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COALA POSTLICEAL SANITAR CAROL DAVILA BUCURETI

LUCRARE DE DIPLOM

COLECISTITA ACUT

COORDONATOR: ABSOLVENT:PROF. NURSINGTOFAN RUXANDRA

2004

referat.cl!tel.r

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C U P R I N S

CAPITOLUL 1

INTRODUCERE..pag.3

CAPITOLUL 2

ANATOMIA I FIZIOLOGIA FICATULUI I A CILOR

BILIAREpag.4

CAPITOLUL 3

COLECISTITA ACUT..pag.13

CAPITOLUL 4ROLUL ASISTENTEI MEDICALE N NGRIJIREA

BOLNAVULUI CU COLECISTIT ACUT..pag.!

CAPITOLUL V

CAZURI CLINICE..pag.3"

BIBLIOGRAFIEpag.4#

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CAPITOLUL 1

INTRODUCERE

Clec"#t"ta ac$t% e#te afec&"$'e care #e ('t)l'e*te la r"ce +ar#t%, c$ -a"-$- /efrec+e'&% la +)r#ta -"lc"e.

Ra!rt$l fe-e"1ara&" e#te /e 31, "ar frec+e'&a (' r)'/$l !!$la&"e" a/$ltea!r"-at"+ 0567.

8' 967 /"' ca:$r", #tarea "'fla-atr"e a +e:"c$le" "l"are e#te /eter-"'at% /e"'cla+area $'$" calc$l la '"+el$l ca'al$l$" c"#t"c, !e care (l #tr$ea:%, afec&"$'e /e'$-"t%l"t"a:a "l"ara. Ea e#te c$'#c$t% /e -$lta +re-e, !r"-a -e'&"'are *t""'&"f"c% fac$t% /ePARACELSUS (' $r$l a'$l$" 600. La '" (' &ar% are frec+e'&% /e 222,61000lc$"tr", c$ -a"-$- (' /eca/a a c"'cea.

I'c"/e'&a real% a clec"#t"te" ac$te e#te ;re$ /e a!rec"at eact #tat"#t"c, (' acea#ta"'ter+e'"'/ factr" /e erare< fr-ele c$ "'te'#"tate re/$#% #a$ cele c$ trata-e't ecl$#"+-e/"ca-e't#. Cert e#te fa!t$l c% !e -a#$ra !rel$';"r"" /$rate" -e/"" /e +"a&% ea /e+"'e

tt -a" frec+e't% la /eca/e a+a'#ate =605>0 /e a'"?, e!r"-)'/ *" !r"' acea#ta ra!rt$l/"rect /e ca$:al"tate c$ l"t"a:a "l"ar%.@ra+"tatea clec"#t"te" ac$te e#te /"rect !r!r&"'al% c$ fr-a a'at-!atl;"c%,

c$ "'te'#"tatea !rce#$l$" #tr$ct"+ #" "'fec&"#, c$ +ar#ta !rec$- *" c$ /e:ec"l"releelectr"l"t"c *" -etal"c #ec$'/are.

8' !re:e't, '$-%r$l /e clec"#tect-"" "'ter+e'&"a c"r$r;"cal% !r"' care #eet"r!% +e:"c$la "l"ar% *" ca'al$l c"#t"c e#te /e /$% r" -a" -are ca cel ala!e'/"cect-""lr.

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CAPITOLUL 2

ANATOMIA I FIZIOLOGIA FICATULUII A CILOR BILIARE

2.1. General!"# $r%n& a$ara!'l &(e)!%

A!arat$l /";e#t"+ c$!r"'/e ttal"tatea r;a'elr care ('/e!l"'e#c "-!rta'&af$'c&"e /e /";e#t"e *" a#r&"e a al"-e'telr =!ree'#"$'e, -/"f"carea f":"c5c"-"c% aal"-e'telr, a#r&"a '$tr"-e'telr *" ecre&"a re:"/$$r"lr 'ea#r"te?. E#te c-!$#/"' t$$l /";e#t"+ *" ;la'/ele #ale a'ee.

D";e#t"a e#te a'#a-l$l /e !rce#e (' c$r#$l c%rra #$#ta'&ele '$tr"t"+e #$'tel"erate /"' al"-e'te, #$ "'fl$e'&a e':"-elr, fra;-e'tate (' c'#t"t$e'&"" lr c"-"c" *"a#r"te. D";e#t"a #e real":ea:% (' #e;-e'tele c'#t"t$t"+e ale tract$l$" /";e#t"+.

A!arat$l /";e#t"+ #e (-!arte (' /$% #e;-e'te

a? Ce*al+ , c$!r"'/e ca+"tatea $cal% c$ ;la'/ele a'ee *" far"';ele. 8' acea#t%!r&"$'e al"-e'tele #$'t !r"'#e /e $:e, /"'&" *" l"-a, #$'t tr"t$rate, l$ref"ate /e#al"+% *" tra'#!rtate (' #e;-e'tele "'fer"are !r"' /e;l$t"&"e. Or;a'ele lfact"+e *";$#tat"+e c'trlea:% c-!:"&"a c"-"c% a al"-e'telr.

? Tr'n+al , c$!r"'/e !r&"$'ea /e la r";"'ea e#fa;$l$" !)'% la a'$# e#fa;,#t-ac, "'te#t"' #$&"re =/$/e', e$', "le'?, "'te#t"' ;r# =cec, a!e'/"ce, cl'a#ce'/e't, tra'#+er#, /e#ce'/e't *" #";-"/"a' *" rect?.

E#fa;$l e#te /ar $' c'/$ct /e tra'#!rt. Tra'#fr-area al"-e'telr ('ce!e ('#t-ac *" #e /ef"'"t"+ea:% (' "'te#t"'$l #$&"re, $'/e #$#ta'&ele '$tr"t"+e #$'t a#r"te ('

ca!"larele #a';$"'e *" l"-fat"ce. La ace#t '"+el (' /";e#t"e "'ter+"' f"cat$l, !a'crea#$l *" $''$-ar -"c /e ;la'/e /"' !eretele "'te#t"'al. 8' "'te#t"'$l ;r# re#t$r"le al"-e'tare'ea#r"te #$'t c'/e'#ate !r"' /e#"/ratare, /et"f"cate !r"' c'$;are, tra'#fr-ate(' fecale !r"' fer-e'ta&"e *" !$trefac&"e, tra'#!rtate *" el"-"'ate la '"+el$l rect$l$" *"a'$#$l$".

@la'/ele a'ee ale t$$l$" /";e#t"+ #$'t ;la'/ele #al"+are, f"cat$l *" !a'crea#$l.

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2.2. Ana!-a *+a!'l'

F"cat$l e#te cea -a" -are ;la'/a /"' cr!$l $-a'.

A/e0are :E#te #"t$at (' ca+"tatea a/-"'al% eta$l #$!ra-e:cl"c (' !artea#$!er"ar% /rea!ta, "-e/"at #$ /"afra;-, "ar l$l #a$ #t)'; #e ('t"'/e !)'% (' e!";a#tr$.Lc$l c$!at /e f"cat #e '$-e*te la e!at"c%.

C-n*('ra#a e!ern" :Are fr-a $'$" #e-"+"/, a*e:at tra'#+er#al (' a/-e',c$ l$';"-ea /e a!r"-at"+ 2 c-, /"a-etr$l a'ter5!#ter"r /e c-, ('%l&"-ea /e c- *" ;re$tatea /e a!r"-at"+ 400 ;. are c$lare r*"e5c%r%-":"e, /atr"t% ca't"t%&""-ar" /e #)';e !e care c'&"'e.

F"cat$l !re:"'t% tre" fe&e

a Fa#a )'$er-ar" =/"afra;-at"ca? e#te c'+e% (' #$# *" +"'e (' ra!rt c$/"afra;-$l *" c$ !eretele a'ter"r al a/-e'$l$", /e aceea " #e -a" #!$'e a'eter5#$!er"ar%. Pe ea #e #er+% l$l /re!t *" l$l #t)';, /el"-"ta&" /e l";a-e't$lfalc"fr-. L$l /re!t !re:"'t% "-!re#"$'ea arc$l$" c#tal, "ar cel #t)'; ('t"!%r"t$racar/"ac%.

Fa#a n*er-ar"=+"#cerala? e#te c'ca+% *" +"'e (' ra!rt c$ #t-ac$l, /$/e'$l,

cl'$l, -e:cl'$l tra'#+er#, r"'"c"$l /re!t *" ;la'/a #$!rare'ala /rea!t%. Peacea#t% fa&a #e afl% tre" *a'&$r" *a't$l a'ter5!#ter"r =#a;"tal? /re!t. A/%!#te*te (' !r&"$'ea a'ter"ar%

+e:"c$la "l"ar%, "ar (' cea !#ter"ar% +e'a ca+% "'fer"ar%. *a't$l a'ter5!#ter"r =#a;"tal? #t)';. A/%!#te*te (' !r&"$'ea a'ter"ar%

l";a-e't$l rt$'/, "ar (' cea !#ter"ar% l";a-e't$l Ara't"$#. *a't$l tra'#+er#. Se ('t"'/e ('tre cele /$% *a'&$r" #a;"tale.

C'&"'e "l$l f"cat$l$" fr-at /"' ele-e'tele !e/"c$l$l$" e!at"c artera e!at"c%,+e'a !rt%, /$ct$l e!at"c, l"-fat"cele *" 'er+"".

Ace#te *a't$r" /el"-"tea:% !atr$ l" /re!t, #t)';, ca$/at *" al l$" S!"e;el.

+ Fa#a $-)!er-ar" c't"'$% !e cea #$!er"ar% *" +"'e (' ra!rt c$ !eretele!#ter"r al ca+"t%&"" a/-"'ale la '"+el$l +erterelr T>5T.

Ml-a+e &e *are :S$'t re!re:e'tate /e l";a-e'te, +e'a ca+% "'fer"ar% *" !e/"c$l$l

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e!at"c.

S!r'+!'ra :F"cat$l e#te ('+el"t !e !er"t'e$l +"#ceral =t$'"ca #era#%?, care #ec't"'$% c$ !er"t'e$l !ar"etal, /"' care #e fr-ea:% l";a-e'tele cr'ar, tr"$';"$lar#t)';, tr"$';"$lar /re!t *" falc"fr-, ace#ta /"' $r-a c'&"')'/ (' -ar;"'ea #a l"er%

l";a-e't$l rt$'/. S$ acea#t% t$'"c% #e afl% -e-ra'% f"ra#% =ca!#$la @l"##'? *"a!" !are'c"-$l e!at"c.

Ca!#$la @l"##' !%tr$'/e (' f"cat !r"' "l, $r-%r"'/ tra"ect$l +a#elr #a';$"'e *"fr-ea:% !ere&" la-elar" c'$'ct"+" care, (-!re$'% c$ re&ea$a +a#c$lar% (-!art!are'c"-$l e!at"c (' l$l".

L$l$l e!at"c re!re:"'t% $'"tatea a'at-"c% *" f$'c&"'al% a f"cat$l$". Are fr-a$'e" !"ra-"/e a*e:ate c$ a:a #!re #$!rafa&a f"cat$l$" *" +)rf$l #!re "'ter"r. I' #ec&"$'eatra'#+er#al% are a#!ect$l $'$" !l";' c$ 65 lat$r". 8' #tr$ct$ra l$" /"#t"';e- ca!"lare#a';$"'e, cel$le e!at"ce, ca'al"c$le "l"are *" f"lete 'er+a#e +e;etat"+e. 8' ce'tr$ are +e'% ce'trlc$lar%, "ar la !er"fer"e !r"' al%t$rarea a -"'"- tre" l$l" e!at"c" #e

fr-ea:% #!a&""le !rtale ="er'a'?. Ace#te #!a&"" c'&"' &e#$t c'$'ct"+, ra-$r% a+e'e" !rte, ra-$r% a artere" e!at"ce, $'$l #a$ /$% ca'ale "l"are, l"-fat"ce *" f"lete'er+a#e. S)';ele c"rc$l% /e la #!a&"$l !rt #!re +e'a ce'trl$lar%, "ar "la /"' ce'tr$ll$l$" #!re #!a&"$l !rt.

Cel$lele e!at"ce #$'t a*e:ate (' cr/a'e Re-arG, /"#!$#e ra/"ar (' c"$r"lere&ele" ca!"lare "'tral$lare. 8'tre cel$lele e!at"ce *" !eretele ca!"larelr #e afl% #!a&"$l/e trecere D"##e. 8'tre cel$lele e'/tel"$l$" +a#c$lar #e #"t$ea:% cel$lele $!ffer, fa;c"tece !art"c"!% la /e;ra/area e-;l"'e". 8'tre cr/a'e #e fr-ea:%, !r"' #"-!la lral%t$rare, #!a&"" (';$#te '$-"te ca'al"c$le "l"are, care '$ a$ !ere&" !r!r"".

S!re !er"fer"a l$l$", ca'al"c$lele "l"are (*" c'#t"t$"e $' !erete !r!r"$, '$-"t

cla';"la. Cla';"lele /"' l$l"" ('+ec"'a&" #e $'e#c ('tre ele *" fr-ea:% la '"+el$l#!a&""lr "er'a', ca'alele "l"are !er"l$lare. Ca'alele "l"are !er"l$are #e $'e#c ('treele *" /a$ 'a*tere la /$% ca'ale e!at"ce /re!t *" #t)'; cre#!$':atare celr /" l"a" f"cat$l$", care !ar%#"'/ f"cat$l, la '"+el$l "l$l$", #e $'e#c *" fr-ea:% ca'al$l e!at"cc-$'. D$!% $' tra"ect /e 354 c-, ca'al$l e!at"c c-$' #e $'e*te c$ ca'al$l c"#t"c *"alc%t$"e#c (-!re$'% ca'al$l cle/c, care #e /e#c"/e (' /$/e', (-!re$'% c$ ca'al$lH"r#$';, la '"+el$l car$'c$le" -ar".

Ca'al"c$lele "l"are *" ca'alele "l"are !er"l$lare fr-ea:% c%"le "l"are"'trae!at"ce, "ar ca'al$l e!at"c c-$' *" ca'al$l cle/c alc%t$"e#c c%"le "l"areetrae!at"ce.

Ac"'$l e!at"c re!re:"'t% #$$'"tatea -rff$'c&"'al% a l$l$" e!at"c. E#tec'#t"t$"t /"' ttal"tatea cel$lelr "r";ate /e acela*" +a# *" care (*" +ar#% "la (' acela*"ca'al"c$l "l"ar.

Va)+'lar0a#af"cat$l$" e#te real":at% /e

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a? Artera e!at"c% "a 'a*tere /"' tr$'c"$l cel"ac. La ('ce!$t c't"'$% /"rec&"aace#t$"a *" c)'/ ('tal'e*te +e'a !rt% #e /"+"/e (' /$% ra-$r" ter-"'ale e!at"c%!r!r"e *" artera ;a#tr/$/e'al%.

Artera e!at"c% !r!r"e #e /"+"/e la '"+el$l "l$l$" e!at"c (' ra-$ra /rea!t% *"#ta';%. D% #er"e /e claterale artera !"lr"c%, artera c"#t"ca, ra-$r" ter-"'ale.

Artera ;a#tr/$/e'al% #e "f$rc% (' artera ;a#tre!"!l"c% /rea!t% *" arterele!a'creat"c/$/e'ale a'ter"ar% *" !#ter"ar%.

? Ve'a !rt% e#te tr$'c"$l +e'# clectr al #a';el$" /"' tract$l /";e#t"+#$/"afra;-at"c, !e care5l a/$ce la f"cat. Ia 'a*tere /"' +e'a -e:e'ter"c% "'fer"ar%care /re'ea:% cl'$l #ta';. Ace#ta #e +ar#% (' +e'a #!le'"c%, care #e $'e*te "'c't"'$are c$ +e'a -e:e'ter"ca #$!er"ar* =care /re'ea:* "'te#t"'al #$&"re,!a'crea#$l *" cl'$l /re!t? *" care e#te c't"'$at% c$ /"rec&"a #!re f"cat /e +e'a!rt%.

Tr$'c"$l +e'e" !rte fr-at la '"+el$l +ertere" L2, ('a!"a !a'crea#$l$", -a"!r"-e*te +e'a ;a#tr"ca #ta';%, +e'a !"lr"c% *" +e'a !a'creat"c/$/e'al* #$!er"ar%/rea!t%.

Ve'a !rta $rca #!re "l$l f"cat$l$" $'/e #e ter-"'a "f$rc)'/$5#e (' /$% ra-$r" Drea!t%, #c$rt% care !r"-e*te cele /$% +e'e c"#t"ce *" #ta';%, l$';% care e (' le;at$r% c$cele /$% +e'e l"terate, ca'al$l l$" Ara't"$# *" +e'a -"l"cal% a l";a-e't$l$" rt$'/.

Ve'a !rt% are l$';"-e /e 50 c- *" $' cal"r$ /e 6 --.Ve'ele #$!rae!at"ce =4 ;r$!e? !r"'c"!ale *" acce#r"" a$'; la fa&a !#ter"ar% a

f"cat$l$", !e -ar;"'ea +e'e" ca+e.

L"-fat"cele f"cat$l$" #$'t #$!erf"c"ale #" !rf$'/e.

Iner%a#a f"cat$l$" #e face !r"' f"letele 'er+a#e #"-!at"ce !e care f"cat$l le!r"-e*te /e la !le$l cel"ac *" f"lete 'er+a#e !ara#"-!at"ce /e la 'er+$l +a; !r"' -"c$le!"!l'.

2.3 Cale lare e!ra5e$a!+e

S$'t c'#t"t$"te /"'

a? Calea "l"ar% !r"'c"!al% re!re:e'tat% /e ca'al$l e!atcle/c.

>

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Ca'al$l e!at"c c-$' #e fr-ea:% !r"' $'"rea celr /$% ca'ale e!at"ce,/re!t *" #ta';. El cara (' -ar;"'ea l"er% a -"c$l$" e!"!l' *"f$:"'ea:%, la '"+el$l -ar;"'"" #$!er"are #a$ ('a!"a !r"-e" !r&"$'" a/$/e'$l$", c$ ca'al$l c"#t"c +e'"t /e la +e:"ca "l"ara, fr-a'/ ca'al$lcle/c. Acea#ta /e#cr"e c$r$ra c$ c'ca+"tatea #!re /rea!ta #" a'ter"r

#" #e ter-"'a la '"+el$l tre"-"" -"lc"" a cele" /e a /$a !rt"$'" a/$/e'$l$". a#ara "' -e/"e 6 c-, "ar +alr'le#te /e 6 --.

Ca'al$l cle/c !re:"'ta 4 #e;-e'te #$!ra/$/e'al, retr/$/e'al,retr!a'creat"c #" "'tra!ar"etal ="' !eretele /$/e'$l$"?. Se ter-"'a !r"'tr5$'r"f"c"$ c-$' c$ ca'al$l !a'creat"c, $'"'/$5#e c$ ace#ta "' a-!$lae!at!a'creat"ca a l$" Vater. I' acea#ta :'a e"#ta "-!rta'tafr-at"$'e -$#c$lara =#f"'cter$l l$" O//"?, a care" f$'ct"'are crectaa#";$ra tra':"t$l 'r-al al "le" #!re /$/e'.

? Calea "l"ara acce#r"e re!re:e'tata /e +e:"c$la "l"ara #" ca'al$l c"#t"c.Ve:"c$la "l"ara =clec"#t$l? e#te $' re:r+r a'eat ca"lr /e ecret"e a

"le", "' care acea#ta #e ac$-$lea:a "' "'ter+al$l /"'tre !ra':$r". E#te #"t$ata"' f#a +e:"c$le" "l"are /e !e fata +e#cerala a f"cat$l$". Are l$';"-e /ea!r"-at"+ 0 c-, lar;"-e /e 4 c- #" ca!ac"tate /e 6050 -l.

Pre:"'ta 3 !rt"$'" f$'/$l, cr!$l #" cl$l.

F'n&'l %e0+'le larec'#t"t$"e etre-"tatea e" a'ter"ara #" ra#!$'/e "'c":$r""c"#t"ce /e !e -ar;"'ea "'fer"ara a f"cat$l$". Pe +"$, el #e !r"ectea:a !e !eretelea/-"'al a'ter"r, "' !$'ct$l $'/e l"'"a -"l"c5a$"l"ara /rea!ta "'tal'e#te arc$lc#tal. E#te "'+el"t "' !er"t'e$ #" are -are -"l"tate.

C-r$'l %e0+'le laree#te !artea a/ere'ta la fata +"#cerala a f"cat$l$". El #e"';$#tea:a tre!tat #!re cl, $lt"-a !arte a #a e#te /e'$-"ta "'f$'/"$l. V"'e "' ra!rt "'#$# c$ f"cat$l, "ar "' # c$ cl'$l tra'#+er# #" c$ /$/e'$l. Fat #$!er"ara a/era #la laf"cat !r"'tr5$' te#$t c'$'ct"+ #traat$t /e +e'e !rte acce#r"". Ea #e !ate /e:l"!" $#r"' c$r#$l !erat"e" /e et"r!are a +e:"c$le". Fata "'fer"ara e ac!er"ta /e !er"t'e$ #"le;ata /e cl'$l tra'#+er# !r"' l";a-e't$l c"#t"c5cl"c.

C-l'l fr-ea:a etre-"tatea !rf$'/a #" a#c$t"ta a +e:"c$le" "l"are. Are fr-ac'"ca #" #e c't"'$a fara l"-"ta !rec"#a c$ ca'al$l c"#tr"c. E#te l"er, '$ a/era la f"cat.I' #$# #" "' #ta';a +"'e "' ra!rt c$ ra-$ra /rea!ta a +e'e" !rte, "ar "' # c$ !rt"$'ea#$!er"ara a /$/e'$l$".

S!r'+!'ra %e0+'le lare la eter"r e#te ac!er"ta /e !er"t'e$ =t$'"ca#era#a?. S$ acea#ta #e :are#te $' #trat #$#er# "'e /e:+ltat, /e 'at$ra c'$'ct"+alaa. Ur-ea:a t$'"ca f"r5-$#c$lara, fr-ata /"' te#$t cla;el !re/-"'a't #" f"reela#t"ce, "' care #$'t c$!r"'#e f"re -$#c$lare 'ete/e fr-a'/ -a'$'c"$r" r"e'tatel"c. I-!re$'a c$ f"rele l';"t$/"'ale #" c"rc$lare, ace#tea fr-ea:a retea "' care f"rec$ r"e'tare /"fer"ta #e c't"'$a $'ele c$ altele. La "'ter"r +e:"c$la e#te ca!t$#"ta /et$'"ca -$ca#a fr-ata /"'tr5$' e!"tel"$ #"-!l$ #" /"'tr5$' cr"'. E!"tel"$l c't"'e

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cel$le a#ra'te c$ !lat$ #tr"at #" !$t"'e cel$le calc"fr-e. I' re;"$'ea cl$l$" #e ;a#e#c;la'/e /e t"! -$c#, al carr !r/$# #e a-e#teca c$ "la. Cr"'$l e#te fr-at /"' te#$tc'$'ct"+ la #" ret"c$lar. E!"ter"$l e#te "-!er-ea"l !e'tr$ !";-e'&"" "l"ar"". Cel$lele#ale !art"c"!% la !rce#$l /e re#r&"e a a!e" =c'ce'trarea "le"? *" la elararea $'rc'#t"t$e'&" "l"ar" =;ra#"-" *" cle#terl?.

Va)+'lar0area %e0+'le laree#te le;at% /e +a#c$lar":area f"cat$l$"

Artera c"#t"c%, ra-$r% a ra-$r"" /re!te a artere" e!at"ce !%tr$'/e (' +e:"c$l% la'"+el$l ;)t$l$" *" #e (-!arte (' ra-$r"le /rea!t% #" #ta';%.

Ve'ele c"#t"ce =/$%? #$'t #atel"te artere". Se +ar#% (' ra-$ra /re!t% a +e'e" !rte.L"-fat"cele /re'ea:% (' l"-f'/$l$"" ;)t$l$" *" l"-f'/$l"" -ar;"'"" a'ter"are a

"at$#$l$" H"'#lJ. De acl a$'; la '/$l"" retr/$/e'!a'creat"c".

Iner%a#a %e0+'le lare e#te f%c$t% /e f"re +e;etat"+e =#"-!at"ce #"

!ara#"-!at"ce? care +"' (' !le$l e!at"c a'ter"r.

F'n+#le %e0+'le lare #$'t $r-atarele /e re:er+r, /e c'ce'trare *"re#r&"e, /e #ecre&"e *" /e c'tract"l"tate. Ca'al$l c"#t"c e#te c$/at !e cl$l +e:"cal < #e ('/rea!t% (' #, la #t)';a *" ('a!" *" #e

ter-"'% (' $';" a#c$&"t (' fla'c$l /re!t al ca'al$l$" e!at"c, fr-)'/ ca'al$l clectr.L$'; (' -e/"e /e 3 c-, cal"r$l #%$ #e /"-"'$% /"'#!re cle/c #!re +e:"c$la.$ca#a /e la '"+el$l cl$l$" *" a ca'al$l$" c"#t"c fr-ea:% +al+ele #e-"l$'areKe"#ter. La le;%t$ra /"'tre cl *" ca'al$l c"#t"c #e afl% #f"'cter$l +e:"c$lar.

2.4. F'n+#le *+a!'l'

F$'c&""le f"cat$l$" #$'t "-!rta'te *" +ar"ate "a !arte la /";e#t"a "'te#t"'al%,/e!:"tea:% (' el !arte /"' #$#ta'&ele care /e!%*e#c 'e+"le "-e/"ate ale r;a'"#-$l$",/e;ra/ea:% *" #"'tet":ea:% /"fer"te #$#ta'&e, "a !arte la -e'&"'erea c-!:"&"e" !la#-e",-e'&"'e ec"l"r$l ;l$c"/"c, tra'#fr-% ;r%#"-"le (' fr-e care #e "/ea:% -a" $*r,#"'tet":ea:% fer-e'&"" 'ece#ar" f$'c&""lr !r!r"" #a$ ale altr r;a'e, re;le:%

-etal"#-$l a!e" *" c'trle:% /e"t$l #a';$"', !re*te !%tr$'/erea t"'elr ('r;a'"#-, are rl (' fr-area ;l$lelr r*"", "'ter+"'e (' ter-re;lare, #ecret% *" ecret%"la.

2.6. Bla / r-l'l e 7n -r(an)

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B"la e#te fr-at% /e cel$lele e!at"ce *" cel$lele $!ffer. E#te !r/$#% (' -/c't"'$$ a#tfel ('c)t (' 24 re #e real":ea:% ca't"tate /e 005200 -l. R"t-$l #ecre&"e"e#te -a" re/$# 'a!tea *" -a" cre#c$t :"$a. B"la #e el"-"'% (' /$/e' /ar (' c$r#$l/";e#t"e" al"-e'telr. I'tre t"-! ea #e ac$-$lea:% trre!tat (' +e:"c$la "l"ar%, $'/e #$fer%

$' !rce# /e c'ce'trare !r"' a#r&"e /e a!% *" "'" *" !r"-e*te ca't"tate /e -$c$#.

C-$-0#a le

A$" 89; S"r'r lare 81;. Ele re!re:"'t% cel -a" "-!rta't c'#t"t$e't al "le" *" #$'t

re!re:e'tate /e ;l"clat *" ta$rclat /e #/"$.Prce't$l #%r$r"lr "l"are +ar"a:% (' f$'c&"e /e al"-e'ta&"e. A$'#e (' "'te#t"', ele trec

(' c"rc$la&"a +e'e" !rte *" a$'; /"' '$ la f"cat, $'/e #t"-$lea:% fr-area /e '" #%r$r""l"are. I' fel$l ace#ta #e #ta"le*te c"rc$"t$l e'tere!at"c al #%r$r"lr "l"are.

S%r$r"le "l"are ('/e!l"'e#c $r-%tarele f$'c&"" . La '"+el$l "'te#t"'$l$" e-$l#"'e:% ;r%#"-"le *" !te'&ea:% l"!a:a !a'creat"c%.2. Fr-ea:% c$ ;r%#"-"le c-!lec*" cle"'"c" #l$"l" (' a!%, !er-"&)'/ a#tfel

a#&"a ;r%#"-"lr *" a +"ta-"'elr l"!#l$"le A, D, E, *" F.3. St"-$lea:% !er"#talt"#-$l "'te#t"'$l$" rl laat"+.4. e'&"' ec"l"r$l flre" -"cr"e'e a "'te#t"'$l$" ;r#, c-%t)'/ flra /e

!$trefac&"e rl a't"!$tr"/.6. St"-$le:% fr-area "le" rl cleret"c.

P(en# lar 8

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#l/ea:% c$ a!ar"&"a "cter$l$" =c$larea ;ale'% a te;$-e'telr *" a #clerelr? at$'c" c)'/"l"r$"'a cre*te !e#te +alarea /e 2 -;7. Reac&"a Va' /er Ber; 'e a$t% #% +e/e- cefel /e "l"r$"'% #5a ac$-$lat *" #!re ce ca!"tl /e !atl;"e 'e ('/re!t%- ate'&"a.

D$!% ce a$ a$'# (' "'te#t"', !";-e'&"" "l"ar" #$fer% (' c't"'$are #er"e /e-/"f"c%r". B"l"r$"'a e#te tra'#fr-at% #$ "'fl$e'&a flre" "'te#t"'ale (' $r"l"';e'. O

-are !arte /"' ace#ta e#te "/at *" tra'#fr-at (' #terc"l"';e', care #e el"-"'% !r"'fecale. Re#t$l /e $r"l"';e' #e el"-"'% !arte !r"' $r"'% *" !arte e#te re#r"t *" a/$#la f"cat =c"rc$"t$l e'tere!at"c?.

C-le)!er-l'l 81>2;e#te $' !r/$# /e "/are. Pr+"'e /"' /$% #$r#e #)';e *" f"cat.8' #a';e a$';e /"' al"-e'te ;ate (' cle#terl, "ar (' f"cat e#te #"'tet":at /e ace#ta /"'ac"/ acet"c *" ;r%#"-" /e;ra/ate.

Ca't"tatea /e cle#terl cre*te (' t"-!$l #arc"'"", !rec$- *" (' al"-e'ta&"a ;at% ('l"!"/e< ea #ca/e (' l"!#a ace#tra #a$ (' ca:$l $'r le:"$'" ;ra+e ale f"cat$l$".

e'&"'erea ra!rt$l$" cle#terl5#%r$r" "l"are ='r-al 120 130? are /e#e"t%"-!rta'&%. C)'/ ace#ta #ca/e #$ 13#e fa+r":ea:% !rec"!"tarea cle#terl$l$", carefr-ea:% calc$l" "l"ar".

8' "'te#t"', 30507 /"' cle#terl e rea#r"t !r"' -$c"a#a /$/e'e$'al%=c"rc$"t$l e'tere!at"c?, re#t$l f""'/ tra'#fr-at /e flra "'te#t"'al% (' c!r#terl *"el"-"'at !r"' fecale. Are rl (' #"'te:a $'r r-'" crt"c#$!rare'al"e'", #e$al"ac":"lr "l"ar" *" +"ta-"'a D3.

Le+!na 87 a!% *" 37 re:"/$$ $#cat =#$#ta'&%r;a'"c% *" a'r;a'"c%?< la %e0+'lar" #e +ar#% (' /$/e' /"' +e:"c$la "l"ar% '$-a" (' t"-!$l

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al"-e'ta&"e". E#te -a" +)#ca#% =c'&"'e -$c$# /"' -$ca#a +e:"c$le"? *" -a" c'ce'trat%(' !";-e'&" "l"ar" =(' t"-!$l ac$-$l%r"" e" (' +e:"c$l% !arte /"' a!% #e rea#are !r"'!ere&"" ace#te"a?.

Me+an)'l )+'r(er le 7n &'-&en

El"-"'area "le" /"' +e:"c$la "l"ar% #e face !e cale $-ral% *" !e cale refle%.a? Pe +ale '-ral" ,ecre&"a "le" (' /$/e' e c'/$#% /e clec"#tG"'"'%, r-'

care #e fr-ea:% la c'tact$l -$ca#e" /$/e'ale c$ c'&"'$t$l ac"/ al ace#te"a *" $'ele!r"'c"!"" al"-e'tare. Trec)'/ (' #)';e, clec"#tG"'"'a a$';e la c%"le "l"areetrae!at"ce *" !r/$ce e+ac$area "le" (' /$/e'.

? Pe +ale re*le" ,!r"' !%tr$'/erea ra'e" (' /$/e' #$'t ec"ta&" rece!tr""

Ce'tr"!e&" /"' -$ca#e< ec"ta&"a a$';e la #"#te-$l 'er+# ce'tral *" /e acl, !e calea'er+"lr +a;" ='er+" !ara#"-!at"c"?, !r'e#c "-!$l#$r" la #f"'cter$l +e:"c$le" "l"are *" la#f"'cter$l O//", /eter-"')'/ relaarea lr. Tt/at% are lc c'trac&"a +e:"c$le" *" "la /ere:er+% ="la +e:"c$lar%? e#te el"-"'at% (' "'te#t"'. C)'/ +e:"c$la #5a ;l"t, #f"'cter$l e" #e('c"/e, /ar r%-)'e /e#c"# #f"'cter$l O//", a#tfel ('c)t "la +e'"t% /"rect /e la f"cat ="lae!at"c%? trece (' "'te#t"', at)ta t"-! c)t /$rea:% /";e#t"a.

D$!% ('cetarea /";e#t"e", #f"'cter$l O//" #e ('c"/e *" #e /e#c"/e #f"'cter$l +e:"c"""l"are, a#tfel ('c)t ac$- "la e!at"c% "a calea +e:"c$le" "l"are, $'/e #e ac$-$lea:%.C'trac&"a #f"'cterelr #e /atrea:% 'er+"lr S!la'"c" =#"-!at"c"? care a$ ac&"$'e c'trar%+a;$l$".

T"-!$l /e el"-"'are al "le" /e!"'/e /e 'at$ra al"-e't$l$", /e ee-!l$ /$!%"';erarea /e la!te "la #e el"-"'% t"-! /e 65> re, "ar /$!% !)"'e 59 re.

F'n+#le le #$'t "-!rta'te *" #e refer% la fe'-e'ele /e /";e#t"e *"-etal"#-

. B"la c'tr"$"e la 'e$tral":area reac&"e" ac"/e a a-e#tec$l$" al"-e'tar ##"t /"'#t-ac (' "'te#t"'.

2. I'ter+"'e /ec"#"+ (' /";e#t"a ;r%#"-"lr, fa+r":)'/ e-$l#"'area lr. St"-$lea:%fer-e'&"" #!ec"f"c" =l"!a:ele?< a$t% la a#r&"a ac":"lr ;ra*" *" a $'r #$#ta'&e#l$"le (' ;r%#"-" =+"ta-"'ele?.

3. C'tr"$"e la ('tre&"'erea !er"#talt"#-$l$" "'te#t"'al.4. C'tr"$"e la -e'&"'erea ec"l"r$l$" /"'tre /"fer"&" "'" (' c$r#$l /";e#t"e".6. C'tr"$"e la el"-"'area $'r !r/$*" /e ecre&"e =!";-e'&" "l"ar", -e/"ca-e'te,

-etale?.. Ac&"'e:% ca a;e't acter"#tat"c, "'")'/ cre*terea $'r ;er-e'" !at;e'".

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CAPITOLUL 3

COLECISTITA ACUT

3.1. De*n#e

Clec"#t"ta ac$t% e#te afec&"$'e a +e:"c$le" "l"are, caracter":at% a'at-5!atl;"c !r"' "'fla-a&"a r;a'$l$", "ar cl"'"c !r"'tr5$' #"'/r- /$rer# a/-"'al ac$t,('#&"t /e fer% *" -/"f"c%r" lcale.

3.2. E!-$a!-(ene , *a+!-r *a%-r0an#

/"f"c%r"le -rfl;"ce *" cl"'"ce ce caracter":ea:% clec"#t"ta ac$t% #$'t/eter-"'ate (' e#e'&% /e #tr$c&"a "'f$'/"$l5c"#t"c%.

Acea#ta are -a" -$lte ca$:e. l"t"a:a +e:"c$lar% *" c"#t"c%

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T$a$l /$/e'al

Anal0a L!e *0-l-(+e Vara# 7n +a&r'l -l /+-n &e $r-&'+ere

Ke-le$c;ra-a c-!let%5Ke-at""5Le$cc"te5Tr-c"te5Pl"'$cleare 'e$trf"le e:"'f"le a:f"le5''$cleare l"-fc"te -'c"te !la#-c"te

5Ke-;l"'% %rat fe-e"e5Ke-atcr"t %rat fe-e"e

456 -"l.1--3

4.00050.0001--3

26.0005400.0001--3

6725370,657

265275>7555

3,65>,6 ;725 ;7

456373547

Le$cc"t:a cre*te !)'% la6.0001--3 (' fr-ele'ec-!l"cate ale l"", c$'e$trf"l"e.

Le$cc"t:a cre*te !e#te20.0001--3 (' fr-elec-!l"cate.

La l'a+"" +)r#t'"c" #a$ c$#"#te- "-$'"tar /ef"c"tar+alr"le #$'t 'r-ale *" ('

fr-ele #e+ere ale l"".

V"te:a /e #e/"-e'tare ae-at""lr

356 -- la r%650 -- la 2 re

Pate cre*te (' !re:e'&a"'fec&"e".

E':"-ele #er"ce T@O tra'#a-"'a:a

;l$ta-alacet"c% T@P tra'#a-"'a:a

;l$ta-!"r$+"c%

453 U.I.

65> U.I.

Cre#c +alr"le (' !re:e'&a"cter$l$".

A-"la:e #er"ce A-"la:e $r"'are

23052.>00 U.I.16.0005.000 U.I.1

K"!era-"la:e-"e *""!era-"la:$r"e -/erat%, ('ca:$l a#c"er"" c$ fe'-e'e/e !a'creat"t% ac$t%.

B"l"r$"'a ttal% /"rect% =c'$;at%? "'/"rect% ='ec'$;at%?

0,5 -;70,026 -;7>07 /"' ttal

K"!er"l"r$"'e-"e, c$!re/-"'e'&a cele" /"recte ('"'fla-a&"a ca'al$l$" cle/c

#a$ (' calc$l:a cle/c"a'%.Te#te f$'c&"'ale e!at"ce cle#terl ttal cle#terl e#ter"f"cat l"!"/e ttale f"r"';e'

605260 -;79050 -;7400500 -;72005400 -;7

Sca/ rar, at$'c" c)'/ !rce#$l"'fla-atr "'+a/ea:% !at$l+e:"c$lar *" c)'/ !are'c"-$l:'e" e#te "'+a/at /e !rce#e'ecrt"ce !er"clec"#t"ce.

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8' !ract"c% #e efect$ea:% t$a$l elt:er5L' *" -a" rar t$a$l -"'$tat. Pr"'"'tr/$cerea (' /$/e' a $'e" #'/e E"'r' #e +a etra;e c$ #c! e!lratr la A 8+-le&-+an"=;ale'5a$r"e. Se "'#t"lea:% #$lfat /e -a;'e:"$. la B 8%e0+'lar"=+)#ca#%, ca#ta'"$ ('c"#%. la C 85e$a!+"=;ale' clar%. Prele A, B *" C #e recltea:% (' e!$rete #ter"le care #e +r ea-"'a /"' !$'ct /e+e/ere "cr#c!"c #e !t e+"/e'&"a cel$le e!"tel"ale #a$ 'e!la:"ce, le$cc"te (' '$-%r

-are =!rce# "'fla-atr?. C"tl;"c #e e+"/e'&"a:% e+e't$al"" !ara:"&" =la-l""?. Bacter"l;"c /"' "la B #e real":ea:% "l"c$lt$r% *" a't"";ra-%. B"c"-"c #e /eter-"'% ca't"tatea /e #%r$r" "l"are, +)#c:"tatea *" !K5$l.

La etra;erea "le" !t a!%rea $r-atarele #"t$a&"" !atl;"ce

. L"!#a "le" A arat% e"#te'&a $'$" #tacl cle/c"a' =calc$l #a$ t$-are?, e!at"t% t"c% #a$ "'t"ca&"e c$ c"$!erc".2. B"la A "e#e a-e#tecat% c$ #)';e fa!t ce arat% e"#te'&a $'$" ca'cer /$/e'al #a$ al

ca!$l$" /e !a'crea#.3. Dac% "la A "e#e t$l$re e"#t% a';"cl"t%.4. L"!#a "le" B re!re:"'t% e"#te'&a $'$" #tacl =calc$l #a$ t$-are? la '"+el$l

cl$l$" +e:"cal #a$ ca'al$l$" c"#t"c.6. E+ac$area "le" B (' ca't"tate farte -are, $r-at% /e a-el"rarea e+"/e't% a #t%r""

l'a+$l$", rele+% "!t'"e "l"ar%.. L"!#a "le" C rele+% #tr$c&"a ca'al$l$" e!at"c c-$'.

>. A!ar"&"a tar/"+% a "le" C (' ca't"tate -"c% *" ('#&"t% /e /$rere (' "!c'/r$l/re!t, rele+% "!ert'"e "l"ar%.

. Eaene ra&-l-(+e

Ra/";raf"a a/-"'al% !e ;l !ate e+"/e'&"a calc$l" ra/"!ac", +e:"c$l% deporelan, "l% calc"c%, calc$l" (' "le', aer (' arrele "l"ar =(' ca:$l f"#t$lelr"l"/";e#t"+e? #a$ "-a;"'e ;a:a#% (' l$-e' *" (' !eretele +e:"c$lar =(' clec"#t"tae-f":e-ata#%?. Clec"#t;raf"a e#te ra/";raf"e c$ #$#ta'&% /e c'tra#t Ra:e"l5 talete

a/-"'"#trate ral. Se fac 6 f"l-e ra/"l;"ce, la "'ter+ale /e t"-! "'e #ta"l"te, care/a$ "'fr-a&"" a#$!ra !re:e'&e" calc$l"lr *" a#$!ra f$'c&"e" clec"#t$l$". Cla';";raf"a =clec"#tcla';";raf"a? e#te ra/";raf"e c$ #$#ta'&% /e c'tra#tP"la' 407 a/-"'"#trat "'tra+e'#. E#te $' ea-e' -rfl;"c =/% a#!ecte /e#!refr-a, #e/"$l, /"-e'#"$'"le clec"#t$l$"? *" f$'c&"'al =arat% !$terea /e c'ce'trare,c'tract"l"tatea *" e+ac$area clec"#t$l$" /$!% !r)':$l B/e'?. Se face c$ !r$/e'&%, /ar

9

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at$'c" c)'/ "l"r$"'e-"a #ca/e #$ 3 -;7. Are "'/"ca&"e -ar% (' #$#!"c"$'ea cl"'"c%/e l"t"a:% cle/c"a'%. Sc"'t";ra-a e!at5"l"ar% /e el"-"'are e#te -et/% /e e!lrare ra/"":t!"c%.Fl#e*te ca tra#r ":t!$l 995Tec'e&"$, a#c"at c$ #$#ta'&% care #e el"-"'% /"'e!atc"t (' c%"le "l"are.

+. Al!e eaene

Ec;raf"a e#te farte +alra#% (' #ta"l"rea /"a;'#t"c$l$" /e l"t"a:% "l"ar%. Ea fer%"'fr-a&"" /e#!re clec"#t, #tarea e!atcle/c$l$" *" -/"f"c%r"le !a'creat"ce #atel"te.

De "ce" arat% $' clec"#t -%r"t (' +l$-, farte /e#t"'#, c$ !eretele (';r*at,e/e-a&"at, a/e#ea c$ /$l$ c't$r. C'&"'$t$l l$" '$ -a" e#te tra'#'"c, c" /atr"t%!$r"$l$" #a$ 'r"$l$" "l"ar, a!ar "-a;"'" ec/e'#e, far% $-r%, !l$t"'/ (' c'&"'$t.Frec+e't #e e+"/e'&"a:% calc$l" "'cla+a&" (' re;"$'ea "'f$'/"$l5c"#t"c%.

T-;raf"a c-!$ter":at% !ate !rec":a ;r#"-ea !ere&"lr +e:"c$lar", calc$l""='$-%r, /"-e'#"$'e, a#!ect?, /e'#"tatea c'&"'$t$l" "l"ar. Se !ate face c'c-"te't c$cla';";raf"a. Electrcar/";ra-a (' ca: /e #$fer"'&% cr'ar"a'% !ree#te't%, clec"#t"ta ac$t%

acce't$ea:% fe'-e'$l /e "#ce-"e cr'ar% *" a;ra+ea:% e!"#a/ele /e a';"'% la+ec"" a';"'*", at)t cl"'"c c)t *" electrcar/";raf"c.

3.. Da(n-)!+

D"a;'#t"c$l !:"t"+ /e clec"#t"t% ac$t% #e !$'e !e a:a a tre" factr". a'a-'e:%

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Va !re;%t" !#""c l'a+$l, l"'"*t"'/$5l, e!l"c)'/$5" c$ #l"c"t$/"'e *" fer-"tate (' cec'#t% ea-e'$l *" "-!rta'&a l$". 8l a$t% #% #e /e:race, c$ -$lt tact *" f"'e&e, !e'tr$ a'$ !r+ca -"*c%r" "'$t"le *" /$rera#e. Ea are ;r"% ca (' t"-!$l ea-"'%r"" ;ea-$r"le #%f"e ('c"#e *" #% '$ #e c"rc$le !r"' ca-er%. Pe'tr$ a &"'e #ea-a /e #"-&$l !$/r""l'a+$l$" ea +a ":la !at$l $'/e are lc ea-e'$l c$ $' !ara+a'.

8'a"'tea !al!%r"" +a #f%t$" l'a+$l #% $r"'e:e. A#"#te'ta -e/"cal% (l +a a/$ce ('!:"&"a a/ec+at% ea-"'%r"" /ec$"t /r#al c$ ra&ele ('t"'#e *" relaate /e5a l$';$lcr!$l$", -e-rele "'fer"are ('/"te /"' ;e'$'c", c$ -$#c$lat$ra a/-"'al% relaat%.La cererea /ctr$l$" (l +a r%#$c" (' /ec$"t lateral /re!t *" /ec$"t lateral #t)';, a/$c)'/(' acela*" t"-! -)'a la ceaf%. Ea +a #ta (' fa&a /ctr$l$", /e cealalt% !arte a !at$l$" *" (l+a #er+" c$ tt ce are 'e+"e. La ter-"'area ea-e'$l$" +a a$ta l'a+$l #% #e (-race *"#% #e a*e:e (' !:"&"a !referat% =a'tal;"c%?.

4.2. C-n&'!a &e 'r(en#" a a))!en!e e&+ale lan!ernarea 'n' -lna% +' +-l+" lar"

A#"#te'ta -e/"cal% +a a*e:a l'a+$l (' re!a$# la !at. Va reclta #)';e !e'tr$ea-e'ele $r;e'te '$-%r%tarea le$cc"telr, "l"r$"'e-"a, T@O, T@P, "';ra-%#a';$"'%, re:er+a alcal"'%, a-"la:e-"e, ;l"ce-"e *" $r"'% !e'tr$ $r"l"';e' *" !";-e'&""l"ar".

Va !re;%t" -e/"ca-e'te !e'tr$ cal-area /$rer"" *" "'#tr$-e'tar$l #ter"l 'ece#ar, /ar'$ +a a/-"'"#tra l'a+$l$" '"c" $' cal-a't f%r% "'/"ca&"a /ctr$l$", !e'tr$ a '$ -a#ca

e+l$&"a ac$t% a l"" #a$ !erfra&"e.A#"#te'ta -e/"cal% +a a/-"'"#tra an!al(+e:Al;cal-"' 4 f"le1:" #a$ Q f"l% Frtral. Dac% cl"ca '$ ce/ea:% +a

a/-"'"#tra "al;"' 00560 -; la 5 re< an!)$a)!+e: Sc$t"l c-!$# 253 f"le1:", #$lfat atr!"'% 0,6 -; #.c. /e 253 r"1:",

Pa!a+er"'% 4 f"le1:", N"tr;l"cer"'% #$l"';$al #a$ "'ecta"l 52 -; =254 talete? la6520 -"'$te --1

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@l"ce-"e90 -;7 Ke-;l"'%437 Tr-c"te30.0001--3

Cle#terl ttal201-;7

F"r"';e'300 -;7 T@O>U.I. T@P2U.I. B"l"r$"'% ttal%, -;7 B"l"r$"'% /"rect%0,64 -;7 B"l"r$"'% "'/"rect%,2 -;7 Uree30 -;7 Creat"'"'%0,9 -;7 Ac"/ $r"c3,2 -;7

A-"la:e #er"ce300U.I.1 A-"la:e -"'re.000U.I.1

La "'ter'are #e -a" c'#tat% c% te-!erat$ra e#te /e 3,C, /"$re:a /e .200 -l,-"c&"$'" f":"l;"ce.

Ne%- $r-r!are $er!'ra!e:

I. Ne%-a &e a ea / &e a n+a:

A. Sene &e &e$en&en#": D$rer" (' "!c'/r$l /re!t O#eal% la efrt Al"-e'ta&"e 'ecre#!$':%tare C'#$- r"/"cat /e al"-e'te ;ra#e @$#t a-ar, ar#$r" e!";a#tr"ce, al'%r".

B. S'r)a &e &*+'l!a!e: Datr"t% 'ec$'a*ter"" !r"'c"!""lr al"-e'tare.

C. Pr-lea: Al"-e'ta&"a"'a/ec+at% !r"' /ef"c"t.

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D. Oe+!%e: Pac"e't$l #% c$'a#c% *" #% re#!ecte !r"'c"!""le $'e" al"-e'ta&"" crecte (' /ec$r#

/e 4 re.

E. A+#'n:1 !ciuni cu rol propriu"

8" e!l"c !ac"e't$l$" !r"'c"!""le $'e" al"-e'ta&"" crecte 8" ('+%& +alarea '$tr"t"+% a al"-e'telr C'*t"e't":e: !ac"e't$l a#$!ra "-!rta'&e" re;"-$l$" al"-e'tar ('

-e'&"'erea #%'%t%&"" #ale E!lre: ;$#t$r"le *" "ce"$r"le al"-e'tare *" (' f$'c&"e /e ace#tea ("

('tc-e#c $' re;"- al"-e'tar

Fac "la'&$l l"c"/elr "';erate *" al celr el"-"'ate A/-"'"#tre: -e/"ca&"a !re#cr"#% /e -e/"c (-!tr"+a ar#$r"lr, al'%r"lr *"#e':a&"e" /e ;rea&%

Sta"le#c c$ !ac"e't$l $' rar /e -e#e re;$late 8l #f%t$"e#c #% e+"te c'#$-$l /e al"-e'te *" l"c"/e rec"

# !ctiuni cu rol delegat"

Perf$:"" c$ ;l$c:% 67, .600 -l1:" Al;cal-"' 3 f"le1:" Pa!a+er"'% 4 f"le1:" V"ta-"'a B, B, C200c)te 2 f"le1:" Sc$t"l c-!$# f"l% la re

F. E%al'"r: Pac"e't$l a ('&ele# 'ece#"tatea re;"-$l$" al"-e'tar *" !r"'c"!"le $'e" al"-e'ta&""

crecte A "';erat (' 24 re .600 -l l"c"/e *" a el"-"'at .200 -l Re#!ect% /"eta a/ec+at% /e !rtec&"e a f"cat$l$" *" clec"#t$l$"

II. Ne%-a &e a elna

A. Sene &e &e$en&en#": C'#t"!a&"e

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a'"fe#t%r" !r"' #tare /e /"#c'frt Bal'%r"

B. S'r)a &e &*+'l!a!e: Al"-e'ta&"e 'ecre#!$':%tare

C. Pr-lea: C'#t"!a&"a

D. Oe+!%e: Pac"e't$l tre$"e #% a"% $' tra':"t "'te'#t"'al (' l"-"te f":"l;"ce =24 re?

E. A+#'ne:1 !ciuni cu rol propriu"

Deter-"' !ac"e't$l #% "';ere ca't"tate #$f"c"e't% /e l"c"/e Ser+e#c !ac"e't$l$" cea" 'e('/$lc"t, c%l/$&, #$!% /e -rc+" (' a*a fel ('c)t

(' !r"-ele 2454 re #% a"% al"-e'ta&"e l"c"/% Sta"le#c !ac"e't$l$" rar /e eerc"&"" f":"ce Sta"le#c $' rar re;$lat al al"-e'ta&"e" (' f$'c&"e /e act"+"t%&"le l$" Sf%t$"e#c !ac"e't$l #% e+"te al"-e'tele ;ate (' f"ra#e

Ur-%re#c *" 'te: (' fa"a /e #er+a&"e c'#"#te'&a *" frec+e'&a #ca$'elr A/-"'"#tre: la "'/"ca&"a -e/"c$l$" laat"+e

# !ciuni cu rol delegat"

S$!:"tare c$ ;l"cer"'%, #$!:"tr Laat"+ /rae$ #eara

F. E%al'"r: Pac"e't$l a a+$t 2 #ca$'e (' !r"-ele 3 re, "ar (' a 4 :" *"5a rec%!%tat tra':"t$l

"'te#t"'al 3 #ca$'e1:" D"$re:a e#te 'r-al% /e .300 -l

III. Ne%-a &e a )e -&5n / &e a &-r

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A. Sene &e &e$en&en#": D"#c'frt la tre:"re 8" e#te tea-% /e ala #a Are !rle-e la #er+"c"$

A'"#, a!at"c I'#-'"e Pl"ct"#eal% *" 'er+:"tate Sc%/erea !$ter"" /e c'ce'trare

B. S'r)a &e &*+'l!a!e: Prle-e /e #er+"c"$ Tea-a /e ala #a

C. Pr-lea:

I'#-'"e relat"+%

D. Oe+!%e: Pac"e't$l #% a"% $' #-' 'r-al, c'fr- 'ece#"t%&"lr #ale *" #% /"#!$'% /e $'

!r;ra- /e /"'%

E. A+#'n:1 !ciuni cu rol propriu"

8'tc-e#c $' rar cre#!$':%tr /e /"'% *" #-' D"-"'$area a'"et%&"" !e'tr$ e!r"-area #e't"-e'telr *" e-&""lr E/$c l'a+$l !e'tr$ !ract"carea -et/elr /e relaare *" /e#t"'/ere 8" /"-"'$e: "'c'frt$l, a#";$r)'/$5" $' -e/"$ a/ec+at c)t -a" a!ra!e /e

"ce"$r"le !ract"cate la /-"c"l"$ 8" fer ca'% c$ la!te cal/ #eara ('a"'te /e c$lcare A/-"'"#tre: trata-e't$l -e/"ca-e't# la "'/"ca&"a -e/"c$l$"

# !ciuni cu rol delegat"

Fe'ar"tal -;1G; cr! la 24 re

Etra+eral 52 c-!r"-ate la 'e+"e

F. E%al'are: Pac"e't$l a#c$lt% -$:"c% ('a"'te /e c$lcare 8" !lace #% ea la!te cal/ #eara A ('+%&at te'"c" /e relaare

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A /r-"t re (' a /$a 'a!te Are #-' l"'"*t"t, 'ea;"tat f%r% +"#e

CAUL CLINIC Nr. 2

.S. (' +)r#t% /e 2 a'", !e'#"'ar, /"a;'#t"cat c$ clec"#t"t% cr'"c% $r-ea:% #%f"e !erat !e#te /$% :"le. El !re:"'t% clra&"e ('c"#% a te;$-e'telr, /$rer" care #eacce't$ea:% !r;re#"+, at"';)'/ "'te'#"tate -a"-% (' c)te+a re *" ce/)'/ r$#c.D$rerea ra/"a:% #$ rer/$l c#tal /re!t re;"$'ea /r#l-ar%, #ca!$lar%, (' $-%r$l/re!t. Bl'a+$l !re:"'t% #tare fer"l% c$ tra'#!"ra&"" a$'/e'te, fr"#a'e *" #tare ;e'eral%alterat%. La ea-e'$l -e/"cal efect$at #e #er+% +e:"c$la "l"ar% !al!a"l% *" #e'#""l%.Pre:"'t% re#!"ra&"e ;rea"e, e#te a'"#, a;"tat *" 'er+# /"' !r"c"'a /$rer"lr.

.S. e#te fa-"l"#t, lc$"e*te c$ #&"a #a ('tr5$' a!arta-e't c$ /$% ca-ere. Se('&ele;e "'e c$ f"$l #%$ *" are rela&"e ar-'"a#% c$ +ec"'"" /"' lc. A/e#ea -er;e ('!arc #e !l"-% #a$ ac% tale c$ !r"ete'"". Pac"e't$l !re:"'t% ";"e'% cre#!$':%tare,are $' rar /e -e#e re;$lat.

F""'/ !e'#"'ar *" el *" #&"a #a #e ;)'/e#c *" #e te- /"' !r"c"'a #t%r"" lr /e#%'%tate, a#c$':)'/ ('#% acea#t% tea-% (' fa&a f"$l$" lr !e'tr$ a '$5l (';r"ra.

Re0'l!a!'l anal0el-r: Ke-at""4 -"l.1--3

Le$cc"te.001--3

Ke-;l"'%27 Ke-atcr"t37 VSK6 --1 Tr-c"te360.0001---3

T@O0 U.I. T@P4 U.I. L"!"/e ttale60 -;7 F"r"';e'360 -;7

@l"ce-"e20 -;7 Cle#terl ttal90 -;7 Cle#terl e#ter"f"cat20 -;7 Uree2 -;7 Creat"'"'%0,>6 -;7 Ac"/ $r"c2,9 -;7

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B"l"r$"'% ttal%2 -;7 B"l"r$"'% /"rect%0,6 -;7 B"l"r$"'% "'/"rect%,36 -;7 A-"la:e #er"ce2.600 U.I.1

A-"la:e $r"'are.400 U.I.1 T"-l2 U.acLa;a'

La "'ter'are, la ea-e'$l cl"'"c, !ac"e't$l !re:"'t% te-!erat$ra 3,60C, !$l# 3at%"1-"'., re#!"ra&"e /"f"c"l%52 re#!"ra&""1-"'., ('%l&"-e >0 c-, ;re$tate >0 G;, ;r$!#a';$"' B=III?. Bl'a+$l a a+$t +ar"cel% la 2 a'" *" !art% celar" /e +e/ere.

Ne%- $r-r!are $er!'ra!e:

I. Ne%-a &e a +-'n+a

A. Sene &e &e$en&en#": Stare ;e'eral% alterat%, a'"# Tea-a /e al% *" /e %tr)'e&e Ner+:"tate, 'el"'"*te Tea-a /e !era&"e, /e al% a#c$'/e fa&% /e fa-"l"e

B. S'r)a &e &*+'l!a!e: Def"c"t /e c$'*t"'&e

C. Pr-le": Fr"ca /e al% *" /e "'ter+e'&"e c"r$r;"cal%

D. Oe+!%e:

Pac"e't$l #%5*" ('+"';% tea-a, #% *t"e *" #% f"e "'fr-at /e#!re al% *" /e#!re'ece#"tatea "'ter+e'&"e" c"r$r;"cale (' /ec$r# /e 24

E. A+#'n:1$ !ciuni cu rol propriu"

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A/-"'"#tre: l'a+$l$" trata-e't$l !re#cr"# /e -e/"c !e'tr$ cal-area/$rer"lr

8" e!l"c $'ele '&"$'" /e#!re al%, "-!rta'&a *" 'ece#"tatea !era&"e" 8l ('+%& c$- #% #e (';r"ea#c% !#t!eratr

A$t !ac"e't$l #%5*" rec$'a#c% *" #%5*" ('+"';% a'"etatea 8l ('+%& te'"ca /e relaare#$ !ciuni cu rol delegat"

Fe'ar"tal -;1G; cr!124 N"tra:e!a- 2 c-!r"-ate #eara la c$lcare

F. E%al'"r: Pac"e't$l a ('+%&at #%5*" ('+"';% tea-a E#te -a" !t"-"#t, -a" l"'"*t"t, -a" !$&"' a'"#

Pac"e't$l a ('&ele# 'ece#"tatea "'ter+e'&"e" c"r$r;"cale A ('+%&at te'"c" /e relaare A ('&ele# 'ece#"tatea /e a c-$'"ca c$ ce" /"' $r

II. Ne%-a &e a re)$ra / &e a a%ea - 'n" +r+'la#e

A. Pr-lea: Alterarea r"t-$l$" re#!"ratr

B. Oe+!%e: Pac"e't$l #%5*" (-$'%t%&ea#c% r"t-$l re#!"ratr

C. A+#'n:

1$ !ciuni cu rol propriu"

8" a/-"'"#tre: !ac"e't$l$" trata-e't$l !re#cr"# /e -e/"c

P:"&"'are (' !at 8'cerc #% $-e:e#c aer$l /"' ('c%!ere Aer"#e#c ca-era (' -/ c'#ta't A/$c !ac"e't$l$"$' a!rt #$f"c"e't /e l"c"/e Ur-%re#c c"rc$la&"a !r"' -%#$rarea !$l#$l$" *" te'#"$'"" arter"ale O#er+ /e!r"'/er"le /e a re#!"ra ale l'a+$l$" I'#tr$"e#c l'a+$l #% fac% eerc"&"" re#!"ratr""

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#$ !ciuni cu rol delegat"

"f"l"' f"l%1:"

D. E%al'"r: a /$a :" !ac"e't$l a+ea /"-"'ea&a 24 re#!"ra&""1-"'. "ar #eara 22

re#!"ra&""1-"'. !ac"e't$l *"5a rec%!%tat r"t-$l re#!"ratr

III. Ne%-a &e a>/ $")!ra !e$era!'ra 7n l!e n-rale

A. Sene &e &e$en&en#": Te-!erat$ra 3,60C Fr"#a'e, /"#!'ee Tra'#!"ra&"" a$'/e'te Icter Stare ;e'eral% alterat% A'"#

B. S'r)a &e &*+'l!a!e: Dere;l%r" f$'c&"'ale /ate /e al%

C. Pr-lea: K"!erter-"e

D. Oe+!%e: Pac"e't$l #% r%-)'% (' 24 la te-!erat$ra 'r-al%

E. A+#'n:1$ !ciuni cu rol propriu"

Aer"#e#c ca-era A#";$r (-r%c%-"'te leer% $*ar% *" c$rat% 8' fr"#' ('c%l:e#c !ac"e't$l c$ #t"cle c$ a!% cal/% Sc"- le'er"a r" /e c)te r" e#te 'e+"e A$t la -e'&"'erea ";"e'e" te;$-e'telr

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Pre;%te#c !#""c !ac"e't$l Ofer !ac"e't$l$" l"c"/e Fac "la'&$l ('tre ca't"tatea /e l"c"/e "';erate *" el"-"'ate

F. E%al'"r: Fer"l"tatea a #c%:$t, !ac"e't$l a+)'/ te-!erat$r% /e 3,0C /"-"'ea&a, "ar a

/$a :" 3>,60C

CAUL CLINIC Nr.3

I.P. +"'e la #!"tal *" 'e !+e#te*te c% (' $r-% c$ /$% re /$!% ce a #er+"t -a#%c'#"#te't%, c$- /e altfel "*'$"e*te, a ('ce!$t #% #"-t% /$rer" (' !$'ct$l c"#t"c, #$-ar;"'ea "'fer"ar% a f"cat$l$".

Se !l)';e c% a #"t (' $r-a /e!la#%r"" !)'% la #!"tal /"' !r"c"'a #e/e'tar"#-$l$"*" a e:"t%&"". Pac"e'ta (' +)r#t% /e 40 a'" are ('%l&"-e /e 0 c- *" ;re$tate /e 4;. Lc$"e*te c$ #&$l ('tr5 ;ar#'"er%, e#te ca#'"c% *" (*" c)*t";% e"#te'&a /"' /"+er#el$cr$r" !e care le tr"ctea:% *" a!" le +"'/e.

La "'ter+"$l #&$l$" care a ('#&"t5 la #!"tal af"r-% c% l'a+a "e#e rar /"' ca#%,e#te c-/%, are $' r"t- /e +"a&% #e/e'tar, el f""'/ 'e+"t #% a$te la ;#!/%r"a ca#e".I.P. are $' a#!ect 'e(';r""t, !re:e't)'/ tra'#!"ra&"" a$'/e'te *" ";"e'a te;$-e'telr e#te'ecre#!$':%tare. 8" !lac al"-e'tele ;ra#e, are al"-e'ta&"e ece#"+% *" '$ are $' rarre;$lat /e -e#e.

Pac"e'ta a a+$t -e'ra&"a la 6 a'", c"cl$l -e'#tr$al 36 /e :"le 'ere;$lat, fl$'r-al, '$ are '"c" 'a*tere *" *a#e a+rt$r". Ea a #$fer"t cl"c% "l"ar% (' $r-% c$ 4l$'".@r$!a #a';$"'% AB =IV? *" e#te aler;"c% la al;cal-"'.

La "'ter'are a+ea te-!erat$ra 3,90C, TA 010 -- K;, 2> re#!"ra&""1-"', !$l#>, are -"c&"$'" f":"l;"ce, tra':"t "'te#t"'al (';re$'at, /"$re:a 600 -l.

Re0'l!a!'l anal0el-r e*e+!'a!e: Ke-at"" 4 -"l1--3

Le$cc"te 2.0001--3

Tr-c"te 20.0001--3

Ne$trf"le 37 Ke-;l"'%& 2,37 L"-fc"te 27 Ke-atcr"t 337 VSK 0 --1

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T@O 4 U.I. T@P U.I. A-"la:e #er"ce 290 U.I.1 A-"la:e $r"'are >00 U.I.1

T"-l 6 U acLa;a' B"l"r$"'% ttal% 4 -;7 Cle#terl ttal 2967 L"!"/e ttale >0 -;7 B"l"r$"'% /"rect% 2,6 -;7 B"l"r$"'% "'/"rect% ,46 -;7 F"r"';e' 220 -;7 @l"ce-"e 6 -;7 S$-ar /e $r"'% $r"l"';e' =?< /e'#"tate 00< !K ac"/< ;l$c:%

a#e't%< al$-"'% a#e't% T"-! /e #)';erare T"-! /e ca;$lare > T"-! $"G 2

R =? Uree 30 -;7 Creat"'"'% 0.4 -;7Ne%- $r-r!are $er!'ra!e:

I. Ne%-a &e a>/ $")!ra (ena !e('en!el-r

A. Sene &e &e$en&en#": U';"" -$r/are "r# 'e!l%c$t /e tra'#!"ra&"e Ka"'e 'e(';r""te A#!ect 'e!l%c$t

B. S'r)a &e &*+'l!a!e: De:"'tere# !er#'al

C. Pr-lea: I;"e'% 'ecre#!$':%tare

D. Oe+!%e: Pac"e'ta #% f"e c$rat%, (';r""t% *" #%5*" reca!ete ";"e'a te;$-e'telr (' 24 re

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E. A+#'n:!ciuni cu rol propriu"

Rec-a'/ !ac"e'te" a"a ;e'eral% A#";$r te-!erat$ra a!e" *" a a!e" E!l"c (-!rta'&a ";"e'e" !er#'ale *" !er"cl$l /e (-l'%+"re A$t !ac"e'ta #%5*" (';r"ea#c% $';""le, (" rec-a'/ #% fl#ea#c%

/e/ra't *" !$/r% /e talc /$!% a"e A#";$r le'er"e c$rat% *" $#cat%

F. E%al'"r: Pac"e'ta ('&ele;e "-!rta'&a ";"e'e" !er#'ale Ea /e+"'e !rec$!at% /e !r!r"a "-a;"'e

II. V-a &e a ea / &e a n+a:

A. Sene &e &e$en&en#": Cre*tere !'/eral% Tra':"t "'te#t"'al (';re$'at D$rere (' !$'ct$l c"#t"c Bal'are

B. S'r)a &e &*+'l!a!e: Nec$'a*terea!r"'c"!""lr al"-e'tare

C. Pr-lee: Al"-e'ta&"e ece#"+%

D. Oe+!%e: Pac"e'ta #% a"% al"-e'ta&"e cre#!$':%tare, #% c$'a#c% *" #% re#!ecte re;"-$l

al"-e'tar "'/"cat /e -e/"c (' 24 re

E. A+#'n:1$ !ciuni cu rol propriu"

E!l"c !ac"e't$l$" !r"'c"!""le al"-e'ta&"e" C'*t"e't":e: !ac"e'ta a#$!ra 'ece#"t%&"" re#!ect%r"" re;"-$l$" al"-e'tar

"'/"cat A/-"'"#tre: -e/"ca&"a !re#cr"#% *" #ta"le#c $' rar /e -e#e re;$lat

#$ !ciuni cu rol delegat"

4>

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S"l$t"' 3 /rae$r"1:" ('a"'te /e -a#%

F. E%al'"r: Pac"e'ta face efrt$r" +":""le !e'tr$ a !$tea #% re#!ecte re;"-$l al"-e'tar #ta"l"t A /$a :" #e #"-te -a" "'e *" e#te -a" c'+"'#% /e 'ece#"tatea re;"-$l$" A re$*"t #% e+"te c'#$-$l al"-e'telr ;ra#e *" a /$lc"$r"lr

III. Ne%-a &e a )e /+a / a a%ea - 'n" $-)!'r":

Sene &e &e$en&en#": Oe:"tate "*c%r" ;rea"e O#eal% la efrt

Bl-(ra*e

1. IFRIM M. , C-!e'/"$ /e a'at-"e. E/"t$ra t""'&"f"c% *"E'c"cl!e/"c%, B$c$re*t", 9.

2. PAPILIAN V. Atla# /e a'at-"a -$l$". E/"t$ra -e/"cal%,B$c$re*t", 992.

3. SARAGEA M. Tratat /e f":"!atl;"e. E/"t$ra Aca/e-"e"R-)'e, B$c$re*t", 994.4. MOGO G5. , U;e'&e (' -e/"c"'a cl"'"c%. E/"t$ra D"/act"c% *"

Pe/a;;"c%, B$c$re*t", 992.6. PRICU Al. , C"r$r;"e. E/"t$ra D"/act"c% *" Pe/a;;"c%, B$c$re*t",

992.

4

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?. TITIRCA LUCREIA , Ur;e'&e -e/"c5c"r$r;"cale. E/"t$ra-e/"cal%, B$c$re*t", 994.

. TITIRCA LUCREIA , Bre+"ar /e e!lr%r" f$'c&"'ale. E/"t$ra-e/"cal%, B$c$re*t", 994.

@. SEGU B. ,D##"er# e/"c5c"r$r$;"ca$ /e l"'fer-"ere. N.0.

al"'e S.A. E/"te$r, Par"#, 90.9. BLANC D. ,Ca"er# /e l"'fer-"ere N.>. a##' E/"te$r, Par"#,

9>>.