si 04
TRANSCRIPT
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SEMIOLOGIE MEDICALA
CURS IV
EXAMENUL CLINIC GENERAL
SEF LUCR. DR. CAMELIA SCARNECIU
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INSPECTIA GENERALA
ETAPESTATICA – atitudinea bolnavului in pat
(decubitusul)
- atitudinea bolnavului in ortostatism
DINAMICA - mersul
- miscari segmentare
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INSPECTIE STATICA
ATITUDINEA BOLNAVULUI IN PAT (DECUBITUSUL)
DECUBITUL INDIFERENT
DECUBITUL PATOLOGIC (INSTINCTIV)
- antidispneizant - antialgic
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DECUBITUSUL HOMOLATERAL
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INSPECTIE STATICA
DECUBITUSUL PATOLOGIC
AFECTIUNI CARDIACE - ortopnee – IVS - semnul “rugaciunii mahomedane” –
pericarditaAFECTIUNI PULMONARE - decubit contralateral afectiunii – pleurita - decubit omolateral afectiunii – pleurezieAFECTIUNI MENINGEALE - “cocos de pusca” – meningita - epistotonus – tetanosCOLICA ABDOMINALA - apasa abdomenul cu mainile - “cocos de pusca”PERITONITA - nemiscat
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INSPECTIE STATICA
ATITUDINEA BOLNAVULUI IN ORTOSTATISM
NU POATE PASTRA ORTOSTATISMUL
PASTREAZA CU DIFICULTATE ORTOSTATISMUL (putin timp, baza larga, ameteli, cadere)
– boli neurologice: miastenie, sindrom cerebelos
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INSPECTIE DINAMICA
MERSUL – TIPURI
DROGAT – isterie, simulantCOSIT – hemiplegieEBRIOS – suferinte labirintice, cerebeloase, stare de
ebrietatePARKINSONIAN – baza larga, pasi miciSTEPAT – paralizie sciatic popliteu externOPRIT INTERMITENT – claudicatie intermitenta
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INSPECTIE DINAMICA
MISCARI SEGMENTARE
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INSPECTIE
ANTROPOMETRIE
POTENTIAL INFORMATIONAL (varsta, sex) - PERIOADA DE CRESTERE STATURO-PONDERALA - ADULTI - valori standard - depozite adipoase - tonicitate musculatura PRINCIPIU - TEHNICI STANDARDIZARE+COMPARARE MATERIALE - CANTAR - TALIOMETRU - BANDA CENTIMETRICA
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ANTROPOMETRIE
TEHNICA GREUTATE - pacient dezbracat - kg, o zecimala TALIE – cm PERIMETRU ABDOMINAL -
ortostatism/decubit dorsal
PERIMETRU TORACIC CIRCUMFERINTE SEGMENTARE - coapsa – 1/3 superioara - gamba – 1/3 medie - brat – deltoid
REZULTATE CALCULARE INDICI COMPARARE - date standard - valori ideale - succesiva
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ANTROPOMETRIESTARE DE NUTRITIE
INTERPRETAREA REZULTATELOR
CALCULARE GREUTATE IDEALA (GI)
- formula Lorentz ♂ - GI = 50+(talia-150)x0,75 GI = 50+(talia-150)x0,75+(V-20)/4 ♀ - GI = {50+(talia-150)x0,75}x0,9 GI = {50+(talia-150)x0,75+(V-20)/4}x0,9 - formula Broca (simplificata) G (kg) = talia-100
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ANTROPOMETRIESTARE DE NUTRITIE
STARE NUTRITIE - DEFINITIE NORMOPONDERAL - GI±10%GI SUBPONDERAL - GI - (10-20%GI) – EMACIAT - GI - >30%GI – CASECTIC SUPRAPONDERAL - GI + (10-20%)GI OBEZ – GI + >30%GI
INDICE DE MASA CORPORALA (IMC) IMC = G(kg)/I2(m) NORMOPONDERAL - ≥18,5-24,9 SUBPONDERAL - <18,5 SUPRAPONDERAL - ≥25-29,9 OBEZ - ≥30
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ANTROPOMETRIESTARE DE NUTRITIE
OBEZITATE GINOIDA
OBEZITATE ANDROIDA = RISC CARDIOVASCULAR
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ANTROPOMETRIETALIE
TALIE ADULT
NORMAL 151-185 cm NANISM 120-150 cm HIPERSTATURAL –cu 10-20% peste
media populatiei 185-190 cm GIGANTISM – cu >20% peste media
populatiei ♂>200 cm ♀>190 cm
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NANISM-armonic,disarmonic
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ANTROPOMETRIEPERIMETRE
PERIMETRUL ABDOMINAL
evalueaza obezitatea tip android = factor de risc cardiovascular = intra in definitia sindromului metabolic
ORTOSTATISM
NORMAL ♂<92 cm OBEZ >104 cm
NORMAL♀<80 cm OBEZ >88 cm
- diferenta normala aparuta intre masurarea perimetrului abdominal in ortostatism si clinostatism este de 1-2 cm; o valoare mai mare pune in evidenta hipotonia musculara
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ANTROPOMETRIE
PERIMETRUL TORACIC FORMULA DE CALCUL = Talie/2 INDICE ROBUSTITATE = Talie (cm)-G+P toracic = 10 (N) – la adult CIRCUMFERINTE SEGMENTARE COMPARATIV STG/DR ASIMETRIE N < 1 cm – coapsa < 0,5 cm – brat PLIU CUTANAT TRICIPITAL SUBSCAPULAR N ♂ 1,2 cm N ♀ 2,3 cm RAPORT PLIU DELTOIDIAN/TROHANTERIAN N = 1/2 ABDOMINAL N 1-1,2 cm
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INSPECTIE
TULBURARI DE SENSIBILITATE
HIPERESTEZIA – accentuarea sensibilitatii (psihostimulante)
HIPOESTEZIA – diminuarea sensibilitatii (intoxicatii)
ANESTEZIA – abolirea sensibilitatii (boli neurologice)
Tipuri sensibilitate - tactila
- termica
- dureroasa
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HIPERESTEZIE DUREROASA DENTINARA
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INSPECTIE - STAREA PSIHICA
1. TULBURARI DE PERCEPTIE
ILUZIILE – perceptii eronate, cu obiect
● conditii de ceata, intuneric
● psihoze – alcoolice
HALUCINATII – perceptii false, fara obiect
● auditive
● vizuale
● tactile
● olfactive
→ stari toxice
→ boli psihice - schizofrenia
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ILUZIE OPTICA
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ILUZIE OPTICA
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HALUCINATII
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HALUCINATII
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HALUCINATII AUDITIVE
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INSPECTIE - STAREA PSIHICA
2. TULBURARI DE MEMORIE
HIPOMNEZIA – scaderea memoriei (somnolenti, convalescenti)
HIPERMNEZIA – accentuarea memoriei (oligofreni, psihoze)
AMNEZIA – pierderea memoriei
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INSPECTIE - STAREA PSIHICA
3. TULBURARI DE GANDIRE DE FORMA – modificarea vitezei → fuga de idei (↑) → bradipsihie (↓) → baraj psihic (-) DE FOND → idei prevalente → ipohondria → fobia: claustrofobia, zoofobia, cancerofobia → delir – idei false nereale ● sistematizat: expansiv, paranoia ● nesistematizat: idei haotice (intoxicatii, stari febrile,
psihoze)
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BRADIPSIHIA(cretinism )
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CLAUSTROFOBIA
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ARAHNOFOBIA
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INSPECTIE - STAREA PSIHICA
4. TULBURARILE AFECTIVITATII
HIPERTIMIA = exagerarea trairilor afective - euforia - atitudinea pesimista - anxietatea – fara obiect - angoasa – anxietate exagerata – senzatie de moarte iminenta (sindrom nevrotic anxios depresiv)
HIPOTIMIA = diminuarea starilor afective - apatia sau indiferenta – nevroza astenica
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HIPERTIMIA
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ATAC DE PANICA
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HIPOTIMIA-DEPRESIA
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CATATONIA
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INSPECTIA - STAREA PSIHICA
5. TULBURARI DE CONSTIENTA CONSTIENTA - integrare in timp si spatiu - in relatie cu mediul inconjurator In ordinea severitatii: SOMNOLENTA – molesit, vorbeste greu OBNUBILAREA – reactii lente, raspunsuri inadecvate,
orientare dificila STUPOAREA – dezorientat in timp si spatiu, amnezic PIERDEREA CONSTIENTEI ● de scurta durata: sincopa, lipotimia ● prelungita: coma
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INSPECTIA - STAREA PSIHICA
SINCOPA = pierdere de constienta de scurta durata cu amnezie retrograda
CAUZE
→ ↓ TA – act mictional, defecare
→ cardiace – tulburari de ritm
→ neurologice – accident ischemic tranzitor
→ metabolice – hipoglicemie, intoxicatii cu alcool, cu monoxid de carbon
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INSPECTIA - STAREA PSIHICA
COMA = pierdere de constienta de lunga durata
Pacient - insensibil - nu poate fi trezit la stimuli verbali, durerosi - atitudine pasiva - mobilitate voluntara absenta - reflexe scazute/abolite - functii vitale scazute/abolite
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INSPECTIA - STAREA PSIHICA
COMA - TIPURI
- PRECOMA – raspuns inadecvat la stimuli (geme, miscari necoordonate)
- COMA VIGILA – are ochii deschisi, nu raspunde la stimuli
- COMA PROFUNDA – reflexe absente, functii vitale deprimate
- COMA DEANIMATA – dispar functiile vitale, necesara intubarea
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COMA
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EVALUAREA GRAVITATII COMEI -SCALA GLASGOW
DESCHIDEREA OCHILOR - spontana cu respectarea ciclului veghe- somn – 4
- la comanda – 3
- la durere – 2
- nu deschide ochi -1
RASPUNS VERBAL - orientat -5
- confuz - 4
- inadecvat:conversatie imposibila - 3
- de neinteles - 2
- fara raspuns – 1
RASPUNS MOTOR - raspuns adecvat la comanda – 6
- orientat; flexie la durere – 5
- raspuns neorientat, dar flexie rapida, de evitare a cotului la durere – 4
- decorticat: membrul superior in flexie lenta, membrul inferior in extensie – 3
- decerebrare: membrul superior in rotatie interna si hiperextensie,
membrul inferior in extensie si flexie plantara – 2
- nici o reactie -1
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EVALUAREA GRAVITATII COMEI -SCALA GLASGOW
Cel mai bun scor Glasgow este 15
Cel mai grav scor Glasgow este 3
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INSPECTIA - STAREA PSIHICA
COMA - ETIOLOGIE
- leziuni cerebrale: traumatisme, AVC, tumori
- intoxicatii: alcool, barbiturice
- tulburari metabolice: diabet, uremie
- infectii grave: septicemii
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VORBIREA
BRADILALIA – lentoare in exprimare (hipotiroidie)
DISLALIA – vorbire neinteligibila
MODIFICARI ALE VOCII
- disfonie (raguseala)
- afonie – imposibilitatea de a emite sunete
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INSPECTIE – TEMPERATURA CORPORALA
ASPECTE GENERALE
- temperatura corporala este o constanta
- valori normale ale temperaturii periferice in intervalul 36-36,90C
- temperatura centrala are valori mai mari cu 0,5-10C
- valoarea temperaturii masurata matinal este mai mica decat valoarea temperaturii masurata vesperal
- temperatura periferica ≤ 350C → hipotermie
- temperatura periferica ≥ 370C → hipertermie
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INSPECTIE – TEMPERATURA CORPORALA
TERMOMETRIZAREA
MATERIAL – termometru clasic/electronic
METODA, TEHNICA - periferica (axilar, frunte) - centrala (bucal, rectal)
FACTORI DE EROARE - tehnica inadecvata – instrumentar defect - pozitie inadecvata - axila umeda - timp insuficient (< 3 min) - bolnav interesat – contamineaza rezultatul
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TERMOMETRIZARE
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TERMOMETRIZARE
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FEBRA (PIREXIE)
FEBRA = temperatura corporala cu valori constant mai mari de 370C
SITUATII DE APARITIE - efort muscular - deshidratare - hipertiroidie - boli - SNC - inflamatorii - infectioase - neoplazii
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FEBRA
EVOLUTIE – 3 etape
1. stadiul de debut - disconfort - astenie - inapetenta - cefalee - mialgii - frisoane ± subfebra 2. faza de stare - hiperemie - febra ± palpitatii, dispnee, delir, convulsii 3. faza de declin (defervescenta) – transpiratii - temperatura poate scade lent (lissis) sau brusc (crissis)
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FEBRA
ANALIZA 1. MODALITATE DEBUT – brusc - insidios 2. DURATA – scurta - prelungita (sd febril prelungit > 3 sapt.) 3. GRADUL FEBREI – subfebrilitate: 37-37,90C - febra: 38-40,90C - hiperpirexie: ≥ 410C 4. ASPECTUL CURBEI TERMICE - febra continua (in platou) - febra remitenta - febra intermitenta - febra ondulanta - febra neregulata 5. FENOMENE DE INSOTIRE - frisonul: intermitent/continuu → la debut - transpiratia – pierdere caldura → la sfarsit
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CURBE FEBRILE
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CURBBA FEBRILA -MALARIE
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FEBRA
SITUATII EXTREME
HIPERTERMIE - sincopa termica ≥ 410C - soc termic - crampe musculare - in caz de insolatie HIPOTERMIE - tulburari psihice ≤ 350C - tulburari motorii - tulburari respiratorii - coma
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FINAL
☻ /☻?? ☻!!!
☻?
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SARMIZEGETUSA REGIA
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SARMIZEGETUSA REGIA
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GENTIANA CRUCIATA (tonic general si antidot)
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