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  • 7/24/2019 Prezentare de Caz - Tbc

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    PREZENTARE DE CAZ

    TUBERCULOZA PULMONARA

    1. ANAMNEZA 6-7 minute;

    2. EXAMENUL OBIECTIV 6-7 minute

    3. DATE DE LABORATOR 6-7 minute

    1. ANAMNEZA

    Date clinice

    - nume !i "#enume$

    - %!t&$

    - "#'(e!ie )*'+ ,e mun+&$ "#e+ie& unit&tii$- ,'mi+i*iu )!t&/i*0 (*'t&nt #e&*$

    - !te +i%i*&$

    - +'"ii.

    Data internarii

    Diagnosticul de trimitere si unitatea medicala

    Antecedentele heredocolaterale

    - +& ,e t/+ t/+ !i ,$ ne'- +& "neum' te#en &t'"i+

    - +'nt&+t t/+ +u +ine !i +&n,

    - ('+ t/+ "'!i/i*it&ti ,e +'nt&iune "#in +'&/ite )2$ 24;- +'"ii n#$ !te ,e !&n&t&te$ +5imi'"#'(i*&ie in t#e+ut +u +e !i +&t tim";

    Antecedente personale i!iologice"

    - men&$ UM0&men'#ee !e+un,&$ A/ !"'nt&ne$ CU$ in(e#ti*it&te$ !te#i*it&te!e+un,&$ N$ !+ini )"&t'*'i+e$ *e5ui&.

    - C'nt#'* me,i+&* "e#i',i+$ u*timu* R8 +u ITN- Te!ti IDR &nte#i'e$ CV ,u"& BC9;

    Antecedente personale patologice

    - "#im'in(e+tie t/+ '+u*t& )%i#&: tu/e#+u*ini+$ !&*t tu/e#+u*ini+$ 5i"e#eie$ te!tiIDR !&u m&ni(e!t&$ IDR$ CV$ +5imi'"#'(i*&ie;

    - t/+ "u!ee e%'*uti%e$ !"it&*ii$ T- !+5eme$ #e&+tii &,%e#!e !&u int'*e#&nte$

    &/&n,'n$ ,$ u*+e# &!t#',u',en&*$ "!i5'"&tii +'#ni+e$ 5e"&tite +'#ni+e$ !i*i+'&$t#&t&mente +'#ni+e +u +it'!t&ti+e !&u +'#ti+'!te#'ii$ IV.

    Conditii de #iata si munca- u#/&nie #e+ent&$

    - "#'(e!ie "e#i+*it&t&0"e#i+*it&nt&$

    - &n&:&t "e#m&nent0 i*ie#$

    - n&%et& i*ni+&0!&"t&m&n&*&$- %enit me,iu *un$

    - n'e "#'(e!i'n&*e$

    - !u"#&!'*i+ite (ii+& !i "!i5i+&- (um&t$ &*+''*$

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    - *'+uint&.

    $storicul %olii- ,e"i!te R8 "&!i%& !&u &+ti%e;

    - !CR

    2

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    3. !umu* ,e u#in& =0- "#'/& A,,i!$ u#'+u*tu#i;

    ?. *i+emie =0- *i+'u#ie$ "#'/& 5i"e#*i+emiei "#'%'+&te;

    . u#ee$ +#e&tinin& !e#i+&$ +*e&n+e;6. "#'/e 5e"&ti+e ),i!"#'teinemie;

    7. /i*i#u/inemie$ ('!(&t&& &*+&*im&;

    @. "#'tein'#&m& =0- imun'#&m&;. VDRL$ IV.

    1. te!te imun'*'i+e;

    E'amenul %acteriologic al sputei

    - / M=C *& inte#ne !i "e "+u#!;

    - AB9 / !&u (*'#& ne!"e+i(i+&t&;

    - E mi+'*'i+ )tu! ,e C5in&$ &/'u#&u,;- 8*'#& /&n&*& )9#&m$ &*/&!t#u ,e meti*en;

    E'amenul citologic si %iochimic al sputei +#ite#ii ,e "u#u*ent& & !"utei$ +e*e*e &ti"i+e$+'#"i &/e!t'i+i$ (i/#e e*&!ti+e$ AB ;

    E();Pro%e unctionale respiratorii !"i#'#&m&; "#eti!m'#&(ie; &'met#ie;

    E'amene radiologice in dinamica #&,i't'm'#&(ii !t&n,,$ RMN$ CT$ !+inti#&(ie$

    &ni'#&(ie$ =0- /#'n5'#&(ie;

    E'amenul %ronhoscopic &!"e+tu* &n,'!+'"i+$ /i'"!ie$ &!"i#&t )/$ (*'#& ne!"e+i(i+&$

    +e**u*e &ti"i+e$ /#'!&:$ *&%&: /#'n5i'*'&*%e'*$ =0- /#'n5'#&(ie;

    Toracocente!a &!"e+tu* m&+#'!+'"i+ &* *i+5i,u*ui "*eu#&*$ e&menu* +it'+5imi+ =

    /&+te#i'*'i+ )/$ (*'#& ne!"e+i(i+&t&.

    Pentru diagnosticul dierential"'t (i +e#ute +'mi!iei- IDR C&!'ni;

    - E+'#&(ie &/,'min&*&;- E ORL &u,i'#&m&;

    - E O(t&*m'*'i+ 8.O.

    - E +,i'*'i+;

    - E neu#'*'i+;- E /'*i ,e nut#itie;

    - E /'*i ine+'*'i+e.

    ?. EX>UNEREA

    $* +ta%ilirea diagnosticului complet de- %oala, organ, etapa )I$ II$ "#im'!e+un,&$ stadiul e#oluti# )&+ti%e e%'*uti%&$

    #e#e!i%&$ !e+5e*&$ !t&/i*i&t&$ in&+ti%&$ orma anatomoclinicoradiologica, locali!are$

    - diagnostic %acteriologic / M=C T'$ +5imi'!en!i/i*it&te )t't&*& !&u "ti&*& !&u

    +5imi'#ei!tent$- conirmata histopatologic$

    - diagnostic e#oluti# "#im "u!eu "#im t#&t&ment$

    - grupa dispensariala +& n'u$ +& #e&,mi!$ +#'ni+$- diagnostic unctional$

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    - complicatii;

    - %oli asociate;

    E 1. TBC "u*m'n& !e+un,& &+ti%e e%'*uti+& in(i*t#&ti% e!+&%&t& LD$ / "'iti% M

    !i C in *un& & III-& ,e t#&t&ment$ AB9 +u !en!i/i*it&te t't&*&$ +& n'u *& "#im t#&t&ment$

    +'n(i#m&t in ,&t& ,e2. DVR +u #e,u+e#e& Vm& +u ?4. 3.. Di&/et &5&t in!u*in',e"en,ent. ?. Anemie

    (e#i"#i%& !e+un,&.

    $$* E'punerea etapelor de e'aminare a %olna#ului

    1. B'*n&% M.V.$ ,&te +i%i*e$ !-& inte#n&t in$ "ent#u e "+u# i!t'#i+u*$ AC$

    A>$ ,&te*e e"i,emi'*'i+e ,&+& ei!t&;

    2. E '/ie+ti% ,&te*e "&t'*'i+e enume#&te$ +& !i &"&te*e !i !i!teme*e +u #e*&tii+*ini+e n'#m&*e;

    3. Din ,&te*e "&+*ini+e &m #etinut ,&te*e "&t'*'i+e R$ /&+te#i'*'i+e$ *&/'#&t'#.

    $$$* Diagnosticul sta%ilit "'&te (i "#eumti% !&u ,e +e#titu,ine$ (iin, !u!tinut ,e

    u#m&t'e*e umente e"i,emi'*'i+e$ ,e/ut$ ,&te +*ini+e$ #&,i'*'i+e$ /&+te#i'*'i+e$

    e%'*uti& !u/ t#&t&ment; Elemente de diagnostic po!iti# in t%c

    1. m',&*it&te& ,e ,e"i!te;

    2. ti"u* ,e/utu*ui;

    3. +'ntetu&* e"i,emi'*'i+;?. e&menu* #&,i'*'i+ - ,e!+#ie#e& #&,i'#&(iei t'#&+i+e !t&n,,

    - ,e!+#ie#e& +'ntinutu*ui !i & +'ntin&t'#u*ui;

    - ,e!+#ie#e& '"&+it&ti*'# *'+&*ie&$ ,imen!iune&$ numu* *'#$ ('#m&$+'ntu#u* )#eu*&t !&u ne#eu*&t$ !t#u+tu#& !i inten!it&te&;

    - ,e!+#ie#e& 5i"e#t#&n!"ente*'# '"&+it&te& +e ,e*imite&& !i +'ntu#u*

    inte#i'# )ine* "e#i+&%it

    . ,i!+#e"&nt& +*ini+'-#&,i'*'i+&;6. +'n(i#me& /&+te#i'*'i+&;

    7. &!"e+tu* en,'!+'"i+ &* mu+'&!ei /#'n!i+e;@. +'n(i#me& 5i!t'"&t'*'i+&;

    . &*te e*emente "&t'*'i+e "ent#u t/+ !i m&*&,ii*e &!!'+i&te;

    1. "#'/& te#&"euti+&.

    $-* Diagnosticul dierential

    Am e+*u! "neum'ni&$ ne'"*&!mu*$ mi+'&$ et+ ,e'e+e.

    In +&u* t/+ /= !e &t& +& ,i&n'!ti+u* ,i(e#enti&* e!te "u# +*ini+'#&,i'*'i+; In +&u* t/+ / !e e*imin& &(e+tiuni*e +e*e m&i :u!ti(i+&te;

    -* Etiopatogenia ca!ului

    In +&u* t/+$ eti'*'i& & ('!t !t&/i*it& "#in e%i,entie#e& /=. In +&u* t/+ /- eti'*'i&

    "#e!u"u!& e!te ,&t'#&t&.

    Patogeniat/+ - "#'+e!! +'m"*e;

    - %!t& "#im'in(e+tiei ,&+& !e +un'&!te; - "e#i'&,& ,e *&tent& int#e "#im'in(e+tie !i (tiie;

    8tii'ene& #e"#eint& #eu*t&tu* inte#&+tiuni*'# +'m"*ee ,int#e &,& )&(*&t& in

    +'n,itii imun'*'i+e "#e+e !i /&+i*u* tu/e#+u*'!$ in(*uent&te ,e un +umu* ,e (&+t'#ine(&%'#&/i*i.

    ?

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    Me+&ni!me

    1. me+&ni!mu* en,'en "#in #e&+ti%e& in !itu &

    - ('+e*'# "'!t"#ime ,e ,i!emine 5em&t'en& "&u+i/&+i*& im'n A/#i'!'%+e &" *& 2 &ni ,u"& "#im'in(e+tie$ !unt &"i+&*e$ /i*&te#&*e !i !imet#i+e !i "'t

    &%e& "'tenti&* (tii'en ,u"& ' *un& "e#i'&,& ,e *&tent&;

    - ('+e*'# n',u*e &"i+&*e *im('5em&t'ene "#e+'+e$ ('+e*e initi&*e M&*m#'!!e,F&** +e &" in +'ntinuit&te& unei "#im'in(e+tii (tii'ene *& &,u*tu* t&n )*&

    &"#'im&ti% 1 &n ,u"& %i#&: !i "'t e%'*u& "#'#e!i% !"#e in(i*t#&te*e (tii+e"#e+'+e$ &%&n, +e* m&i me "'tenti&* (tii'en;- #e*i+%&te*'# "#ime +&*+i(i+&te )!t&*"ii (une#< C5'met &((e+t "#im +u

    *'+&*ie "#e(e#enti&*& *& ni%e*u* #eiunii me,i'/&&*e +e &u &"ut int#-' et&"&

    &nte#i'& & %ietii ),&+& ei!t& A>> ,e "#im'in(e+tie$ !"unem +'n+#et !i !-&u

    #e&+ti%&t ,&t'#it& "e#!i!tentei /&+i*i*'# tu/e#+u*'!i ,'#m&ni$ +u #e*ue& +i+*u*ui ,emu*ti"*i+e in +u#!u* unui e"i!',e ,e imun',e"#e!ie.

    C'n('#m +e*'# &(i#m&te ,e Re,ee# G'#i+e in,i%i, +e !i-& (&+ut "#im'in(e+ti& t/+$

    "'!t"#im& +&t#e (tiie e!te ,'min&te ,e "'tenti&*u* (tii'en &* ('+u*ui )24 /"e#!i!t& in *eiuni*e +&*+i(i+&te in +'ntetu&* (*e+tii !t&tu!u*ui imunit &* &,ei.

    A"#'&"e 4 ,in ('+e*e &"i+&*e mi#e&& !i e%'*ue&& in !en! (tii+ in #eiuni*e

    #et#'- !i !u/+*&%i+u*&$ (&"t e"*i+&/i* "#in !u/!t#&tu* &n&t'mi+ +'mun )t#un+5iu*/#'n!i+ +'mun "ent#u +e !emente*e &"i+&* !i "'!te#i'#. 634 e%'*ue&& in !itu !i

    2@4 in %e+in&t&te& *eiuni*'# "'!t"#ime.

    2. me+&ni!mu* &n*ien )"#in (i!tu*ie& &n*i'/#'n!i+& !i in!&m&nte

    &,en'/#'n5'en& !&u "#in "#'"&e *im('en& #et#'#&,e !&u 5em&t'en!u!tinut in (un+tie ,e &!"e+tu* *eiuni*'# ,e *& inte#ne )"e#i5i*$ mi*i&$ ('+e

    m&+#'n',u*e 5em&t'ene;

    C'n+e"ti& &n*i'/#'n!i+& !u!tinut& ,e +5Ft +'n!i,e#& +& in(i*t#&te*e (tii+e !i+5i *eiuni*e n',u*e &"i+&*e &" "#in +&ei(i+e& !i (i!tu*ie& unui &n*i'n

    t/+ +u "#'"&e& in(e+tiei "e +&*e /#'n5'en& eHui!e+t'#i&* )*eiuni *'+&*i&te

    :ut&5i* = (i!tu*& &ni'/#'n!i+& e%i,enti&t& /#'n5'!+'"i+.

    3. me+&ni!mu* e'en i* !u!tinem ,&+& ei!t& +'nt&+t t/+ #e+ent in i!t'#i+u*/'*n&%u*ui; ,&+& nu$ nu "'&te (i e+*u! +& "'tenti&* (&+t'# ,e+*&n!&t'#.

    Du('u#t &"#e+i& #'*u* "&t5'en &* !u"#&in(e+tii*'# e'ene m&!!i%e !i#e"et&te +u / in &"iti& (tiiei. In !u"#&in(e+tii*e e'ene$ '#iine& ('+e*'#

    (tii+e (&+e t5e'#eti+ "'!i/i*& *'+&*ie& in '#i+e #eiune & "*&m&ni*'#.

    u"#&in(e+tii*e "&t'ene "'t (i ini(en!i%e !&u "'t ,& n&!te#e *& ('+e &/'#ti%e.

    -& emi! i"'te& +& "'t Ge+it& ('+e*e *&tente$ "#'%'+&n,$ "#in #e&+tii('+&*e ,e ti" tu/e#+u*ini+$ #e&+ti%e& *'# en,'en& !&u !im"*& "#e*uni#e &

    !u"#&%ietui#ii e#meni*'# ,'#m&nti &,uiti ,e &+e!te ('+e.

    A!++5'(( - >u5* &u ,e!+#ie! ('+e*e ,e #ein(e+tie e'en& )+u &"iti&t,i%& (&t& ,e m'mentu* "#im'in(e+tiei +& n',u*e "#ein(i*t#&ti%i *'+&*i&ti

    !u/&"i+&*$ (& +&*+i(i+i$ ,e inten!it&te !*&/&$ &%&n, "'tenti&* m&i me ,e

    t#&n!('#me (tii+& ,e+&t +ei im'n.

    8&+t'#ii (&%'#i&nti enume#e

    - !eu* )t/+ m&i (#e+%ent& ,e 2-3 '#i *& //&te %! (emei;

    - %!t& (tii'en& !&u %!te*e &%&n!&te ),e+*ine /i'*'i+ !i te*e '#&ni+e +&"&t'*'ie &!'+i&t&;

    - eti*i!mu* +#'ni+$ t&/&i!mu*;

    - !u/nut#itie +#'ni+&$ +ente "#'ti,i+e !i %it&mini+e$ *'+uint& in!&*u/#&)&*'me#&tie$ +'n,itii iieni+e "#e+e$ !u#men&:u* (ii+ !i inte**e+tu&*$

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    t#&um&ti!me !&u ,e"#e!ii "!i5i+e *e&te ,e "en!i'ne$ ,eee& (&mi*iei$

    ,e+e!u* unui mem/#u ,e (&mi*ie$ !+5im/e& me,iu*ui ,e %i&t& )u#/&nie$

    !t&iu* mi*it AB=+'*&"!$ !'+;

    - "u#"u#& t#'m/'+it'"eni+&;

    - &nemie 5em'*iti+& &+ut&;

    - IRA "#in ne(#it& ,e 5i"e#!en!i/i*ie *& ,#' !&u ne+#'& tu/u*&;- I+te# n'n5e"&titi+ )&,mini!t#e 707 *& eti*i+i$ 5e"&ti+i$ /&t#

    - Ce(&*ee$ (#i!'n !i &!+en!iune (e/#i*e *& 2-6 '#e ,u"& &,mini!t#e )(*u *ie

    !

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    D&+& !unt ne+e!e &*te me,i+&mente$ in +& ,e int'*e#&nt&$ !u/!titui#i*e !e (&+ "#in

    - IN !&u RM> in (&& II +u M=>ZM;

    - M +u M;- >ZM +u EMB;

    T#&t&mentu* !"e+i(i+ &ntitu/e#+u*'! +u me,i+&mente ,e #&n !u"e#i'#$ +u &+tiune/&+te#i+i,&$ &+ti%e in +&u* in%e!ti&t )+5imi'!en!i/i*it&te &,mini!t#&t in ,'e

    te#&"euti+e$ !u/ ,i#e+t& '/!e#%e$ "e ' ,u#&t& ,e tim" !u(i+ient&$ +un'!+ut (iin,+&+te#u* *ent &* #e#e!iunii *eiuni*'# t/+$ t#e/uie !& in,u+& ' !te#i*ie *ei'n&*&&"#e+i&/i*& in me,ie 6 !i 12 *uni ,e *& in!titui#e& DOT.

    Me,i+&ment m0+0#itm 707 m0+0#itm 307

    IN 1

    RM> 1 1

    >ZM 3

    EMB 2 1

    M 1 1

    M 1-3 1-3

    CM 1-3 1-3A 1-1 1-1

    ETM 1-2 1-2

    C 1-2 1-2

    C>X $7-1$ 0i $7-1$ 0i

    O>X $6-$@ 0i $6-$@ 0i

    T#&t&ment !

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    - "neum't'#&;

    - *eiuni (i/#'&!e #et#&+ti*e $ +u !in,#'m #e!t#i+ti%e$ >T ,e >I8;

    - *eiuni !ten'&nte *& ni%e*u* /#'n5iei ,e ,#en&: +u '/!t#u+tie !&u &te*e+t&ie;- %in,e+i ,e!+5i!e )14;

    - tu/e#+u*'m;

    - #e(& ,e "#'+e!! m&*in "e +i+&t#i+e;- #e(& ,e &!"e#i*'m )mi+et'm in *eiuni*e +&%ite #e!t&nte;

    - >T /#'n!iti+$ /#'n!ie+t&i+$ !u"u#&ti%$ "i'!+*e#'&;

    Complicatii posi%ile datorita tratamentului incorect

    - ,i!emini /#'n5'ene;

    - "*eu#eie;

    - "neum't'#& $ "i'"neum't'#&;- e!e+ t5e#&"euti+;

    - #e+i,i%& in "#imu* &n ,e *& !i!te& T *& #e&n&:e;

    - +5imi'#ei!tent&;

    Prognostic indepartat 1uo ad sanatione

    - a#ora%il +&n, / !e ne&ti%e&&$ *eiuni*e !e !t&/i*ie&& #&,i'*'i+$ (&,e(i+it (un+ti'n&*; e "'&te !t&/i*i ,&t& #ein+&,#ii;

    - nea#ora%il +&n, *eiuni*e !unt /i*&te#&*e$ etin!e )!e*e+ti'ne ,e e#meni /

    #ei!tenti$ %in,e+e +u !e+5*e$ ,e(i+it (un+ti'n&*$ !in,#'m "'!ttu/e#+u*'!; Ri!+u*

    ,e #e+i,i%& e!te m&im in "#imii 2 &ni.- -indecarea !e &"#e+i&& in (un+tie ,e !te#i*it&te& /&+te#i'*'i+& & !"utei$

    im'/i*it&te& im&inii #&,i't'm'#&(i+e$ T +'##e+t &,mini!t#&t )!&n!e ,e

    !te#i*ie *ei'n&*&$ pro%a timpului(iin, mt'#u* +e* m&i (i,e* / n&&ti% *&T12 !i T2?.

    Epidemiologie

    2 lupta in ocar;2 masuri adresate sursei inde'" - i'*e = DOT; - (i!& T *& ete#ne;

    - +'n,itii *& ete#ne;

    - #e+'m&n,i;

    - ,i!"en!ie in+&,#e& /'*n&%u*ui in #u"& ,i!"en!i&*& un,e %& !t& 12 *uni$ +'nt#'* / 2 "#',u!e mi+#'!+'"ie$ 2 "#',u!e +u*tu#& *& 2$?$6$@$1$12 *uni ,e

    *& in!titui#e& t#&t&mentu*ui;

    - *& 6 *uni /i*&ntu* ,e et&"& +#ite#ii ,e "#e*uni#e DOT; - *& 12 *uni$ in +&u* t/+ +u /= MT' !&u +&%it$ (i!& ,e /i*&nt t5e#&"euti+ &

    +&u*ui !u#!&;

    - ,&+& +&u* e!te /= *& 6 *uni$ t#e+e in &*t& #u"& ,i!"en!i&*&;

    2 isa de anuntare a ca!ului de tu%erculo!a in "#ime*e i*e ,e *& initie#e& T;

    2 ancheta epidemiologicain "#ime*e 3 i*e ,e *& &nunte& +&u*ui in ,i!"en!u* t/+

    te#it'#i&*$ ,e ti" ,e!+en,ent +u ,e!+'"e#i#e& !i +&t&(ie#e& +'nt&+ti*'# int#& !i

    et#&,'mi+i*ii;

    2 masuri adresate contactilorin(e+t&ti !&u im/'*n&%iti )+'nt#'* >>D$ R90R8$ /$

    +5imi'"#'(i*&ie +u IN *& +'nt&+tii +u %!t& +u"#in!& int#e -2? &ni &ne#i+i !i

    &*e#i+i$ +'nt#'*u* "e#i',i+ &* +'nt&+ti*'# &,u*ti !i +'"ii;

    2 de!inectia curenta si terminala in ocar

    @

  • 7/24/2019 Prezentare de Caz - Tbc

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    2 rea%ilitarea ca!ului #ein!e#tie in !'+iet&te;

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    -$$*Particularitatea ca!ului

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