,
dizabilitate, handicap
Localizare :
Generalizata vs regionala
Articulare vs Periarticulare (abarticulare)
Alte sedii enteze, neuropate, os, muschi
Caracter temporal:
Acuta vs Cronica
Intermitent vs progresiv
Aditiv vs saltant
Exemple :
Guta
Durerea metastatica osoasa
Care
1.
2.
Durere intensa
3.
4.
Instalare in zile
5.
Femeie tanara
Care
1.
Barbat varstnic
2.
Durere nocturna
3.
Ameliorare la repaus
4.
5.
6.
Durata : ?
< 6 saptamani
Durata
> 3 luni
Se identifica leziunea si
cauza evidenta
Evolutie liniara
Evolutie ciclica
Cedeaza la antialgice
SIMPTOM
BOALA INSASI !
Conditii neurologice 4%
Rani 5%
Boala cardiaca ischemica
cronica 5%
Durere simptomatica 9%
Artrita/artroza 20%
Durere generalizata,
difuza si imprecisa cu
minim sau fara focus pe
articulatii
peste tot
Axiala, dreapta si stanga,
supra si subcentura
Fibromialgie
Alte boli sistemice: PMR,
PAR, LES, hipotiroidism,
hipertiroidism
GENERALIZATA
Umar
Mana
Genunchi
Lombalgie
Cervicalgie
Cauze diverse: inflamatorii
sau degenerative
REGIONALA
Miscarile contraresistenta nu
accentueaza durerea
Articulatiile sensibile la
palparea interliniei articulare
Intensa
Semne celsiene tumor,
rubor, calor
Pulsatila
Nocturna si matinala
Insotita de redoare matinala
(morning stiffness), geling
stiffness, oboseala, astenie
Ameliorata de efort
Agravata de repaus
Raspunde bine la
antiinflamatoare AINS sau CS
Durere inflamatoare
Intensitate <
Fara semne celsiene
deformari, angulatii, etc
Diurna
Fara redoare matinala ff
scurta
Agravata de efort
Ameliorata de repaus
Raspunsul la antiinflamatoare
mai putin evident
Durere mecanica
Boala
Durerea
Impotena funcional
ex. Imposibilitatea de a mica un deget
Disabilitatea
ex. Dificulti la cantatul la vioar
Handicapul
ex. Pierderea locului de munc, implicatii
familiale si sociale, depresie
- Principala cauz de incapacitate de a lucra i de
pensionare precoce impact economic !!!
Boala
Prevalenta
estimata
SA
0,5-1%
Fibromialgie
~ 2%
AGC
0,2%
Guta
~ 1-2%
Durere lombara
(lifetime, > 2 sapt)
> 80%
Artroza (simptomatica)
12%
Polimialgia reumatica
0,7%
Artrita psoriazica
0,1%
Poliartrita reumatoida
1%
30%
25%
20%
15%
10%
5%
0%
dexteritate, mobilitate
Examenul
articular
(GALS)
Why the joint ?
Why this joint ?
PAR
Guta
Spondilartrite
Artroza
Durata:
acut (ore, zile)
cronic (> 6(saptamani sau luni)
Numarul articulatiilor afectate:
monoarticular septica, hemartroza traumatica, cristalina, artroza
oligoarticular (24 jarticulatii) spondilatrite, artrita reactiva , artroza
poliarticular (> 5 articulatii ) PAR, LES, infectii virale (parvovirus B19, HCV)
Spondilartrite
Psoriazis
Uveite
Boala intestinala
inflamatorie
Dermatomiozita
Boala Behcet
Eruptii cutanate
Afectare
pulmonara, cardiaca, diges
tiva
Afte
Patergie
Guta
Policondrita
recidivanta
Vasculite sistemice
Tofi
Condrite cu sedii
particulare
(nas, urechi, trahee, pleoa
pe, etc)
LES
Eruptii, fotosensibilitatea
Alopecia
Afectari de organ multiple
orice
Sclerodermie
fenomen Raynaud
Teleangiectazii
Afectare digestiva, pulmonara,
Febra
Manifestari generale
Boala inflamatoare
oculara
Boala pulmonara
Boala cardiaca
Manifestari cutanate
Afectare digestiva
Afectare renala
1.
Papule Gottron
2.
Eruptia verspertilio
3.
Facies de harciog
4.
5.
Unghii intepate
a)
Sclerodermia
sistemica difuza
b)
Sdr Sjogren
c)
Lupusul eritematos
sistemic
d)
Dermatomiozita
e)
Artropatie psoriazica
Cu
1.
2.
Dermatomiozita
3.
Sclerodermia sistemica
4.
Vasculite sistemice
5.
Sindrom Sjogren
VINDECARE ?
SATISFACIE
Eficienta;
Toxicitate diferita
prednison
dexametazona
betametozona
hidrocortisone
0,75
0,75
25
Infectiile cu oportunisti
2.
3.
4.
Psihoza cortizonica
5.
Diabetul steroid
Nume
Doza
Indicatie
Efecte
secundare
frecvente
Monitorizare
Antimalarice
Hidroxiclorochina
200-400mg/zi
Retinopatie
Consult
oftalmologic
Sulfasalazina
1,5 3 gr/z
Citopenii,
cefalee, rash,
tulb digestive
Hematologic la
max 3 luni
Methotrexate
10
25mg/sapt !!!
Citopenii,
hepatotoxicitate,
greata,
stomatita,
alopecie,
pneumonita
HBV, HCV la
pornire
Hematologic la
max 3 luni
Supliment acid
folic
Leflunomide
10-20 mg/zi
Hepatotoxicitate,
diaree, scadere
ponderala, rash,
teratogen !
Sarcina
HBV, HCV la
pornire
Hematologic la
max 3 luni
Nume
Doza
Indicatie
Efecte
secundare
frecvente
Monitorizare
Azatioprina (Imuran)
1-2,5mg/kgc
Mielosupresie,
hipersensibilitate,
pancreatita
Hematologic la
max 3 luni
Micofenolat mofetil
(Cellcept)
1,5 3 gr/zi
LES (nefropatie),
vasculite, miozite,
Greata, diaree,
tulb digestive,
leucopenie,
hepatotoxicitate
Hematologic la
max 3 luni
Cyclosporina
(Sandimun)
2,5 -4 mg/kgc/zi
HTA,
nefrotoxicitate,
hirsutism
NU da citopenie !
TA monitorizata
Functia renala
(creatinina ) la 2
saptamani
Ciclofosfamida
(Endoxan)
Oral: 2mg/kgc/zi
Iv pulse 0,50,75mg/m2/lun
a
Mielosupresie,
cistita hemoragica,
cancere (vezica),
sterilitate
Hematologic lunar
Hidratare
Monitorizare
urinara
Sarcina !!!
Supraveghere permanenta
Nume
Mecanism de actiune
Indicatie
Monitorizare
Infliximab (Remicade)
Iv la 2 luni (incarcare)
PAR
SpA (SA, AP)
TBC
Infectii , etc
Etanercept (Enbrel)
Sc sapt
PAR
SA, AP
JIA
TBC
Infectii , etc
Adalimumab (Humira)
Sc la 2 sapt.
PAR
SA, AP
JIA
TBC
Golimumab (Simponi)
Sc la 4 sapt
PAR
SA, AP
TBC
Certolizumab (Cimzia)
Sc la 2 sapt (incarcare)
PAR
TBC
Abatacept (Orencia)
Iv, sc sapt (incarcare)
PAR inclusiv
nonresponder la TNF,
JIA
Tocilizumab (RoActemra)
Iv la 4 sapt
PAR
Promitator in Still, JIA
sistemica
Profil lipidic,
hemoleucograma,
hepatotoxicitate
Rituximab (Mabtera)
Iv la 6 luni (z 1,15)
Ac monoclonal antiCD 20 LB
PAR, inclusiv
nonresponder la
antiTNF
LES, vasculite, etc
Belimumab (Benlysta)
Iv lunar (incarcare)
Ac monoclonal LB Blyss/BAFF
LES
Nivel IgG
Criterii diagnostic;
Manual de criterii
Criterii de urmarire cantitativa:
Durerea, NAT,NAD;
scoruri (DAS, scor cutanat, HAQ, SF 36, 6 min walking test);
indici de activitate (DAS, SLEDAI, etc)
Egalizarea evaluarii
Baze de date, antrenamente pentru evaluare egala, conditii
pentru examinare unitara
ACCESIBILITATE
Sa mai faca teste laborator (FR, CCP, AAN, ANCA, complement, etc. )
Staud R, Smitherman ML, Curr Pain Headache Rep, 2002, 6, 259 266
Sarchielli et al. Curr Pain Headache Rep, 2007, 11, 343 351
Durere
Tulburari de
somn
Durere
difuza, generalizata, cr
onica > 3
luni, migratorie sau
constanta (Tot timpul)
somn
neodihnitor,
adormire
dificila, treziri
frecvente
Descriere:
inteapa, apasa, arde, c
ontracta, ..
stoarce, epuizeaza
anomalii in
continuitatea si
arhitectura
somnului
Oboseala
Fizica, psihica sau
emotionala
epuizanta
100%
oboseala cronic
81%
redoare matinala
77%
tulburri de somn
75%
62%
cefalee
52%
tumefieri articulare
50%
anxietate
47%
depresie
33%
xerostomie, xeroftalmie
35%
79%
Caldura
78%
Schimbari de temperatura
66%
Umiditate
59%
Somn neodihnitor
76%
Galagie
24%
Examen obiectiv
Cervical inferior
Costocondral a II-a coasta
Epicondil lateral
Genunchi
Occiput
Trapez
Supraspinat
Gluteal
Trohanter mare
fenomen Raynaud
nimic de remarcat
semne celsiene
efuziuni articulare
proliferri sinoviale
neurologice
16,7 %
Nici una
!!!
Oprii explorrile !!!
Dg
Index de durere generalizat (widespread pain index WPI): notai ariile n care pacientul a avut durere n ultima
sptmn ? Scorul poate fi intre 0 - 19
Centur scapular stg + drpt, bra superior stg + drpt, brat inf drpt + stg, sold (fes, trohanter) stg + drpt, membru inf proximal drpt +
stg , membru inf distal stg + drpt , mandibul stg + drpt , torace, abdomen, spate superior, spate inferior, ceaf
Simptome somatice :*
0 = fr simptome
1 = puine simptome
2 = moderate simptome
3 = foarte multe simptome
Scala SS = suma scalei severitate pentru cele trei simptome + extensia (severitatea ) simptomelor somatice in general.
migren
cefalee de tensiune
colon iritabil
vezic urinar iritabil
dismenoree primar
sindromul picioarelor nelinitite
depresie, atacuri de panica, tulburari
anxioase, distimie, sindom stress
postraumatic
Elemente comune:
predominan feminin
dureri musculare
absena modificrilor
testelor de laborator
coloratura psihica
particulara
stress socioeconomic
abuzuri, traumatisme,
accidente
Prognostic
Self-management
Terapie medicamentoasa
Top 10 Reasons
10. We do not pay as many taxes as most other docs (OK, I
was reaching a little here).
9. We see and care for patients of all ages.
8. We take care of the whole patient, not just an organ.
7. We practice the art as well as the science of medicine.
6. We get lots of hugs from our patientsboth literally and
figuratively.
5. Rheumatology self-selects happy people.
4. We have excellent therapies and get to see excellent
results.
3. We are diagnosticiansthe Sherlock Holmes of the clinic
often the court of last resort.
2. We get to take care of, and form long-term relationships
with, our patients.
1. We are in control of our lives, practice, and time.
Therefore, most of us know our childrens names.
James R. ODell, MD. The Rheumatologist, July 2012
Problemele
Confuzia
Cursurile
Reumatologia
specialitate