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ACCIDENTE VASCULAR-CEREBRALE: Deficit neurologic caracteristic cu debut BRUSC, antecedente: HTA,DZ, VALVULOPATII, ATEROSCLEROZA, semne neurologice prezente= interesarea

unei regiuni cerebrale A.INFARCTUL CEREBRAL 1.AIT- ischemie tranzitorie dureaza max 24h, in general sub 1h 2.INFARCT LACUNAR: leziuni cerbrale mici ( sub 5 mm ) frecvent intilnite la nivelul: ggl. bazali, punte, cerbel. Cauza : HTA prost controlata si DZ . Frecvent sindroame intalnite : deficit motor/senzitiv controlateral, ataxie ipsilaterala+pareza crurala+dizartrie. Prognostic de recuperare bun, cu rezolutie completa dupa 4-6 sapatamani; 3.AVC COMPLET: ocluzia trombotica/embolica a unui vas mare cerebral Cauze: 1.embolia origine cardiaca: RAA, aritmii, mixom atrial, endocardita infectioasa, DSA, IMA, valvulopatii( SM cu Fia ) 2.Ateroscleroza 3. Malformatii vasculare ( disectie ) 4. CID, sindroame de hipervascozitate - in functie de terit interesat=> diferite semne neurologice. FACTORI DE RISC: HTA, DZ, obezitate, fumat etc ; Ocluzia arterei cerbrale anterioare: pareza mb. Inf controlat+ pierdere sensibilitate, pareza usoara a mb sup, abulie/confuzie franca, incontinenta urinara; Ocluzia arterei cerbrale medii si de ACI: hemiplegie controlaterala, pierderea sensib la niv hemicorpului, hemianopsie omonima, privire spre leziune, =/- afazie. Edemul cerebral coexistent duce la instalare comei; Ocluzia arterei cerebrale posterioare: sindrom talamic: tulb de sensib la niv hemicorp controlat, hemipareza usoara, pasagera, alexie, miscari involuntare; Ocluzie de artera bazilara sau ambe vertebrale: coma, mioza punctiforma, tetraplegie flasca, pierderea sensibilitatii; Tratament: - tromboliza i.v apoi p.o: daca deficitul progreseaza si este instalat recent ( atentie la HEMATOM si HEMORAGIE INTRACRANIANA nu se face; se exclude CT). Se face in primele 3 h de la instalarea AVC; - corticoizii, agenti hiperosmolari( glicerol sau manitol ): pentru reducerea edemului cerbral; - anticoagulante doar daca exista sursa de embolie cardiaca si nu exista surse de hemoragie cerbrala; - blocante ale can de Ca - recuperare deficit motor prin fiziokinetoterapie ;- tratam bolilor asociate;- eventual revascularizare daca e cazul; - profilaxia trombozelor B HEMORAGIA CEREBRALA : CAUZA: HTA, ANEVRISME, ANGIOAME;SEMNE/SIMPTOME: varsaturi, cefalee, pierderea constientei, apoi se instaleaza semne de focar. Cel mai frecvent loc de producere a hemoragiei intarcerebrale hipertensive: ggl bazali;
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Hemoragie cerebeloasa instalare brusca, cadaere de parte leziunii, greata, varsaturi , cefalee, pierdere de echilibru, resp periodica, ataxie, fatal in 48 h; Hemoragia pontina: coma, tetrapareza, mioza;Hemoragie talamica: pareza privirii verticale, ochii spre nas, diminuarea atentiei, afectare a sensib unilat ; Hemoragia subarahnoidiana: apare prin ruptura unui anevrism sacciform la niv polig Willlis; cefalee brusca, sindrom meningeal, varsaturi., greata, diplopie, hemipareza, tulb cardiace; Hemoragie de putamen: hemipareza senzitivo-motorie; Dg: clinic, ex LCR , Rg toracica, CT ,uzuale, TQ, APTT, electroliti, glicemie; TRATAMENT : conservator si suportiv profilaxia trombozelor : heparina, dupa 24 h de la inceputul hemoragiei;evacuarea hematomului pe cale chirurgicala;tratam edemului cerbral ADENOPATIA: Dg clinic: -ex ggl: moale, dureros la palpare (inflam.acuta), dur,indolor si eventual aderent in profunzime (frecv malign), adenopatie localizata (inf locale- amigd, etc-sau boli maligne), generalizata(inf virale ex HIV sau in limfom malign.-cautarea focarului infectios (dentar, amygdale, sinusuri paranazale, abcese) -daca se constata un ggl marit se exam toti ggl -intotdeauna se exclude splenomegalia(palpare,eco) DG dif: Infectii: mai lae mononucleoza si HIV, Colagenoze: artrita reumatoida, Medicamente:Fenitoina,hidralazina, Limfoame maligne: leucemie, histiocitoza maligna, metastaze, hipertiroidism, sarcoidoza, amiloidoza, tezaurismoze; ALCOOLISM: Manie care survine la o peronalitate anormala, dependenta si autodistructiva; tendinta irezistibila de a consuma alcool; consum continuu si excesiv de alcool, insotita de fenomene de dependenta fizica si psihica; dupa 5 ani de zile duce la aparitia tulburarilor psihice si somatice. TULBURARI PRODUSE: 1.aparat digestiv (BRGE, gastrita, steatoza hep, HC, CH, pancr ac, pancr cr, Ca bucal, ca esof, ca gastr, ca pancr) 2.ap C-V ( cardiomiopatia alcoolica, TR, arteriopatia oblit) 3.sist endocr(hipogonadism,sdr pseudoCushing) 4.SN (polinevr alc, encefalop, nevrita optica) 5. tulb psih (depend alc, dipsomania, del trem, tulb psihiatrice, dementa) TULB PSIH: abuz de alcool, depend, intox, sevraj, amnezie, psihoze, de dispozitie, anxioase, sexuale, somn, dementa. PARTICULARIT:tend compuls de a cons alc, dific de a-si contr comport priv cons de alcool,apar semne de toler la alc,tend de a consuma cant din ce in ce mai mari, neglij preocup famil, profess si soc, persist cons de alc in ciuda consec neg, apar semne de sevraj la intrerupere. SEMNE DE SEVR: transpire, tahic, trem maini, gret, varsat, agit psihomot, cefal,insomn, anxietate,haluc viz, tact, audit, delir, crize convulsive de grandmal.
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AMETEALA: Senz de instab. de nesigur in mers, de clatinare, incetos vedere, scade forta musc, de cadere iminenta etc. CAUZE 1.periferic(tulb labirintice=vertij mneiere, ATS, otospongioza, traum labir, otita medie, labirintita, fistula labir, sech labir, intox, tum, rau de transp; tulb retrolabir =nevrite vestib, arahnoidite, tum pontocereb, neurinom de acusticintox) 2.centrale (inf SN, mening, encef, abc cereb, ats cereb, insuf vertebro-bazil, scler in placi, af cardiovasc, HTA ,hTA, TR, tum cer, traum cerebr, spondil cerv, intox alcool/strepto/barbit/antihist) DG DIF AMETEALA /VERTIJ: senz de instab, nesid, dezech, clatin/car rotator, gret, vars. SEMNE SI SIMPT ASOC: 1.gret, vars, paloare (sdr meniere,migr) 2.tulb de auz,acufene(otoscler,neurinom de acustic) 3.cefalee, acuf, fosf (HTA, ATS cereb, migr) 4.dur cervic, tulb de ved, amauroza, diplopie, parestezii (insuf vert-baz, sdr BarreLieou, spondil cerv, ATS cereb) 5.disfag, dizartr, pareza fac (sdr Wallenberg, tromb art cerebel inf) 6.febra cu sur auric (ot ac) 7.febra cu cefal si red ceafa (men vir/bact,encef) 8. febra cu fen resp (gripa, adenovir, vir resp) 9. miros de alcool; ANAMNEZA: 1.caracter (gyrator, senz de dezech, de instab, de cadere, de dezorient) 2.mod de apar (brusc, trept, evol remitenta) 3.cond de apar (schimb br a poz, misc cap, duprasol neurops,strss,cons alc,exc alim,medic,menstr abund,menop) 4.exist altor boli(HTA,hTA,TR,DZ,hipoglic,Iren,IH,tum cer,ATS cer,insuf vertbaz,mening,encefal,b infect) 5.simpt associative(cef,gret,vars,tulb auz/senzoriale,palpit,dur precord/cervic,manif neuron,febra,eruptii) OBIECTIVE EX CLIN: 1.st gen(lucid,anxios,obnub) 2.orient in spatiu/timp,intox cu alc sau subts chi 3.cul teg(pal,vultuoase) 4.ex craniu(urme de traum) 5.ex oki(nistagmus,tulb de ved,ex FO) 6.ex otic(dur auric,scurgeri,oroscopic) 7.col cerv(mobil,cracmente) 8.puls,frecv,TR,consult cord,sufluri,palp/ascult carot 9.ex pulm(pneum,embol pulm) 10.ex neuron(nistagmus,refl pupil,ex nervi cran,mers,proba Romberg,index-nas,tremor extremit)
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TRAT Repaus la pat in caz de sever , Medicatie: emetiral ,torecan, vasodil(cinarizina), anticolin(atrop,scobut), tranchil(diaz), antihistam; hta-antihipert; insuf vert-bazil=ainfl,vasodil; DG DIF VERT PERIF/CENTRAL: Debut brutal/mai put brut; vert girator/senz de nesig, instab; tulb veget sgom greturi, vars/absente sau moder; hipoacuzie, acuf/fara; nistagmus unidir orizon/mai put marcat, variabil, disritmic, nesigur; Romberg cadere de partea lez/tend de largire a bazei de sust; dev mers in stea/dev mers nesistem. TIPURI DE VERTIJ PERIF: 1.vert meniere(distensia labir membranos,vert orizontorotator in crize parox,gret,varsat,tulb unilat de auz,acuf,nistagmus spontan,orizontal,Romberg +) 2.sdr Barre-Lieou(irit simp cervic,vert menieriform,fav de misc bruste cap,tulb de vedere,scotoame,lacrimare,distensie,tulb vasomot ale fetei) 3.Kinetoze (determ de transport,vert rotator,senz de instab,gret,vars,oscil tension,puls modif) 4.neurinom de acustic(vert rotator,acut,hipoacuz unilat,cefal occ,mers cerebelos,dison,disfagie) 5.traum labirintice (scufund,vert labirintic,cefalee,tulb de auz/vedere/psihice,evol fav in cateva zile) TIPURI DE VERT CENTRAL; 1.insuf vert-bazil(spondil cerv,ATS cereb,senz de vert,instab,cef occ,tulb ved,incetos ved,diplop,amauroza,disfag,dizart,parest buco-faring,nist spont,acuf,evol in pusee) 2.scler in placi(vert atipice,senz de instab,tulb mers,nist spontan,hipoacuz,acuf,evol pusee) 3.sdr Wallenberg(tromb art cerebel inf,vert intens,gret,varsat,disfag,disfonie,par fac,sdr ClaudeB-H) ANEMII: Scad Hb sub val norm coresp varstei: 13.5-20.5g/dl la copil 13-17-barb 12-15.5 fem. CAUZE: 1.pierderi exces(hemorag ac si cr) 2.distr exces(a hemol,Hb-patii,b de sist) 3.prod defic(def de Fe, aport insuf, tulb de abs,ulcer,menometroragii, diverticuli, parazitoze intest, sechestr Fe, def B12, lipsa fact intrins, gastr atrof, def de ac fol, afect mad hematopoietice, limfom, MM, tulb endocr, hipotir, inf cron, IRC) CLASIF CLIN: usoara=Hb 11-8/Ht 39-30; medie=8-6/30-22; severa= 6-2/22-10;

CLASIF DUPA CONT Hb: 1.hipocroma(HEM<28pg,prin def de Fe,sechestr de Fe,inf cron,Ca) 2.normocr(28-32,posthemor ac,hemol) 3.hipercr(>32,def b12,ac folic,in intoxic,alcoholism); CLASIF MORFOL: macrocitara(diam 7/VEM >953/CHEM 34%/HEM >32pg) microcitara(<7/<80/<32/<26) normocitara(7/82-92/32-34/32) MANIF CLIN 1.piele si muc(paloare,glosita,cheilita,tulb trof fanere) 2.ap dig(disfagie,anorex,gret,vars,tulb tranz,diar,constip) 3.SN(amet,fatig,cef,asten,tend la lipot) 4.CV(palpit,dur prec,sufl card,tahic,puls capilar) INVEST PARACL: semne clin>invest pcl(Hb,Ht,Nr GR)>confirm sdr an>frotiu sange perif>VEM: 1.microcitoza=feripriva, sideroblast, talas>sideremia, transf,ferit, pct medul; 2.normoc=posthemor,hemol,IRC,a aplast; 3.macroc=Bierm, malabs, postgastrect, hipotir>test Sciling, endosc,pasaj baritat,punct medul) CAUZE ANEM FERIPR 1.carente,pierd sau tulb de abs Fe(car alim,menometror,UGD,CaG,tulb abs,RCUH,parazit intest) 2.sechestr macrofagica fe(inf cron,TBC,supur cron,PNC,endocard lenta,b maligne) MANIF CLIN An FERIP: Sdr anemic(teg muc conj palide,asten,cef,amet,palp,tahic,polipnee) sdr car de Fe(fatig,tulb fanere,stamatita angular,glosita,atrof paile ling,limba rosie neteda luc,gastr atrofica) b cauzala(tulb genit,dig,parazit,inf cron,b maligne,b degenerative) TRAT MEDIC glutamate feros 100mg=22mg Fe,fumarat feros,sulfat,gluconat) ANGINE(VEZI IACRS COPIL) ARTROZE: B atrozica,osteoartrita,artrita hipetrofica =b degener a a rtic caract prin degeneresc cartel si apar focare de hipertrofie os la niv marg artic cu manif infl minime. CLASIF IDIOP: 1.primara sau idiopatica(mana=noduli Heberden,Bouchard;picior=artroza metatarsofal,haluce,halus valgus/rigidus; genu=gonartroza; sold=coxart; col vert=spondil cerv,torac,lomb;umar;temp-mandib)

2.secundara(traum=contuzii,fract,hemartroze;infect=germ piog sai BK;inflam=AR sau spondilartr; metab=guta, hemocromatoza; endocr = acromeg, obez, hiperpth; trofice=ostnecroze septice;altele=b paget,osteocondrita) ARTR COLOANA VERT Discovertebrala=deb cu afect disc intervert care pot sa hern fie lat afect form nerv fie median afect mad spin;interapofizara=alunec ant a corpi vert-spondiloestezis 1.spond cerv:dur occip sau irad de-alung plex brahial, ametz, tulb ved,scotoame,diplopie,nistagmus,poate determ sdr clinice: torticolis, migrena, nevralgii locale,periatrt scapulo-humerala,insuf vertrbazilara) 2.spondil torac=la tin consec epifizitei vertebrale ,dur dorsale si cifoza ; ostefite unite in punti>spondiloza hiperstenozanta; 3.spondil lomb: sdr radicular tip S1=dur pe fata post coapsa si gamba si pe fata plant picior,abol refl achil,pareza sc popl ext;sdr radic L5=dur fata lat coapsa gamba fata dors picior si dif de a merge pe calc;tip L4=dur fata antint coapsa si abol refl rotul; ARTR GENU Dupa trauma sau lez menisc sau fem dupa menop.dur loc pe fata ant genu acc de misc si urd scari; crest in vol artic si sensib la palp port ant si anteromed a genu,cracmente; ATRT SOLD 60ani,dur in reg fes sau dur in reg trohant cu irad pe fata post coapsa ,acc de mers si aten la rep.mers schiop TRAT 1.analg 2.AINS 3.inh Cox2 vezi PAR 4.geluri ,ung(diclosal,apireven,saliform) 5.cortic(diprophos 2-4mg periartic,triamcinolon) 6.stimul de sint de proteoglicani 7.inh activ proteinaze ASTENIA: Simptome:mai greu de explicat de pacient. Astenia sau moleseala, slabiciunea ,oboseala,letargia sunt explicabile in totalitate prin fact obisnuiti cum sunt: suprasolicitarea,lipsa de antrenament fizic,calitatea si cantitatea somnului inadecvate,obezitatea, ,stresul si probl emotionale. Trebuie facuta o anamneza amanuntita. Afect care produc in mod obisnuit astenie include tulb endocrine (hipertiroidism,hipotir), afect cardiace (ICC,hipoTA de etiol neurological), infectiile (endocardita,hepatita), af resp(BPOC,apnea nocturna),anemia,artrozele si affect asoc acestora,cancerul,alcoolismul,ef sec medicamente(B bloc si sedativele),ca si tulb psihologice(insomnia,depresia) sau af. psihosomatice(<50%). Af psihiatrice care includ astenia:depresia,distimia,tulb somatoforme,atacurile de panica si abuzul de alcool.
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ASTM BRONSIC: Crize de disp parox expir,uneori f severe si poate avea o evol progres favor apar emfiz a HTP si a CPC. ETIOPAT: B cron inflam a CR asoc cu hiperreact brons pe fondul careia pot aparea crize per de dispn. MECANISME EP: 1.alergice:teren atopic,sensibilizare primara,activarea LyT helper,LyB,sint IgE,atas IgE de mastoc si Eo,cont ulter cu alergenul,degran mastoc,elib de subst chi active,crest permeab vasc,chemotactism,citotoxic,bronhoconstr,edem bronsic,secre brons,dispn expir 2.neuronale:sist cholinergic,bronhocosntr,vehiculat de vag,mediat de acetilcolina,rec muscarinici M1 M2 produ bronhocontr,secr de mucus,refl cholinergic bronhoconstrictor,stim de histamine,bradikin,praf fum factori mecanici. 3.hipereactiv bronsica:fav de degranul epitel si expun termin nv la act fact patogeni,praful,fumul,ef fiz,aer rece,bradikinina,pot prod bronhoconstr prin excit term nv din submuc,teste de prov cu histam si methacolina. EF SUBST ELIB DE Mastoc si Eo : 1.bronhoconstr:histam,adenozina,PGD2,PGF2,TXA2,PAF,LTC4,LTD4,LTE4,CysLT1,CysLT2 2.edem:histam,kinine, PAF,LTC4,LTD4,LTE4 3.secr bronsica: histam, PAF ,LTD4. CLASIF CRIZE AB: 1.usoara(dispnee usoara,poate vb fraze,este capabil sa se aplece,nu folos ms respire auxil,wheezing moderat,puls sub 100/min,puls paradoxal sub 10,PEF>80%) 2.moderata(dispn moder,poate vorbi propoz,prefera sezand,folos ms resp acces,raluri in exp,AV 100-120/min,puls paradox intre 10-25,PEF 50-80%) 3.severa(dispn severa,poate vb cuvinte,incap sa se aplece,folos ms expir auxil,raluri atat inexp cat si in inspir,puls peste 120,puls paradox peste 25 PEF sub 50%. FORME CLINICO-EVOLUTIVE: 1.intermitent usor(crize scurte<2/sapt,nocturne <2/luna,asimpt intre crize,PEF>80%,variabilitate PEF <20%) 2.persitent usor(crize>2/sapt;<1/zi,crize noct>2/luna,poate afecta active si somnul,PEF>80%,variabilitate PEF >30%) 3.persistent moderat(crize ziln,nocturene >1/sapt,affect active si somn,neces util ziln abetastimulante,PEF 60-80% ,variab PEF>30%) 4.persist sever(crize frecvente,bronhospasm perman,crize noct frecv,active fiz limit,PEF<60%,variab PEF>30%)

FORME CLIN PARTIC: 1.atopic(varste tin,antec famil de b alerg,decl de cont cu alerg sensibiliz,teste cutan + si IgE cresc) 2.neatopic(x intrinsic,deb la adult,fara AHCsa APP de b alerg,decl de inf recur,cu tuse si expect mucopur,teste cut si IgE=N) 3.de effort((copii si tineri,la cateva min dupa incet ef fiz,pot fi prev cu betaagon sau cu anti leucotr adm inaintea ef) 4.indus de aspirina(inhib COX,la 1-2 ore de la ingestie) 5.profesional ; MANIF CLIN: Deb brusc, dupa exp la fact declans, semne prodromale itritabil, rinoree, starnut, sete de aer, senz de sufoc, ortopnee, st de nelin, pal sau cian, coaste orizont,dispn expir,wheez,bradipn,hipersonorittate,MV dim,rionfl si sibil,tuse,expect perl; INVESTIG PCL 1.explor funct resp a. din timpul crizei(scad VEMS cu >15%,indice Tiffneau <70%,PEF scade cu >20%,VR si CPT cresc,gaze sanguine scadere PaO2,crest PaCO2 si crest Ph) b.intre crize(pot fi N,se fac probe de provocare) c.variabilit obstr(se stab prin masur PEF de cateva x/zi,dimin,seara inainte si dupa adm bronhodil.N=10%) 2. alte invest pcl(Rx-hiperinfl,hipertransp,pntx;ex sputa-Eo,spir Cursch,crist CharcotLeyden,si in cazul infectiei-leuc;HLG-Eo-filie;teste serol-IgE spcif; test cut-sensib la dif alergeni)} DG POZITIV 1.dg astm(semne clin:wheezing,bradipnee,tiraj,cornaj,tuse,expect perlata, torace hiperinfl, hipersonor pulm, raluri sibil; paracl: scad VEMS,PEF,Rx,bioch,imun) 2.dg de sever(frecv crize,diurne,noct,simpt intercritica,val PEF) DG DIF astm cardiac(disp inspire,asoc cu simpt de b card:cardiomeg,zg de gallop,tahicard), BPOC(dispn inspire cron,tuse,expect mucopur), obstr CR,tromboemb pulm,vasculite,sdr carcinoid. COMPLIC:enfiz,HTP,pntx,inf resp,complic postrtat:osteopor,sdr cushingoid,diabet steroid. OBIECTIVE TRAT: 1.comb & preven crize 2.pastr f resp in lim N 3.pastr capac de ef 4.evit ef sec ale medic 5.prev obstr irevers 6.preven complic 7.imbunat cal vietii
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TRATAM CRIZE: 1.beta2 agonisti 1-2 puf(salb,terbut,fenoterol) 2.corticoizi IV(HSHC 50-100mg,prednis 250mg,metilpredn 250mg) 3.metilxant-(miofilin 240mg lent iv,1-2tb a 100mg po) 4.anticolin(ipratr 1-2 puf) TRAT DE FOND: 1. antiinfl a. corticost inhal 1-2x2/zi(beclomet,budesonid,flutic,triamc) b. coric sist(predn 5-10mg/zi,metilpredn 20-80mg la 2 sapt) c. cromogl disodic 1-2 pufx2/zi d. nedocromil 1-2pufx2/zi e. antileucotr(montelukast-singulair 10mg/zi,zafirlukast-accolate 20mg/zi] 2 .bronhodil a. beta2agon 1-2puf/zi(salb,salmet,fenot) b. metilxant(aminof2-3tb/zi,teof 2tb/zi) c. antichol(ipratr-atrovent 1-2 pufx2/zi) TRAT CR IN F DE SEVER BOLII A.intermitent usor(criza:bet2ag la nev,beta2ag sau cromogl in de ef sau cont cu alerg;cron:nu este nec trat de intretz B.persitent usor( crize:beta2ag inh la nev nu >2-3x/zi;cron:cortic inhal 200-500mcg/zi sau cromogl sau nedocromil sau teofil retard sau antiLT) C:persist moderat(Crize:b2ag la nev nu >3-4x/zi;cron:cortic inhal 500-1000mcg/zi,la nev b2ag inh sau pos au teo retard) D:persitent sever(crize:aprec in f de grd in care forma fiz si psih infl active crt a indiv;cron:cort inhal 1-2g/zi,b2ag inh sau po,la nev cortic po) BPOC: Reuneste 2 boli:BC si EP.BC:hipersecre de mucus,infl cron a CR si obstr progress a cai aeriene. Forme clin de BC: 1.simpla(tuse,expect,toal matinala,fara dispn,raluri brons,ronfl,sibil,subcrep,VEMS-N) 2.obstructiva(tuse,expect,dispn progres,wheezing,raluri sibil in expir,crepit in inspir,hipersonor pulm,VEMS scaz) 3.astmatiforma(tuse,expect,dispn progress,crize de dispn expir,raluri ronfl si sinil,hiperinfl pulm,VEMS scaz). EP:dilat sp aeriene determ de distr peretilor alveoli de catre enz proteol. EVAL DISPN IN EP.GRD1.la urc 2-3 etaje,sau alerg pe teren plat,grd 2 mers pe ter plat cu pers de acc varsta grd 3.mers pe teren plast in ritm propriu grd 4. spalt si imbrac grd 5.repaus. PARTICULAR CELOR 2 TIPURI DE BPOC: 1.tip A,pinkpuffer(EP-dispn progress,torace in butoi,hipersonor,cord hipertransp,hipoxemie moder,hipercapnie moder,Ht 40-50%) N,fara cian,rx
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2.tip B blue bloatter (BC-epis bronsitice,torace N,raluri brinsice,cord marit,cu cianoza,desen bronhovasc acc,hipoxemie severa,hipercapnie moder,Ht 50-60%) STD BPOC: I=dispn gr1,capac de ef pastr,VEMS >60%,gazometrie N,cal vietii putin infl ; II.dispn gr2-3,capac de ef redusa,VEMS 40-60%,hipoxemie,cal vietii afectata; III:dispn grd 4-5,incap de ef,VEMS<40%,hipox severe,cal vietii prof afectata. OBIECT TRAT BPOC: 1. red irit brons 2. comb f de risc 3.dezobstr bronsica 4.trat inf brons 5.red cant de mucus 6.favor elim secr 7.amelior schimb resp 8.amel f resp 9.prev sit rat acutiz 10.preven si trat acutiz 11.imbunat cal vietii TRAT IN F DE SEVER: 1.forma usoara(beta2 adren inhal,anticolin inhal,aminofilina,mucolitice la nevoie) 2.forma moder(beta2 adren inhal,anticolin inhal,aminofilina,mucol,cortic inhal sau po) 3.forma severe(beta2 adren inhal,anticolin inhal,aminofilina iv,mucol,cortic iv,antib,oxygen) BRGE: Det de reflu cont gastr in esof,intov sau nu de lez ale muc esof,cu epis de pirozis. EP: 1.fact fiziopat(scad pres jonct esogastr,insuf mecan de curat esof,scad secre de saliva,intaz gol stom) 2.anatomici(unghi His larg,hernie hiatala,crest pres abd) 3.scad capac de apar(scad str de mucus,tulb de vasc a muc esf) MANIF CLIN; 1.digest(pirozis,regurgit la anum alim,la clinost,dur la deglut,disfag,dur retrostern) 2.respir(senz de arsura ,disp expir,tuse noct,disfag) FORME CLIN PARTIC 1.cu dur torac(acc de ef fiz,frig,emotii) 2.din sclerodermie(af musc neted cu scad pres jonc esogastr) 3.din sarcina(crest pres intraabd)

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DG DIF 1.cu alte b ale esof(tulb de motil esof,acalaz,disfag,divertic,tum) 2.cu b ale org invec(ang pect,hern hiat,sdr disp,UGD,LB) TRAT: 1.ig-diet(evit gras,alc,caf,cioco,citrice,evit culc dupa masa,evit alim inaite de culc,evit unor medic-antichol,nitritimmiofil,cof,diaz,dopam,bloCa) 2.medic(antacide-maalox,dicarbocalm;prokin-metocl,domperid;antisecrcimet,ranit,famo;bloc pompa prot-omez,lanso,panto;medic de prot muc-sucralfat) CANCER BRONHOPULM CARACT: tuse, dispnee, hemoptizie, anorexie, scadere ponderala CLASIF.HISTOLG.: CARC CU CEL SCUAMOASE, ADENOCARCINOM, CARC CU CEL MICI, CARC.CU CEL MARI. SDR PARANEOPLAZICE : 1 . endocr: sdr.cushing,ginecomastie,hiperca; 2. osos:degete hipocratice; 3. neuroms:miastenie,dermatomiozita, 4. neuropat peri; 5. c-v:tromboflebita, endocardita nebact; 6. hematlg:anemie,cid,eosinofilie,trombocitoza; 7. cut:acanthosis nigricans. 5%=sdr.de vcs,sdr.claude bernard horner,sdr.pancoast n.frenic,laringeu.

tobias,paraliz

de

PARACLINIC Rx sau ct+mase tum care cresc progresiv,infiltrate,atelectazii,cavit,interesare pleurala; citlg:(sputa,lich.pleural)-confirma dg.; complic:sdr de vcs,paraliz de nerv frenic,laringeu. TRATAMENT chirg.de electie cu exceptia: mts extratorac, t.la niv trah, paraliz n.laring, frenic, sdr.vcs, alter fct.pulm.ca cel mici=chimio asociata, radio in scop simt std.II-IIIchirg urm. de chimio(3drog)dupa rezectii complete. CANCER MAMAR: FACT DE RISC-varsta avans,rasa alba,ahc(mama,sora,fiica),markeri , APP-ca san controlat,ca endometrial, APF:menarha precoce,menopauza tarzie,paritatea-nulipara,sarcina la varst,inaintata.

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SEMNE semne precoce:t.unica nedurer la palp,dura/ferma,marg.imprecis delim. semne tardive:retractie teg/mamelonara,limfadeno axilara,marire san,erit,edem,durere,fix tum la piele/perete torac. de vol

DEPISTARE metode de screening, autoexam, mamogr(calcific); paracl:vsh cres,fa cresc,ca cresc,markeri-ca15-3,cea, rx toracic, ct, hep cerebr, scintigr, biopsia, citologie; DIAGN DIF:displazia mamara,fibroadenom,lipom ,necrozaa; Forme cl:boala paget,ca inflam,ca din sarcina,ca mamar bilat,ca neinvaziv; TRATAM curativ(I,II) paleativ(stdIV)TRAT CONSERV,TERAP SIST ADJ; trat paleativ:radio,hormonal,chi CANCER DE COL: SEMNE:metroragie,secr vag,lez cerv,tenesme vezic ,rect,fistule. PARACLINICl:papanic,biopsie cerv,chiuretaj endocerv; COMPLICATII:mts,edem mbinf,fistule colporectale; TRATAMENT 1. urg: hemostaza in hemorag,tamponament vag; 2. specific: ca in situ:hister totala, ca invaziv-hister simpla-IA,hister radicala IB,IIA/RADIO. CARDIOPATIA ISCHEMICA: Result unui dezech intre nev si aport de o2 dat unor tulb de circ coron EP: A.fact coronarieni(ATS coron 95%,anom art ,embol ,vasculite ,tromboze,tulb ale coron mici) B>extracoron(crest nev energ ale mioc,hipertir,tulb de ritm,st febr,HTA,scad flux coron,sten mitr,IAo,HTP,tulb metab) INFL HIPOXIEI:modif metab9anaerob,acum ac lactic piruvic,scad ATP,crest Na,Ca sis cad K ic)ale f contract(alter f sist,scad compl la umplre,crest resist la umpl,crest pres telediast), ECG(modif ale ST-T,tulb de ritm),apar dureriisubts acide,bradikinmhist,serot)

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FACT DE RISC 1.induviduali,nemodificabili(genetici,AHC,varsta,sex) 2. indiciduali modificabili(alim hiperlip si hipercal,fum,alc,sedent,stress) 3.caract patol modificabile(crest col tot,LDL,scad HDL,DZ sau scad tol la gluc,obex sau sdr X,etab,HTA,fact trombogeni) CLASIF IN F DE DUR 1.Ischemica dureroasa(ang pect stab si instab,IMA) 2.isch nedur(moartea sub coron,tulb de ritm ische,IC de orig isch,desc ECG intampl) CLASIF DUPA SOOC INT DE CARDIO 1.opr card primara 2.ang pect,(de effort,de novo,agravata,stabila,spontana) 3.IM(acut,definit,posibil/vechi) 4.IC de nat isch 5.aritm card de nat isch MODIF ECG 1. intre crize(asp normal 30%,supradeniv ST-lez subendo,unda T neg-lez subepi,uT inalta-lez subendo,red ampl sau invers T,along QT) 2.in criza(asp N 30%,subdeniv ST,unda T neg sau turtita,blocuri intraventr) DG PRECOCE 1.depist f de risc(vezi sus) 2.efect unor invest paracl(col,tg,LDL,HDL,apolipopr A si B,ECG si de effort,eco) TRAT MEDIC 1.NITRATI(nitrog retard 2.5mgx3/zi,isomono/isodin/pentaeritril 20mgx2, 2.BETABLOC(propr 10-20mgx3-4.meto 50mg x2,ateno,betaxo,carvedi) 3.bloCa(knifed 10-20x3,felod,verap 40-80x4,dilt 30-60x4) 4.metabolice(trimtezidina-preductal 20mgx3) 5.antiagreg(aspir 100mg/zi,plax\vix 75,ticlopidina) 5.antihiperlipidemic(statine,fibrati,ac nicotinic,rezine) CATARACTA Clinic : tulburari de vedere, instalate progresiv, in decurs de luni sau ani. Absentadurerii si eritemului, opaciefierea cristalinului(pot fi vizibile cu ochiul liber). Diagnosticul pozitiv se face chiar in stadii precoce , prin vizualizare prin pupila dilatata, cu ajutorul oftalmoscopului. Tratament : chirurgical, se inlatura cataracta prin una din tehnicile care conserva delicata capsula posterioara a cristalinului. O alta tehnica este fragmentarea ultrasonica (facoemulsificare) a nucleului cristalinului. Introducerea intraoperatorie a unei lentile intraoculare elimina necesitatea purtarii ochelarilor.

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CEFALEEA CEFALEEA DE TENSIUNE Dif de conc, cefalee zilnica descr ca o strangere sau comprimare a capului. Poate fi exagerata de stersul emotional, oboseala, zgomot, lumina intensa Poate fi generalizata sau in zona occipit su nucala. NU e asoc cu simpt neur de focar TRAT Analgezice sau antimigrenoase CEFALEEA DE DEPRESIE Mai intensa dimineata la trezire, uneori elem central al unei cenestopatii TRAT Antidepresive triciclice Consultatii psihiatrice MIGRENA Cefalee pulsatila lateralizata , aparitie periodica, debut in adolesc sau perioada de adult tanar. Poate fi si generalizata, constanta sau pulsatila, se poate asocia cu anorexie, greata, varsaturi, fotofobie, fonofobie. Apare gradat si dureaza cel putin cateva ore. Se pot asocia tulb de vedere, FACT DECLANSATORI Stres emotional, lipsa sau exces de somn, modif orarului de masa, unele alimente ca ciocolata, bauturi alc, menstruatie, contraceptive orale TRAT Evitarea fact precipit, Analgezice (aspirina) CEFALEEA IN CIORCHINE (NEVRALGIA MIGRENOASA) Afect frecv pers de varsta medie CAUZE Neclare, dar afect cefalgica de tip vascular, perturb a mec serotoninergic CLINIC Durere severa , unilat, periorbitala, apare zilnic timp de cateva sapt si pot fi insotite de congestie nazala unilat, rinoree, lacrimare, congestie conj, sdr. Claude-Bernard-Horner. Episoadele apar de obicei in timpul noptii. Multi relateaza ca alcoolul declanseaza un atac. CEFALEEA POSTTRAUMATICA Cefaleea apare in decursul zillei sau in ziua consec traumat CLINIC durere permanenta, caract pulsatil, acomp de greata, varsaturi. Pierderea echil, tulb de memorie, scad puterii de conc, iritabilitate TRATanalgezice usoare, amitriptilina CEFALEEA DE TUSE CEFALEEA DAT ALTOR CAUZE NEUROL. CIROZA HEPATICA Asoc necrozei hep cu proc de fibroza,de regener si de alter a arhitect hep. EP:alcool,virus hep BCD,hep autoim,staza bil intrahep,staza bil extrahep,staza ven, hemocromatoza,b Wilson,by-pass intestinal, unele medic, metotrexat, izoniazida, alfametildopa, amiodarona. MANIF CLIN PE STD EVOLUTIVE: 1.CH compens(uneori asimpt ori cu simpt spec,ast fiz,fatigab,anorex,gret,varsat,crampe musc,scad in greut,ficat mare,splenomegalie)
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2.CH decompnes parenchimatos(denutr,gingivorag,epist,echim,stel vasc,erit palm,ginecomast,atrof testic,icter,febra,fic mic si dur) 3.CH decomp vasc(circ colat,var esof,var anorect,splenomegal,gastr portalhipertensiva,asc,edeme) DG DIF: 1std compnes(hepcron,hepatop alc,ca hep,chist hid,ICD,abces hap,sdr Budd-Chiari) 2.std decomp(ascita=ICD,pericard constrict,SN,TBC perit,Ca periton,sdr Meigs; icterul=hep vir,Ca cap pancr,ca hep,angicol,LB ; HDS=UGD,CaG) COMPL:HDS,encefalop port,perit bact,neo hep,sdr hep-renal,sdr hep-pulm) FORME CLIN:postvir,postalc,biliara primit,bil secund,cardiaca,sdr Wilson,hemocromatoza,sdr hepato-renal,sdr hepato-pulm TRAT: 1.cir compens(reg igdiet,colchicina,corticoizi,interferon 2.trat cir decomp(reg alim,repaus la pat,anemie-acid folic,ascita-reg alim hiposdat,spironolactona,furosemid,paracenteza,albumina) 3.trat hemorag:reechil hemodin,oprirea hemor-balonas si scleroza,scad presiuniisomatostatin,octeotrid,preven recur hemor:propran 10-120mg/zi,isodinit) COLECISTITA ACUTA: Inflam cataral,supurata sau gangrenoasa a colecistului caract prin apar unor dur viol in hipoc dr,intov de febra si fenom de irit periton. EP:staza bil det de atonia vez bil sau de bloc can cistic de catre un calcul,malform sau tumora;F de risc:LB,obez,DZ;staza bil>iritatie>inf cu e coli,clstr,stafil,salmon>contin purulent. MANIF CLIN:dur viol hipoc dr,irad umar dr,exacerb la misc trunchi,exacerb la misc resp,bloc resp,hiperestez in hipoc dr,apar muscul,impast locala,Murphy +,gret ,varsat,st gen alter,transp profuse,febra si fris repet,uneori st toxico septica,tahic si tend la colaps. FORME CLIN PARTIC: 1.forma catarala(colica biliara,febra,frison,hiperstez cutan,apar muscul); 2.forma supur(col bil,hiperpirexie,fris repet,hiperestez accent,apar muscul,hidrops vesicular,plastron biliar) 3.forma gangrenoasa(colica biliara,stare toxico-septica,tahicardie,puls filiform,tend la colaps,abd destins,hipotermie inselatoare) DG DIF: 1.col biliara,UGD penetrant,UGD perforat,hep ac,abces hep,angiocol,chist hidatic infectat,PA, apendic acuta, colica ren dr, colica pielonefritica, pneum dr, pleur diafragmatica, IMA; TRAT:combat inf: ampi 4g/zi, genta 160mg/zi, metronid 50mg/zi, cefotaxim 3-6g/zi; combat dur=scobut,papaverina,analgezice;reechil HE.
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Budd_Chiarri,b

COMPLICATIILE SARCINII: ECLAMPSIA: PREE=HTA+EDEME+PROTEINURIE; ECLAM=HTA+EDEME+PROTEINURIE+CONVULSII; poate sa apara de la 20sapt de gest pana la sapt 6 postpart; CLINIC:se rap la:snc,rinichi,ficat,vase sg,sange,unit feto-placentara; snc(hiperreflex,cefalee,mioclonii,convulsii), rinichi(proteinurie0.3-4g/24h-5g/24h,debit20-30ml/hpana la sub 20-30ml/h); hepatic(AST/ALTnorm saucresc,ruptura hep); sange(Trpeste 100000sau sub 100000in ecl grava,HbN/CRESC), vase sg(Tasub160/110saupeste 160/100in severit,retina-spasm arteriolar pana la hemorg retin); unit fetoplacent(intarz in crest intraut.abs-prez,sufer fetala abs sau prezin forma severa); DIAGN DIF ; HTA,afect renale cr,convulsii primare,afect bilare,pancr,sdr hemolitic uremic,purpura trombocitopenica) DEFICIENTA MINTALA(DEMENTE): Dimin trept a f psih dat modif organice ale creier. SIMPT 1.tulb de memor 2 de gandire 3.afective CLASIF DEM: 1.degenerative(Pick,Alzheimer) 2.vasculare(ATs cereb,dupa AVC) 3.secudn(postraum,tox,postinf,tum,hidrocef,hemat subdur,b neurol) MANIF CLIN DEM: 1.tulb cognitive(de mem,de comunic,de intel,de vorb,dific de a-si gasi cuvinte,necun onor lucruri commune,dezor temporo-spat) 2.tulb psih(depr,anxiety,suspic,idei delir,halucin,tend de izol 3.de peronalit(modif personal,agit,apatie,rigiditate,incapatz,iritab,logor,manif explosive) 4.de desf a activ curente(tulb de cond auto,de a manipula bani,de a face cumpar,de a pregati alim,neglijenta personala) I NTREBARI:ce zi a sapt,data,luna,anotimp,anul,unde ne aflam,ce etaj,localitate,denum 3 obiecte comune,ce este asta(ceas,creion),impatur hartie,cititi si exec ce scrie pe billet,va reamint ob recunosc anterior,copiati un desen.

16

FORME CLIN PARTIC: 1.b Alzheimer:rol in apar=fact gen care intervin in sint amiloid,scad nr de synapse,nr de neur,apar placi senile,de amiloid,tulb neurotransmitatorilor;affect mem episodice,verbale si spatiale,a afectiv, fct cognitive cu o perturb prof a a active curente. 2.b Pick:tulb de comport,atentie,neglijenta,boln distrat,euforic,preocup sexuale,slab capac de memorie,reduc ideatiei pana la st de indfierenta apato-abulica. 3.b cu corpi Lewy:tulb cognit fluctuante,haluc viz,parkinsonism. 4.dementa vascul:affect creier prin infarcte repet sau tulb de circul,in HTA,DZ,semne neurol de focar,incontin urin,tulb de mers etc 5.b Jakob-Creutzfeld:semne neur de ataxie si disartrie,care se acc trept si se asoc cu tulb psih grave. TRAT: 1.nefarmac:psihoterapie,muzicoterapie,ter ocupat,ambianta adecvata,terapie familiala pt sust part sanatos 2.medic: a.depresia psih=inhib select de recapt a serot ; b.tulb psihotice=haloperidol,torazin; c.tulbcognitive=donezepil,rivastigmina; d.alte=piracetam,sermion,tanakan,antoxidante,cerebrolizin DEPRESIA: St de deprim prof resimt de boln ca o durere morala si asoc cu o lentoare ingandire si in activitate. CLASIF 1.tulb reactive insot de depr psih 2.tulb depresive:epis depr major,distimia,tulb depres fara alet partic,depr atipica,tulb afect sezon,tulb disforica premenstr,tulb depres postpartum 3.tulb bipolare:epis maniacal,tulb ciclotimice 4.tulb sec unor medic; MANIF CLIN:debut lent,st de disconf psih,lipsa de interes si plac,atit pesim fata de viit,senz de destertac,lipsa de sens a vietii,devaloriz person,sentim de culpabil si dispret,tend masoch,idei de sinuc,tend de izol,asten marc predomin matinala,misc lenete si greoi,senz corporale neplac,crest sensib dur,dur dif sau localiz,asp neingrij,facies deprim,voce dimin,dific de conc atentie,tulb de memorie,gand lenta,idei negat,de subset,tulb de somn tardiv,tend la izol,dific de comunic,asoc cu anxiet,st disforica,instabil ostila. CRIT DE DG:lipsa de interes si placere,scad reactive emot,idei de culpabil si devalor,atit pesim fata de viit,lent in active,predom matin a simpt,scad apt si a greut corp,scad libid,idei sau acte de autoagres sau suicid. F CLINICE PARTIC: 1.distimia 2.depr cu trasat atipice 3.cu manif paranoide
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4.la varstnici 5.secundare 6.mascata 7.dupa IMA 8.postpartum 9.la copil si adolesc 10.medicamentoasa; TRAT: 1.psihoterapie 2.terap sociala 3.medic:antidepr tric(ami,nortript,imi,clomi,trimiparamina,doxepin); heterociclice (maprotilina,mianserin,venlafaxin) ; inhib recapt serot(fluvoxamin,paroxetin,sertralin) DERMATITELE ALERGICE CARACTERISTICI ESENTIALE: Eritem si edem, prurt, aparitia de vezicule si bule in reg de contact Ulterior leziuni umede, cruste sau inf sec. Adesea atcd la agentul respectiv Teste alerg de obicei + DERMATITE INFECTIOASE ERIZIPELUL CARACT ESENTIALE: placard bine delimitat, eritematos, edematiat, temp locala cres cu/fara form de vezicule sau bule, fata e frecv afectata, durere, frisoane, febra si semne toxicitgenerala. Este o forma superf de celulita TRATAMENT Aspirina pt durere si febra Repaus la pat Antib in primele zile penicilina V 250 mg, dicloxacilina 250 mg, cefalosp gen I CELULITA Coci Gram +, bacili gram + Inf difuza a tes subcut, lez calda si rosie. Acutiz repetate duc la afectarea vaselor limf edem solid TRAT Dicloxacilin, cefalexin 250-500 mg , 7-10 zile ERIZIPELOIDUL Inf benigna la pescai si macelari Placard rosu, violaceu, bine delim, indurat, centru clar, localiz frecv pe un deget sau fata dorsala a mainii. Simp articulare, se poate instala endocardita TRAT Pen V 250- 500 mg po x4/zi 7-10 zile, ciprofloxacina

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DIABET: Tulb a metab gluc determ de car abs sau rel de ins care antren dupa ea si alte tulb metab. CLASIF ETIO: 1.DZ 1(distr cel beta,defic abs de ins=mdiat imunoloic,idiopatic ) 2.DZ2 (def rel de ins de la def secret pana la ins-rezist) 3.alte tipuri(def gen a cel beta,Mody1,2,3;def gen a ins=ins-rez tip A,sdr Donahue,diab lipoatrofic;b ale pancr exocr=pacreatita,traum/pacrectom,neo,fibr chist,hemocromat,panpatia fibrocalcara;endocr-patii=acromeg,sdrCush,glucagom,feocr,hipertir,somatostatinon,tum Conn; Indus de medic=h tir,glucocort,beta agon,tizide,interferon;infectii=rub cong,CMV;forme rare diab med imun=Ac anti rec ins;sdr gen cu DZ=down,klinef,turner,cor Huntington) 4.DZ gestational. DEOSEB ETIPOPAT INTRE DZ1/DZ2: varsta de deb=<20/>40; antec ered=10%/30%;ereditatea:30-50% la monozig/90% la monozig; substr gen=HLA/polygenic;mec autoim=prez/abs; obez=abs/>80% prez;ins-emia=hipo/hiper;sens cel beta=N/scaz; tend la cetonemie=marcata/abs; trat oral=inef/efic; trat cu ins=oblig/opt; EF DEF DE INS:hipergl,foame cel,diur osm,deshidr extracel,pierd elecroliti,pierd de baze tampon,acidoza,hiperprod de cetoacizi,glicozil prot,tulb permeab capil,glicoz lip,active caii poliol,cred radic lib,stress oxidative,dislipd,crest agreg pach,crest sint fact I,VII,VIII,X,scad fact antitrombotici si fibrinolitici. PERS CU RISC:obez cu greut >120%,fem care au nasc macrosomi, gravide, hipertensivi, HDLcol<35mg/dl sau TG>250, pers cu glic ajeun anorm, pers cu sacd toler la gluc, pers >45ani odata la 3 ani. DG STADIAL: 1.preDZ(glic aj<126,TTGO-N,fact de risc-dz la ambii par,greut nast>4000,mame cu feti morti,gliozurie in sarcina,hiperglic dupa inf si b grave,HLA DR3/4) 2.DZ latent(gl aj >126,TTGO N) 3.DZ chimic(gl aj >126,TTGO N,scad toler la gluc) 4.DZ manifest (glic aj >126, glic postprand>200, glicozurie prez) COMPLIC 1.acute (coma acidocetozica, hiperosmolara, lactacidemica,inf cut, urin, bucodent) 2.cron(glomeruloscler,retin/arterio/neuron/dermato/cardiopatia diab,gangr,pic diabetic)

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STADIAL NEFROP DIAB: 1.rin vol cresc,hiperfct ren,CrCl>150ml.min,alb0urie N,TA-N; 2.ingros MB,expans mezang,alburie N,ClCr N,TA-N; 3.nefrop diab incip,obstr glomer incip,microalburie progresiva,HTA de gran progresiva) 4.nefrop par\tenta,sclera glom sev,alburia >200mg/min,edeme,HTA,FG scade progress,RAF) 5.rin mic sleroz,scad nr nefr,scad filtr elemetar<10ml.min,HTA,evol fat in cateva luni) EVOL RETINOP DIAB: 1.simpla(dil ven,microanev,microhem pctf,exud dure,dep prot) 2.preproliferativa(exud moi,vatuite,oblit si dil capil,,hemor retin intinse,hemor in vitro) 3.prolif (vase de neof,frag cu tens la rup, hemor in div stadii,cic postehemor,dezl de ret,pierd ved) NEUROP DIAB: somatica perif (poli/mononevrite, radiclupatii), somatica centrala (mono/hemi/tetraparze, paral nv cran) vegetative (vasculara=hTA,TR;dig=gastropareza,enteropat diab;urogen=vez neurogena,tulb sex;ostart=pic diab; cut=mal perfor plantar) MANIF CUT: 1.caracteristice(rubeoza pometi,necrobioza lipidica,mal perf plantar) 2.asoc(prurit,ecz,xanteme,psori,pioderm,erizip,abc,flegm,furunc) 3.secudn terap(liodistrof insul,alerg insul,alerg la ADO) STAB RAT ALIM LA UN DIAB: a.stab toler la gluc:in spital,adm reg standardizat,det glic,abs glicoz-toler buna,glicoz 140g/24 toler nula; b.stab neces cal:se cantar boln,se stab ef fiz depus,se inm nr de kg cu 35kcal/kgc/zi; c.stab cont ratie alim:se calc cant min de gluc prin imp la 10 a neces caloric,gluc 50%,lip 30%,prot rest d.intocm ratiei:alim cu cant coresp de gluc,lip,prot(liste) e.repart pranzuri:in f de activ ziln si de trat cu ins,5 mese pe zi) MEDICAM: 1.insulina(act hipogl prin crest capt gluc de catre cel adip si musc,scade glicogeneza si neogluc,creste lipog si scade lipol=rapide,intermed.lente,mixte) 2.sulfamide hipoglic(stim secre de ins,scad rez perif,scad prod hep de gluc,crest stoc gluc,scad neoglucogenezei=gener1-tolbut, clorpropamid, carbutamid, gener 2-gliclazid, glipizid, gliquinon) 3.biguanide(crest util perif,inhib neoglucogenezei,scad abs intest a gluc,scad prod hep de gluc=metformin,buformin) 4.inhib de alfaglucozidaza(inh AG,scad abs intest gluc)

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TRATAM COMPLIC; 1.retinop(Ca dobes,trof vasc,antiagr plach,antoxid,fortocoag laser) 2.neurop(analg,antiinfl,B1,B6,B12,ac tioctic,ac alfalipoic) 3.nefrop(reg hipoprot,IEC,hemodial) 4.pic diab(vasodil,rep,trat inflam si necr) 5.arteriop oblit(vasodil,pentoxi,antiagreg plac) DISLIPIDEMII: Hipercolesterolemii usoare-col 200-250 mg/dl, TG-SUB200; moderate-250-300,TGsub200;severe-PESTE300,TG sub200 Hipertrigliceridemii-moderate-col sub 200,TG200-400;severe-col sub 200,TG peste400; Dislipidemii mixte- moderate- col200-300, TG-200-400; severe-col peste 300, TG peste400 TRAT statine- simvastatina, lovastatina, fluvastatina, atorvastatina; fibrati-fenofibrat, ciprofibrat, bezafibrat; acid nicotinic; rezine-colestiramina (rasini chelatoare). DISPNEEA: atat semn cat si simpt,senz de sufoc,sete de aer,resp dific,efort resp,resp dev proces const,det st neplac,anxiet si teama de moarte. CAUZE 1.crest ventil pulm[a.hipoxie(ef fiz,altit,atm pol) b.crest metab baz(st febr,tireotox) c.acid metab(coma diab,urem,intoxic)] 2.tulb ventil pulm[a.oblit CRS(edem glotic,corpi straini,tum aer,gusa,adenop,AnAo) b.obstr CRI(AB,BC,bronsiolita) c.invad cu lich(EPA,hemoptiz) d.red supr resp(pneum,brpneum,emfiz,tum pulm,Si,TBC) e.compresia plam(pleurezie,htx,tum per tor) f.limit amplit resp(nevralgii intercost,fract cost,spondilita,cifoscol)] 3.tulb circ pulm[crest pres pulm:sten mitr,valvuop ao,ICS,HTA,miocardopat,IMA] 4.tulb transport[red cant de Hb:a feripriva,a postehemor] 5.tulb regl nerv[a.lez centri resp(AVC,tum cer) b.subst chim(acidoze,intoxic)] 6.tulb psih[infl psih asupar centri resp;nevroze,st de anx,depr,sdr de hiperventil] CLASIF CLIN: 1.obstructiva(a.CRS:corpi str,gusa,hipertrof timus,AnAo,edem/spasm glotic,tum=de tip inspire,insot de tiraj si cornaj;b.CRI:spasm,exudat,edem-bronsiolite,AB=dispn de tip expir, wheezing) sau 2.restrictiva(pneum,brpneum,pntx,Si) 3.sdr de detresa resp acuta(dispn,cianoza,hipoxemie-pneum,septic,soc septic,atelect pulm,insuf resp ac) PARTIC CLIN: 1.mod de debut[a.brusc(corp str,emb pulm,pntx,AB,traum) b.progres(pleur,pneum,EP,fibr pulm,IC)] 2.cond de apar-fact declans:ef fiz,stress,inf resp,traum,alergeni,tox,iritante 3.modif frecv resp 1.polipnee(stress,ef fiz,febra,b pulm,pleurale,inima,anem,hipertir,alcaloza,hipox) 2.bradipn(obstr CR,edem glotic,AB,BC,BPOC) 3.modif ritm resp[a.cheyne-stokes(insuf circ cereb,IC,tulb metab,AVC)
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b.Kussmaul(coma diab,uremica,hep,intox cu acide) c.Biot(TCC,encef,tulb metab,intox) d.de tip invers(brpneum la copii) e.apnee in somn(centrala,obstructiva) 4.poz boln[a.ortopneeICC;b.inspir fortat-AB] 5.simpt asoc-in f de boala-tiraj,cornaj,wheez,tuse,expect ser,rozata,perlata,spum,raluri,MV modif,matitate,cardiomeg,TR,edeme,febra,st de soc,pierd cunost) COND DE APAR DISPN: 1.la indiv sanat(ef fiz,stress,exp la noxe,corpi str,traum,hipoxie,somn) 2.la boln cron(a.respir:inf,alerg,noxe;b.CV:ef fiz,poz agrav,tromboembol;c.metab:CH decomp,Iren decomp,DZ decomp;d.neuropsih:nevroze,suspin,oftat,resp incompl, hiperventil, alcaloza, tetanie) 3.la bolnavi acuti(a.resp:agrav b acute,sdr de detr resp; b.CV:IMA,miocardita; c.infect: sepsis, septic,soc sept,plam de soc; d.nerv:AVC,come tox,metab) CRIT DE GRAVIT I=la urc a 2-3 etaje sau alerg pe ter plat : II=mers pe ter plat cu pers de ac varsta; III=mers pe ter plat in ritm propriu ; IV=spalat si imbracat ; V=repaus; SEMNE SI SIMPT ASOC:tiraj,cornaj(obstr CRS);wheezing(AB);cianoza(sdr de detr resp); febra(inf resp);junghi(penum,embol pulm);tuse(pneumop acute) ;expect(BC); edeme(IC); paralizii(AVC); pierd cosnt(coma cetoacidozica);dur intercost,sufluri card,mat pulm(pleurezii); DG DIF: debut brusc(AB,astm card,EPA,emb pulm,pntx),deb progres(pneum),disp inspir(astm card,EPA,emb pulm,pntx,pneum),disp expir(AB),bradipn(AB),tahipn(astm card,EPA,emb pulm,pntx,pneum),ortopn(AB,astm card,EPA),tuse(AB,astm card,EPA,pntx,pneum),expect muc(AB,pneum),expect rugin(pneum),expect muc (EPA); wheez(AB); ronfl, sibil (AB, astm card), crepit (EPA,pneum), subcrep(astm card,pneum), MV dim (AB,embol, pneum) ,Respir asim (pntx), condens pulm(embol,pneum),hipersonor(PNTX),MV disp (embol,pntx,pneum), junghi(embol,pntx,pneum),febra,fris(pneum),Tahic(embol,pntx,pneum),zg de gallop, sufluri (astm card, EPA),cianoza (AB,astm card,EPA,emb pulm,pntx,pneum),edeme(astm card,EPA) DURERI ABDOMINALE: EP:viscerala,parietala,vasculara,centrala sau reflexa. FACT DECLANS:1.dist brusca a capsulei unor org parenchimat(hepatalgia,prostatita acuta) 2.dist sau spasm org cavit(dil brusca de stomac,lit ren,LB) 3.act unor stim chim(gastr hiperac,CaG,UD,PA) 4.tract mec a mezouri sau ligam(tors de org pediculate,volvulus,hernia strangulata) 5.ischem org abd(inf mezent,inf splenic) 6.proc inflam(abc subfrenic,apendic ac,salpingita,peritonita) 7.tox endog au exog(uremia,cetoacid,toxinf alim,intox cu Pb).

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CLASIF DUR de orig ABD: 1.difuza(perit,ocluz int,angor abd,inf mezent,dis ac de Ao,necr ac a pancr,rupt org abd,enterocol ac,colon irit,b Crohn,spasmofilia,limfadenita mezent,periarterita nod,purp Henoch-Schonlein) 2.epigastrica(sdr dyspeptic,gastr ac,UGD,PA,hern diafr,ocl de colon transv,AnAo,angor abd) 3.hipoc dr(colecist ac,LB,apendic inalta,abc hep,subfrenic,col hep,rend r) 4.hipoc stg(UG perf,inf speln,ocl de colon stg,abc subfren,rupt de spl,colic aren stg) 5.periombilic(apend ac,hern epig,adenop mezent) 6.fosa il dr(append ac,pielita ac,hern strang,SEU,chiso ovar,salpingita,pelviperitonita,ileita termin) 7.fosa il stg(pieilita acuta,hern inghin,SEU,chist ovar,rcuh,pelviperit) 8.hipgastru(prostatita,ret ac de ur,lit vezic,SEU,avort,pelviperit,abc fund de sac Douglas). CLASIF DUR ABD DE orig EXTRAABD: 1.B card(IMA,AP,pericardita) 2.b pulm(pmeum,embol pulm,pntx,plurez diafr) 3.b metab(uremia,acid diab,porfiria,tetania) 4.intox(morf,Pb,medic) 5.b nerv(radiculite,migr abd,apilepsie abd) 6.b psih(nevroze cu tulb vegetative,depr masc,hipocondria). SEMNE SI SIMPT ASOC:disfagia,pirozis,regurg,eruct(dg dif intre gastr ac,cron,hern hiat,acalazia card),gret(dg dif intre gastr ac/cron,sdr disp,ileus mec,sarc,intox medic,sdr vertigo,migrena),varsat(dg dif intre gastr ac/cron,UGD,CaG,ileus mec,colecist ac,apendic ac,colica ren,IMA,mening,tum cereb,uremia,intox medic,sarc,migre,sdr vertigo,dur retrostern,constip,opr transit,diaree(dg dif intre enterocol ac,intox ciup,intox Pb,sdr de malbs,b Crohn,col irit),febra(dg dif intre ITU,colecist ac,abc subfren,periton,pancr ac,b crohn,RCUH),meteorism,clapo intest,apar musc(dg dif intre perf org cav,inflame periton,perit bact,periton chim,PA),icter(dg dif intre hep ac/cron,angiocolite,ciroze,ca hep,LB,tum bil,ca cap pancr,sdr Rotor,sdr Dubin-Johnson),ascita,hematemeza(dg dif intre varice esof,UGD,gastr ac,sdr Malory_Weiss,Ca gastr),rectorag,melena(dg dif intre UGD,Ca colon,polip intestine,invag intest,divert Meckel,b crohn),paloare,tahic,st de soc. EXAMEN CLIN:1.observ(abd n conf,retractat,marit de vol,er cutan) 2.palp(abd suplu,dur spont,provoc,apar musc,prez tumori,prez lich) 3.perc(disp /apar unor matit,sonor acc) 4.tuseu vagin(semne de sarc,sensib Douglas,exist format tumor,avort in curs,sensibil anexe) 5.tus rect(fisuri rect,hemoro,ad de prost,ca rectal,de prost) 6.auscult(clapotaj,zgomote ocluzive) 7.punct f de sac Douglas(cand se ban o hemor intreperit,SEU,pelviperitonita) INVEST PCL:1.Rx(lit ren,LB,UGD,var esof,ocl intest,perf org abd,pneumoperit,tum abd,abc subfrenic) 2.eco(lit ren,LB,chist abd,ascita,hepatomeg,anc abd,AnAo,pancr ac,hidronefr,tum abd,colecist,hidrops vez,limg abd) 3.endosc(esof de reflux,var esof,UGD,gastr,CaG,duodenite,sten pil,HDS) 4.colonosc(RCUH,b Crohn,ca colon,polipoza colica) 5.rectosc(RCUH,nfis anale,hemoro,pol rect,ca rect) 6.scintig(HC,Ca hep,chist hep,pancrita,ca pancr) 7.punct hep(hep ac,cir,ca hep) 8.punct abdom(ascita,periton,Ca perit,mts periton) 9.ex bacterio(enterocol,abc abd,periton,gastr,sdr dispet,inf genit) 10.ex
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paraz(ascarid,tenia,giard,amibia,blastoc,tricocef,schistos) 11.ex bil,col ren,sdr de malabs,angiocol,periton,b crohn,tum abd) DURERI LOMBARE:

lab(PA,ITU,DZ,apendic,col

EP:1.tulb de statica(scolioze,cifoze,lordoza,spina bifida,sdr trofostatic de menopauza) 2.tulb degenerative(discartroze,prolaps discal,artroze interspinoase) 3.tulb inflam(spondil anchiloz,PAR) 4.tulb infect(morb Pott,bruceloza,stafilo) 5.tulb endocrmetab(osteoporoza,osteomalac,hiperpth,b Paget) 6.traum col(fract vert,fract apof spin,tasari corpi vert) 7.proc maligne(tumori primare,mts ale canc de prostate,de saunter,rin,MM,b Hodgkin) 8.b organe vecine(pielonefr,lit ren,UGD,pancr,b inflame pelv) 9.tulb psih(psihonevroze,depr psih,stresuri psih,hipocondrie) LUMBAGO:dur pare brusc,boln acuza dur vie care il imobil la pat si care se exacerb la cel mai mic effort,tuse,stranut;boln poate ramane in flexie;localiz lomb,sacrat si nu are iradiere;la ex oboect poz antalgica si contract muschi paravert,mobil coloanei este limitata;Rx=modif degenerative si pensare a discurilor paravert;trat= algocalm, parac, aspir, indomet, ibuprofen, inh COX2,nimesulid,miorelaxante,infiltr cu xilina,hidrocortizon,tart fizioterapic,cu diadinamice, ionizari, hidroterapie si masaj. LOMBOSCIATICA:dur cu irad in mb infer,brusc dupa ef fiz sau treptat,irad dep de rad nv sciatic afecta(L5-dur irad pe fata post-ext coapsa,fata ext gamba,fata ext glezna si fata dors picior pana la haluce;S1=irad partea post coapsa si gamba pana la calcai),parestezii,tulb sfincteriene;poz antalgica,contract ms paravert si limit mobil col lomb;semn lasegue,Bragard,tulb de sensibilitate,defic motor al ms lojei post gamba; trat=idem lumbago; DUREREA TORACICA: Etiopatogenie A.Dur de origine toracica 1.Parietale(mialgia,nevralgia,zona Zoster, Sd Tietze, Mielom multiplu, osteosarcom) 2.Traheobronsice (traheite, bronsite) 3.Pleurale (pleurita, pleurezie, pneumotorax) 4.Pulmonare (pneumonia, bronchopneumonia, abces pulmonary, embolia pulmonara, cc pulmonary) 5.Diafragmatice (pleurezia diaphragm, hernia diaphragm) 6.Esofagiene: esofagita de reflux, cardiospasm, esofagita flegmonoasa, cc esofagian) 7.Mediastinale (emfizem mediast, mediastinita, anevrism dis Ao, cc mediastinal) 8.Cardiace: AP,A instabila, IM, Prolaps valva mitrala)] B.Dur de orig extratoracica[ 1.Abdominale:UGD,colica biliara,hernie diaphragm,pancr acuta; 2.Articulare:periartrita scapulo-hum, spondiloza cervico-dorsala, spondilita; 3.Psihice: Sd Da Costa] Particularitatile dur toracice:localizare:precordial(miocardite,pericardite),retrosternal(AP,IM,esofag de reflux,cardiospasm, mediastinite), in centura(nevralgie ic,z Zoster), la baze (pleurezie, pneumotorax, hernie diaphragm, la varfuri (spondiloza cervicala, periartrita scapulohum, cancer)24

caracter:constrictiv (gheara):AP,IM, violent(TEP,Pneumotorax,anevrism dis Ao, IM), arzator(Z Zoster), surd(mediastinite), intepator (nvroze cutanate)- iradiere:in brat stg:(AP,IM), in umar(colica biliara,periatrita scapulo-hum,IM), abdominal(anevrism dis de Ao,IM)context:dupa effort(AP), dupa alimente (esofagita, gastrita, h diaphragm), inf resp(pneumopatie ac), expunere la frig (nevropatii, miozite, radiculite) -debut:brusc(IM,TEP),progresiv(cc,pneumonie) ENDOCARDITE: ETIO(in ord frecventei): S. aureus ,str.Viridans,Enteroc,staf Coagulaso-negat,Str bovis,Other strept,bact gram-negative,Fungi. FACT DE RISC:injectii intravenoase,proteze valvulare,proceduri diagnostice intravasculare,malf card,istoric de endocardita,HIV,sarcina, fistule arterioven pt hemodial,Central venous and pulmonary artery catheters,Peritoneovenous shunts for the control of intractable ascites,Ventriculoatrial shunts for the management of hydrocephalus. CRITERII DE DIAGNOSTIC: Pathologic criteria[Microorganism(demonstrated by culture or histology in a vegetation, or in a vegetation that has embolized, or in an intracardiac abscess) OR Pathologic lesions(vegetation or intracardiac abscess, confirmed by histology showing active endocarditis)] Criteriile DUKE(prez unui criteriu major si unul minor sau a 3 criterii minore) Major criteria: 1.Positive blood cultures for IE(A.Typical microorganism for infective endocarditis from two separate blood cultures :Viridans strept,Str bovis, including nutritional variant strains,HACEK group (Haemophilus spp,. Actinobacillus actinomycete comitants, Cardiobacterium hominis, Eikenella spp, and Kingella kingae),Staf aureus Community-acquired enterococci, in the absence of a primary focus; B.Persistently positive blood culture;C:Single positive blood culture for Coxiella burnetii) 2.Evidence of endocardial involvement(A.Positive echocardiogram for IE B.New valvular regurgitation) Minor criteria: 1.Predisposition - predisposing heart condition or intravenous drug use; 2.Fever - 38.0C; 3.Vascular phenomena - major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions; 4.Immunologic phenomena - glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor; 5.Microbiologic evidence - positive blood culture but not meeting major criterion as noted previously (excluding single positive cultures for coagulase-negative straphylococci and organisms that do not cause endocarditis) OR serologic evidence of active infection with organism consistent with IE ; EXAMEN CLINIC new regurgitant murmurs or heart failure; Associated peripheral cutaneous or mucocutaneous lesions of IE include petechiae, hemoragii unghiale in aschie, Janeway lesions, Osler's nodes, and Roth spots, focal neurologic deficits, renal and splenic infarcts,glomerulonephritis, arthritis, septic pulmonary infarcts.
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LABORATOR: hemoculturi positive, VSH/PCR cresc, normochromic normocytic anemia,The white blood cell count may be normal or elevated in patients with subacute presentations of endocarditis; however, most patients with staphylococcal endocarditis have leukocytosis and some may have thrombocytopenia. Hyperglobulinemia, cryoglobulins, circulating immune complexes, hypocomplementemia, elevated rheumatoid factor titers, and false positive serologic tests for syphilis all occur in some patients. TRAT EB Acute:oxacilina + genta TRAT EB subacute:1.str viridans=penicilina(+aminoglicozid) sau ampi sau cetriax daca penic nu este dispon. 2.s pneumoniae=penic sau ceftriax. 3.enterococ=ampi sau peni,vanco+aminoglicozid; 4.s aureus=oxacilina(+aminoglicozid) 5.staph epidermitis=vanco+genta; 6.HACEK=ceftriaxona; EPILEPSIA/CONVULSII: contr musc involunt parox cu car clonic,tonico-clonic care pot fi insotite de peierderea cunostintei. EP:result desc sincrone ale unor grupe de neur sit in cortex sau subcort. CAUZE: 1.mecanice (TC,traum obstetr, tum cereb,anom vasc) 2.metab ( tulb HE, edeme cereb, hipogl, tulb ac aminati,tulb PH, hipox) 3.sevraj brusc(alc,stupef,antidepre,antiepil,neurolept) 4.toxice (intox.endog,acidoza,cu organofosf,CO,imipram, stricn, hirazina,ephedrine) 5.febra(b inf) CLAS ETIO:1.acute ocazion(inf snc,hemor cer,edem cer,b gen ce affect SN,tulb metab,intox medic,crize HTA) 2.cron recurente(epilep idiop,in abs unor lez cer decelabile,epilep symptom pe fondul unor lez decel) CLAS ETIO IN F DE VARSTA 1.NN(hipox neonat,traum perinat,inf SN,malf SN,erori inasc de metab,hipogl) 2.sugar(inf SN,b inf,malf sSN,erori inasc de metab,sech perinat,hipoCa,tulb metab,deshid) 3.copil mic(inf SN,intox, erori inasc de metab,sech perinat,epil postraum, idiop) 4.copil mare(inf SN,malf vascul,epil postraum,sechelara,idiop) 5.adult tanar(epil postraum, tumor, alcoo ,idiop,sechel, malf vasc) 6.adult matur(epil postraum, tumor,sechel,alcoo, vasc) 7.varstnic(epil vasc,tumor primit sau mts,asoc cu dementa) PARTIC CRIZE CONVULS 1.context de apr (traum ostret,TCC,inf cer,sdr febr,ingest medicam,intox,sevraj) 2.caracter (tonice,clonice,t-c,mioclonice,hipotonice) 3.localiz(generaliz,localizate la o jum a corp,fata membre) 4.durata(cateva sec,minute,unice,recurente) SEMNE SI SIMPT 1.febra(conv febrile,conv din inf SN) 2.bomb fontan(men,encef) 3.red ceafa(men) 4.relax sfinct(grand mal) 5.halucin(crize psihomot) 6.hemipleg tempor(sdr gastaud,hemiconv-hemipleg) 7.pierd cunost(crize grand mal,petit mal,tonice pure,clonice
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pure,hipot,psihomot) 8.fara pierd cunost(akinetice,Jackson) 9.amnezia crizei(grand/petit mal,psihomot,hipot) PARTIC CONV FEBRILE: 1.simple(apar la crest brusc a atemp,sunt mai frecv decat cri febr complic,apar intre 1-5 ani,sunt unice,dur 5-6min,bilat,tip tonico-clonic,f rar hipotonice,nu sunt urm de defic postcritic) 2.complicate(apar la crest bruste t,rare,sub 1 an,unilat,>15min,se pot repeat in aceasi zi,apar la cop cu dezv anorm,pot fi urm de def postcrtitic) MANIF CLIN 1.crize t-c de GM(>80% din care apar peste 3 ani,deb brusc cu pierd const,contr ton generaliz,ochi dati peste cap,cap inntextensie,maxil inclest,MS contaact,flexie,MI in extensie,20-30sec,urm de crize clon,secuse micocl general,tulb resp si circul,boln isi poate musca limba,relax sfincetere,coma postepile,amenzia crizei) 2.ton pure(pierd brusca a cunost,contr ton a tr si mb,rigid musc,nu sunt urm de contr clonice,apar mai ales la sugar) 3.clon pure(deb br cu contr clon,gener sau local la o jum a corp,urm de hemipleg trecat) 4.Hipot(deb br cu hipot gener,isi pierde cunost,cade 1-2min,sub 3-4 ani) 5.encef miocl(caract sugar,contr musc gat,tr,mb,de cateva sec,car repet,flexia cap si mb,pierd cunost) 6.criz akinetice(1-3ani,fond de inters psihomot,cad br-pierd tonus postural,cateva sec,fara pierd cunost) 7,petit mal(sau abs epil,bruste si scurte,pierd cunost,devine inexpres,priv in gol,sis intrer active,dupa 5-10 sec isi reia active,cu amnez atac,crize repet in ac zi) 8.jakson.(localiz,contr clon la fata,ms,mi,apar de o sg parte a corp,nu sis pierde cunost) 9.psihomot (det de un focar cortical in lob temp, comport anorm, stereotip, automatisme, haluc,amnesia atac) DG POZITIV: manif clin, APP, semne si simpt asoc, EEG, CT, RMN, glic, ex LCR, Rx craniu DG DIF:sincopa, lipotimia, migrena, vertij, pavor nocturn, isteria, crize HTA,eclampsia, ticuri, intox alcool,intox insectofungicide,tulb HE, deshidr severa, come TRATAM:DIAZ:ad:10-20mg iv lent sau 10mg rectal/cop 0.2-0.3mg/kgc iv lent sau 0.5mg/kg oral se paote rep dupa 5min; clonaz;ad:1-2mg iv lent se rep dupa 5min;cop:0.2-0.5mg iv lent se rep dupa 5min; loraz:ad:4mg ivlent,cop 2mg ivlent; fenitoin ad 15-20mg/kg iv lent in bolus sun 50mg/min,cop 7-10mg/kg iv boluslent sun 50mg/min PREVEN CRIZE mg/kg/zi,ad/cop:carbamaz 10-20/20-25, amet, somnol, diplop, anem, leucop, valpr Na 15-20/20-25, tremur, alopec,crest greut; fenit 3-5/4-7 amet, hTA, TR, gret,varsat feno 2-3/3-4:iritab,scad atentie, sdr stevens Johnson; clona 0.05-0.1/0.05-o.1 somnol,iritab,gret,vars,depresie.

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GASTRITE: proc inflame a muc gastr,eritem,hemor subepit si eroz. ETIO:1.infect(H pylori,virusuri,fungi) 2.autoimune(atrofica) 3.antiinflam(gastrop cr react) 4.reflux biliar(gastrop cr react caract) 5.alcool(gastrop cr react) 6.HTP(gastrop portala) 7.boli inflam(b Crohn,gastrita limfocitara) CLASIF: 1.clinicoevolutiv (acute, cr, specif ) 2.etiol (infect, autoim, medic,specif) 3.topogr (antrala, fundica, multifoc, totala) 4.endosc (eritematos-exudativa, macilo-eorziva, papuloeroziva, atrofica, hipertrofica, hemoragica) CLASIF SIMPLIF: 1. erozivo-hemor (medic, alcool, prod de stress, portala) 2.neonerozivo-specifice (Cu H pylori, atrofica) 3. specifice (din b Crohn, limfocitara , eozinofilica,hipertrofica) TRAT:1.cu H pylori(omez+amoxi+metro sau omez+claritro+tinid sau omez+amoxi+claritro) 2.atrofica(autoimuna:prep cu HCl ,pesina si B12 inject;antrala:alim care stimul secr HCl dar care sa nu irite,sar de Bi si Al,metoclopr) 3.la AINS 4.de reflux GLAUCOMUL Glaucomul cu unghi inchis: Caracteristici esentiale: instalare rapida, durere severa, , apare in special la varstnici si la hipermetropi, ochi rosu, pupile dilatate, glob ocular dur la palpare. Dg. Diferential : conjunctivita acuta, uveita, afectiuni corneene. Tratament : Glaucomul primar cu unghi inchis, iridotomia periferica cu laser, precedata de scaderea tensiunii oculare cu acetazolamida administrate intravenous. Glaucomul secundar cu unghi inchi, acetazolamida i.v. Glaucoml cu unghi deschis: Clinica: Debut insidios, in special la varstnici. Pierderea progresiva a vederii periferice pe parcursul mai multor ani, ducand la vederea in tunnel.halourile in jurul luminilor nu apar decat tardiv, cand presiunea intraoculara este mult crescuta. Etiologie: drenajul anormal al umorii apoase. Dg: asymptomatic de cele mai multe ori, tonometria, vizualizare oftalmoscopica a nervului optic si testarea campului visual central sunt cele trei teste principale de diagnostic si evaluare a evolutiei glaucomului. Presiunea oculara >24 mm Hg indica aparitia glaucomului. Tratament : Timolol 0,25% sau 0,5% la fiecare 12 ore, cu posibilitate de reducere a dozei la numai o data pe zi dupa 3-6 luni. Latanoprostul 0.005 un analog de prostaglandine, administart o data pe zi, pare a fi tot atat de eficient ca si timololul, dar s-au observat modificari definitive ale culorii ochilor. Trabeculotomia cu laser este utilizata ca si adjuvant al terapiei topice, pentru temporizarea tratamentului. Prognostic : fara tratament, orbire completa.

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HEPATITE ACUTE VIRALE: PARTICUL EP 1.transm fecal orala=A,E,F; 2.parenter=BCDG; 3.perinat=BCD prob FG; 4.sex =BCDG 5.incub in zile;A=15-45;B=45-180;c:35-75; d=21-50; e=30-45; 6.profilaxie:vacc VHA,VHB ; MANIF CLIN: 1.per preict(incub var ,deb variabil,st gen alter,febra,asten,dur musc,artic,coriza,gret,varsat,dur epig,urtic) 2.per ict(dupa 6-7zile,febra scade,st gen amel,apare ict,ur inchisa la cul,scaun decolor,fic mare si sensibil) MANIF CLIN COMPAR :1.deb pseudogripal: ABCE; 2.reumatoid: ABC; 3.urticar: ABC; 4.dispetic: toate; 5.neurastenic: toate ; 6. icter : ABDE si 90%C 7 hepatosplenomeg : toate ; 8.deb scurt : ABCDE; 9.deb prelung: BC; 10.evol grava: BCDE; 11.colestaza: BCD; 12.evol prelung : BCD; 13.cronic:BC; PARACL:teste de disproteinemie,citoliza,creste TGO,TGO,sideremie,pigm biliari;crest BD apoi BI,UB in urina,leucopenie,limfocitoza,monocitoza,Av HVA,B,C,D,markeri HVB; DG DIF;1.in per preict(gripa,urtic,colecist ac, toxinf alim, nevroza astenica, bruceloza) 2.per ict (ict mec, LB, ca hep, ca cap pancr, ict hemol, medicam, angicolita, ict infect, MNI,lepto) TRAT:int in spit, rep pat, reg igdiet de protectie; medic simp,hepatoprotect;forme colest si sevre=cortic; HEPATITA CRONICA: afect parench hep prin process inflamator cronic. ETIO: virusuri hepatice,toxice hepatice,fact autoimuni,alcool PATOG: mecan infect,imunit,tox CLASIF: 1.vir(B,C,D+B) 2.metab(hemocromat,b.Wilson,def de alfa1AT) 3.hep cr.toxice si medicam 4.hep cron idiopatice; MANIF CLIN A HEP CRON 1.antec hep vir 2.cons de alc 3.exp la tox 4.cons medic tox hep 5.exist b asoc 6.fatig 7.inap,varsat 8.intol alim 9.tulb de nutr 10.slab in greut 11.atrof musc 12.tend hemoragipare,gingivoragii,echimoze 13.stel vasc 14.eritem tenar si hipotenar 15.hepatosplenomeg ; INVESTIG PCL:1.functia parenchimatoasa(col tot,alb ser,lipoprot plasm,fact coag,sint ac hipuric,test elim BSP) 2.citol hep(transom,alte enz,siderem,cuprem) 3.inflam mezench(teste de disprotein,det Ig plasm,imunelectroforeza) 4.secr biliara(bilirubinemia dir si indir,PA,urobil,test elim BSP) 5.markeri inf virala(AgHBs,Ac anti HBe,AND-VHB,ARN-VHC,Ac antiVHC,AGVHD,ARN-VHD,IgM anti HD) 6.det unor antic(autoAc antimembr hep,autoAc antiprot spec,autoAc anti sialoglucoproteinreceptor,autoAc antinucl,antifibra musc neteda,antimicrosomali,antimitoc,anticitoplasm neutrofilica) 7.explor hamtologice(Rx barit esof,colecistografia,colangiografia,scinti,eco,CT,punctia hep,laparoscop hep)
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DG DIF INTRE HC STABILIZATA/ACTIVA:1astenie:postprand/marcata 2.scad apet/scad greut 3.hepatalgie moder/marcata 4.ficat consist normala/ferma 5.splenomegalie:cu/fara 6.subicter pasager/icter progresiv deseori 7.transam usor cresc/marcat 8.gamaglob N sau us cresc/intens cresc 9.BSP ret usuara/crescuta 10.Bilirub N/cresc 11.album N/scaz 12.TP-N/cresc 13.PA-N/cresc 14.autoAc abs/prez 15.alter cel discrete/piecemeal necrosis 16.arhitect lobulara pastr/alterata 17.fara boli sist asoc/cu.. 18.progn fav/nefav MANIF CLIN:1.sdr.neurasteniform(asten fiz si psih,anx,tulb de somn si somnol postprand) 2.sdr dyspeptic(scad apt,gret,eruct,dist abd,flatul,intol alim) 3.sdr cutaneo-mucos(cul teros teg,pigm cicatrici,cheiloza,eritem buze si cav buc,erit palmar si stel vasc) 4.sdr hemoragipar(gingivorag,epistaxis,echimoze) 5.sdr endocrin(amenor,hirsutism,atrof testic,ginecomast,tulb sex,scad toler la gluc,obezit,osteopor) 6.sdr icteric 7.sdr hepatomegalic 8.sdr hepatalgic. TRAT:1.hep cron persist(evit ef fiz,alc,tox hep,regim alim,nu neces trat m,edicam dar necesita suprav) 2. hep cron active (re gig-diet-evit ef, repaus iar medicam depinde de cauza: autoimuna = prednisone, azatioprina; cu virus B =interferon, acyclovir, ganciclo, lamivudina; vir C=interferon, ribavirina) HIPERTIROIDISM: CARACT:TRANSPIR,SCAUNE DIAREICE,INTOL LA CALD,ANXIETATE,TAHIC,TEG CALDE,UMEDE,EXOFTALMIE,TREMOR,BOALA GRAVES, PARACLINIC :TSH SCAZUT,T4cresc,GENEZA=boala graves=marire difuza a tiroidei, hiperfunctie, cauza autoimuna, frecv la femei; se poate asocia cu anem megalo, miastenia gravis ,DZ.=HLA-DR3,HLA-B8; adenoame toxice- unice-plumer,multiple-gusa toxica multinod,;tiroidita subac;boal basedow;struma ovari;hipersecr hipofizara de TSH=CAUZE=ADENOM HIPOFIZAR,HIPERPLAZIE HIPOFIZARA;SARCINA SI TUMORI TROFOBLASTICEHIPERTIROID GEST.; SEMNE:nervoz, neliniste, intol la cald, fatigab , transp excesive, crampe ms, sacd pond, palp, dureri anginoase, tulb maenstr, ,paralizii periodice hipokalemice; CLINIC=plafon privirii, clipire rara, tahic, IM rar.oftalmopatia graves=chemosis, conjunctivita, protruzie glob oc, infiltr limfo, compr nerv optic,uscarea corneei); PARACLINIC:T3,T4cresc,ca cresc,TSH scazut,FA cresc,anem,granulocitopenie,Ac antirecept TSH cresc,Ac antinuclaeari cresc,Ac anti AND dublu cat cresc;DD:satri maniacale,tulb psihice ac,stari hipercatab, feocrom, acromegalia, FiA, AP, osteoporoza, DZ, b.Addison. COMPLIC=FiA,nefrocalcinoza,osteoporoza TRAT=b.graves=simpt=propranolol;tiamazol30-60mg/zipropiltiouracil(de electie in sarc,alptare,criza tiroidiana),subst de contrast iodate,iod radioactiv,chir tiroid. HIPOTIROIDISM: CARACT:astenie, fatigab,intol la frig,constip, bradicardie, depresie, rot intarziate, anemie, hiponatremie, teg uscate, absorb de rasina a T4 scazuta, radioiodocaptare redusa, modif de greut.TSH-secr de hipofiza si stim captarea iodului, leg iod de tirtozina, cupl monoiodtirozinei de diiodtiroz pt a forma T3 ,T4SI ELIB T3 SI T4. CAUZE:afect la niv tiroidei,o lipsa a TSH hipofizar. SEMNE
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semne precoce: oboseala, letargie, artralgii, mialgii, intol la frig, constip, cefalee, menoragii, teg uscate, unghii subtiri, friabile, subt firului de par,pal teg; semne tardive:vorbire rara,dispar sudoratiei, edeme perif,voce ragusita, crampe, dureri ms, dispnee, crest pond,scad ac audit, amenoree, macroglosie, carotenodermie, revarsate pleurale,peritoneale,pericardice,cardiomaegalia. PARACLINIC T4 scazut,TSH cresc, colcresc,TGP cresc,TGO cresc, hipoglicemie, anemie, titrurile Ac cresc, DIAG DIF ;satri de astenie,tulb menstr neexplic,mialgii,modif pond,hiperlipemie,anemie,amiloidoza primara,psihoze primare,adenom de hipofiza; COMPLICATII ICC,SUSCEPTIB LA INFECTII,MEGACOLON,PSIHOZE ORGANICE,STERILITATE,larg seii turcesti,risc de avort,tum secr de TSH,stare de obnubilare,coma mixedematoasa(hipoterm,hipoventil,hipoxie,hipotens,hiponatremie,hipercapnie); TRAT :levotiroxina-dz intret-100-200microg;tineri=dz initiale-50-100microg/zi cresc pana la norm TSH;la vasrt=dz init mici 20-25microg. HTA: crest val TA>140/90mmHg,b cu evol extensive afectand treptat o serie de org vitale (inima ,creier,rinichi) putan det aapr unor complic (IC, AnAo, IR, encefalop HTA, EPA, hemor cer, IM,disAo, eclampsia. FACT DE RISC SI MEC DE ACT: 1.genetici(modif ale membr cel,tulb transp de Na,ret cresc de Na,crest sensib rec cel la subts vasopres) 2.varsta(red elastic vasc,complaintei,f renale,sensib barorec) 3.ap cresc de sare(crest Na ic,Caic,tonus cel musc,sensib rec cel) 4.fumat(crest secr de catecol,constr vasc,crest frecv card, TA, lip plasm,scad HDL) 5.cons crescut de alcool(crest secr de catecol,debit card,frecv card,active simp) 6.sedent(necons subst energy,fav obez,favor diab,scad HDL,fav ATS) 7.stress psihic(crest horm catab,frecv card,debit card,TA,scad HDL crest LDL) 8.obez(resist la insul,hiperinsul,hipertrof cel pariet,creste rez vasc perif,vol plasm,deb card,TA) CLASIF ETIO A HTA 1.esentiala avan fa f de ric f genet,varsta,sex,fum,cons de alc,aport cresc sare,sedent,stress,ATS,DZ,diateza urica 2.secundara [a.renoparench (GNA, GNC, nefrop diab, rin polichist, hidronefr, IRC, rin mic unilat, PNC) b.renovasc(sten art ren,embol vase ren,tromb vase ren) c.endocr (feocr,hiperaldost primar,sdr Cush,hipertir,acromeg) d.cardiovasc (Co Ao,IAo,fist arterioven,sdr hiperkin) d.neurol (tum intracr,encefal,polio,sdr GuillainBare) e.medicam (contracept,glucocort,mineralocort,ciclosp,epo) CLAS IN FUNCTIE DE VALORILE TENSIUNII: 1.N <130/<85mmHg ctrl la 2 ani 2.de granita130-139/85-89 ctrl la 1 an 3.std I usoara 140-159/90-99 confirm prin urm timp de 2 luni 4.std II moderata 160-179/100-109 eval compl prin urm timp de 1 luna 5.std II severa >180/>110 eval compl prim urmar timp de 1 sapt EVAL PROGN A RISCULUI C-V LA BOLNAVII CU HTA IN FCT DE VAL TENS SI FACT DE RISC:
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1.scazut:Hta usoara fara fact de risc 2.mediu:HTA moder singura sau cu prez 1-2 fact de risc sau HTA usoara cu 1-2 fact de risc 3.inalt:HTA sevra fara alti factori sau HTA uspara sau moderata cu 3 sau >3 fact de risc 4.f inalt:Hta severa cu 3 sau >3 fact de risc sau boli associate FACT DE RISC Ccv:-niv TA,barb >55ani,fem >65ani,fumat,chol>250mg,DZ,antect de b CV premature,scad HDL,crest HDL<microalbuminuria in DZ,toler scaz la gluc,obezit,sedentar,grup socioecon sau etnic cu risc cresc. ATINGERE ORG TINTA:HVS,protteinurie sau Cr 1.2-2mg/dl,placi ats la niv carot,iliace,femur,ao,ingust arte retin PATOLOG ASOC:acc vasc isch,hemor cer,ang pect,revacul coronariana,ICC,nefrop diab,IRC>2,anevr disecant,arteiopat symptom,hemor si exsud retin,edem papil. MANIF CLIN HTA:1.o per de timp asimpt 2.init apar semne spec 3.cefalee occ seara dim la trez 4.asten fiz 5.insomn 6.ametz 7.eritem fata 8.tulb de ved,fosfene,scotoame 9.vaj in urechi 10.parestez 11.palpit 12.dispnee us 13.jena precord 14.in std inaint apar complic card ren si nerv 15.dispn acc 16.apar dur angin 17.tulb de ritm card 18.poliur cu nictur 19.alter st de const 20.defic mot 21.AIT 22.AVC maj INVEST PCL IN HTA:1.Initiale(ex de ur:dens,alb,gluc,sedim;Addis,urocult,Ht,Hb,Cr,BUN,AU,Col,TG,HDLcol,Ionogr,K,Na,fund ochi,Rx tor,ECG,echocord) 2.speciale(urogr cu subst contr,angiogr ren,doz catecol plasm,doz metanefrine si AVM in urina,determ active ren palsm,doz cortiz in urina,ex Doppler al art ren) COMPLIC HTA:1.cardiovasc(IVS,b coron,aritm,AnAo,disAo,tromboze) 2.cerebr(tulb de circ ,isch ,tromb ,hemorag) 3.renale(nefroangiscleroza,IRC) OBIECT TRAT :1.constient si motiv bolnav 2.reduc val TA 3.incet evol bolii 4.comb f de risc 5.modif stil de viata 6.cult fact sanog 7.preven complic 8.red morbit asoc 9.prel vietii 10.inbunat vietii OBIECT TRAT NEMEDICAM:1.Combaterea obezitatii 2.Reducerea consumului de sare 3.aband fum 4.red cons de col si gras satur 5.red cons de alcool sub 30ml etanol/zi 6.asig unui reg optim de K,Ca si Mg 7.efect unor exerc fizice usoare MEDIC UTIL : I.INHIB ALE SIST SIMP 1.centrale(metildopa 250-1000mg/zi,clonid 0.1-0.2x2/zi,guanfac,reserp=stim rec alfa2,inh elib de norad,scad tonus simp,scad DC,scad RV>EA:hTA,depr,usc muc,tulb sex) 2.perif(reserp0.25-0.50mg/zi,guanetid 5-30mgx1-2/zi,guanadrel=inh elib de norad la niv neur perif,scad RVP>EA:somn,asten,depr,tulb sex,red debit regional) 3.alfabloc(pra 2-20mgx2/zi,tera,doxazosina=bloc rec alfa2,relax musc arter,vasodil>EA:hTAO,cef,amet,fatig) 4.betabloc neselect(propran 20-80mgx2/zi,oxpren,timol,sot=scad secre de renina,inh active simp,inh elib de norad,scad DC>EA=bronhosp,bradic,tulb metab gluc,fen Raynaud) 5.betabl select(acebut,aten,metopr 50-200mg/zi,betaxolol.EA:asem fara bronhosp) 6.betabl vasodil(labet,carved:act asupra rec alfa1 si a rec beta neselct>EA:asem plus hTAO) II.INHIB SRAA 1.IEC(capto 25-50 mgx2/zi,enala 5-40mgx2/zi,rami,benaz,cilaz=inh conv Ag1 in Ag2,red secr de aldo,red sint de endotelina,bloc degrade bradikin,stim sint de prostagland>EA:hTAO,hiperK,tulb digest,er cut)) 2.inh rec angiot(losart 20-100mg/zi,vals,epro,telmi=bloch rec pt Ag2,scad moder TA>EA;mai reduse nu product use) III.BLOC DE Ca:
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1.dihidropiridine(knifed 10-20mgx3/zi,nicard,felod,amlo=bloc can de Ca,depr contr,reduce vasodil,scad DC>EA:cef,ametz,cong fac,edeme,tahi,hTAO) 2.non dhp(dilt 60-120mgx3/zi,verap 180-240mgx2/zi=vasodil moder,scad mai acc a DC>EA:amet,edeme,poliur,constip,bradic) IV:VASODIL DIRECTE(HIDRALAZ 50-100mgx2/zi,MINOXI=ACT DIR ASUPRA FIBREI VASC,RED Ca ic,desch can de K>EA:cef,tahic,cong naz,er cut) V>DIURETICE: 1.Tiazidice(HCTZ25-50mg/zi,indapamid=cresc elim de Na,det hipovol,reduce RVP,stim secr de Pg>EA:hipoK,hiperuirc,scad toler la gluc,crest LDLcol) 2.de ansa(furos 20-40mgx2/zi,bumetanid=ef mai put,spoliere electrol mai redusa>EA:hipoK mai red,nu infl metab gluc) 3.econ de K(spiron 25mgx3/zi,triamt,amilor=inh ef aldost,red secr de K>EA:hiperlipemie,ginecomastie) TRAT HTA ASOC: DZ(pref:blCa,alpfabl,IEC evita:betabl,diur) IC(IEC,Betabl,diur/bloc de Ca,hidralaz) CIC(betabl,bloc ca,IEC/guanet,hidralaz) IR(blocCa,alfa,beta/guante,diur care econ K) AB(bloCa,IEC/beta,diur in doze mari) depr psih(IEC,bloCa/reserp) ICC(nicerg,IEC,bloCa/guanet) HIPERURICEMII,GUTA: CAUZE primara-crest prod de purine-idiopatica,defecte enzimat;scad clearance-ului renal al ac.uric; secundara-crest catab si turnover purinic-af mieloproliferative,limfoprolif,carcinoame,sarcoameanem hemo,psoriazis,med citotoxica;scad clearence renal al ac uric in af renale intrinseci,diabet insipid,sdr bartter,acidoza lactica,inanitie,cetoacidoza diabetica. guta:debut ac ,nocturn,monoart,loc la niv art metatarsofalang,prurit, descuam postinflam,cu perioade asimpt intre crize,de etiolg heterogena, cu caract fam. teg supraiacent cald, rosu, destins, febra frecv, tofii apar la niv:ureche ext, maini, picioara, olecran, bursa rotuliana; PARACLINIC:ac.uric peste 7.5mg/dl,in acutizari-VSH cresc,GA cresc;din tof se evid-cristale tipice de urat de sodiu=conf diagn. DD:celulita,pseudoguta,rar poliartrita reum cr,sarcoidoza,mielom multiplu,hiperparatiroidism,guta saturnina din intox cr cu plumb TRATAINS-indometacin;colchicina-in primele ore de la apar simpt-0.5mg oral din ora in orapana la max 8mg.corticosteroizii-in guta poliart,iv metilprednisolon40mg/zi cu scd trpt a dozei sau oral40-60mg/zi;analgezice-opiacee;; repausul la pat; in periaoda intercritica-dieta- Nu carne, organe, fructe de mare drojdii, bere, fasole, mazare spanac; evitarea tiazidicelor, aspirinei, ac nicotinic; med uricozurica-probenecid, sulfinpirazona, allopurinol initial100mg/zi,1sapt,apoi doza creste la200-300mg/zi. INFECTII CAI URINARE: inglobeaza mai multe entitati:cistita,PN,TBC ren,pionefroza,uretrita,prostatita. ETIOPATOG: E coli,proteus,klebsiela,enterob,enterococ,staf aur,pseud,piocianic,str fecalis,gonococ,chlamidia,trich vaginalis,mycopl hominis,candida albicans;cale de propag de obicei ascendenta but can be also hematogen sau limf;patogeni cap sa se dezv in urina ,resist la fagoc si la active bactericida a serului precum si capac de adez la tract urin.;partic locale=RVU,obstr cai urin,malf cong,subs cu rol ntrit in ur,migr leuc scaz.
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URETRITE: 1.gonococica:la barb,la cateva zile de la cont sex infectant apar dur uretr,disurie,polka,secr purul abund,la femei semne clin min,usoara vulvo-vaginita;comlplic locale la barb=locale:epididimita,prostatita si de dist:artrite,tenosinovite,endocard;la fem det boala inflam pelvina;dg=frotiu din secr uretrala;trat=cefalosp doz unica:cefotaxim 2g sau ceftr 1g im,sau cipro 500mg sau oflox 400mg po;data soc ciu chlam se rec asoc dozi 100mgx2/zi sau eritro 500mg/x4/zi 7 zile; 2.nespecifica:mycop,chalm,strp,tric vagin;secr uretr purul,cant mica si mai ales dimin;dg=semne clin si frotiu;Trat:chlam,myco=doxi 100mgx2/zi sau eritro 500mgx4/zi,oflox 400mg/zi 7 zile; CISTITA; Manif clinice:disur,polka,nictur,tenesme vezic,senz dur hipog,urini tulb,sau hemor,fara dur lomb,fara manif gen.TARAT CIST:1.doza unica:fem tinere,negravide,fara febra sau dur lomb,fara antec urol sau gineco=biseptol 4tbpo,amoxi 2gpo,nitrofurant 300mg po,oflox 400mg po,genta 80mgim ;3.schema scurta 3 zile:fem tin la care trat incepe dupa 3 zile de la deb: biseptol 2x2tbpo,amoxi 2x1gpo,nitrofurant 2x150mg po,oflox 2x200mg po,genta 2x40mgim; 4.sch lumga 7-10zile:cele cazuri,recidive= biseptol,amoxi ,nitrofurant,cefuroxim 1g oral PIELONEFR AC: Manif clinica: deb brusc,inst in cateva ore,febra,frison,dur lomb,caract colic,uni sau bilat,st gen alter,cefalee,gret,varsat,polka,sensib loje ren,Giord +,antec ITUJ,antec inf dig,anted gineco. INVEST PCL IN PNA: ex ur,proba Addis=crest nr leuc, urocult, HLG=leuc cu dev stg a FL,Rx=crest vol rin,litiaza,malf ren;eco=dil zona pielocalic. FORME CLIN PARTIC PNA: 1.forme febrile(st febr,alter st gen la batr si tarati su semne urin minime sau fara) 2.necroza papil(la diab si alcooloici,febra,fris,alter st gen,lombalg,hematur,tend la IR,fragm papil in sedim urin) 3.PN la gravide(fact favoriz;compreisa uter,risc matern,HTA,septicemia,risc fetal,premmaturit,moarte fat) TRAT PNA: rep la pat,caldura,alim us,multe lichide,antitermice,antispatice,analgeziceamoxi,cipro,cefalosp inject INSUFICIENTA CARDIACA incap inimii de a prelua sau de a trimite in arboreal circul cant de sange care sa acopere nev metab ale org. CAUZE:1,suprasolic fiz a mioc(crest RVP,HTA,sten Ao,sten pulm,crest vol de intoarcere,insuf mitr,DSA) 2.scad contract mioc(miocardopatia isch,infla mioc,intoc cron,alcoholism,tulb metab) 3.tulb umplerii(scad compl card,pericard contrictiva,obstr intracard,scurt diastolei) CLASIF NYHA I.dispn la ef f mari,urc a 8 trepte cu o greut de 10kg sau mers plast cu 25kg; II.dispn le ef obisn,mers plat,gradinarit III.dispn la ef mici,inbrcata,mers lent IV:dispn de repaus,la pat; MANIF CLIN ICS:dispn de ef,de rep,ortopn,parox noct,astm cardiac,Epa,tuse irit,astenie,paloare,cianoza,crest mat card,zg protodiast,suflu sist de insuf mitr funct,mat si raluri subcrep la baze,tahic puls slab,TA scaz. MANIF ICD:cianoza,subicter,jug turgesc,hepatalg de ef,refl hepatojugul,balon abd,olig,nictur,hepatomeg,revars pleur,zg protodiast,suflu de insuf tricusp funct,edeme declive
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PARACLINIC:Rx thoracic(mar cord,semne de staz pulm,dilat vene hil,edem interstit reticular,revars pleur) ecocord(eval dimens cord,cavit,pereti mioc,aprec kineticii,stab fract de ejectie) ECG(hipertrof ventr,cardiop isch,TR) biochimie(transom si bilir cresc in staza hep,ret azot in scad perf ren,modif ionice,scad K in trat cu diur) DG DIF ICS:AB,BPOC,pneumopatii ac,scleorze pulom,emfizem Dg Dif ICD:sdr nefr,GNC,CH,pleurezia,pericardita TRAT MEDIC 1.IEC/scad sint AG2,vasodil,red postsarc,reduce staza pulm,reduce presarc,cred DC,red deterior mioc/ind:toate formele de IC/CI:sarc,hTA,hipoNa,hiperKa,IR/capt 6.25-50mgx3,enal 2,520mgx2,lisin,rami 2.betabloc/red activ adrenergica,red cons ox,red TR,scad frecv,amelior tol la ef/ind:IC cls I,II,II,cardiomiopatia dilatativa/CI:IC severa,bronhospasm,bradic,tulb de cond,SSS/metop 2575mg/zi,carved 12.5-25x2,bisopr) 3.diur/inh res tub a Na,red volem,red presarc,red staza pulm/ind:toate IC simptomatice/CI:tulb HE,hTAO,tromboembolii/hctz 25-50/zi,furos 20-40,spiro 25/zi 4.tonicardiace/cresc tonus fibra mioc,cresc DC,scad pres diast,depr cond card,red frecv inima,cresc diureza/ind:IC cu dispn de repaus/CI:bradic,BAV,cardiomiop obstr,insuf cu baraj mechanic,tulb de rimt ventr/digoxin 0.25x4,lanatosid 0.5x3; STRATEG TRAT 1.asimptom(evit ef exces,red cons sare,trat b de baza,trat fact agrav,IEC,betabl) 2.simprom(lime f fiz la 4-6h/zi,reg alim hiposod,IEC,betabl,diur,digox la nev) 3.simpt cu dispn de repaus(rep in poz sezanda,reg alim hipos,sare fara Na,IEC,betabl,diur,spiro,digox) 4.simpt cu dispn de rep veche(rep la pat,reg alim hipos >1g/zi,red ap de lich,diur,IEC,spiron,digox) IRA deteriorare rapid progresiva a functiei renale prin scadere critica a irigatiei sangv. Sau prin lezare directa a celulelor tubulare. Se ajunge la pierdera acuta a fct renale cu sau fara infl cap de filtrare.; - prerenala ( Soc cardioge/hipovolemic/septicemie; arsuri; intoxicatie cu medicamente aminoglicozide, chimioterapice; vasoconstrictie renala) - intrarenala( boli renale: GNRP, nefrite interestitiale, stenoza/tromboza/embolia de a renala) - post renala ( obstructie de cai urinare prin calculi/ tumori) STADII CLINICE 1. faza de gersiune: de la h pina la zile- oligurie pana la diureza normala;2. oligurie pana la anurie: 7 10 saptamani; hiperhidratare, hipekaliemie, acidoza metabolica, uremie, supradozare medicam prin cumulare;3. poliurie: zile saptamani; regres manif de uremie; deshidratare, hipotensiune, tahicardie, pierdere de K si Na;4. refacere: durata de piana la 12 luni in medie 1-3 luni: DIAGN: clinic: edeme/ deshidaratare, culoare piele, frecatura pericardica, staza pulmonara, durer lombara la percutie, TA, glob vezical etc-;HG, creatinina, electroliti, LDH, mioglobina, bilirrubina, glicemia, VSH, fibrinogen, proteina Cr, teste de coagulare;Sumar urina; proteinurie ;EKG- semne de hiperkaliemie, tulb de ritm;Rx toracic rev pericardic/pleural;Eco abdominal; TRATAMENT: ajustarea posologiei medicam; inlat Fac. Cauzatori; trat bolii de baza; tratam complicatiilor; ultima alegere dializa;IRA oligurica are un prognostic mai prost
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IRC: result distr progres si irevers a nr de nefroni cu afect f secret de elim a subst tox a f de elim a apei si electroliti si a f endocr a rin(renina,EPO). EP:adulti=glorerulopat(40%),PNC(19%),nefrop vasc(5),nefrop medic(3);Copii= nefrop ered(21),glomerulop(21), hipoplaz ren(20),malf ren(20),nefrop vasc(9) STADIALIZARE : 1.insuf funct renala=nr nefr restanti >50%,creat 1.2mg%,dens ur <1022,GR 4mil; 2.compensat prin poliurie 50-53/1.2-2/<1018/3.5-4; 3.compens prin ret azot fixa:33-25/24/<1016/3-3.5; 4.std decomp 25-10/4-8/<1014/2.5-3; 5.std de uremia <10/>8/1010/2-2.5; MANIF CLIN: 1.std de deb:asimpt,semne clin ale nefrop cauzale,ClCr <70ml/min,dens<1022,Ur/Cr-N dar cresc la ing de prot sau in hipercatab prot,GR-N; 2.std compens prin poliurie:poliur,nictur,opsur,ClCr 40-60,Ur 50-80,Cr 1.2-2,dens <1018,GR 3.5-4; 3.std comp prin ret azot fixa:poliur,nict,semne anem,paloare,ametz,asten,ClCr 40,Ur 80-100,Cr 2-4,dens <1016,Gr 3-3.5 ; 4.stddecomp;poliur,nict.,ametz,paloa,asten,ClCr 30,Ur >100,Cr 4-8,dens <1014,tulburari HE,hipoCa,hiperP,acid metab, Gr 2.5-3; std uremic:tulb dig,CV, cut,nerv, ostart,ClCr 20,Ur 200-300,Cr>8,dens 1010,tulbHE,hipoNa,hipoCa,hiperK,hiperP,hiperMg,Gr 2-2.5 MANIF CLIN: 1.digest(anorex,gretz,vars, sughit,gura usc,limba incarc,gingivita,fetor uremic,gastr uremica,diaree); 2.CV(HTA,pericard ur,frec peric,TR,cardiomiop ur) 3.Resp(plam ur,dispn,ortopn,tuse,ral umed,resp Kussmaul,pleur ur) 4.Neuro(obos,apat,somnol,conf,coma ur,crampe,fascic,mioclon,polinevr ur) 5.cut(teg usc,prurit,hiperpigm,dermat) 6.ostart(osteitafibroasa,osteomalac,calcif mts,asimpt sau dur ostart) 7.hemat(anem,scad nr hem sub 3 mil,amet,asten,paloare,dispne) 8.endocr:scad libid,impot,tulb menstr,crest pth,prl,cortiz,scad test,estrog,h tir) MODIF BIOL 1.crest ret azot(crest Ur,Cr,AU,amon) 2.Tulb HE(scad Na,Ca,crest K,P,Mg) 3.tulb EAB(scad rez alcal,acid metab) 4.modif endocr(scadEPO,test,FSH,insul,crest pth si prl) 5.hemato(scad nr hem,scad coag) DG IRC 1.suspect(desc ret azot,cr>1.2,ur>40,desc sdr an sever,HTA sev,nefrop cauz)2.dg +(ex clin,antec de nefrop glomer,de nefrop interst,ex unei b de sist,DZ,effect Pcl) 3.dg etio(inf rinofar repet,abuz de AINS,de amalg,IU in antec,prez SNi,hemturie,HTA,edeme,prez SNo,proturie masiva,edeme,hipoalb,semne de staza urin,b de sist,DZ) OBIECT TRAT: 1.identif si indep cause 2.cercet fact agrav 3.incet evol 4.trat simpt 5.trat complic 6.suplin f ren 7.transpl ren TRAT:1.ig diet:red ef fiz,repaus la pat 2.reg alim:red ret azot,comb fosfatemiei,si acid,ref EHE,asig unei nutr coresp 3.aport hidric;diureza +500ml 4 aport subst miner:red aport sare,red
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aport K,combat hipoca 5.medicam:comg tulb EAB,EHE,a hipo/hiperca,hiperpth,anem,inf urin,HTA 6.suplin f ren:hemodializa,dial periton,transplant EDUC BOLN CU IRC:not de anat ssi fiziol a rin,cauzele IRC,manif clin,import investing pcl,tratam,imp ctrl medic periodic LITIAZA RENALA classic symptoms of renal colic and hematuria; asymptomatic or have atypical symptoms such as vague abdominal pain, acute abdominal or flank pain, nausea, urinary urgency or frequency, difficulty urinating, penile pain, or testicular pain. ETIOLOGY Eighty percent of patients with nephrolithiasis form calcium stones, most of which are composed primarily of calcium oxalate or, less often, calcium phosphate [The other main types include uric acid, struvite (magnesium ammonium phosphate), and cystine stones. The same patient may have more than one type of stone concurrently (eg, calcium oxalate and uric acid). Risk factors The risk of nephrolithiasis is affected by certain diseases and patient habits. For calcium stones, these include hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia, and dietary characteristics such as a low calcium intake, high animal protein intake, high sodium intake or low fluid intake Increased intake of Vitamin C has been variably associated with a higher risk of stones; A history of prior nephrolithiasis; Patients with a family history of stones have an increased risk of nephrolithiasis; The risk of stones is increased in individuals with enhanced enteric oxalate absorption; Low fluid intake is associated with increased stone risk; A persistently acidic urine promotes uric acid precipitation; CLINICAL MANIFESTATIONS-Patients may occasionally be diagnosed with asymptomatic nephrolithiasis when a radiologic imaging study of the abdomen is performed; Pain is the most common symptom and varies from a mild and barely noticeable ache, to discomfort which is so intense that it requires parenteral narcotics. The pain typically waxes and wanes in severity, and develops in waves or paroxysms that are related to movement of the stone in the ureter and associated ureteral spasm. Paroxysms of severe pain usually last 20 to 60 minutes; Gross or microscopic hematuria occurs in the majority of patients; nausea, vomiting, dysuria, and urgency. Complications Nephrolithiasis may lead to persistent renal obstruction; DIFFERENTIAL DIAGNOSIS: Bleeding within the kidney can produce clots that lodge temporarily in the ureter; ectopic pregnancy;aortic aneurysm; Acute intestinal obstruction or appendicitis;DG PCL:rx standard,echo,urografie iv,CT; TRAT:analgezice,antispatice,AINS; LEUCEMIA ACUTA LIMFOCITARA fatigab,febra,sangerari la niv pielii,mucoaselor,metroragii,epistaxis, hipertrofie gingivala, cefalee, confuzie, dispnee, citopenie, pancitopenie, mai mult de 30% blasti in mad os, in sg perif peste 90% din cazuri; bastonasul auer patognom in diagn LMASUBDIVIZATA IN: CU BLASTI NEDIFER, LAM CU MIELOBLASTI BINE DIFER, PROMIELOCITARA AC, MONOBLAST AC, ERITROLEUCEMIA, MEGACARIOBLAST. DD:LAM deLMC,sdr mielodisolazice;LAL de LLC,limfoame,leuc cu cel paroase. TRAT:LMA-chimio cu daunorubicina sicitarabina intensiv;LAL-chimio combinatadaunorubicina,vincristina,prednison,asparaginaza.
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LEUCEMIA MIELOIDA CRONICA: crest f mare de leucucite, heperprod de cel mieloide; in std precoce (faza cr) nu se comporta ca o boala maligna; debut varsta medie 42ani, fatigab, transp nocturne, subfebrilit, splenomegalie, stern sensib la palp PARACLINIC leucocitoza-150000, seria mielocitara deviata la stg, %blasti sub 5%, bazofilie,eozinofilie, TR=N/cresc, mad osoasa hipercel, FA scazuta, B12 cresc, ac uric cresc, crom philadelphia prez in sg perif/mad os ;pe masura ce boala progres- anemie progr, TR scad, iar proc de balstidin sg si mad cresc; DIAGN de LMC in criza blastica=blastii repr mai mult de 30%din cel mad os. DD:leucocitoza reactiva,policitemia vera,mielofibroza.trat:alfa interferonul recombinat a inloc hidroxiueea;trat eficient este transp de mad os alogena. LLC:=AF MALIGNA CLONALA A Lf B ;imunodepresie,insuf med,infiltr cu lf a unor organe; e boala varstnicilor, limfadenop. splenomeg, hepatomeg; 4std:0-numai limfocitoza, I-limfocitoza +limfadenop, IIorganomegalie, III-anemie, IV-trombocitopenie.in 5% apare sdr richter. DD:leuc cu cel paroase,limfoamele in faza leucemica,infect virale cu limfocitoza; TRAT: fludararbin;complic gen anem hemo autoimuna , trombocitopenia imuna necesita prednison sau splenectomie;LLC agresiva-transp de mad os alogena. LITIAZA BILIARA: the stones are the cause of the symptoms (ie, gallstone disease) or are an incidental finding. CLINICAL FEATURES :Gallstones on imaging studies but without symptoms (category 1) Typical biliary symptoms and gallstones on imaging studies (category 2) Atypical symptoms and gallstones on imaging studies (category 3) Typical biliary symptoms but without gallstones on imaging studies (category 4) Biliary type symptoms In most patients,recurrent pain attacks generated by the gallstones (biliary colic). Less frequently, the initial symptoms are those of one of the complications of gallstones (most commonly acute cholecystitis, acute biliary pancreatitis, acute cholangitis, or choledocholithiasis with extrahepatic cholestasis). The pain is usually constant and not colicky,intense dull pressure-like discomfort in the right upper or mid abdomen or in the chest that may radiate to the back and the right shoulder blade,follows ingestion of a fatty meal (about one to two hours after) and usually does not occur during fasting. The pain is often associated with diaphoresis, nausea and vomiting. It is not exacerbated by movement and not relieved by squatting, bowel movements, or flatus. Physical examination do not have fever or tachycardia, no peritoneal signs since the pain is purely visceral without gallbladder inflammation. Physical examination can also help distinguish patients with acute cholecystitis. A Murphy's sign. Laboratory studies screening tests: Liver biochemical tests (serum AST, ALT, total bilirubin, alkaline phosphatase).Serum amylase and lipase,Complete blood count (to evaluate for leukocytosis and anemia) Urine analysis. IMAGING STUDIES: echo,rx abdominal, Oral cholecystography,CT,scinti. ATITUDINE: gallstones but no symptoms (category 1) left alone,follow; biliary symptoms and gallstones (category 2) prophylactic treatment to patients who have or had biliary type symptoms or complications (such as cholangitis, pancreatitis, cholecystitis, choledocholithiasis, gallstone ileus and Mirizzi syndrome). gallstones but atypical symptoms (category 3) unlikely to be
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caused by the gallstones. An empiric trial of oral dissolution therapy with ursodeoxycholic acid is reasonable if other serious illnesses such as cardiac disease or peptic ulcer disease have been excluded. 4.typical biliary symptoms but without gallstones on ultrasonography (category 4) small stones (microlithiasis) or sludge that were missed,sphincter of Oddi dysfunction. MANAGEMENt:1.Biliary colic pain control-meperidine IV, which is preferred to morphine since it has less of an effect on sphincter of Oddi motility;NSAIDs) can produce effective analgesia : ketorolac (30 to 60 mg then ibuprofen 400 mg PO la nevoie. :elimin chir sau dizolvare medicala. LUPUS EP:AAN care react asupra struct proprii intret o r inflame in toate tes si org;complexe immune se depun,active complem ducand la form de subst boil active,chemotactice si proinfla;poate parea vasculita a vaselor micidin dif org si tes=manif clin variate;o serie de medic(chinid,procainamida,metildopa,resepr,nitrofurant,clorpromaz si contrac orale pot det manif asem lupus,cu deb acut,febra,mialgii,rash,serozita,manif renale. MANIF CLIN:1.artic(dur,redoare,artrite interfalang si MCF,pumni,coate,genu,tenosinovite) 2.cutan(erit fac fluture,eru mac-pap erit,lez dicoide,alopecie,lez muc) 3.pulm(pneum lupica,pneumop interst,pleurez) 4.card(endocard,miocard,pericardita lupica,vasculite coron) 5.digest(dur abd,disfag,pancr,hepatomeg,ascita) 6.renale(nefrita lupica focala,mezangiala,membranoasa,interstit) 7.nerv(cefa,conv,psihoze,neurop perif) CRIT DE DG(prez min 4):1.rash malar(eritem fix pe pom obraji cu tend de lim la niv sant naziolabial) 2.rash discoid(pete erit descuamative si atrof consec) 3.fotosensibil(rash cut dup exp la soare) 4.ulcer orale(or si nasofaring durer) 5.artrita(cu sensib si tumef la cel putin 2 artic) 6.serozita(pleurita sau pleurez) 7.afect ren(proteinurie >0.5g/24h,cil hem,granulose,tubulari) 8.afect neur(convulsii sau psih) 9.afect hemat(anemie,leucop,limfopen,trobocitopen) 10.tulb imunol(prez cel LE,Ac anti AND,Ac antiAm,test + lues) 11.AAN(crest titrului inafara de cele induse de asoc medic) TRAT:evit exp la soare,ef fiz prel,consum medic,sarcina;AINS,antimalarice de sint(hidroclorochina),prednisone( affect ren) asoc la nev cu ciclofosfamida sau azthioprina. MENINGITE: EP:arbovir,entero,adeno;meningococ,pneumoc,staf,strept,E coli,klebs,enterob,prot,pseudom,bK;protozare;toxopl;metzoare;cisticerci;fungi-candida. MANIF CLIN MEN VIR:deb brusc,febra ridic,cefal,fotof,amet,hiperst cut,mialgii,vars,semne de irit mening-red ceafa,semn Kernig,Brudzinski; PARACLINIC MEN VIR:ex LCR=clar,cateva sute de elem/mm3,la incep PMN apoi pred Ly,Mo,Plasmoc,glucorah si clorurorah f put modif,teste serol si de izol vir. TRAT MEN VIR:symptom,reg igdiet.rep pat,alim us,antiterm,ainfl,doze mici cortic. MANIF CLIN MEN BACT:1.per de debut(deb brusc,febra rid,frison,varsat,fotof,bradic,semne de irit men) 2.per de stare( dupa 1-2zile,agrav st gen,febra creste,event tulb psih,un tahic si crest TA,cefal acc,hiprest cut,opistotonus,intens sdr mening) PARACLINIC MEN BACT:LCR purul,crest PMN. TRAT MB:trat igdiet,rep pat,alimentar,antipir,ainfl,comb convulsii,antib:amoxi,ampi,ceftr,cefotax(NN-pred Str,coli,listeria) sau ampi,amoxi plus genta(sug si copmic-meningoc,pneumoc,h influ) sau penic doze mari+genta sau vanco; DG DIF MEN BACT/VIR/TBC/HEMORAGIA MENINGEE:
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1.deb brutal/brusc/lent/brutal; 2.febra ridic/moder/moder/subfebr; 3.sdr mening f intens/discr/int/int; 4.tulb de cosnt frecv/rar/tardiv/rar 4.antec: focare septice/vir resp,oreion/tbc/HTA,ATS MENOPAUZA inc cu ult menstr si este caract de car perman si defin a secr he estrog. MANIF CLIN:1.vasomot(bufeuri,transpir,palpit) 2.atrofice(uscac piele,verget,usc vagin,dispareunie) 3.endocrine(hipogonad,hirsut,scad libid) 4.neuropsih (obos, irit, fatig, cef, insomn, amet) 5.metab(crest greut,sdr metab de menop) PATOLOG ASOC:1.modif apar genit(atrof vagin,vulvara,dispareunia) 2.apar urin(atrof uretra,cistite recur,incontin urin) 3.metab(osteoporoza tipI,sdr metab de menop) 4.crest risc cardiovasc(crst incid HTA,CI) OSTEOPOR:scad dens os.dur,tasari vert,fract;scad in ainalt,cifoza,microfracturi,fract col;trat=prep Ca,calcitonina,bifosfonati-fosamax,raloxifen,ster anabol.; SDR METAB DE MENOP:cresc(col tot,TG,LDL-col,AU,Fg,rez insul);scad(HDL-col,secr insul,toler la gluc) TRAT:1.comb obezit 2.dislipdem 3.osteopor 4.fitosteroli 5.exerc fizic 6.medic; estrogeni (nature=estrona, estriol;sint=etinilestr, cloritrianisen); progesterone (medroxi,levonorgestrel); CI:HTA,trombofleb,tulb coag,hipercolesterol,HC,IR,fibrom,tum estrogendepend,Camamar,caovar. MONONUCLEOZA : Etiologie:virus Epstein Barr, eliminare prin saliva,boala sarutului. Tablou clinic:Incubatie:3 -30 zile;Debut:insidios si rapid progresiv cu angina febrila;Starea generala se deterioreaza treptat ,dar nu f mult, alaturi de febra facandu-si aparitia si dureri difuze (curbatura sau cefalee) ,astenie si inapetenta.Treptat apar si adenopatiile superficiale in special in loja submandibulara ,mai putin caracteristic latero-cervical sau axilar ;ggl.sunt mari,uneori f mari,vizibili,fara edem sau periadenita si nedurerosi . Ex. Faringe:angina eritematoasa , necaracteristica,,cu depozit confluent in false membrane ce acopera tonsilele ,putand fi extinse si pe lueta sau stalpii anteriori ai faringelui.In plus, splenomegalie(moale,nedureroasa,friabila),hepatomegalie moale nedureroasa ,exantem macupo-papulos cu aspect rujeoliform sau urticarian ,necaracteristic(apare rar , mai ales in cazurile tratate cu ampicilina-test diagnostic) cu durata de 7-10 zile. Enantem (pete hemoragice pe mucoasa palatala) in 25-30% din cazuri.Edeme palpebrale tranzitorii, necaracteristice. Evolutia este variabila in timp. Dupa 10-14 zile de la debut febra scade iar celelalte semne se atenueaza. Tratament; Nu exista tratament etiologic. Bolnavii se izoleaza in conditii de repaus la pat si dieta de crutare. Tratament antiinflamator asociat cu Eritromicina sau Clotrimoxazol pe o durata de inca 3-5 zile dupa scaderea febrei. Nu exista profilaxie specifica. NEFROP GLOMERULARE: b care affect cu prepond glomer renali,aler permeab glomer,determ red supr de filtrare si tulb excr apei si electroliti.

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CLASIF:1.predom sdr nephritic(GN poststrept,nefrop cu IgA,GNRP,sdr Goodpasture,purp henoch-schon,granulomatoza Wegener) 2.pred sdr nefro(GN cu lez min,Gn membr,GNmembrprolif,nefrop diab,nefrop LES) 3.ambele sdr(GNMP,din LES) ETIOPAT:fact infectiosi(str beta hemolytic-GNPS,inf vir CR-nefrop cu IgA,b Berger,purp hesch;endocard subac-GNRP) fact metab(DZ,amiloidoza) boli sist(LES,affect maligne,trat cu saruride Au,penicilamina);ei act prin mecan imunit,apar Ac anti MBG(GNRP) sau unor complex circulante ce st retin de glomeruli.(GNPS) CLASIF SDR NEFRI :evolutiv(ac,subac,cron) etiologic(primit,second) pathogenic(ac anti MB,CIC) MANIF CLIN GNPS:astenie,febra,fris,dur lomb,sdr nefrit(olig,hemat,edeme,HTA) MANIF CLIN SDR NEFR:edeme uneori disc alteori general,uneori anasarca,oligurie,asten,paloare,inapet,inf repet,uneori HTA; CLASIF CLIN A SDR NEFROT: 1.PUR(proteinurie select,80% albuminurie,abs hematur <5000/mm3,abs HTA) 2.impur(protur neselect,50% alb-urie,hematur >10000,HTA severa) TRAT: 1.GN poststr(reg ig diet-repaus,red ap sare,lich si prot,penicilamina ,nifedipxclonid,furosemid) 2.GNRP(prednis,azatioprina,ciclofosf) 3.sdr nefrotic(ig diet,reg hipercaloric,diuretice pt edempatogenicpredn,indometacin,azatioprinaxciclofosf) NEFROPATII INTERSTIT affect infect a CU sup si a interst renal. CAUZE: 1.obstr urin(calculi,aden de prost,sten uret,malf congen) 2.inf urin(ascendente,hematog,limf) 3.tulb metab(guta,hiperCa,hipoK,amiloid) 4.tulb imunol(b autoim,sdr,Sjogren,nefrop imunol) 5.afect neopl(limf,leuc,MM) 6.toxice(met grele,medic,analg,antib,subst contr) FACT CARE FAV APAR PNC:staza urin,lit urin,ptoza ren,malf ren,strict uretr,aden de prost,RVU,b de col vezical,sarcina. ETIO MICROB A PNC:1.gram -(Ecoli,Proteus,Klebs,Enterob,Pseud) 2.gram+(Str. Facalis,Staph epidermitis,aureus) MANIF CL PNC:asten fiz,fatig,subfebr,transp noct,inapet,scad greut,pal,dur lomb,sensib la palp rin,Giordano+,polka,nictur; NEVRALGIA DE TRIGEMEN Indidenta max in decada a II a si a III de viata, afect mai mult femeile Epis scurte de durere faciala lancianta, cu aparitie brusca frecv in zona comisurilor bucale, iradiaza instantaneu catre ochi sau narina ipsilaterala FACT DECL. Stimulare tactila, miscare, mimica, masticatie. In cazul unui pac tanar trebuie suspicionata scleroza in placi Se efectueaza CT pt excludere tumori. Tratament : carbamazepina ; 1200mg/zi, dar trebuie cu monitorizare hemoleucograma, si probe fct hepatice ; si baclofen
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NEVROZE: grup de b caract prin prez unor tulb psih,som si comportamentale in abs unor modif morfol si fizio, decelabile. EP:rezult unor conflicet int determ de dificult de rezolv a proble existent,care declans o serie intr de sufer care reptr o modal de aprare a eului;sufer sunt domin de o traire anx care se poate asoc cu trairi fobice sau depressive care se pot transfera pe plan somatic. MANIF CLIN 1. anxioasa(st de disconf gener,de tens,de nelin,de astept tensionata,de pericol difuz,se acc la singur,nelin psihomot,sentim tragic al exist,senz de esec,fatigab,slabic,epuiz fiz si psih,plictis,tulb de somn,cefalle,dur musc,amteli,diston neuroveget,tulb card,palp,dur precord,tulb respire,dur abdom,dispepsii,col irit,tulb urin,menstr,sex,angoasa,vertij) 2.fobica(anxiety asupra obmpers,sit,fobii constient absurde,tensiune perman,impos inlat fricii,timid,retragere in sine) 3.obsesiva(stare de disconf psihic det de imp unor idei,sentim,conduite,obsesii constinet absurde,ast fiz,abulie,criza de constiinta,indoieli,sent neimplin,timid,inhib soc,rigidit morala,meticul,perfectionism,agit spihomot sterile,ticuri,sterotip,tend de izol) 4.depresiva(resemnare,la pers introvert,deziteres,traire negative a even,ganduri sucidare,lamentare,depend de alte pers,tend de cons drog si alc,tend spre depr majora) 5.astenica(ast fiz si psih,result unor suprasolic,insatisf,oboseal penibila,dific de mobiliz,descuraj,epuiz,cefalee,tulb de somn,rau matinal) 6.isterica(pareza,paraliz,fara semne de lez sist priam,contr spastice,tremor,ticuri,amauroza,diplop,surdit,alter st de constyiinta,sincope,catatonie,amnezie,palpit,conv ton-clon) 7.tulb de somatiz sau nevr de organ(manif som capabile sa sug o b org=dur abd, tor, precord, member, vertebr, palpit, gret,varsat,diaree,meteor abd,intol alim,dispn si respire incompl,tulb vedere,ametz,tulb ciclu menstr,sexuale) CRIT DE DG PT SDR DE SOMATIZ:caract funct al acuze som,abs modif boil,nr cresc de acuze somatice funct,variabil acuze somatice,prez stresuri psih,antec nevrotice, prez anxiety si nevroze,traumat sufer som,nr mare de consult medic. OBEZITATEA: b nutritional-metab caract prin acumul gras care det o crest ponder >20% fata de greut ideala. EP:bilant energeic pizitiv-dezech dintre aport si consum de energie:crest ingestiei-rezult al tulb mec de regl a ap alim(h stimul=noradr,opioide endo,fact de elib a h de crest,h melanostimul,neuorpetid Y,orexine;horm inhib=serot,dopam,cck,fatc elin a horm corticotrop,neurotens,polip pancr,glucag) CAUZE: 1.obez prim(fact gen,endocr,metab,nerv,alim,psihocomport,sociocult,cons alc,sedent) 2.secundara(tulb endocr,sdr Cushing,insuf tir,insuf gonad,ovar polichistic,obez de menop.hipotalamica,sdr adiposo-genital) COMPLIC: 1.CV(HTA,CI,IC,varice MI,ulcere varic,trombofleb) 2.resp(tulb ventil,alter sch gaz,hipovent alveoli,sdr apn in somn) 3.ostart(coxartroza,gonartr,spond lomb,tendinita,talalgii) 4.piele(verget,ecz,intertrigo) 5.metab(DZ,dilipid,hiperuric) 6.digest(LB,steat hep,RGE) OBEZ LA COPIL: sdr Prader_Willi(obez,ret mint,hipogonadism) sdr Laurence-Moon_Bieldbardet(obez,ret mint,hipogonadism,retinita pigm) sdr Alstrom(obez,surdit,cecit,hipogon).Determ de alim artif necoresp.HTA mai frecv la cop obezi.,de as bronhosp,laringita etc.OBIECT TRAT:scad greut corpor,ment greu scaz,comb f de risc,reven complic,imbunat comport alim,imbun cal vietii.
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STRATEGIE 1.IMC25-29(scad mder in greut,dieta hipocal,red gras 30%,modif comp alim,act fiz sust,ment noii greut,trat b asoc) 2.IMC30-39(idem plus trat medic la nevoie) 3.IMC>40(idem plus dieta hipocal severa_) PRINCIPII DIETA HIPOCAL: 1.stab alim a caror ap trebuie control 2.evit alim cu dens cal mare 3.evit cons alc 4.asig unei diete echil nur 5.fract mese de 5-6x/zi. OCHIUL ROSU DUREROS: SEMNE SI SIMPT OCULARE: 1.senz de arsura(blefar,conjunct,kerat,pterigion,episcler) 2.fotofobie(conj,uveite,migr,nevr de trig,nevr optica) 3.prurit(conj,blefar,oki uscat,st alerg,lent cont) 4.lacrim(uveita ant,ectropion,ulcer corn,corpi str,obst canal nazolacrimar) 5.scad vedere(cataract,glauc,degener macul,retinop diab,nevr opt,dezlip ret) 6.ved dubla(paral nv oculomot,tum cereb,tromb de sinus venos,indsuf vertr-bazilara) 7.edem palpebr(blefar,conjuct,cellulite,ectropion,erizip,insuf ren,IC,hipotir) 8.ptoza palpebr(sdr horner,paral nv III,mist gravis) 9.congestie(conj,blef,ker,dacriocistite,pterigion,uveite ant,eroz corneene,clerite,glaucoma) EP DUR INSOT DE CONGESTIE:1.cauze oculare(tulb de refr,de acomod,oki usc,glauc cr cu unghi inchis,neurop optica,corioretinita post) 2.cauze extraocul(sinus,arterita temporala,nevralgia faciala,de sfenopalatin,migrena). BOLI OCHI ROSU FARA DURERE: blefarite,conjunctiv,episclerite,dacriocistite,hemorag subconjunctivala.OKI ROS+DUR:criza de glauc,sclerita,irita ac,iridociclita,kerat virale,bacter,keratoconjunctivite. SEMNE SI SIMPT ASOC :gret,varsat(criza de glauc),cefalee(glauc,sclerite),ameteli(tulb de acom si refr),fotofob(conjunct,kerat,episcler,uveita ant),lacrim(conj,ker,epics,uv ant),prurit(blefar,r alerg),ed palpebr(blef,conj,orjelet),secr mucopur(conj,dacriocistite),erit pericorneean(uv ant),halouri color,midriaza(glauc),mioza(uv ant),affect acuit viz(uv ant,ker,glauc) MANIF CLIN ALE B IN CARE APARE: 1.blefarita eritematosa(infl marg lib pleoape,jena ocul,senz de ars,prurit,lacrim,hiperem,edem marg lib a pleooape,nu affect acuit viz) 2.conjuctivite(infl muc conj,jena ocul,senz corp str,hiperem conj,fotofob,hipresecr ap/muc/mucopur,edem conjunctival,hiperplazie papilara si foliculara,eroz conjunctivale,hiperplazie papilara si folic,eorz conjunctivale,sufuz sang,nu affect acuit) 3.hemor subconj(acumul subconj de sange din vase mici,chiar si in abs traum,o event fragil capil,se rem spont,nu affect acuit) 4.orjelet(inf gl piloseb de la niv marg libere a pleoape,se manif ca un mic focar infla rosu,indurate,dur spontan si provocat,evol spre colectie si abcedare) 5.dacriocistite(infl sac lacrim,obstr can lacrim,jena ocul,tumef gl lacrim,lacrimare,cong unghi into chi,edem regional,nu affect acuit) 6.keratite(infl corn,dur ocul,cong pericorneeana,lacrimare,fotofob,lez corneene,edem palpebral,scad acuit) 7.episclerite(infl str supf al sclerei,apar lez circumscrise,bine delim,jena ocul,lacrim,fotofob,apar nodul conj,limitat,de cul rosu-violaceu,nu affect acuit)
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8.sclerite(infl str prof sclera,dur ocul intense,cefal,fotofob,lacrim,apr nodul inflame,congestive,rosu-violac,nu affect acuit) 9.uveita ant(irita,iridocicl,ciclita,infl tunica medie,dur int,acc la pres globi,fotof,lacrim,cong conj,eritem pericorn,mioza,noduli irieni,sinechii iriene,affect acuit viz) 10.glauc(crest pres intraoc peste 22mmHg,dur ocul int,incetos ved,halouri color,lacrim,midriaza,edem corn,gret,varsat,affect acuit) TRAT:1.conj bact(sol antib,event cortiz) 2.conj alerg(sol cortiz si antihist) 3.kerat fotoelectrica(ung vit A,ung oft cu dexpanthenol si un anest local) 4.dacriocist(ab local, sau general la nev) 5.iridocicl(adm loc midriatice,ab,event cortiz si AINS po) 6.orgelet(ung oft cu ab si cort) 7.criza glauc(urgenta oftalm;betabloc topic-timolol ;acetazolamida,diur osmoticmanitol;trat chir dupa calmarea crizei) OTITE: afect inflam ale urechii. CLASIF: 1.externe[o.e.difuza(staf,prot,str,e coli;otoscop=infl dif si ingust can audit,prez secr purul;dur conduct exacerb la pres sau mobil pavil;trat=toale reg,instill sol Rivanmcloramina,ainfl,antib),impetigo,furuncul,condrita si pericondrita,o.e.maligna] 2.medii[disfunctie tubara si nu se mai poate effect dren fiziol(seromucoasa,medie ac perfor/neperf,ac necrozanta,otomastoidita) MANIF CLIN DISF TUBARA:senz de ur infundata,plenit auriculara,autofonie,hipoacuzie de transmisie,timp retractat,de cul cenusiu albastru; MANIF CLIN OT SEROMUCOASA:hipoaciuzie,acufene,ameteli,otalgie,timpusor ingros,reduc transparentei,cul gri-violacee,bombare,red mobil) MANIF CLIN OTITA MEDIA AC LA COPIL:dupa o inf resp ac,pers sau reaprae febra,agit,ititabil,semne de rinofaring,tuse,varsat,diaree,conjunctivita,cop isi freaca urechi,capul d eperna,acuza dur auric,dur la pres tragus,hipoacuz de transm,timp rosu,congestionat,opacifiat,bombat,mobil redusa. TRAT:daca nu a mai fact rat antib se incepe ci amoxi si daca in 3 zile nu da rez se cont cu augm,cefurox,ceftriax;daca a facu se inc cu augm sau cefurox si fdaca nu da rez se cont cu ceftriax,clindam eventual timpanocenteza. PALPITATIILE: perceptia unor senz dezagreabil ale batailor inimii,descrise ca batai nereg,falafaituri,bat mai puternice,pulsatii. EP:1.omul sanat(ef fiz,stress,emotii put) 2.boli CV(TR,CI,IAo,IMi,IC,DSA,miocardite,PVM) 3.b endocr(tireotox,spasmofil,feo,menop) 4.b de sange-anemie 5.b psih(stress,nevr asten,hipocondria) 6.b digest(aerofagie,BRGE,hern hiat) 7.medic(adren,atrop,efedr,tiroxina,miofilina) 8.toxice(alcool,ceai,cacao,tutun,cafea) PARTICULARIT 1.cond de apar(a.dupa effort-sanatos,simpaticoton,tahi sinus;b.dupa alc,tutun,cafea-intox,predisp simpaticotonie) c.dupa o viorza-miocardita) 2.mod de apar(a.brusc-tahi parox,FiA;b.lent-Flutter atr) 3.frecv(a.rapida-tahi sin,tahi parox,FltA,TV;b.lenta-bradi sin,BAV,intox digit) 4.ritm(a.regulat-tahi parox;b.nereg-FiA,ESV) 5.durata(a.minute-tahi parox,FiA;b.ore-FiA;c.zile-FiA)
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6.dispar(a.brusca-tahi parox;spont-tahi parox) SIMPT ASOC: 1.dur precord(FiA,FltA,TPA,TPV,extrasistolia,nevr astenica) 2.dispn(FiA,TPV,PVM,SSS,SM) 3.ameteli(FiA,FltA,TPA,SSS,BAV) 4.varsaturi(TPA,TPV) 5.anxietate(TPA,FiA,FltA) 6.lipotimie(TPA,TPV,FiA,FltA,SSS,BAV). PARAZITOZE CUTANATE SCABIA CARACT ESENTIALE: Prurit generalizat, vezicule si pustule prurig dispuse in santuri sau galerii, interdigital, pe eminente tenare , pliurile artic pumnului Microscop: vizibili parazitiioula, punste brune (fecale) Prezenta de papule sau noduli rosii pe glandul si corpul penian e patognomonica. La femei pe mameloane. TRAT Steroizi topici Dezinfestare LINDAN, PERMETRIN CREMA 5% PEDICULOZA CARACT ESENTIALE : prurit, escoriatii, lindini pe firele de par, frecvent deasupra urchilor, paduchi pe piele si haine. Uneori, in infest cu paduchi pubieni, macule azurii pe fetele mediale ale coapselor sau pe abd. Inf TRAT Pt paduchii pubieni LINDAn Pt pediculoza capului : PERMETRIN CREMA 1% PARKINSON: sdr extrapiramidal-tulb de motilitate EP:scad dopam in locus niger si locus ceruleus sau de un dezech dintre sist cholinergic si sist dopaminergic in urma unor infectii-postencefalitic,proc degenerative-aterosclerotic,intoxicatiiCO,sulf de C,medic. TULB DE MOTILITATE:1.sdr pyramidal(simpt defic motor,affect motil voluntare,tulb tonus muscular,misc involunt,modif ROT,apar refl patol) 2.extrapiramid(sdr hiperton-hiperkinetic,b Parkinson,sdr hipotono-hipokinetic,correa syndeham,b Wilson) 3.cerebelos(tulb de echil,de coord misc,de coord misc fine) 4.vestibular(vetrtij meniere,nevrita vestibulara,neurinom de acustic,insuf vertr bazil,ATS cereb,tum) 5.sdr de neuron mot perif(radilculite,polinevrite,poliradiculonevrite,lez corn anterior,sclera lat amiotrofica) 6.sdr muscul(miopatic,miozitic,miotonic,miastenic) CLASIF SI ETIO TREMURATURI:1.tremor postural,5-9Hz,cand mb sunt posit import gravit,tremor fiziol,essential,sevr de alc,tulb metab,prod de medic,psihogen;2.de repaos,36hz,cand mb sunt in repaus,b parkin,paraliz supranucl progress,Indus de medic,psihogen 3.intentional,3-10hz,la dif misc volunt,lez cerebel,psihogen; MANIF CLIN:debut lent progresiv(trem de rep extreme,unilat dar se general,dimin la misc active,rigiditate plastica,ced in roata dintata,bradikinezie,instab postur progresiva,facies imobil,tremor prioral,dif de mers,mers cu pasi mici taraiti,abs balans natural,tend de cad,us deterior intellect FORME CLIN PARTIC:1.postencefalitic 2.ats 3.medic 4.toxic
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TRAT:1.precurs dopamine-levodopa 2.inh decarboxilaza-carbidopa 3.agon dopaminergicibromocriptina 4.inhib MAO-B-selegilina 5.anticolinergici-trihexifenidil 6.antidepresivetriciclice-amitript,notript,imipramina 7.altele-amantadina PAROTIDITA EPIDEMICA: ETIOLOGIE :infectie cu virusul urlian. MANIF CLINICE :Incubatie:2-3 sapt. Per prodromala:nespecifica - febra mica , anorexie, cefalee; Per de stare: 1.dupa o zi apar dureri si discreta tumefactie la palparea gl parotide ipsilaterale. Glanda se mareste progresiv in urmatoarele 2-3 zile , cu stergerea santului retromandibular .Tumefactia apare de regula la o glanda si in cateva zile afecteaza si glanda contralaterala.1/4 din pacienti pot avea afectare unilaterala. Orificiul canalului Stenon este edematos si eritematos. Apare trismus , cu dificultati de vorbire si masticatie .Sucul de fructe citrice exacerbeaza durerea . In primele 3 zile temperatura atinge 40 gr Celsius. Dupa ce glanda parotida atinge maximum temperatura si durerea scad rapid-revenirea la marimea obisnuita in 7 zile. Afectarea altor gl salivare:10 % din bolnavi (submandib, subling), asociaza edem presternal prin obstructia limfaticelor din aceasta regiune sec. maririi gl salivare. 2. afectarea SNC:51%modif LCR fara man clinice ,10%-meningita manifesta de regula la 4 zile dupa parotidita , encefalita urliana 1 caz la 400-6000 de bolnavi, surditate unilaterala cu fct vestib normala , ataxie cerebeloas, paralizie facial, mielita transversa, poliradiculonevrita ascendenta (sd Guillain-Barre) si sd poliomielita-like.,stenoza de apeduct Sylvius cu hidrocefalie interna dupa infectia SNC cu v. urlian. 3.Orhi-epididimita:20-30%din pac masculini postpubertal,bilaterala la 1 din 6 pac ,rar inainte de pubertate; Uneori precede parotidita sau apare ca unica manif clinic;Debut brusc, cu febra(41gr Celsius), frisoane, cefalee, varsaturi si dureri testiculare; EX CLINIC :tumefactie +edem+eritem al testicolului si scrotulu;Prezenta in 85% din cazuri din cazuri si precede orhita;Testicolul poate avea dimensiuni de 3-4 ori mai mare ca normalul;Febra scade in 5 zile,durerea in 2 saptamani;Luni-ani dupa episod se poate constata un grad de atrofie in 50% din cazuri;Chiar si la cei cu afect bilat impotenta nu este o sechela iar sterilitatea este rara.4.Ooforita:5% din femei postpubertal;febra ,greturisi varsaturi ,dureri abdominale.Rar afect fertilitatii sau menopauza prematura5.Afectare articulara : rara.Poliartrita migratorie frecv descrisa.6.Pancreatita-rar sevara; 7.Modif ECG-15%:miocardita; 8.Nefrita; 9. Alte manifestari :tiroidita, mastita, prostatita, hepatita si trombocitopenie. COMPLICATII :Avort spontan,in primul trim de sarcina; Malformatii congenitale:fibroelastoza endocardica; Diabet juvenil-rol neprecizat; TRATAMENT:Simptomatice:antialgice,antitermiceaplicatii topice cu antiflogistice; Reechilibrare hidro-electrolitica in meningite si pancreatita;Orhita:repaus la pat , suspesot,antialgice, punga cu gheata.Nu exista dovezi ca utilizarea corticosteroizilor este eficienta.Interferon alfa-2-reduce simpt. si riscul de atrofie. PREVENIRE :Izolare;IG nu reduc simpt. Sau incidenta meningitei si a orhitei;Imunizarea activa : virus viu atenuat , 1 adm sc protectie in 95% din cazuri;risc f mic de meningita aseptica .vaccinare>varsta de 12-15 luni:personal medical neprotejat, barbati adolescenti fara inf urliana in antecedente.Nu se adm la gravide, la cei cu imunodepresii severe , boli febrile. PNEUMONII: inflame a parench pulm care interes alv pulm,brohiole si tes interstit care real un tablou radio de condensare pulm. ETIO:
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1.primitive(a.bacteriene:str.pneumoniae,str.pyogenes,str.aureus,bac Friedlander,H influenzae,Legion pneumophila,Morax catharhalis;b.alte microorg:Myco pneum,ricketsii; c.virus:gripal,adeno,VSR,ruj,varic;d.inhal subst tox:gaze,pulb,lipoizi) 2.secundare(a.prin tulb circul:hipostatice,dupa edem pulm;tulb bronsice:Cabrons,bronsiectazii) CLASIF: 1.comunitare: imun norm,flora obisn; 2.nosocomiale:imun rel norm,flora de spital;la imunocomprom:imun comprom,flora speciala; ETIOL IN ORD FRECV AG PATOG:pneumococ,H infl,Leg pneum,bac gram -.vir grip,adeno,staf aur,altii. MANIF CLIN IN PN COMUNIT:deb brut,febra,facies vultuos,herpes labial,limba saburala,frison solemn,junghi tor,polipnee 40-50/min,cianoza,tuse,expect rugin,delimit amplit resp,matitate,exacerb vibr voc,dimin MV,suflu tubar,ral crep,tahic,tend de scad a TA. MANIF CLIN A PN VIRALE:deb lent,febra,frison,cefalee,dur retroorbit,curbatura,catar orofaring,tuse usc,suparat,tahipn,semne pulm sarace,dimin MV,raluri bronsice diemin,abs semne de condens pulm. DG DIF PN VIR/PN PNEUMOC:deb brusc/progress,febra ridic/moder,frison solemn/frisonete,junghi tor prez/abs,tuse rara/suparat,expect rugin/red,st gen alter/moder,sdr de condens prez/absent,HLG leucocitoza/leucopenie,affect CRS abs/prez. ETIOL PN NOSOC IN ORD AG PATOG:ps aerug,staf aur,klebs,e coli,h influ,proteus mirabilis,enterobacter,str pneum. PARTIC PN IN F DE ETIOL:1.stafil(auriu,mai laes nosoc,la indiv debility,la batr,copii,stare tox,tend la colaps,asp de bronhopn,abc multiple,r pleur,stare sept,leuc pronunt) 2.Friedlander(mai rara,tarati,alc,diab,st gen alter,st de prostratie,dispn pron,tend la colaps,sputa brun inchisa,tend de aforma abc,opac nodul disem) 3.Legion(deb pseudogrip,pneum extinsa,tend la bilateral,r pleur,affect hep sir en,tend la insuf resp sir en) 4.chlam(deb pseudogrip,semne fiz sarace,manif nerv,forma tifoida,leucopenie,opac hil difuze) 5.H influ(dupa inf virale,dispn acc,tuse,junghi,st gen aletr,semne fiz sarace,rx umbre mici disem pe ambii plam) PARTIC IN F DE VARSTA SI TEREN:1.copil(reactive cresc,posib apar tulb toxicoinfect,tulb cardioresp,tulb HE,tens de stop crdiresp) 2.la batrani(poate evol cu symptom stearsa,febra red sau afebril,st de adinamei,tend la colaps) 3.la tarati(deb mai lent,st toxicseptic,fris repet,tend la bilateral,raluri crep si subcrep disem,nu se pto depista zone de matit,rx opac nodul bilat) APREC GRAV PN LA COPIL(moderata/severa/f severa):1.tahipnee moder/acc/f acc;2.tiraj abs/moder/acc;3.alim orala posibila/posib/imposib;4.cianoza abs/abs/prez;5.geamat abs/prez/prez;6.deshidr abs/ans/prez;7.st de const prez/prez/abs ;8.tens la stopCR abs/abs/prez. TRAT AB ORIENTATIV PN: 1.pneumoc (penic, ampi, amoxi, augm, cefotaxim, eritro) 2.stafil(meticilina,cefalotina,cefazolina) 3.H infl(doxi,bisept,cefuroxim,cefaclor,claritro) 4.legion(eritro,cipro) 5.anerobi(genta,metro) 6.virala(simpromatic,acyclov,imunoglob) ANTIB REC IN TRAT AMBUL AL FORME MEDII:penic 50000u/kg la 6h;amoxi 20mg/kg oral la 8h;augm 10-15mg/kg oral la 8h;eritro 10mg/kg po 6h;cefixim 8mg/kg po 6h;claritro 7.5mg/kg oral la 12h;biseptol 5mg/kg oral 12h.
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POLIARTRITA REUMATOIDA b inflam cron de cauza nec care interes in mod deos sinoviala artic si se manif clin prin infla artic persist,evolut,sim si centripete care prind mai ales artic mici ale mainii. EP:apar Ac antiIgG,AAN,Ac antimitc,anticolag,pe teren imunogenetic sust de agreg famil si prez HLA specif.iar la decl pot intev o serie de fact int si ext ;Ac-antiIgG(fact reum) secre de ly din sinov form cu IgG compl immune fagoc de cel polinucl,monoc si vor intret proc inflame;cel implic:Ly,macrof,PMN,cel sinov,cel endot;subts implic:PG,LT,sist complement,monokine,limfok,TNF,PGF etc. MANIF CLIN:Deb insidios,asten,irit,insomn,scad greut,mialg,poliartralg fug,fen raynaud,red matin,interes cu predom a artic mainii,artrita artic interfalangieneproxim,metacarpofalang,interes sim,evol cetripeta,prind artic cot si genu,noduli reumatoizi,evol trenanta in pusee,deform degete,asp fusiform,atrofii musc,evol spre fibroza,anchil si deform artic,mana reumatoida in forma de ghara,atrof piele,manif viscer,cardiomiop reumat,pericard reumat,fibr pulm,polineuropat,keratoconjunct,iridociclita. CRIT ARA(minim 4) 1.redoare matin d emin 1h,cel put 6 sapt 2.tumef cel put 6 sapt a min 3 artic 3.tumef cel put 6 sapt a artic radiocarp,metacarpofal si interfalang proximale 4.afect sim a a artic 5.prez noduli reum 6.modif Rx tipice aartic mana 7.prez FR; STADIALIZARE: 1.algic=red matin,dur art mana,fen Raynaud,asten,insomn,scad greut,inv pcl N sau modif min 2.inflamator=tum artic interfal prox si MCF prin interes sim,deg cu asp fuzif,evol tren si centrip,VSHcresc,a hipocr,FR si prot faza ac,Rx-osteopor epifiz,pens spat artic si microgeode; 3.deformant=proc de fibroza,anchil si deform,dev ulnara a mainii, deg in gat de lebada,cota si gen art in f de maciuca,atrof peile si muschi,VSH cresc,PR si PFA prez,Rx eroz ale extreme epifiz si def artic 4.anchiloza=mobil artic compromisa,fibr si osif artic,mana in ghara,tulb viscer,card,pulm sir en,HSH cresc,FR si PFA,Rx def artic,fibr sau osif artic) OBIECT TRAT:combat dur,inflame,pastr f artic,prev deform,stabil bolii,recup boln. MEDIC:1.analg(parac.algoc,apir 1-1-5g/zi) 2.AINS(diclof 25-100mg/zi,nurofet cca 1g/zi,indometacin 75-150,vioxx 25) 3.corticoizi(prednisone 5-7.5,pr-solon 5-20) 4.antimalarice(clorochina,hidroxiclorochina) 5.saruri de Au(tauredon) 6.ac aminosalicilicsulfasalazina 7.deriv tiolici(d penicilamina,piritinol) 7.imunosupresive(metotrexat,ciclosporina,azatioprina PREVENIREA RAHITISMULUI Profilaxia prenatala adm calciu si vit D femeii garvide in special in ultim luni de sarcina si prevenirea nasterii premat Profilax postnatala expunere la soare, alim naturala, adm medicamentoasa vit D SCHEME 1. Adm zilnica in doze orala, fractionate egale cu nev zilnica de vit D. Incepe la 7 zile , 400-800 UI/zi pana la 2 ani (1-2 pic) Aceasta este tehnica cea mai fiziologica 2, Adm periodica de doze depozit(stoss) intramusc. Prima doza 200 000 UI in maternitate, restul la 6-8 sapt (in total 1.200.000 UI in primul an) Adaosul de Ca se impune numai la prematuri sau copii care primesc < 400 ml lapte/zi, in doza de 50 mg/kg/zi calciu elemental

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RINITE: symptoms: Sneezing Rhinorrhea (anterior or posterior) Nasal congestion Nasal itching; ALLERGIC RHINITIS risk is increased in individuals with eczema or asthma. peak in childhood and again in the 30s or 40s .Patients with seasonal allergic rhinitis often have associated allergic conjunctivitis, characterized by itchy, red, irritated eyes. Common allergens causing seasonal allergic rhinitis are tree, grass, and weed pollens Indoor allergens in house dust such as dust mites, cockroaches, animal proteins, and fungi. NONALLERGIC RHINITIS chronic presence of: nasal congestion, rhinorrhea, and postnasal drainage, absence of nasal and ocular itching.Triggers :tobacco smoke, diesel and car exhaust, changes in temperature, strong fragrances, cleaning products, newsprint, and alcoholic beverages . Vasomotor rhinitis is variably considered a subtype of nonallergic rhinitis and is characterized by watery nasal discharge, intermittent congestion, and an exaggerated reaction to nonspecific irritants such as air pollution or temperature changes, especially exposure to cold, dry air . Gustatory rhinitis is a episodic condition with prominent watery rhinorrhea triggered by hot or spicy foods, which may be caused by a vagally-mediated reflex . MIXED RHINITIS combination of allergic and non-allergic rhinitis. OTHER CAUSES Rhinitis medicamentosa over-the-counter decongestant nasal sprays. Systemic medications oral contraceptives, erectile dysfunction drugs, some antihypertensives, some antidepressants, non-steroidal antiinflammatory drugs, and some benzodiazepines Structural abnormalities congenital, enlarged adenoids, foreign bodies, septal deviation and perforation, nasal polyps and tumors. Pregnancy rhinitis ,Atrophic rhinitis nasal congestion, crusting, and a persistent bad smell Systemic diseases Wegener's granulomatosis, sarcoidosis, midline granuloma, cystic fibrosis, hypothyroidism, immotile cilia syndromes, and immunodeficiencies. RUBEOLA: EP:contag cale resp,f contag,imun durabila,vir cu act teratogena la gravide. MANIF CLIN:1.per de inv(incub 16-18zile,deb insidios,anorex,faring,disfag,febra moder,adenop retroauric,asubocc,indolore,persist.)2.per eruptiva(er dupa 2-3 zile,pe fata,se gener pe tr si mb,un prurig,raman zone indemne,sur 2-3 zile,un apare enantem bucal) PCL:leucopen,limfocit,plasmocitoza TRAT:izolare domic,rep pat,alim usoara,antipiretice,antiinfl,antibiotice. RUJEOLA: EP:vir rujeolic,transm dir pe cale resp,boln contag de la ult zile incub pana la sf erupt,lasa imun durabila. MANIF CLIN:1.per de invazie(incub 8-11zile,febra ascend 39-40,st gen alter,inap,curbat,adenop submax,latero-cerv,retroauric,catar oculonaz ,resp si digest,stranut,conjunctivita,fotofobie,tuse usc,gret,varsat,diar,enantem bucal,hiperemie difuza,puncte congestive uneori hemor,puncte albe,semn Koplik) 2.per eruptive(acc febra,st gen alter,exantem descendent,intai retroauric,fata,frunte,apoi tor,abdom,mb,macropapule confluente,zone de piele sanat,neprurig,catifelat,dur 5-6 zile,dispin ord inverse,lasa pigm posterupt,descuamatie) COMPLIC: 1.respir(laring,bronsiol,PNI,BrPneum) 2.nerv(mening,conv,encef)
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3.digest(stomat,gastroenter,apendic) 4.ORL(otite,sinuz) TRAT;ig diet-reg hisrozahar-alim usoare,trat symptom tuse febra,izol boln;preven=vacc SARCINA EXTRAUTERINA: dezv ou inafara cav uter.Localiz:95% tubulara 2% abdom,1% cervicala,1% ovar EP:tulb de pasaj al oului prin trompa.fact derisc=avorturi repet,salpingite,endometrioza,fibr uterin,met contracept. MANIF CLIN:dur abd infer,car variabil,event parox,car colicativ,irad epig,lombe,coapse,intov de amenoree,semne funct de sarcina,gret,varsat matin,turgesc sani,tulb neuroveg,event sanger vagin dupa o per de amenoree,cant redusa,cul bruna,col uterin normal,sau usor cartifelat,orif uter inchis,uter usor marit dar neconcordant cu varsta sarcinii,palp unei format parauterine,usor durer,care creste de la un ex la altul. DG DIF: avort,b trofoblastica,chist luteinic,tum ovariene,tors de pedicul ovarian,salpingita,apnedicita acuta,inflame pelvine. COMPLIC SEU: 1.avort tubar(intensif dur abd,accent sanger genit,elim caducei uterine,semne de irit periton,tenesme vezic,sensib fund de sac Douglas) 2.rupt tubei(dur abd,bal abd,sensib la palp abdom,matit mobila pe flanc,pal,amet,lipot,strigat Douglas,tahic,scad tens arter,soc hemor) TRAT:metotrexat,actinomicina,chirurgical. SCARLATINA: EP:sursa e omul bolnav cu scarlatina sau alta infectie streptococica cu tulpina secretorie de eritrotoxina;convalescentii,purtatorii sanatosi;cale de transmtere :aerogena sau indirecta;poarta de intrare:faringiana , cutanata sau conjunctivala(rar) CLINIC:Incubatie:3-5 zile; Debut : brusc,cu febra (39-40 gr.Celsius), frisoane ,odinofagie, alterarea st generale, cefalee, greturi, varsaturi, dureri abdominale. Ex. clinic:angina,adenopatie submandibulara dureroasa;Per. de stare:dupa 1-3 zile:a. Exantem:apare intr-un singur puseu,care se extinde 12-24 ore,rareori este generalizat,prezinta zone de electie: gat ,torace , abdomen(antero-lateral) , fese , fata anterioara a bratelor si coapselor, fond eritematos difuz presarat cu papule mici(varf de ac ),numeroase ,eritematoase,aspre,de tip congestiv, nepruriginoasa , respecta fata : masca lui Filatov(facies palmuit)+paloare periorificiala,respecta palmele si plantele, Semnul Pastia-Grozovici : linii echimotice orizontale la nivelul plicilor de presiune;b.Enantemul:angina eritematoasa,eritematopultacee,ulcero-necrotica;ciclul lingual:ziua 1 limba alba slaninoasa(de portelan), apoi se dezepitelizeaza(cele 2 V-uri),ziua a5-a limba zmeurie,reepitelizaree in zilele 6-8(limba lacuita);Per. de convalescenta:2-3 saptamani. COMPLICATII Toxice;nefrita in focar/miocardita/suprarenalita/artrita/encefalita/soc septic/componenta hemoragica; Septice:locale sau sistemice(din sapt a 2a); Tardive:alergice:RAA,GN acuta difuza,purpura Henoch-Schonlein,eritem nodos. TRATAMENT Izolaree in spital 15 zile;Tratament igienodietetic;Patogenic:antitermice,simptomatice;Etiologic:Penicilina G 2-3 MU/zi la 6-8 ore
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interval,timpde 7 zile ,apoi Benzatinpenicilina G:1,2 MU im.La cei sensibilizati la Penicilina se utilizeaza un macrolid timp de 10 zile;Supraveghere clinica si de laborator 3 saptamani. PROFILAXIE :Izolare+tratament corect;Ancheta epidemiologica ;Supravegherea contactilor;Igiena individuala si a colectivitatii SCHIZOFRENIA SI ALTE PSIHOZE: Caracteristicei esentiale::Izolare sociala, usor progresiva, insotita de deteriorarea autoingijirii Stergerea limitelor eu-lui, Pierderea asocierilor logice, gandire lenta, trecerea de la un subiect la altul Atitudine autista= preocupare excesiva pentru ideile personale preocupari cu caracter sexual sau religios Halucinatii auditive, depreciative Iluzii, grandoare, sau de persecutie Simptomele dureaza cel putin 6 luni Alte semne : apaltizare afectiva, hipersensibilitate la stimulii de mediu, senzatia de perceptie senzoriala crescuta, comportament dizarmonic, gandire concreta fara abstractizare, simbolism inadecvat, afectarea puterii de concentrare, depersonalizare, Clasificare : schizofrenia, tulburari paranoide (iluzii de persecutie, afectare minima a activitatii zilnice), tulburari schizoafective (simptomatologie afectiva ce preceda sau se dezvolta in paralel cu manifestarile psihotice), schizofreniforme (durata mai mica de 6 luni), psihotice reactive de scurta durata (mai putin de 1 saptamana), psihoza varstei inaintate (>60 ani), atipice(dependenta de droguri, disfunctia de lob temporal, infectia HIV) Tratament : medicatia antipsihotica : antipsihotice tipice : haloperidol 2-5 mg, tioridazina 100400 mg, clorpromazina 100-400mg ; atipice : olanzapina 5-10mg, quetiapina 150-450mg, risperidona 2-6mg, clozapina 300-450mg Sub antipsihotice scade : hiperactivitatea, halucinatiile, ostilitatea, agresivitatea, iluziile, irascibilitatea, insomniile. Sindromul neuroleptic malign : semne extrapiramidale, modificari ale presiunii arteriale, alterarea constientei, hiperpirexie, rigiditate musculara, congestie pulmonara, diaforeza. Evolueaza spre coma si deces. Cauza : trat prost supravegheat, deshidratare, litiu plus antipsihotic, poate aparea si la doze mici de antipsihotic. TRatament : mentinerea echilibrului homeostatic, scaderea febrei, bromocriptina, dantrolen. Post SNM, tratamentul se va face cu clozapina sau terapie cu electrosocuri Alte efecte adverse : akatisia : dorinta subiectiva de a fi in miscare, plus imposuibilitatea de a sta linistit. Risc de suicid, sentimente de spaima, furie, teroare. Distonia acuta : spasme musculare cu aspect bizar, care apar la nivelul capului, gatului si limbii : se trateaza cu benztropina mesilat, medicatie antiparkinsoniana Parkinsonism iatrogen : akinezia, rigiditate, disparitia reflexelor posturale, tremor : tratement : amantadina, antiparkinsoniene, Diskinezia tardiva : miscari involuntare stereotipe ale fetei, gurii, limbii, trunchiului si ale membrelor. Apare dupa luni/ani de tratament cu antipsihotice. Factori predispozanti : DZ, fumat, tratament indelungat TRATAMENTUL schizofreniei nonfarmacologic : Social : : intrajutorare, invatamant si ajutor mutual, reabilitare profesionala Psihologic : psihoterapie de grup, suportiva, ca sa isi refaca potentialul de munca, sa devina un observator bun al propriilor sale simptome pentru a preveni recaderea Comportamental : tehnici comportamentale, intarire pozitivva, muziica Prognostic : simptomele pozitive au prognostic bun, cele negative, rezervat.

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SDR.CUSHING: CARACT obezit de tip central, pierderea masei ms, piele subtire, echimoze, hirsutism, vergeturi, osteoporoza, hta, hiperglic, leucocitoza, limfopenie, hipopotasemie, glicozurie, crest cortizol seric si urinar, ,abs inhibitiei norm la dexa. TESTE DIAGN: screening- adm dexa 1mg la ora 23 si recolt serului la ora 8dim =sub 5microg/dl se exclude diagn. colectarea urinei din 24orept det cortizol si creat urinare,diagn sust de cortizol liber urinar cresc anormal,cortizolemie peste 7.5microg/dl la miezul noptii e patognom. TRAT DE ELECTIE rezectia adenom hipofizar si hidrocortizon SDR NEFROTIC edem ,anasarca, oligurie, astenie, paloare, inapetenta, infectii urinare,; ex.s.u.=proteinurie peste3g/24h, lipidurie=peste 1g/24h, corpi grasi,cristale de col.;ex sg=hipoproteinemi sub 6g5,HIPOALBUNIMENIE SUB 3G%,HIPERLIPEMIE PESTE 1G/DL,HIPERCOL PESTE 300MG/DL,ANEM FERIPRIVA(SCAD Hb,scad Fe) SDR.PSIHICE DE INVOLUTIE: Def: dementele sunt caracterizate de diminuarea treptata a functiilor psihice datorita modificarilor organice ale creierului. Spre deosebire de nevroze reprezinta o afectare a structurii creierului si au un grad foarte mic de reversibilitate.Clasificare etiologica : degenerative (Pick, Alzheimer), vasculare (ateroscl, post AVC), secundare (posttraumatice, toxice, postiinfectioase, tumori, hidrocefalie, hematom subdural, b. neurologice) Clinica: tulburari (t.) cognitive (t de memorie, comunicare, intelegere, vorbire, dezorientare temporospatiala); t. psihice (depresie, anxietate, suspiciuni, idei delirante, halucinatii, izolare) ; t. personalitate (modificarea personalitatii, agitatie, apatie, rigiditate, incapatanare, iritabilitate, logoree) ; t. de desfasurare a activitatii curente (dificultati de conducere a automobilului, de a manipula bani, da a face cumparaturi, mancare, neglijarea igienei corporale) CONFORM DSMIV : 1. T. de memorie=imposibilitatea de a invata lucruri noi si de a-si aminti lucruri invatate anterior ; 2. cel putin una din urmatoarele :tulburari de limpaj, imposibilitatea de a efectua unele activitati motorii in pofida integritatii sist motor, imposibilitatea de a recunoaste sau de a identifica diferite obiecte, tulburari ale functiei executive, planificare, organizare abstractizare. Forme clinice particulare : Alzheimer : factorii genetici f importanti. Poate debuta inainte de 50 de ani. 2/3 din totalul dementelor;Pick : lobii frontali si temporali : tulb de comportament, tulb ale atentiei, neglijenta : distrat, euforic, dezinhibat, reducerea ideatiei pana la starea de indiferenta apato-abulica.Lewy : in neuroni exista corpii Lewy : tulb cognitive fluctuante, halucinatii vizuale, Parkinsonism. Evolueaza in pusee.Vasculara: afectarea structurii creierului prin infarcte repetate, tulb de circulatie cerebrala: bolnavii cu HTA, ATS, DZ. Semne neurologice de focar, tulb de mers,, alteleB. Jakob-Creutzfeld : semne neurologice de ataxie si dizartrie, sae asoc cu tulb psihice grave. Tratament : se urmareste oprire evolutiei bolii, combaterea tulb comportamentale, a tulb depresive, a tulb psihotice, cognitive a fact de risc si ameliorarea calitatii vietii;NOnfarma : psihoterapie : coportamentala, prin arta, muzicoterapie, ocupationala;FARMA : tratamentul depresiei : Inhibitori selectivi de recaptare de serotonina (sertralina 50 mg) ; trat tulb psihotice : haloperidol 0.5mg-2 mg pe zi, tioridazina 30mg/zi ; trat tulb cognititve : donepezil 5-10 mg,
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rivastigmina 1.5-3mg ; alte medicamente : piracetam, sermion, tanakan, antioxidante, vit E, neurotrofice cum este cerebrolysin. F. IMP : educatia terapeutica a bolnavului si a familiei : MF va expune apartinatorilor situatia bolnavului, particularitatile bolii, cauzele, manifestarile clinice, evolutia, posibilitati terapeutice. Se va arata importanta controlului medical periodic. Importanta supravegherii bolnavului cu dementa, evaluarea rezultatelor terapeutic si adaptarea tratamentului.Colaborarea cu specialitatile de profil. : neurologul si psihiatrul : MF trbuie sa supravegheze evolutia bolii si sa sustina familia in situatia dificila in care se afla.

SINUZITE: infection paranasal sinuses. viral most frequent etiology small percentage complicated by acute bacterial sinusitis. risk of developing intracranial and orbital complications and of possibly developing chronic sinus disease. ETIOLOGY Viral Rhinovirus, parainfluenza, and influenza viruses .Bacterial(Communityacquired,Nosocomial).Fungal. CLINICAL MANIFESTATIONS nasal congestion, purulent nasal discharge, maxillary tooth discomfort, hyposmia, and facial pain or pressure,headache, fever, halitosis, fatigue, cough, ear pain, and ear fullness. DIAGNOSIS Nasal secretion,Transillumination ,Sinus aspirate culture,Radiologic tests. THERAPY Viral rhinosinusitis antihistamines and NSAIDs (chlorpheniramine (12 mg sustained release) and ibuprofen (400 mg)) Community-acquired bacterial sinusitis Choice of antibiotics amoxicillin, trimethoprim-sulfamethoxazole, or erythromycin: Intranasal steroids ;Nosocomial bacterial sinusitis antimicrobial coverage should be directed at S. aureus and the Gram negative bacteria TBC: boala infecto contagioasa produsa de Mycobacterium tuberculosis(bac Koch) mai rar de Mycob bovis. EP:1.b infecto-contagioasa 2.prod de bK 3.sursa de inf este onul boln care elimina bacilli 4.calea de transm predom aeriana 5.inhal bK det inf primara 6.in maj caz inf prim are evol aculta 7.inf prim det virajul tuberculinic 8.uneori inf prim poate determ complic 9.complexul simplu format din sancru de inoculare si adenop satelita 10.complic benigne,compresia bronsica,fistula gangliobronsica 11.complic grave,pneum,bronhopn,miliara 12.uneori disem alte org rin,SN,sist osteoartic 13.inf prim are de obic tend la vindec 14.incapsul fibr si calcify 15.lez prim se pot steriliza sau pot cont bac in st latenta 16.imun este relat si nu conf prot tot,putan fi infl de fact int si ext 17.scad capac de apar a org poate duce la reactive lez prim 18.astfel dupa o lunga per poate apre tbc second 19 scad capac de apar poate fi prod de inf virotice,hep vir,hiv 20.sau de b maligne,neopl,limf,dializa 21.sau de cond econ precare,malnutr,varsta avans 23.tbc sec poast fi prod de o suprainf 24.deb tbc sec poate fi lent progress sau acut sub forma unei pneum,bronhopn sau hematemeze. FORME CLIN DE TBC PRIM:1.primoinf oculta(>90% din inf tbc primare,evol fara nici o manif clin,fara samen Rx,sg semn este conversia reactie la tuberculina) 2.primoinf simpla(semne clin minore,semne de impregn bacil,asten,anorex,transp noct,rx evid complexul primar,afectul primar pulm,forma rot,de cativa mm si adenop satelita,hialr sau traheobronsic) 3.primoinf cu
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complic benigne(apare mai ales la sug si cop mic,adenop poate pord compresie brons,wheezing,atelect,focare pneum,fist ggl-brons,bule de enfiz) 4.primoinf cu compl grave(forme cezeoase-extensive,manif clin prin pneum,bronhopn,miliara,st gen alter,manif pulm si extrapulm) 5.primoinf tardiva(la tineri si ad care nu au facu inf prim,maj forme sunt oculte,unele se compl cu pleur serofibrin,risc de trec de la forma prim la tbc sec) MANIF CLIN:debut lent progress,subfebril,asten,inapet,scad greut,tuse seaca,uneori debut ac,hemoptiz,pleurez) FORME RADIOL :1.infiltrativa(infiltr nodular,sediu subclav,opac difuze cu car infiltr,opac nodul isolate,sau confluente,conglomer neomog cu asp polimorf) 2.cazeoscircumscrisa(cazeificarea inflitr,tuberculom unic rotund,cu cont net 2-3cm,evol lent spre caverna) 3.cavitara(cavit tuberc,ramol si evac brons a zone cazeif,umbre inelare local mai ales la lobii sup) 4.miliara(numer opac micronod,2-3mm,difuze,rasp pe ambele camp pulm) DG DIF 1.adenop(limfogranulomat benigna,sarcoid,CaP,adenop infect) 2.infiltr pulm(viroze pulm,infiltr eosin,cong pulm) 3.tuberculom(CaP,chisturi pulm) 4.cevarene(chist pulm,abc pulm,ca excavat,enfiz bulos) MEDIC:1.izoniazida,rifampic,pirazinam,etambut,streptomic) TETANIA: CAUZE crampe ms-sportivi; crampe nocturne mb inf(idiopatice,DZ,Parkinson,lez snc,hemodializa)mialgii cimetidina, colestiramina; alcaloza din vars incoercibile; crampe din timpul mersuluidate IVC,hipotiroidism,hipertiroid; crampe nocturne

date

de

HIPOCALCEMIA CAUZE scad aport sau absorb (malabs,scad vit D, bypass intest subtire); pierderi imp (alcoolism, IRC, trat diuretic); endocrilg (hipoparatiroid,septicemie,); fiziolg.frecv cea mai mare=in IRC, hipoparatiroid primar,pancreatita; SIMPT=crampe ms,crest excitab cel nerv, larigospasm cu stridor, semn cwosteck, trousseau(carpal); PARACL=ecg=cresc QT,alungST,cu arit ventr.ca seri scazut,ca ionic sacazut,fosfat seric cresc; TRAT=gluco da ca 10%,iv,,carbonat de ca per os,asoc cu vit D. TRAHEOBRONSITA: r inflam a muc brons la act unor fact infect,fizicochim sau alerg. ETIO:1.virusuri(adeno,rino,entero,coxsakie,echo,gripale si paragrip) 2.bact(pneum,strept,stafil,H influ) 3.chim(vap de ammoniac,acetona,HCl,formol) 4.fizici(aer rece,fum,praf,pulberi,ceata) MANIF CLIN:deb brusc sau dupa inf resp sup,febra,frison,dur musc,cefalee,jana faring,retrosternala,tuse usc urm de mucopurul,expect mucopur,ral ronfl sis sibil,evol fav in 710zile. PCL:HLG-leucopenie,linfocitoza=vir;leucocitoza=bact;
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FORME CLIN PARTIC:1.bronsiolita;prod de VSR,adenov,parag,H infl,chlam sau bac pertussis;frecv la sugar;deb brusc sau dupa a trahbrons ac,febra inalata,dispn inspire,tahipnee,wheez,cian,ral subcrep si crep,tahic,tend la colaps.;aprec grav(frecv resp/sch gaz/deshidr)usoara(<40-60/N/abs) moder(40-70/dimin/minima) severa(>70/f dimin/import); TRAT=rep fizic,alim usoara,comb febra,calm tuse,expector,ampi 200-400mg/kgc iv,clacid 15mg/kgc/zi;cefuroxim 60mg/kgc/zi,cefotax(50mg/zi) TRAUMATISMELE OCULARE Corpi straini conjunctivali si corneeni : diagnosticul se face anamnestic, printr-un istoric concordant, si prin examinarea ochiului dupa instilarea in prealabil a unui anestezic local (proparacaina 0.5%). Corpii straini se vizualizeaza mai bine daca se instileaza fluoresina sterila. Nu este necesara pansarea ochiului, dar trebuie vizualizati dupa 24 ore, pentru a evalua dezvoltarea unei infectii secundare. Corpii straini metalici de obicei lasa o pata de rugina. Se indeparteaza cu un betisor cu vata sterila. Daca nu se reuseste, se truimite la oftalmolog Corpii straini intraoculari, impun tratment de urgenta, efectuat de catre oftalmolog Escoriatia corneeana : Pacientul acuza fotofobie intensa cu durere severa. Exista istoric de traumatism ocular. Pentru vizualizare se instileaza fluoresceina sterila, colorandu-se astfel escoriatia cu verde. Tratament : aplicarea unui unguent cu polimixina bacitracina si aplicarea unui bandaj ferm Contuzii. Contuziile pot produce echimoze, hemoragii subconjuctivale, edem sau ruptura de cornee, hemoragii in camera anterioara, ruptura radacinii irisului, etc. tratament : repaus la pat, pana la recuperare completa, NU SE FOLOSESC ANTIINLAMATOARE. Plagi anfracuoase : La nivelul pleoapelor, pacientul se trimite la oftalmolog, deoarece poate genera o incizura definitiva. La nivelul conjunctivei : se insileaza in ochi antibiotice. La nivelul corneei, trebuie trimisi la oftalmolog, se recomanda reducerea la maxim posibil a manipularilor la nivelul ochiului, intrucat se poate realiza extruziunea continutului intraocular. Se bandajeaza usor si se protejeaza cu un scut metalic, spijinit de partea superioara si inferioara in osul orbital. Daca este vorba de un corps train metalic, se va efectua in vederea diagnosticului TC, nu RMN, dearece exista riscul sa se miste corpul in campul magnetic Keratita actinica (post expunere la razele uv). Exista isoric de expunere la uv( exp. La soare in timpul schiatului, expunerea la flama de sudura). Dupa 6-12 ore pacientul prezinta durere intensa si fotofobie. Tratment : acoperirea ambilor ochi si instilarea de 1-2 picaturi de ciclopentolat 1%. Toti pacientii isi revin in 24 ore Conjunctivita si keratita chimica : istoric de arsura chimica. Se spala cu apa simpla, sau solutii saline, NU se neutralizeaza substante acide cu substante alcaline sau invers, deoarece in acest proces rezulta o mare cantitate de caldura. Se instileaza pilocarpina 2% si se incepe profilaxia antibiotica. TREMURATURILE miscari anormale involuntare :ritmice=tremor(de repaus,postural si intentional) si neregulate.Tremor de repaus:maxim in repaus si mai putin accentuat in miscare(debut insidiosParkinson;debut acut-toxine sau medicamente-fenotiazinele)Tremor postural:maxim cand poz mb e mentinuta active impotriva gravitatiei si e micsorat prin repaus si nu se acc marcat in timpul miscarii catre o tinta(acut-fact toxici sau metabolicie-ex hipertiroidism- sau stress sau insidios-tremor benign sau familial essential)Tremor intentional e mai pregnant in t miscarii catre o tinta si nu e prezent in timpul mentinerii posturii sau in repaus;e semn de boala
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cerebeloasa.Dg dif cu asterixis=inhibitie intermitenta a contractiei musculare.Miscarile involuntare anormale care sunt neregulate sunt caracterizate suplimentar prin viteza lor si locul aparitiei si posibilitatea de a fi suprimate voluntar.Cele mai lente:atetoza si distonia.Rapide:ticuri nervoase,pot fi controlate voluntary.Rapide si nu pot fi controlate voluntary:coreea,hemibalismul si mioclonia. TROMBOFLEBITA (triada Virchow=staza ven,lez perete venos,hipercoagub) CLASIF; profunda,superf; TROMBOZA PROFUNDA :durere coapsa sau gamba,edem,sau asimpt,antec de ICC,chirg recentneo,ac-uri,imobiliz prelung,senzatie de arsura,febra usoara,tahicardie,teg cianotic; PARACL:echo DUPLEX si Doppler,pletismografia prin impedanta,flebografia ascd.cu subst de contrast; DIAG. DIF :celulita,ocluzie arteriala ac,edem gambier bilatchist baker rupt; complicatii:trombembolism pulmonar,IVCr; TRAT 1. masuri locale pic ridicate la 15-20 grade,mobiliz in mai putin de 7-14 zile; 2. trat medical-anticoagheparina -anticoag de electie pt perioada scurta,apoi warfarina,recuper se face in interv de 3-6 sapt. TROMBOZA SUPERFICIALA: induratie,eritem,sensibilitpe traiect ven.superf.frecv la niv safenei mari,frecv dupa untraum recent;frisoanele,febra inalta =flebita septica; DIAG DIF:celulita,eritem nodos,paniculita,fibrozita,tromb profunda; TRATAMENT REPAUS LA PAT, PROCES EXTINS =ligaturare si sect venei safenela niv safeno-femural, anticoag=daca afect este rapid progresiva, germenele frecv=stafilo=antibioterap TULBURARI DE PERSONALITATE CARACT ESENT Istoric indelungat, pana la varsta copilariei, comport maladaptativ recurrent, reducerea capac de autoestimare si lipsa de incredere in sine, capac introspective minima, cu tendinta de a consid ca vina tuturor probl o poarta ceilalti, dif majore in rel interpers, depresie cu anxietatecand comp maladaptativ duce la esecuri CLASIF Paranoid defensive: hipersensib, secretos, suspicios, hiperalert, rasp emotional limitat Schizoid timid, introvertit, retras, evita rel stranse Compulsive: perfectionist, egocentric, indecis, tipare rigide de gandire si necesit de a se controla Histrionic dependent, imatur, seducator, egocentric, vanitos, labil emotional Schizotip superstitios, izolat social, suspicios, capac scazuta de a realize relatii, interpersonale Narcissist exhibitionist, grandoman, preocupat de putere, lipsa de interes, nevoie excesiva de a I se acorda atentie Evitant reactie de teama , hipersensibil la esec, cu putine aspiratii sociale, respect redus fata de sine Dependent pasiv, hipertolerant, incapabil pt decizii, lipsit de incredere
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Agresiv pasiv incapatanat, delasator, suparacios, neajutorat, negativist Antisocial egoist, dur, impulsiv, are probl cu legea Tipul borderline impulsiv, plin de furie, frica, ii lipseste autocontrolul, sinucigas, comp agresiv, sentim de inutilitate, probl de identitate TULB DE RITM: CLASIF PATOG: 1.tulb form impuls sin(tahi sin,bradi sin,aritm) 2.form ectop a impuls supraventric(ESA si jonct,FiA,TPS,flat,scap jonct,disoc AV) 3.form ect a imp ventr(ESV,TV,tors varf,FiV,FltV,scap ventr,ritm idioventr) 4.blocuri(BSA,BAV,intraventric,comp, de ram,incompl,bifasc) 5.sdr.partic(SSS,sdr de preexcit ventr); CLASIF CLIN: 1.modif de frecv(a.tahic-sinusala,FltA,TPA,TPV;b.bradic-sinusala,BSA,BAV) 2.mod de ritm(Ar resp,extrasistlie,FiA,Flt cu blocaj variabil,blocuri inconst) MANIF CLIN SI ECG(frecv/ritm/unda P/interv P-R/compl QRS): 1.TPSV-100-250/regulat/prezenta,uneori fuz cu unda T/nu se poate masura/norm sau modif; TPV-100-250/regulat/neasoc compl QRS/nu poate fi masur/deformate; 3.ESAnormala/nereg/modif in complexele premature/normal/norm sau modif; 4.ESVnormala/nereg/nu preced complexele premature/nu/deformate; 5.FltA-230-300/regulat/inloc cu unda F/nu/deformate; 6.FiA-undaP=100-500,QRS 50-150/neregulat/inloc cu unda J/nu/normale; TRATAMENT CLASIF MEDIC ARITMICE: 1.clasa Ia-deprima faza 0,incetinesc conducerea,prelungesc polarizarea=chinidina,procainamida,disopirmaida,ajmalina; 2.clasa Ib-deprima faza 0,incetinesc cond=lidocaina,mexiletine,fenitoina; 3.clasa Ic-depr faza ),incet cond=flecainida,morizicina,propafenona; 4.cls II-ef simpaticolitic,bloch act catecol=propran,aten,metopr etc; 5.cls III-prelung repolar prin bloc can de K=amiodarona,bretilium,sotalol; 6.clasa IV-bloch can de Ca-verapamil,diltiazem; INDIC PRINC MEDIC ANTIAR: 1.chinidina-conver Fi si Flt,preven recidive,200-200mg,3-4x/zi po; 2.disopiramida-ESA,ESV,FiA,TPSV-100-300mgx3/zi po; 3.lidocaina-aritm ventric in IM-1mg/kg bolus iv; 4.mexiletina-idem ar ventr rez la lidocaina-100-200mg iv sau 400mg po; 5.flecainida-aritm supraventr fara tulb organice 100-200mgx2/zip o 6.propafenona-ar supraventr,sdr WPW-450mg/zip o; 7.propran-aritm suprav,prev aritmia si moartea subita-10-200mg/zip o; 8.atenolol-idem propr,50-200mg/zip o; 9.amiodarona-convert si preven FiA,convert TV-400mg po 7 zile apoi 100-200mg/zi;300mgiv; 10.bretilium-aritmii ventric care nu rasp la alte antiar-5mg/kg bolus; 11.verapamil-aritm supraventr-80-120mg de 6x/zipo,max 480mg; 12.diltiazem-idem-30-80mg x4/zip o,7.5-15mg iv ULCER: b caract prin lez circumscrise unice saul mult ale cont per gastr si duod.
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FACT ETIOL: 1.genetici(de 2-3x mai frecv la cei cu AHC,pred la gr sang O,30% sunt purt Ag HLA specif,masa mare de cel secret mostenita) 2.H pylori(70-90%,enzime si citotixine,ureaza ,fosfolipaza,proteaza,inflam muc,lez cel,stilm secr Hcl si pepsina) 3.stil de viata(fum,alc,caf,conserve,afum,condim,prajeli,stress) 4.medic(AAS, AINS-inh secre Pg,corticoster scad mucus) 5.b asoc(pancr cron,CH,b crohn,BPOC,sdr Cushing,hiperpth) FACT PATOGENICI(agres/protectie)1.hipersecr de HCl /secr de mucus 2.hipersecr pesina/secr bicarb 3.refl bil/rez epit gastroduod 4.ing HP/integr vascul epitel PARTICULAR DURERE: 1,evol(recur,cu per dur de 4-5 sapt,de 1-2x/an,intrer de per de acalmie) 2.localiz(epigastru) 3.caract(foame dur,ars epig,ars retrostern,roadere,dur colicativa) 4.ritmicit(cu alim,apre inainte demasa foame dur calm de alim,repare dupa masa mai prec in UG si tard in UD) 5.periodicit(anuala de 2x,prim si toamna UD si iarana/vara pt UG) DG DIF UG/UD 1.dureri: treim sup epig/treim inf;irad spre hipoc stg/dr ;nu ced la alim/cedeaza ; precoce postprand/tardiv postprand; nu nocturn/da ; 2.varsat:contin alim/cont acid 3.se paote malign/prod stenoze DG DIF CU ALTE BOLI: BRGE ,sdr dyspeptic,hern diaphragm,pancr ac,LB,colecist ac,CaG,CaPanc,b Crohn,and pect,IMA,pneum bazala,pleurez diaphragm,pericardita MEDIC: 1.antisecret a.bloc rec H2(cimet 200-400mg/zi,ranit 2x150mg/zi,famot 40mg seara) b.bloc M3(pirenzepina 100-150mg/zi in 2-3 prize) c.bloc protonpump(omepr 20mg/zi,lanzo 30mg,panto 40mg) 2,antiHpyl(amoxi 2g/zi,claritro 1.5g/zi,metro 750mg/zi,omep) 3.antacide(carb de ca,hidroxid Al,de Mg) 4,stimul mec de apr(form pel protect( De_Nol 2x240mg/zi,sucralfat 4x1g/zi,misoprostol) ULCERUL CRONIC DE GAMBA CARACT ESENTIALE Antec de varice, trombofleb. Ulceratii nereg sit frecv pe fata mediana a gambelor, deasupra maleolei DG sustinut de prezenta edemului mb inf, varicozitati, hiperpigm si zone eritemo-scuamoase (dermatita de staza), ca si a cicatricilor si ulceratiilor mai vechi. CAUZE Insuf venoasa e cea mai frecv SEMNE SI SIMPT Edem cr dermatita (pruriginoasa), hiperpigm, sol de conin tegum, scleroze tegum, gambiere, cruste fibrina TRAT Sistemic dicloxacilina p.o. 250 mg x 4/zi, ciprofloxacina 500 mgx 2/zi Local curatare cu ser fiziologic
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VALVULOPATII: STENOZA MITRALA: impied circ sange de la plam si AS catre VS;calcif inel sau marg libere a valv mitr urm a malf congen sau b de ets conj;dg dif cu mixom atr stg sau cor triatriatum; Fiziopat=crest pres la niv AS,vene pulm,pres capil pulm,staza pulm;dilat atr stg si fibril poate duce la apar de trombi; Dg=staza pulm(dispnee,tuse ,ocaz hemoptizie),zg 1 intarit,clic diastolic de deschidere si uruitura diastolica,ecocord+Doppler; Trat= evit exerc fiz,infectii;diuretice,terap anticoag(heparina,warfarina),trat FiA(digoxina,bloCa,betabloc,cardioversie),profilax endocard infect,trat chir(simpt severe,aria mitr <1cm2/m2) STENOZA AORTICA:calcif si degener valv norm,calcif si fibr unei valve Ao,b valv reum; Fiziopat=gradient presion cresc intre VS si Ao determ crest pres la niv VS>hipertrofie concentrica>scade complianta VS>crest pres telediast VS si neces de O2 miocardic;scade pres de perf miocardica>ischemie subendo; Dg=unul sau mai multe simpt clasice din triada angina/sincopa/IC;puls carotidian cu panta ascend lenta,suflu mezotelesistolic cu car tipic rugos ce diminua cu cu scad deb card si crest grd de obstr;eco Doppler,cateterism; Trat=profilax endocardita infect,evit ef fiz,trat aritmii,digoxina la pac cu IC in prez dilat VS si a unei f sist alter,in SA severa cu obstr fixa la ejectie nu are beneficiu marcat,diuretice pt staza,nitratii si alte vasodilat cu max prud,daca nitrogl det hipotens se adm dobutam sau vasopresina,chirug-SA severa. INSUF MITRALA:degener mixomatoasa a valv mitr,reumat,calcif inel VM,BCI,endocardita infect,b tes conj(Marfan,Enhler-Danlos),ef second la pac cu cardiomiopatie si dilat VS; Fiziopat=suprainv vol a VS ca rez a regurg unei fract a sange din VS in AS>scad fr de ejectie >ICD,ICS;dg=puls carotidiene si suflu holosist apical,eco+Doppler; Trat=profil endocard infect,ter anticoag,vasodialt(nitroprusiat,enalapril,hidralazina),digoxina in prez disf sist a VS,diuretice,nitrati(reduce presarc si a dimens ventric);chir-pc cu simpt moder si sevre rez la terap conserve a fractie de ej; I MiTR ACUTA=disf sau rupt ms papilari deter de isch mioc sau IMA,endoc inf,b mixomat severa cu rupt de cordaje sau trauma; Fiziopat=dif de cea cron prin abs crest compl atriale stg si a VS>crest ac a pres pulm ven si EPA,det frecv soc cardiogen; Trat=scad postsarcinii de urgenta cu nitroprusiat de na,monitor hemodinamica,diuretice monoter sau cu nitrati pt scad stazei pulm,pompa balon de contrapulsatie,chir de urg la cei care nu pot fi control prin trat medic; PROLAPS DE VALVA MITRALA:prolaps uneia sau a ambelor parti ale valvei in atriupe parc mezosistolei;ereditar,b tes conj,affect cong card,deform musculoschel,plastie valva mitrala sau ischemie;se aoc cu tahiaritmii supraventr (sdr.WPW si sdr de QT lung);simpt=fatigabil,anxiety,palpit,cefalee,dur precord,presincopa si sincopa,cei mai multi asimpt,click mezosist urmat de suflu telesistolic; Trat=profil endoc infect,in caz de palpit sau lipot monit Holter si ecocord,daca TV sustin sau nesust(implant defibril),ESA si esv-betabloc,terap anticoag; INSUFICIENTA AORTICA:cause=RAA,endocardita,b tes conj,aorta bicuspida congenit,dilat sau def radac Ao dat HTA,disectie ascend de AO,sifilis,necroza chistica mediala,sdr
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Marfan,spondilita anchilozanta;IA cvron are evol insidioasa;IA acuta se manif ca IC severa sau soc cardiogen; Fiziopat=regurg aortica diast din Ao in VS>crest pres si vol telediast>dilat si hipertrof VS mentin stabil hemodin sis cad pres telediast in VS;Dg=puls amplu,puternic,suflu ao protodiast,ecocord+Doppler sau catter cardiac; Trat=medical pt IA cron stabile sau IA ac severa inaintea trat chir;trat fact etiol-endoc,sifilis,b tes conj,profilax endoc infect,scad active fizice,restr de sare,adm digox,vasodilat(nifedip),nitroprusiat de Na sau ag inotropi +,chir. VACCINARILE LA COPIL 24 ore - Antihepatita B (AHB) 4-5 zile - Antituberculoasa (BCG) - Antipolio (VPOT) - Antidifterica - Antitetanica antipertusis DTP - Antipolio (VPOT) - Antidifterica - Antitetanica antipertusis DTP - Antihepatita B (AHB) - Antipolio (VPOT) - Antidifterica - Antitetanica antipertusis DTP - Antirujeoloasa (AR) - Antidifterica

4 luni

6 luni

9-11 luni 12 luni

- Antitetanica antipertusis DTP - Antipolio (VPOT)

30 - 35 luni - Antidifterica - Antitetanica antipertusis DTP 7 ani 9 ani 13 ani 14 ani - Antidifterica - Antitetanica antipertusis DTP - Antipolio (VPOT) - Antituberculoasa (BCG) - Antidifterica - Antitetanica (DT)

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VARICELA; EP:virus herpetic,trans aerian,imun dur. MANIF CLIN: 1.per de inv(incub 10-20 zile,deb progress,subfebr,rinofaring discr,conjunctiv,indisp gener,inapet,cefalee) 2.per eruptiva(dupa 1-2 zile,car centripet,inters toate teg mai ales cap si trunchi,evol maculapapula-vezicula-crusta,vez au lich l\clar apoi tulbure,cruste,apare in valuri,coex eruptii d evarste dif,prurigin,dur 7-10zile). COMPLIC:de obic benigna:1compl resp:pneum variceloasa 2.nerv:mening,encef,cheratita,orhita,GN. TRAT;izol domic,rep pat,alim us,antipir,antiinfl.,acyclovir.

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