Download - 29600963 Curs 2 Semiologie
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Semiologie Semiologie medicala medicala
generalagenerala 2 2Elena GologanElena Gologan
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cuprinscuprins• 1. Foaia de observatie clinica generala:
examenul clinic obiectiv, evolutia si epicriza
• 2. Metode de examen clinic obiectiv• 3. Atitudinea• 4. Fizionomia• 5. Statura• 6. Tipul constitutional• 7. Starea de nutritie
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1. Foaia de observatie clinica 1. Foaia de observatie clinica generala: examenul clinic obiectivgenerala: examenul clinic obiectiv
= starea prezentaCuprinde date de examen clinic:General Pe aparateExamenul clinic = complet (din
crestet pina in talpi)
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Date ce trebuie consemnateDate ce trebuie consemnate
• Statusul psiho-fizic de ansamblu• Disponibilitatile de participare la
examenul obiectiv• Posibilitatile de interrelatie• Atitudinea
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Explorarile paracliniceExplorarile paraclinice• Grupate dupa importanta raportata
specificului clinicii• Unele obligatorii (de rutina)• Protocoale complete, datate,
semnate (asumarea responsabilitatii)• Solicitarea lor raportata beneficiilor
aduse• Cost/eficienta
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Evolutia Evolutia • Zilnic sau de cite ori este nevoie• Date subiective si obiective• Legate de boala pacientului• Elemente asteptabil modificabile• Ameliorare/agravare• Complicatii• Incidente si accidente ale tehnicilor• Efecte secundare sau adverse
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Foaia de temperaturaFoaia de temperaturaDate zilnice pe momente: D si S• Temperatura• Puls• Respiratii• TA• Diureza• ScauneFoaie suplimentara pentru intervale
mai scurte
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Foaia de medicatieFoaia de medicatie• Zilnica• Numele medicamentului (DCI)• Forma de prezentare• Dozele• Ritmul de administrare• Calea si modul de administrare
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Epicriza Epicriza • Rezumatul FO• Succint dar cuprinzator• Etapele prin care s-a ajuns la
diagnostic (clinic si paraclinic)• Tratamentul prescris• Evolutia sub tratament• Prognostic• Dispensarizare • Tratament la domiciliu• Termene de reevaluare
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2. Metode de examen clinic 2. Metode de examen clinic obiectiv obiectiv
1. Inspectia2. Palparea 3. Percutia4. Ascultatia
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Metode de examen clinic Metode de examen clinic obiectivobiectiv
• Au valoare diferita raportata organului sau sistemului
• Valoare diferita cu entitatea patologica abordata
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a. inspectiaa. inspectia• Cea mai veche metoda• Probabil cea mai importanta• De la primul contact• Valoare extrema pentru unele boli
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Tehnica inspectieiTehnica inspectiei• Pacientul asezat in fata medicului• Lumina naturala• Pe segmente: cap-git-torace-
abdomen-membre• Se repeta posterior• Inspectia posturii si a miscarilor
active
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b. palpareab. palparea• Informatii asupra troficitatii cutanate• Temperatura tegumentelor• Sensibilitate• Dimensiunea, suprafata si
consistenta organelor• Uneori are valoare patognomonica
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Tehnica palpariiTehnica palparii1. Pozitii diferite: decubit dorsal,
lateral, ventral, ortostatism2. Nu se face peste haine3. Se priveste mimica bolnavului4. Miinile calde5. Progresiv 6. Pozitie de preferat la dreapta
bolnavului7. Recomandarile=orientative
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Tehnica palpariiTehnica palparii• Orice metoda este buna• Scop: obtinerea de date maxime• Metode: SuperficialaProfunda: mono sau bimanuala,
balotare, acrosare Se face in totalitateCombinata cu inspectia
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Palparea tegumentelorPalparea tegumentelor• Normal: netede, elastice, usor umede• Elasticitate scazuta: batrini,
deshidartari, colagenoze, edem cronic
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Palparea tesutului celulo-Palparea tesutului celulo-adipos subcutanatadipos subcutanat
Informeaza asupra starii de nutritie• Normal: uniform si armonios• Patologic: 1. Crescut: obezitate2. Redus: casexie3. Edem4. Lipoame, noduli5. Abcese, flegmoane6. Emfizem subcutanat
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Palparea muschilorPalparea muschilor• Date cu privire la: Tonus Dezvoltarea sistemului muscular:1. Hipertrofic (sportivi)2. Atrofic (localizat sau genaralizat) –
afectiuni neurologice, boli terminale
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Palparea sistemului osteo-Palparea sistemului osteo-articulararticular
1. Permite recunoasterea leziunilor posttraumatice
Discontinuitati osoaseCrepitatii osoase
2. Modificari articulareArtriteArtroze
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c. percutiac. percutiaMetode:• Directa sau nemediata• Indirecta sau mediataMetoda directa:• Rar folosita, informatii putine• Lombar - manevra Giordano• Corpi vertebrali
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Metoda indirectaMetoda indirecta• Interpunerea intre degetul percutor si
zona de percutat a unui plesimetru(percutie digito-digitala)Erori sigure la neefectuarea corecta
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Sunetele de percutieSunetele de percutieDiferite ca: intensitate, tonalitate si
timbru• Sunetul sonor: intensitate mare si
tonalitate joasaPlamin – netimpanic (timbru nemuzical)Abdomen – timpanic (timbru muzical)
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• Sunetul mat: intensitate mica si tonalitate mare
Tesuturi si organe fara continut aeric (ficat, splina, muschi)
• Sunetul submat: amestec al celor 2 definite anterior
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d. ascultatiad. ascultatia
Metoda ideala pentru patologia cardio-respiratorie, dar nu numai
Metode practice:• Directa (nemediata)• Indirecta (mediata)
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Tehnica ascultatieiTehnica ascultatiei
• Liniste in jur• Aplicare festa • Nu peste haine• Olive aliniate CAE• Evitarea artefactelor• Acoperirea intregii suprafete
de interes
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Epicriza reprezintă:Epicriza reprezintă:• 1. examenul obiectiv scris în FO• 2. epitaful bolnavului• 3. concluzia rezumativă a FO completată
cu recomandări la externare• 4. prognosticul bolnavului• 5. punctul culminant al FO• 6. date despre dispensarizarea
bolnavului
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Epicriza reprezintă:Epicriza reprezintă:• 1. examenul obiectiv scris în FO• 2. epitaful bolnavului• 3. concluzia rezumativă a FO completată
cu recomandări la externare• 4. prognosticul bolnavului• 5. punctul culminant al FO• 6. date despre dispensarizarea
bolnavului
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FO include:FO include:• 1. date antropometrice despre
pacient• 2. curba termică• 3. orientarea politică a acestuia• 4. orientarea sexuală a pacientului• 5. aspirațiile socio-profesionale ale
pacientului• 6. valoarea TA
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FO include:FO include:• 1. date antropometrice despre
pacient• 2. curba termică• 3. orientarea politică a acestuia• 4. orientarea sexuală a pacientului• 5. aspirațiile socio-profesionale ale
pacientului• 6. valoarea TA
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FO clinică generală trebuie să FO clinică generală trebuie să cuprindă următoarele, cu cuprindă următoarele, cu
excepția:excepția:• 1. datele de identificare ale pacientului• 2. anamneza• 3. examenul clinic obiectiv• 4. explorările paraclinice• 5. epicriza cu recomandări la externare• 6. evoluția pacientului la domiciliu după
externare
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FO clinică generală trebuie să FO clinică generală trebuie să cuprindă următoarele, cu cuprindă următoarele, cu
excepția:excepția:• 1. datele de identificare ale pacientului• 2. anamneza• 3. examenul clinic obiectiv• 4. explorările paraclinice• 5. epicriza cu recomandări la externare• 6. evoluția pacientului la domiciliu după
externare
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3. Atitudinea3. Atitudinea
• Pozitia adoptata spontan de bolnav dictata de obtinerea unui discomfort minim, relationat unei anumite boli
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AtitudineaAtitudinea
Normală: activa, libera,Pasivă: nereactivă, adinamica,
flasca, nu poate schimba pozitiaForțată: sugestivă pentru o anumită
afecțiune, pentru a calma un simptom
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Atitudini forțateAtitudini forțateOrtopneea – AC, EPA, ICCDecubit lateral – pleurezieDecubit ventral – UG, UD
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Atitudini fortateAtitudini fortate• Cocos de pusca – meningita• Genupectorala – pericardita
exsudativa
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Atitudini fortateAtitudini fortate• Torticolis – miozite, afectiuni cervicale sau neurologice
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Atitudini fortateAtitudini fortate• Opistotonus – tetanos• Emprostotonus• Pleurostotonus • Ortotonus
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Atitudini fortateAtitudini fortate
• Decubit dorsal cu coapsele in flexie – iritatie peritoneala
• Colica frenetica – colica renala
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4. faciesul4. faciesul• Ansamblul trasaturilor fizice si
expresive ilustrative unei anumite boli
• Facies # expresia feței• Nu: vesel, frumușel, caraghios,
supărat, distins, etc• Numai corelat cu o afecțiune pe care
o sugerează
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Facies mitral - SMFacies mitral - SM
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Facies acromegalicFacies acromegalic
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Facies mixedematosFacies mixedematos
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Facies basedowian “spaima Facies basedowian “spaima inghetata”inghetata”
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Facies basedowianFacies basedowian
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Facies tetanic “risus sardonicusFacies tetanic “risus sardonicus””
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Facies leoninFacies leonin
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Facies peritoneal sau Facies peritoneal sau hipocratichipocratic
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Facies parkinsonian Facies parkinsonian “masca”“masca”
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Facies cushingoidFacies cushingoid
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Facies lupic - LESFacies lupic - LES
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Facies lupicFacies lupic
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Facies ftizicFacies ftizic
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Facies de “mumie”, “masca de Facies de “mumie”, “masca de ceara”, “icoana bizantina”ceara”, “icoana bizantina”
sclerodermie
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Facies de “paiata”Facies de “paiata”rujeola
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Facies vultuos - PneumonieRubeoza diabetica – DZFaciesul renal - din IRCFaciesul rosu al macelarilor
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Nas în șaNas în șa - sifilis congenital - sifilis congenital
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rinofimarinofima• Forma glandulara• Forma angiomatoasa
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Paralizia facialaParalizia facialaperifericaperiferica
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Paralizia faciala perifericaParalizia faciala periferica
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Paralizia facialăParalizia facială
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Faciesurile din BPOCFaciesurile din BPOC• Tip A – pink puffer• Tip B – blue bloater
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Faciesul pletoric – HTA, Faciesul pletoric – HTA, obezi, PVobezi, PV
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Facies hipopituitar – nanism Facies hipopituitar – nanism hipofizar “infanto-senescent”hipofizar “infanto-senescent”
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Facies addisonianFacies addisonian
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Faciesul consumptivFaciesul consumptiv
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HemangioameHemangioame
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Tipurile de facies nu includTipurile de facies nu includ::• 1. Faciesul addisonian• 2. Faciesul cushingoid• 3. Faciesul trist• 4. Faciesul mitral• 5. Faciesul mixedematos• 6. Faciesul basedowian
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Tipurile de facies nu includTipurile de facies nu includ::• 1. Faciesul addisonian• 2. Faciesul cushingoid• 3. Faciesul trist• 4. Faciesul mitral• 5. Faciesul mixedematos• 6. Faciesul basedowian
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Nu este faciesNu este facies
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5. statura/inaltimea5. statura/inaltimeaDefinită pe criteriul majorității
gaussieneVariații normale cu:• Vîrsta• Constelația genetică• Norma medie a epocii
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Statura normalăStatura normală
130,150 cm 190 (f),200(b)ÎnaltăMedie
Scundă
• Cea mai rapida crestere: primul an si pubertate
• Definitiva la 22 ani
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Statura patologicăStatura patologicăGigantism Nanism
Hipofizar
Tiroidian
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nanismulnanismul
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6. 6. Tipul constituționalTipul constituționalNu este echivalent staturiiInclude:• Statura• Masa• Apartenenta etnica• Factori ereditari si de mediu• Tonusul psihic• Alte caractere antropometrice
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Tipul constituționalTipul constituțional
• Reflectă apariția somato-psihică a subiectului interrelaționată cu decorul socio-uman
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Tipul constituționalTipul constituționalDe la Hipocrate:
sangvin coleric
flegmatic melancolic
Actual: normostenic, astenic, hiperstenic
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sangvinsangvin
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colericcoleric
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flegmaticflegmatic
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melancolicmelancolic
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Tipuri constitutionaleTipuri constitutionale
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normostenicnormostenic
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Tipul constituțional Tipul constituțional melancolic nu are:melancolic nu are:
• 1. astenie marcată• 2. tăcere prelungită• 3. agitație psihomotorie• 4. durere morală• 5. adinamie• 6. halucinații
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Tipul constituțional Tipul constituțional melancolic nu are:melancolic nu are:
• 1. astenie marcată• 2. tăcere prelungită• 3. agitație psihomotorie• 4. durere morală• 5. adinamie• 6. halucinații
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Tipul constituțional picnic Tipul constituțional picnic are:are:
• 1. obezitate• 2. caracter expansiv• 3. anorexie• 4. caracter gurmand• 5. introversie• 6. boli cardiovasculare
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Tipul constituțional picnic Tipul constituțional picnic are:are:
• 1. obezitate• 2. caracter expansiv• 3. anorexie• 4. caracter gurmand• 5. introversie• 6. boli cardiovasculare
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7. 7. Starea de nutrițieStarea de nutriție• Formula Broca: cm peste 1 m =
masa• Grosimea pliului cutanat<1.5cm• IMC=masa/suprafața corporală 27.3f 27.8m
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ObezitateaObezitatea• Masă cu >10% față de cea ideală• Prin panicul adiposClasificări:• Ușoară,medie,severă• Generalizată, segmentară (androidă
sau ginoidă)• !!!! CAUZA
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cauzecauze• Aport exagerat – consum energetic
redus• Endocrină – Cushing, sdr.
adiposogenital, mixedem, menopauza• Psihogenă • Postpartum?• Genetic?• Stres?
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Forme clinice mai rareForme clinice mai rareSindromul PickwickBSomnolentaInsuficienta respiratorieRezistente neelastice
toracoabdominaleRestrictie ventilatorie, apoi respiratorieBoala Dercum
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Nu este obezitateNu este obezitate
–Creșterea masei musculare: culturiști
–Edemul generalizat: anasarcă
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obezitateaobezitatea
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obezitateaobezitatea• În regnul animal
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obezitateaobezitatea
• În artă
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În literaturăÎn literatură
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În artăÎn artă
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În artăÎn artă
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obezitateaobezitatea• În evoluția ontogenetică
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obezitateaobezitatea• În evoluția individuală
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Obezitatea copiilorObezitatea copiilor
motive
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Obezitatea copiilorObezitatea copiilor
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Obezitatea copiilorObezitatea copiilor• aspecte
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obezitatea obezitatea adultuluiadultului
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obezitateaobezitatea
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Obezitatea: celulită și Obezitatea: celulită și vergeturivergeturi
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obezitateaobezitatea
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obezitateaobezitatea
• Consecințe
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obezitateaobezitatea
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Deficitul ponderalDeficitul ponderalDeficit>10% fata de G idealaemaciere – cașexie – marasm
!!! CAUZA
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cauzecauze• Nu are ce: standard social• Nu vrea: greva foamei, boli psihice,
cure de slăbire, declanșează dureri• Nu trece: stenoze esofagiene• Nu are poftă: cancere, tuberculoză,
anorexie mintala• Pierde: diaree, vărsături
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kwashiorkorkwashiorkor
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Obezitatea este o problemăObezitatea este o problemă• 1. Socială• 2. personală• 3. minoră• 4. frecventă• 5. dificil de tratat• 6. invalidantă
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Obezitatea este o problemăObezitatea este o problemă• 1. Socială• 2. personală• 3. minoră• 4. frecventă• 5. dificil de tratat• 6. invalidantă
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Marasmul este:Marasmul este:• 1. endemic în unele zone• 2. adesea letal• 3. consecința deficitului alimentar de
lipide• 4. frecvent în neoplaziile terminale• 5. o problemă socială în România• 6. adesea reversibil
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Marasmul este:Marasmul este:• 1. endemic în unele zone• 2. adesea letal• 3. consecința deficitului alimentar de
lipide• 4. frecvent în neoplaziile terminale• 5. o problemă socială în România• 6. adesea reversibil
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