{"id":105,"date":"2019-12-23T10:34:04","date_gmt":"2019-12-23T08:34:04","guid":{"rendered":"http:\/\/www.dizabil.eu\/info\/?p=105"},"modified":"2019-12-23T10:40:58","modified_gmt":"2019-12-23T08:40:58","slug":"content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap","status":"publish","type":"post","link":"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/","title":{"rendered":"Criteriilor medico-psihosociale de \u00eencadrarea \u00een grad de handicap"},"content":{"rendered":"

\u00cen temeiul art. 84 alin. (5) din Legea nr.\u00a0448\/2006<\/a><\/strong><\/u>\u00a0privind protec\u0163ia \u015fi promovarea drepturilor persoanelor cu handicap, cu modific\u0103rile \u015fi complet\u0103rile ulterioare,<\/p>\n

av\u00e2nd \u00een vedere prevederile:<\/p>\n

– art. 14 din Hot\u0103r\u00e2rea Guvernului nr.\u00a0381\/2007<\/a><\/strong><\/u>\u00a0privind organizarea \u015fi func\u0163ionarea Ministerului Muncii, Familiei \u015fi Egalit\u0103\u0163ii de \u015eanse;<\/p>\n

– art. 7 alin. (4) din Hot\u0103r\u00e2rea Guvernului nr.\u00a0862\/2006<\/a><\/strong><\/u>\u00a0privind organizarea \u015fi func\u0163ionarea Ministerului S\u0103n\u0103t\u0103\u0163ii Publice, cu modific\u0103rile \u015fi complet\u0103rile ulterioare,<\/p>\n

ministrul<\/strong>\u00a0muncii,<\/strong>\u00a0familiei<\/strong>\u00a0\u015fi<\/strong>\u00a0egalit\u0103\u0163ii<\/strong>\u00a0de<\/strong>\u00a0\u015fanse<\/strong>\u00a0\u015fi\u00a0ministrul<\/strong>\u00a0s\u0103n\u0103t\u0103\u0163ii<\/strong>\u00a0publice<\/strong>\u00a0emit urm\u0103torul ordin:<\/p>\n

Art.<\/strong>\u00a01<\/strong><\/p>\n

Se aprob\u0103 Criteriile medico-psihosociale de \u00eencadrare \u00een grad de handicap, prev\u0103zute \u00een anexa care face parte integrant\u0103 din prezentul ordin.<\/p>\n

Art.<\/strong>\u00a02<\/strong><\/p>\n

Autoritatea Na\u0163ional\u0103 pentru Persoanele cu Handicap, Comisiile de evaluare a persoanelor adulte cu handicap, Comisiile pentru protec\u0163ia copilului \u015fi Direc\u0163iile generale de asisten\u0163\u0103 social\u0103 \u015fi protec\u0163ia copilului jude\u0163ene, respectiv ale sectoarelor municipiului Bucure\u015fti vor duce la \u00eendeplinire prevederile prezentului ordin.<\/p>\n

Art.<\/strong>\u00a03<\/strong><\/p>\n

Prezentul ordin se public\u0103 \u00een Monitorul Oficial al Rom\u00e2niei, Partea I.<\/p>\n

-****-<\/p>\n

\u00a0<\/p>\n

<\/p>\n\n\n<\/colgroup>\n\n\n
\n

Ministrul muncii, familiei \u015fi egalit\u0103\u0163ii de \u015fanse,<\/p>\n

Paul P\u0103curaru<\/strong><\/p>\n

Ministrul s\u0103n\u0103t\u0103\u0163ii publice,<\/p>\n

Gheorghe Eugen Nicol\u0103escu<\/strong><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/center><\/p>\n

 <\/p>\n

ANEX\u0102:<\/em><\/h3>\n

CRITERII\u00a0MEDICO-PSIHOSOCIALE<\/strong>\u00a0DE<\/strong>\u00a0\u00ceNCADRARE<\/strong>\u00a0\u00ceN<\/strong>\u00a0GRAD<\/strong>\u00a0DE<\/strong>\u00a0HANDICAP<\/strong>\u00a0din<\/strong>\u00a031<\/strong>\u00a0august<\/strong>\u00a02007<\/strong><\/em><\/h3>\n

 <\/p>\n

CAPITOLUL<\/strong>\u00a01:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0MENTALE<\/strong><\/p>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP LA PERSOANELE CU DEZVOLTARE INCOMPLET\u0102 A FUNC\u0162IILOR MENTALE \u015eI PSIHOSOCIALE*<\/u><\/p>\n

 <\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Evaluarea comportamentului adaptativ respectiv: a. nivelul de dezvoltare bio-psiho-comportamental\u0103, b. capacitatea de \u00eenv\u0103\u0163are (QI, memorie, aten\u0163ie), c. adaptarea social\u0103 Instrumente de lucru: I. examen psihiatric, II. teste psihometrice, III. anchet\u0103 social\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– \u00cent\u00e2rzierea mintal\u0103 u\u015foar\u0103 (QI – 50-55\/70)
\n– Prezint\u0103 capacitate de comunicare oral\u0103 \u015fi scris\u0103, dar manifest\u0103 o \u00eent\u00e2rziere de 2-3 ani \u00een evolu\u0163ia \u015fcolar\u0103, f\u0103r\u0103 ca aceasta s\u0103 fie determinat\u0103 de caren\u0163e educative, dificult\u0103\u0163i de \u00eenv\u0103\u0163are \u015fi g\u00e2ndire deficitar\u0103. Caren\u0163ele se manifest\u0103 numai \u00een cazul solicit\u0103rii intelectuale.
\n– Se pot antrena \u00een activit\u0103\u0163i simple.
\n– Pot desf\u0103\u015fura activit\u0103\u0163i lucrative dac\u0103 beneficiaz\u0103 de servicii de sprijin.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

– \u00cent\u00e2rzierea mintal\u0103 u\u015foar\u0103 (QI – 50-55\/70), asociat\u0103 cu o alt\u0103 deficien\u0163\u0103 senzorial\u0103, epilepsie, tulbur\u0103ri comportamentale sau autism. \u00cen func\u0163ie de severitatea deficien\u0163ei asociate se va trece la handicap accentuat sau grav**.
\n– \u00cent\u00e2rzierea mintal\u0103 moderat\u0103 (QI – 35-50)
\n\u00ce\u015fi \u00eensu\u015fesc cu dificultate opera\u0163iile elementare \u00eens\u0103 pot \u00eenv\u0103\u0163a s\u0103 scrie \u015fi s\u0103 citeasc\u0103 cuvinte scurte; au deprinderi elementare de autoservire \u015fi se adapteaz\u0103 la activit\u0103\u0163i simple de rutin\u0103; au capacit\u0103\u0163i de autoprotec\u0163ie suficiente, put\u00e2nd fi integra\u0163i \u00een comunitate \u015fi s\u0103 desf\u0103\u015foare activit\u0103\u0163i lucrative \u00een condi\u0163ii protejate.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT***<\/p>\n<\/td>\n

– \u00cent\u00e2rzierea mintal\u0103 accentuat\u0103 – (QI – 21-34)
\n– Adaptarea la situa\u0163ii noi nu se realizeaz\u0103 conform v\u00e2rstei cronologice.
\n– Persoana are un ritm de dezvoltare lent, curba de perfec\u0163ionare este plafonat\u0103, av\u00e2nd loc blocaje psihice.
\n– Sunt capabili s\u0103 efectueze sarcini simple sub supraveghere, au nevoie de servicii de sprijin \u015fi se pot adapta la via\u0163a de familie, comunitate.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

– \u00cent\u00e2rzierea mintal\u0103 profund\u0103 – (QI < 21)
\n– Minim\u0103 dezvoltare senzitivo-motorie, reac\u0163ioneaz\u0103 la comenzi simple \u00eendelung executate, au nevoie de asisten\u0163\u0103 permanent\u0103 fiind incapabili de autoconduc\u0163ie \u015fi autocontrol.
\n– Necesit\u0103 asistent personal.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

* Se refer\u0103 la demen\u0163e atrofico-degenerative (demen\u0163\u0103 senil\u0103, demen\u0163\u0103 \u00een boala Alzheimer, boala Pick), boli care afecteaz\u0103 primar, direct \u015fi selectiv creierul, caracterizate prin:<\/p>\n

– pierderea abilit\u0103\u0163ilor intelectuale suficient de sever\u0103 pentru a interfera cu activit\u0103\u0163ile sociale \u015fi profesionale;<\/p>\n

– deteriorarea g\u00e2ndirii abstracte;<\/p>\n

– tulbur\u0103ri ale activit\u0103\u0163ii corticale superioare: afazie, apraxie, agnozie, dificult\u0103\u0163i construc\u0163ionale;<\/p>\n

– modificarea personalit\u0103\u0163ii;<\/p>\n

– starea de con\u015ftient\u0103 clar\u0103.<\/p>\n

Demen\u0163a presenil\u0103 – degradarea progresiv\u0103 a func\u0163iilor cognitiv\u0103, volitiv\u0103 \u015fi prosexic\u0103 f\u0103r\u0103 triada simptomatica (agnozie, apraxie, afazie) – se consider\u0103 demen\u0163\u0103 presenil\u0103 atunci c\u00e2nd tulbur\u0103rile apar dup\u0103 v\u00e2rsta de 40-45 de ani \u015fi demen\u0163\u0103 senil\u0103 atunci c\u00e2nd tulbur\u0103rile apar dup\u0103 v\u00e2rsta de 60 de ani.<\/p>\n

Demen\u0163a Alzheimer – demen\u0163\u0103 atipic\u0103 cu debut precoce sau tardiv, cu atrofie cerebral\u0103 generalizat\u0103, predominant frontal\u0103 \u015fi lobi temporali \u015fi triada simptomatic\u0103 (agnozie, apraxie, afazie).<\/p>\n

Func\u0163iile psihice superioare sunt pierdute, func\u0163iile neurologice clasice, ca \u015fi cele viscerale, sunt p\u0103strate.<\/p>\n

Demen\u0163a Pick – forma mai rar\u0103, afecteaz\u0103 regiunile frontale \u015fi temporale ale cortexului.<\/p>\n

Evolueaz\u0103 cu apatie pronun\u0163at\u0103 \u015fi tulbur\u0103ri de memorie.<\/p>\n

 <\/p>\n\n\n\n\n\n\n\n
 <\/td>\nACTIVIT\u0102\u0162I \u2013 LIMIT\u0102RI<\/td>\nPARTICIPARE \u2013 NECESIT\u0102\u0162I<\/td>\n<\/tr>\n
HANDICAP U\u015eOR<\/td>\n– Dezvolt\u0103, de regul\u0103, aptitudini sociale \u015fi de comunicare \u00een timpul anilor pre\u015fcolari, au o deteriorare minim\u0103 \u00een ariile senzitivo-motorii;
\n– Pot achizi\u0163iona cuno\u015ftin\u0163e \u015fcolare corespunz\u0103toare nivelului clasei a VI-a, cap\u0103t\u0103 aptitudini sociale \u015fi profesionale adecvate pentru auto\u00eentre\u0163inere, pot tr\u0103i
\nsatisf\u0103c\u0103tor \u00een societate daca nu exist\u0103 o tulburare asociat\u0103;
\n– Uneori asociaz\u0103 tulbur\u0103ri de comportament care pot atinge intensitatea unor acte antisociale, adi\u0163ii de substan\u0163e psihoactive.<\/td>\n		– Necesit\u0103 preg\u0103tire \u00een condi\u0163ii speciale;
\n– Au nevoie de sprijin pentru ini\u0163iere \u015fi inser\u0163ie social\u0103 pe pia\u0163a muncii pentru a dob\u00e2ndi abilit\u0103\u0163i de trai independent ;
\n– Monitorizare \u015fi m\u0103suri educative \u00een cazul celor cu comportament deviant.<\/td>\n<\/tr>\n
HANDICAP MEDIU<\/td>\n– Pot beneficia de preg\u0103tire profesional\u0103 \u015fi, cu supraveghere moderat\u0103, pot avea grij\u0103 de ei \u00een\u015fi\u015fi;
\n– Pot efectua activit\u0103\u0163i lucrative
\n– Au nevoie de servicii de sprijin.<\/td>\n		– Au nevoie de sprijin pentru \u00eensu\u015firea unei meserii, \u00een func\u0163ie de abilit\u0103\u0163i\/aptitudini.
\nImplicarea agen\u0163iei de formare profesional\u0103 este necesar\u0103 pentru inser\u0163ia social\u0103 pe pia\u0163a muncii.<\/td>\n<\/tr>\n
HANDICAP ACCENTUAT<\/td>\n– Au o dezvoltare psihomotorie redus\u0103;
\n– Pot dob\u00e2ndi deprinderi igienice elementare;
\n– Pot efectua sarcini simple.<\/td>\n		– Pot desf\u0103\u015fura activit\u0103\u0163i simple;
\n– Au nevoie de sprijin pentru a efectua
\nactivit\u0103\u0163ile pentru care au fost preg\u0103ti\u0163i.<\/td>\n<\/tr>\n
HANDICAP GRAV<\/td>\n– Au nevoie de asisten\u0163\u0103 permanent\u0103.<\/td>\n– Necesit\u0103 asistent personal.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

III.<\/strong>EVALUAREA GRADULUI DE HANDICAP LA PERSOANELE CU TULBUR\u0102RI DE PERSONALITATE*<\/u><\/p>\n

* Se refer\u0103 la tipurile de tulbur\u0103ri de personalitate (boli structurale-psihopatii):<\/p>\n

– Tulburare de personalitate paranoid\u0103;<\/p>\n

– Tulburare de personalitate schizoid\u0103;<\/p>\n

– Tulburare de personalitate antisocial\u0103;<\/p>\n

– Tulburare de personalitate instabil-emo\u0163ional\u0103<\/p>\n

– de tip impulsiv \u015fi<\/p>\n

– de tip borderline;<\/p>\n

Caracterizate prin:<\/p>\n

1.controlul incomplet al sferelor afectiv-voli\u0163ionale \u015fi instinctive,<\/p>\n

2.nerecunoa\u015fterea deficitului structural,<\/p>\n

3.incapacitatea de integrare armonioasa \u015fi constant\u0103 \u00een mediul social.<\/p>\n

\u00cen practic\u0103 se \u00eent\u00e2lnesc aspecte clinice polimorfe care asociaz\u0103 doua sau mai multe tr\u0103s\u0103turi dizarmonice realiz\u00e2nd tablouri simptomatologice complexe – tulbur\u0103ri de personalitate mixte (polimorfe).<\/p>\n

 <\/p>\n\n\n\n\n\n
\n

PARAMETRI FUC\u0162IONALI<\/p>\n<\/td>\n

DEFICIEN\u0162\u0102 USOAR\u0102<\/td>\n\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/td>\nDEFICIEN\u0162\u0102 GRAV\u0102<\/td>\n<\/tr>\n
HANDICAP USOR<\/td>\nHANDICAP MEDIU<\/td>\nHANDICAP ACCENTUAT<\/td>\nHANDICAP GRAV<\/td>\n<\/tr>\n
\n

– examen psihiatric;
\n– teste psihologice
\n(MMSE);
\n– evaluarea degrad\u0103rii intelectuale (IDC);
\n– CT; RMN;
\n– anchet\u0103 social\u0103.<\/p>\n<\/td>\n

– scor MMSE \u2265 21;
\n– deteriorare cognitiv\u0103, atrofie cortical\u0103 u\u015foar\u0103 \/ generalizat\u0103;
\n– uit\u0103 evenimentele recente;
\n– necesitatea de a repeta de mai multe
\nori o relatare \u00een vederea memor\u0103rii;
\n– ezitare \u00een a r\u0103spunde la \u00eentreb\u0103ri.<\/td>\n		– scor MMSE 15 – 20;
\n– tulbur\u0103ri de memorie \u015fi tulbur\u0103ri psihice de intensitate u\u015foar\u0103;
\n– accentuarea tulbur\u0103rilor de memorie;
\n– deteriorare social\u0103 moderat\u0103 cu dificult\u0103\u0163i \u00een activitatea profesional\u0103.<\/td>\n		– scor MMSE 10 – 14;
\n– atrofie cortical\u0103 generalizat\u0103 accentuat\u0103;
\n– uitarea numelor, numerelor de telefon, adreselor;
\n– uitarea conversa\u0163iei recente, a evenimentelor curente;
\n-sarcini neterminate deoarece nu \u015ftie de unde s\u0103 le reia.<\/td>\n		– scor MMSE \u2264\u00a09;
\n– atrofie cortical\u0103 marcat\u0103 cerebral, f\u0103r\u0103 tulbur\u0103ri motorii;
\n– demen\u0163\u0103 Alzheimer – atrofie cortical\u0103 marcat\u0103 \u00een lobii frontali \u015fi parietali + triada simptomatic\u0103;
\n-uitarea numelor, celor apropia\u0163i;
\n– uitarea datelor personale;
\n– incapacitate de memorare;
\n– deteriorarea judec\u0103\u0163ii, a controlului pulsional;
\n– triada patognomonic\u0103 (agnozie, apraxie, afazie)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

NB<\/p>\n

a.\u00cen stabilirea deficien\u0163ei func\u0163ionale se vor avea \u00een vedere:<\/p>\n

– tipul tulbur\u0103rii de personalitate,<\/p>\n

– frecven\u0163a \u015fi intensitatea decompens\u0103rilor (de tip psihotic),<\/p>\n

– durata decompens\u0103rilor,<\/p>\n

– r\u0103spunsul terapeutic \u015fi calitatea remisiunilor,<\/p>\n

– integrarea socio-comunitar\u0103 \u015fi profesional\u0103,<\/p>\n

– profesiunea,<\/p>\n

– toxicofilia asociat\u0103.<\/p>\n

b.Este necesar\u0103 o anamnez\u0103 minu\u0163ioas\u0103 corelat\u0103 cu ancheta social\u0103, urm\u0103rindu-se ob\u0163inerea de date, at\u00e2t privind activitatea profesional\u0103 (ruta profesional\u0103-mobilitatea profesional\u0103) c\u00e2t \u015fi comportamentul longitudinal \u00een familie \u015fi societate.<\/p>\n

c.Examenul psihologic aduce date privitoare la posibilele elemente deteriorative, c\u00e2t \u015fi \u00een eviden\u0163ierea tr\u0103s\u0103turilor dominante \u00een cazul tulbur\u0103rilor mixte de personalitate.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Poate presta orice activitate profesional\u0103 \u00een func\u0163ie de calificare, cu evitarea celor care impun responsabilitate \u015fi contact cu publicul<\/p>\n<\/td>\n

\n

– Participare f\u0103r\u0103 restric\u0163ii – activitatea profesional\u0103 \u00eentr-un loc de munc\u0103 accesibil, av\u00e2nd un rol psihoterapeutic important;<\/p>\n

– Monitorizare medico-psiho-social\u0103 pentru prevenirea decompens\u0103rilor de tip psihotic.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Pot efectua numeroase activit\u0103\u0163i profesionale \u00een func\u0163ie de calificare, f\u0103r\u0103 suprasolicitare psihic\u0103, \u00eentr-o ambian\u0163\u0103 rela\u0163ional\u0103 adecvat\u0103;<\/p>\n

– Transferul activit\u0103\u0163ilor de v\u00e2rf, de responsabilitate \u015fi mai ales decizionale, altor membri ai echipei.<\/p>\n<\/td>\n

\n

– Participare cu condi\u0163ia realiz\u0103rii unui climat profesional tolerant din partea conducerii \u015fi colectivului de munc\u0103, f\u0103r\u0103 tensiuni psihice \u00een scopul inser\u0163iei profesionale sau men\u0163inerii \u00een activit\u0103\u0163i organizate;<\/p>\n

– Monitorizare medico-psihosociala.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Pot executa nenum\u0103rate activit\u0103\u0163i profesionale \u00een func\u0163ie de calificarea \u00eensu\u015fit\u0103 sau \u00een curs de formare, f\u0103r\u0103 solicitare psihic\u0103 accentuat\u0103, responsabilit\u0103\u0163i sau contact cu publicul.<\/p>\n<\/td>\n

\n

Facilitarea rela\u0163iilor interpersonale \u00een colectivul de lucru, \u00een vederea inser\u0163iei sociale.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Pot desf\u0103\u015fura activit\u0103\u0163i lucrative \u015fi au nevoie de servicii de sprijin.<\/p>\n<\/td>\n

\n

– Necesit\u0103 un mediu psiho-socio-familial suportiv \u015fi asigurarea accesului la servicii specializate<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

IV.<\/strong>EVALUAREA GRADULUI DE HANDICAP LA PERSOANELE CU TULBUR\u0102RI ALE DISPOZI\u0162IEI \u015eI PREVALENT DE G\u00c2NDIRE*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

– psihoze cu debut precoce (copil\u0103rie – adolescen\u0163\u0103; ex. schizofrenia, boli afective);<\/p>\n

– afec\u0163iuni psihice majore (psihoze) grefate pe o \u00eent\u00e2rziere mental\u0103, indiferent de gradul acesteia \u015fi de v\u00e2rsta solicitantului;<\/p>\n

– psihoze la care se re\u0163ine o component\u0103 ereditar\u0103 indubitabil\u0103;<\/p>\n

– psihoze la care se asociaz\u0103 o tulburare de personalitate (structural\u0103).<\/p>\n

– psihoze majore, indiferent de v\u00e2rst\u0103, la persoane f\u0103r\u0103 venituri.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen psihiatric (aprecierea clinic\u0103 a intensit\u0103\u0163ii tulbur\u0103rii psihice \u015fi a prognosticului apropiat al afec\u0163iunii);<\/p>\n

– Examen psihologic: testarea a func\u0163iilor cognitive, afective, a comportamentului \u015fi a personalit\u0103\u0163ii (prin teste psihometrice \u015fi probe proiective);<\/p>\n

– Investiga\u0163ii sociale<\/p>\n<\/td>\n

\n

\u00cen forme clinice reziduale, stabilite cu pruden\u0163\u0103<\/p>\n<\/td>\n

\n

\u00cen remisiuni cu dispari\u0163ia fenomenelor delirante \u015fi halucinatorii permi\u0163\u00e2nd reluarea activit\u0103\u0163ii la un nivel inferior<\/p>\n<\/td>\n

\n

\u00cen formele catatonice, dezorganizate (hebrefrenice), paranoide, nediferen\u0163iate.<\/p>\n

NB \u00cen formele care au instituit\u0103 interdic\u0163ia, handicap grav<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie progredient\u0103 sever\u0103 a personalit\u0103\u0163ii \u015fi a comportamentului, cu poten\u0163ial antisocial<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB – De re\u0163inut:<\/p>\n

1.<\/strong>Debutul psihotic poate fi necaracteristic \u015fi, ulterior, se pune diagnosticul de afec\u0163iune psihic\u0103 major\u0103. Debutul este reprezentat de prima consulta\u0163ie avut\u0103 de pacient la un serviciu de psihiatrie (fi\u015fa de consulta\u0163ie este util\u0103).<\/p>\n

2.<\/strong>Schizofrenia, \u00een faza activ\u0103 (productiv\u0103), este caracterizat\u0103 prin:<\/p>\n

a)<\/strong>idei delirante, halucina\u0163ii, incoeren\u0163\u0103, autism, catatonie, afect plat sau evident inadecvat (discordant);<\/p>\n

b)<\/strong>idei delirante, bizare;<\/p>\n

c)<\/strong>halucina\u0163ii proeminente;<\/p>\n

d)<\/strong>\u00een timpul puseului – munca, rela\u0163iile sociale \u015fi auto\u00eengrijirea sunt afectate major;<\/p>\n

e)<\/strong>nu poate fi stabilit un factor organic care a ini\u0163iat sau men\u0163inut tulburarea.<\/p>\n

3.<\/strong>La evaluarea gradului de handicap \u00een schizofrenie se vor avea \u00een vedere:<\/p>\n

a)<\/strong>forma clinic\u0103: catatonic\u0103, hebefrenic\u0103, paranoid\u0103, nediferen\u0163iat\u0103, rezidual\u0103, simpl\u0103 \u015fi depresia post schizofrenic\u0103. Primele patru forme sunt cele mai severe \u015fi au un poten\u0163ial handicapant major;<\/p>\n

b)<\/strong>tipul de evolu\u0163ie:<\/p>\n

– subcronic\u0103 sau cronic\u0103, cu sau f\u0103r\u0103 episoade de acutizare;<\/p>\n

– \u00een remisiune (c\u00e2nd o persoan\u0103 cu schizofrenie nu mai prezint\u0103 nici un semn de tulburare);<\/p>\n

c)<\/strong>cooperarea la monitorizarea medical\u0103 \u015fi eficien\u0163a ac\u0163iunilor psihoterapeutice;<\/p>\n

d)<\/strong>climatul familial \u015fi socioprofesional.<\/p>\n

4.<\/strong>La evaluarea gradului de handicap \u00een psihozele afective se va avea \u00een vedere:<\/p>\n

– mania cronicizat\u0103, formele bipolare, ciclotimia rapid\u0103, depresia sever\u0103 cronic\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Pot presta activit\u0103\u0163i \u00een condi\u0163ii de confort psihic \u015fi fizic din punct de vedere al ambian\u0163ei rela\u0163ionale \u015fi materiale.<\/p>\n

– Sunt contraindicate activit\u0103\u0163ile care implic\u0103 suprasolicitare psihica, stresante \u015fi cu responsabilitate ridicat\u0103.<\/p>\n<\/td>\n

\n

– Sprijin pentru men\u0163inerea \u00een activitate – activit\u0103\u0163i organizate, accesibile;<\/p>\n

– Monitorizarea medico-psihosocial\u0103 la serviciul teritorial de psihiatrie.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Pot desf\u0103\u015fura activit\u0103\u0163i, cu program integral sau par\u0163ial, \u00een acela\u015fi loc de munc\u0103. Schimbarea locului de munc\u0103 se va face numai dac\u0103 acesta este corespunz\u0103tor din punctele de vedere ale solicit\u0103rii psihice \u015fi al rela\u0163iilor interpersonale;<\/p>\n

– Evitarea profesiunilor cu risc de acutizare a tulbur\u0103rii.<\/p>\n<\/td>\n

\n

– Sprijin pentru men\u0163inere \u00een acela\u015fi loc de munc\u0103 sau pentru eventuala schimbare a locului de munc\u0103;<\/p>\n

– Facilitarea rela\u0163ion\u0103rii interpersonale \u00een colectivul de lucru;<\/p>\n

– Sprijin pentru monitorizarea medico-psiho-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Nu pot desf\u0103\u015fura activit\u0103\u0163i profesionale organizate, indiferent de natura \u015fi nivelul de solicitare;<\/p>\n

– Eventual activit\u0103\u0163i \u00een sec\u0163ii de ergoterapie-terapie ocupa\u0163ional\u0103, cu rol psihoterapeutic;<\/p>\n

– Au afectata par\u0163ial capacitatea de autodeterminare \u015fi autoservire;<\/p>\n

– Nu necesit\u0103 supraveghere permanent\u0103 din partea altei persoane.<\/p>\n<\/td>\n

\n

– Sprijin familial pentru respectarea tratamentului de specialitate, cooperare la activit\u0103\u0163ile de psihoterapie sau\/\u015fi terapie ocupa\u0163ional\u0103;<\/p>\n

– Asigurarea unui climat comunitar \u015fi familial de \u00een\u0163elegere, sprijin, f\u0103r\u0103 factori stresan\u0163i psihoafectivi.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Au pierdut\u0103 capacitatea de autodeterminare, autoservire, auto\u00eengrijire.<\/p>\n<\/td>\n

\n

– Monitorizare medico-psiho-social\u0103 permanent\u0103.<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n

– Necesit\u0103 servicii specializate.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/h3>\n

CAPITOLUL<\/strong>\u00a02:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0SENZORIALE<\/strong><\/p>\n

\u00a0<\/h5>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR VEDERII*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Acuitatea vizual\u0103<\/p>\n

(calitatea vederii) mono-binocular\u0103 (cu cea mai bun\u0103 corec\u0163ie, la ochiul cel mai bun)<\/p>\n

Refractrometrie ocular\u0103 (autorefractometru dioptron)<\/p>\n<\/td>\n

\n

1\/2 = 0,5 – 1\/3 = 0,3 (2\/3, 1\/2, 1\/3)<\/p>\n<\/td>\n

\n

VAO \u00eentre 1\/4 (0,25)-1\/10 (0,1)<\/p>\n<\/td>\n

\n

VAO \u00eentre 1\/12 = 0,08 (4m) – 1\/25 = 0,04 (2m)<\/p>\n<\/td>\n

\n

VAO sub 1\/25 < 0,04 (2m) cecitate relativ\u0103<\/p>\n

VAO = pmm pl, fpl = cecitate absolut\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

– C\u00e2mp vizual (manual) la ochiul cel mai bun<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Redus concentric \u00een jurul punctului de fixa\u0163ie la 30 -40 grade<\/p>\n<\/td>\n

\n

Redus concentric \u00een jurul punctului de fixa\u0163ie la 10 – 30 grade<\/p>\n<\/td>\n

\n

Tubular, \u00een jurul punctului de fixa\u0163ie (0 – 10 grade)<\/p>\n<\/td>\n<\/tr>\n

\n

– C\u00e2mp vizual computerizat **<\/p>\n<\/td>\n

\n

\u00cen func\u0163ie de structura ocular\u0103 afectat\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

– Percep\u0163ia luminii la stimuli vizuali***<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

– Poten\u0163iale vizuale evocate (PEV)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Poten\u0163iale modificate<\/p>\n<\/td>\n

\n

Lips\u0103 percep\u0163ie luminoas\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

– Electroretinograma (ERG)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Retina \u00eenc\u0103 func\u0163ional\u0103<\/p>\n<\/td>\n

\n

Traseu stins (retina nefunc\u0163ional\u0103)<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen afec\u0163iunile cronice primar \u015fi secundar oculare, inflamatorii, heredodegenerative, degenerative, traumatice, tumorale, vasculare cu evolu\u0163ie cronic\u0103-progresiv\u0103 sub tratament specific sau cu sechele morfofunc\u0163ionale handicapante.<\/p>\n

Cataract\u0103 cu indica\u0163ie chirurgical\u0103 va fi evaluat\u0103 dup\u0103 interven\u0163ia operatorie.<\/p>\n

Vicii de refrac\u0163ie, de acomodare, nistagmusul.<\/p>\n

** C\u00e2mpul vizual computerizat ofer\u0103 rela\u0163ii privind sensibilitatea retinei cu modific\u0103ri specifice structurii func\u0163iilor vizuale afectate efectiv (are programe prestabilite \u00een func\u0163ie de diagnosticul clinic).<\/p>\n

*** PEV \u015fi ERG utilizate \u00een aprecierea st\u0103rii func\u0163ionale a retinei (teste obiective).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice profesie<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Profesiuni care nu comport\u0103 periclitate oculara sau suprasolicitare vizual\u0103.<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Limit\u0103ri \u00een orientarea spa\u0163ial\u0103, \u00een acomodarea la trecerea de la lumin\u0103 la \u00eentuneric \u015fi invers;<\/p>\n

– Profesiuni care nu comport\u0103 periclitate ocular\u0103 sau suprasolicitare ocular\u0103.<\/p>\n<\/td>\n

\n

– Asigurarea de lupe m\u0103ritoare pentru reperele prelucrate;<\/p>\n

– Afi\u015farea cu litere mari a instruc\u0163iunilor de munc\u0103 \u015fi de protec\u0163ia a muncii;<\/p>\n

– Iluminat mai puternic compensator.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Dificult\u0103\u0163i majore de orientare \u00een spa\u0163iu.<\/p>\n

– Pot desf\u0103\u015fura activit\u0103\u0163i lucrative<\/p>\n<\/td>\n

\n

– Marcarea drumului de acces spre locul de munc\u0103;<\/p>\n

– Schimbarea sistemului de alarm\u0103;<\/p>\n

– Ajustarea ambian\u0163ei luminoase;<\/p>\n

– Loc de munc\u0103 protejat pentru reg\u0103sirea materiei prime \u015fi a uneltelor, eventual cu jalonarea drumului m\u00e2inii;<\/p>\n

– Montarea de ap\u0103r\u0103toare \u00een zonele periculoase pentru munc\u0103;<\/p>\n

– Informarea \u00een munc\u0103 s\u0103 se fac\u0103 verbal sau \u00een Braille;<\/p>\n

– Necesit\u0103 ajutor regulat.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR AUZULUI*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI<\/p>\n

FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

F\u0102R\u0102 DEFICIEN\u0162\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

INFIRMITATE<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Audiometrie (subiectiv\u0103 – liminar\u0103 sau supraliminar\u0103 sau audiometrie vocal\u0103 \u015fi obiectiv\u0103 cu poten\u0163iale evocate), impedansmetrie \u015fi otoemisiuni acustice<\/p>\n<\/td>\n

\n

Sc\u0103derea sau abolirea unilateral\u0103 a auzului<\/p>\n

Tulbur\u0103ri de auz bilaterale cu pierdere \u00eentre 0 – 20 dB<\/p>\n<\/td>\n

\n

Pierdere auditiv\u0103 bilateral\u0103 \u00eentre 20 – 40 dB<\/p>\n<\/td>\n

\n

Pierdere auditiv\u0103 bilateral\u0103 \u00eentre 41 – 70 dB protezabil\u0103<\/p>\n<\/td>\n

\n

– Pierderea auditiv\u0103 peste 70 dB care se protezeaz\u0103 greu asociat\u0103 cu tulbur\u0103ri psihice \u015fi de limbaj;<\/p>\n

– Surditate congenital\u0103 sau dob\u00e2ndit\u0103 \u00eenaintea achizi\u0163ion\u0103rii limbajului \u00eenso\u0163it\u0103 de mutitate (surdocecitate cu demutizare slab\u0103\/nul\u0103), cu pierdere peste 90 dB (cofoz\u0103)<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen afec\u0163iunile cronice auditive de cauz\u0103 divers\u0103: inflamatorie, infec\u0163ioas\u0103, toxic\u0103, vascular\u0103, heredodegenerativ\u0103, traumatic\u0103, tumoral\u0103 – congenitale sau dob\u00e2ndite precoce (copil\u0103rie\/adolescen\u0163\u0103) \u00eenso\u0163ite de hipoacuzie (tip transmisie, neurosenzorial\u0103, mixt\u0103), protezabile sau neprotezabile sau cu surditate (cofoza), cu sau f\u0103r\u0103 tulbur\u0103ri de comunicare (surdomutitate-surdocecitate).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Acces la majoritatea locurilor de munc\u0103, cu condi\u0163ia evit\u0103rii activit\u0103\u0163ilor de comunicare cu publicul.<\/p>\n<\/td>\n

\n

Asigurarea unor sisteme optice de semnalizare \u00eenlocuindu-le pe cele sonore, at\u00e2t \u00een scopul protec\u0163iei muncii, c\u00e2t \u015fi de asigurare a unui flux tehnologic normal, cu preluarea sarcinilor de supraveghere.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

III.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR VESTIBULARE*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI<\/p>\n

FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV*<\/p>\n<\/td>\n<\/tr>\n

\n

Evaluarea reflexelor:<\/p>\n

– vestibulo-ocular (electronistagmografie);<\/p>\n

– vestibulo-spinal (posturo-grafie dinamic\u0103 computerizat\u0103 \u015fi cranio-corpo-grafie)<\/p>\n<\/td>\n

\n

Diferen\u0163e func\u0163ionale la probele provocate \u00eentre cele 2 vestibule de cel pu\u0163in 20%<\/p>\n

Hipo\/hiper excitabilitate vestibular\u0103 bilateral\u0103<\/p>\n<\/td>\n

\n

Diferen\u0163a \u00eentre cele doua vestibule la probele provocate dep\u0103\u015fe\u015fte 30% (nistagmus spontan sau devia\u0163ii nete)<\/p>\n<\/td>\n

\n

Ortostatismul este posibil dar dificil de men\u0163inut, nistagmus spontan, diferen\u0163a mare \u00eentre vestibule (tulbur\u0103ri calitative ale traseului electronistagmografic), tulbur\u0103ri func\u0163ionale echivalente cu 60-80%<\/p>\n<\/td>\n

\n

Ortostatismul este imposibil \u00een criz\u0103, \u00eenso\u0163it de tulbur\u0103ri vegetative.<\/p>\n

Probele spontane \u015fi provocate(dac\u0103 se pot practica) sunt net pozitive.<\/p>\n

Tulbur\u0103ri func\u0163ionale echivalente cu 80-100%*<\/p>\n

Pentru perioade limitate de 6-12 luni, \u00een func\u0163ie de durata \u015fi reversibilitatea tulbur\u0103rilor majore de echilibru la ac\u0163iunile de recuperare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen afec\u0163iunile cronice vestibulare, precum \u015fi a c\u0103ilor acestora, congenitale sau contractate precoce.<\/p>\n

NB: \u00cen general tulbur\u0103rile vestibulare periferice au un caracter pasager, tranzitoriu.<\/p>\n

Tulbur\u0103rile de echilibru survin c\u00e2nd exist\u0103 o diferen\u0163\u0103 func\u0163ional\u0103 mai mare de 20 – 30 % \u00eentre cele dou\u0103 vestibule.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

Restric\u0163ie pentru activit\u0103\u0163ile care se desf\u0103\u015foar\u0103 la \u00een\u0103l\u0163ime<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Locuri de munc\u0103 – f\u0103r\u0103 suprasolicitare postural\u0103 \u015fi deplas\u0103ri posturale de durat\u0103 sau care impun alternan\u0163a rapid\u0103 \u00een variantele posturale;<\/p>\n

– Sunt accesibile, \u00een general, muncile statice, activit\u0103\u0163ile de birou\/me\u015fte\u015fug\u0103re\u015fti.<\/p>\n<\/td>\n

\n

Adaptarea locului de munc\u0103, astfel \u00eenc\u00e2t s\u0103 nu fie suprasolicitat\u0103 postura ortostatic\u0103 sau s\u0103 o faciliteze prin mijloace suplimentare de sprijin, scaune adaptate, etc.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Sprijin pentru autoservire, \u00eengrijire \u015fi autogospod\u0103rire \u00een activit\u0103\u0163ile de baz\u0103 ale vie\u0163ii de zi cu zi.<\/p>\n

– Pentru perioada \u00een care ortostatismul \u015fi mobilizarea nu se pot realiza.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asisten\u0163\u0103 de specialitate.<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a03:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0FONATORII<\/strong>\u00a0\u015eI<\/strong>\u00a0DE<\/strong>\u00a0COMUNICARE<\/strong>\u00a0VERBAL\u0102<\/strong><\/p>\n

\u00a0<\/p>\n

EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA VOCII*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen ORL<\/p>\n

– Examen laringoscopic<\/p>\n

– Examen histopatologic<\/p>\n

– Probe ventilatori<\/p>\n

– Anchet\u0103<\/p>\n<\/td>\n

\n

– Disfonie izolat\u0103 (r\u0103gu\u015feal\u0103);<\/p>\n

– Voce bitonal\u0103 (parez\u0103 coard\u0103 vocal\u0103 – recuren\u0163ial\u0103, unilateral\u0103)<\/p>\n<\/td>\n

\n

Diplegie recuren\u0163ial\u0103 \u00een pozi\u0163ie de abduc\u0163ie sau aduc\u0163ie (cu p\u0103strarea vocii dar cu tulbur\u0103ri de respira\u0163ie), \u00een func\u0163ie \u015fi de specificul profesiunii (profesioni\u015fti ai vocii)<\/p>\n<\/td>\n

\n

– Traheostom\u0103 permanent\u0103 f\u0103r\u0103 laringectomie.<\/p>\n

– Traheostom\u0103 cu laringectomie, determinat\u0103 de procese maligne sau zdrobirea laringelui.<\/p>\n

– Abla\u0163ia laringelui cu traheostom\u0103 permanent\u0103 \u015fi lipsa crigmofonatiei, cu tulbur\u0103ri de vorbire, de ventila\u0163ie \u015fi, eventual, de nutri\u0163ie, \u0163in\u00e2nd seama de cauza care a determinat afectarea structural\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Se refer\u0103 la tulbur\u0103rile fonatorii determinate de afectarea laringelui, cauzate de:<\/p>\n

– stenoze post traumatice,<\/p>\n

– pareze sau paralizii (corzi vocale – n. recuren\u0163iali),<\/p>\n

– procese tumorale benigne, maligne,<\/p>\n

– procese inflamatorii cronice, trenante sau repetitive.<\/p>\n

Func\u0163ia fonatorie poate fi tulburat\u0103 \u00eencep\u00e2nd cu cavitatea bucal\u0103 (stomatolalie) \u015fi p\u00e2n\u0103 la organul fonator principal, laringele, sub form\u0103 de:<\/p>\n

– voce bitonal\u0103 \u00een paralizie recuren\u0163ial\u0103,<\/p>\n

– disfonie prin forma\u0163iuni tumorale,<\/p>\n

– afonie consecutiv\u0103 abla\u0163iei laringelui.<\/p>\n

Cuantificarea tulbur\u0103rilor fonatorii se face \u00een raport de inteligibilitatea vocii de la u\u015foar\u0103 \u015fi p\u00e2n\u0103 la accentuat\u0103, c\u00e2nd este vorba de afonie.<\/p>\n

\u00cen stabilirea gradului de handicap se vor avea \u00een vedere \u015fi:<\/p>\n

– specificul profesiei (profesioni\u015fti ai vocii),<\/p>\n

– efectul terapiei,<\/p>\n

– eventualele recidive (nodului corzi vocale, polipi – recidive tumorale benigne sau malign\u0103).<\/p>\n

NB Func\u0163iile mentale ale limbajului, de articulare, tulbur\u0103rile de limbaj vorbit – mutitatea, limbaj slab cu toate \u00eencerc\u0103rile de reeducare (labiolectura) sunt prev\u0103zute la capitolele respective.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI*<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I*<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 f\u0103r\u0103 suprasolicitare fizic\u0103 mare, \u00een condi\u0163ii de microclimat adecvat, f\u0103r\u0103 varia\u0163ii termice, mediu prea rece sau prea cald sau uscat, f\u0103r\u0103 curen\u0163i de aer, umezeal\u0103.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 cu solicitare redus\u0103, \u00een condi\u0163ii de microclimat, f\u0103r\u0103 varia\u0163ii termice, curen\u0163i de aer, prea umed.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 f\u0103r\u0103 suprasolicitare fizic\u0103 mare, \u00een condi\u0163ii de microclimat adecvat, f\u0103r\u0103 varia\u0163ii termice, mediu prea rece sau prea cald sau uscat, f\u0103r\u0103 curen\u0163i de aer, umezeal\u0103. Pentru profesioni\u015fti ai vocii (profesori, avoca\u0163i, soli\u015fti, c\u00e2nt\u0103re\u0163i vocali s.a.), schimbarea locului de munc\u0103 f\u0103r\u0103 solicitarea vocei, \u00een condi\u0163ii favorabile de microclimat – condi\u0163ii ambientale la locul de munc\u0103 sau profesiei.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 cu solicitare redus\u0103 \u00een condi\u0163ii de microclimat, f\u0103r\u0103 varia\u0163ii termice, curen\u0163i de aer, prea umed. Monitorizare medical\u0103 la serviciul de ORL, tratament adecvat.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Au capacitatea de autoservire \u015fi auto\u00eengrijire conservate.<\/p>\n<\/td>\n

\n

Monitorizare medico-psiho-social\u0103 la serviciul ORL, de logopedie, \u015fi psihologie teritorial\u0103. Sprijin familial \u015fi eventual comunitar pentru unele activit\u0103\u0163i (de autogospod\u0103rire).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen principiu, afectarea vocii pentru anumite profesii \u015fi locuri de munc\u0103 poate fi hot\u0103r\u00e2toare, \u00een timp ce, \u00een altele, unde nu exist\u0103 mesaj vorbit, munca se poate desf\u0103\u015fura normal.<\/p>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a04:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0SISTEMULUI<\/strong>\u00a0CARDIOVASCULAR,<\/strong>\u00a0HEMATOLOGIC,<\/strong>\u00a0IMUNITAR<\/strong>\u00a0\u015eI<\/strong>\u00a0RESPIRATOR<\/strong><\/p>\n

SEC\u0162IUNEA 1: A. FUNC\u0162IILE SISTEMULUI CARDIOVASCULAR<\/em><\/p>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR INIMII*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– EKG de repaus;<\/p>\n

– Test de toleran\u0163\u0103 la efort (TTE);<\/p>\n

– Ecografie bidimensional\u0103, ecografie Doppler;<\/p>\n

Cateterism cardiac, angiografie<\/p>\n

– Monitorizare tensiune arterial\u0103 (TA)<\/p>\n

– Examen fund de ochi (FO).<\/p>\n<\/td>\n

\n

IC Nyha I<\/p>\n<\/td>\n

\n

IC Nyha II<\/p>\n<\/td>\n

\n

IC Nyha III<\/p>\n<\/td>\n

\n

IC Nyha IV<\/p>\n<\/td>\n<\/tr>\n

\n

– Persoana este asimptomatic\u0103 \u00een timpul activit\u0103\u0163ii uzuale sau\/\u015fi profesionale;<\/p>\n

– Tulbur\u0103ri de ritm \u015fi conducere minore, influen\u0163ate de tratamentul specific.<\/p>\n<\/td>\n

\n

– Persoana este asimptomatic\u0103 \u00een condi\u0163ii de repaus, efectueaz\u0103 activit\u0103\u0163i zilnice uzuale, dar nu poate face eforturi fizice prelungite;<\/p>\n

– Tulbur\u0103ri de ritm sau\/\u015fi de conducere repetitive care necesit\u0103 tratament sus\u0163inut continuu la care toleran\u0163a de efort este limitat\u0103 de apari\u0163ia tulbur\u0103rilor func\u0163ionale la eforturi de intensitate mare sau medie.<\/p>\n<\/td>\n

\n

– Persoana prezint\u0103 simptome limitatoare de prestare a activit\u0103\u0163ii zilnice de \u00eentre\u0163inere, prezint\u0103 semne de ICC corectabile sub tratament;<\/p>\n

– Cardiostimulare eficient\u0103 cu tulbur\u0103ri func\u0163ionale la eforturi mici, chiar \u015fi \u00een repaus;<\/p>\n

– Aritmii ES ce nu pot fi controlate prin tratament \u015fi induc tulbur\u0103ri hemodinamice manifeste accentuate \u00een efort.<\/p>\n<\/td>\n

\n

– Persoana este simptomatic\u0103 \u00een repaus, apar semne de ICC, gradul de afectare cardiac\u0103 \u00eentre 85-100%, ireversibil\u0103 la tratament;<\/p>\n

– Tulbur\u0103ri de ritm \u015fi de conducere grave, neinfluen\u0163ate de tratament<\/p>\n

– Cardiostimulare ineficient\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*1.\u00cen afectarea primar\u0103 a func\u0163iei contractile a inimii:<\/p>\n

– Cardiomiopatiile primare, primitive sau idiopatice:<\/p>\n

– CMP dilatativ\u0103 sau congestive,<\/p>\n

– CMP hipertrofic\u0103 sau obstructive,<\/p>\n

– CMP restrictiv\u0103 sau obliterant\u0103,<\/p>\n

2.\u00cen afectarea secundara a func\u0163iei contractile a inimii:<\/p>\n

– Angiopatii congenitale cianogene sau necianogene operate sau neoperate cu insuficien\u0163\u0103 cardiac\u0103 cronic\u0103 clinic manifestat\u0103:<\/p>\n

– DSA, DSV, Coarcta\u0163ie aort\u0103 Stenoz\u0103 de aort\u0103, Stenoz\u0103 de arter\u0103 pulmonar\u0103 asociat\u0103 cu DSV,<\/p>\n

– Tetralogia Fallot, transpozi\u0163ii de vase mari,<\/p>\n

– Atrezia de tricuspid\u0103, anomalia Ebstein.<\/p>\n

– Valvulopatii: de etiologie divers\u0103, complicate sau decompensate neoperate sau operate (protezate), contractate precoce.<\/p>\n

3.\u00cen afectarea ritmului \u015fi conducerii cardiace:<\/p>\n

– Tulbur\u0103ri de ritm \u015fi de conducere persistente \u015fi severe contractate precoce<\/p>\n

(purt\u0103tor de pacemaker).<\/p>\n

4.Complica\u0163ii post-transplant cardiac.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 care nu necesit\u0103 efort fizic mare.<\/p>\n<\/td>\n

\n

Nu se pot adapta la efort fizic de intensitate mare \u015fi durat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Limitarea capacit\u0103\u0163ii de adaptare la efort fizic (profesional \u015fi casnic)<\/p>\n<\/td>\n

\n

M\u0103suri de adaptare a utilajelor pentru reducerea efortului fizic necesar, evitarea pozi\u0163iei for\u0163ate \u00een munc\u0103, deplas\u0103rii posturale pe distan\u0163e mari pe plan \u00eenclinat, urcarea de sc\u0103ri.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Limitare major\u0103 a capacit\u0103\u0163ii de auto\u00eengrijire \u015fi autogospod\u0103rire, de men\u0163inere a st\u0103rii de s\u0103n\u0103tate, de comunicare \u015fi participare la via\u0163a de familie.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Necesit\u0103 servicii specializate.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR ARTERELOR LEGATE DE FLUXUL SANGUIN<\/u><\/p>\n

a)<\/strong>CONSTRIC\u0162IA \u015eI\/SAU OBSTRUC\u0162IA ARTERIAL\u0102 (ARTERIOPATII OBLITERANTE – TROMBANGIOPATII OBLITERANTE – BOAL\u0102 BURGER<\/p>\n

b)<\/strong>ANGINEUROPATII PRIMARE (BOAL\u0102 RAYNAUD)*<\/p>\n

* – Caracterizate prin spasm al arteriolelor de la nivelul degetelor \u015fi, ocazional, al altor extremit\u0103\u0163i, prag sc\u0103zut pentru aplica\u0163ii reci sau orice cauz\u0103 care activeaz\u0103 simpaticul sau eliberarea de catecolamine;<\/p>\n

– \u00cen formele severe se pot forma tromboze ale articula\u0163iilor mici care pot favoriza apari\u0163ia de necroze cu amputa\u0163ii (pierderi tisulare) la nivelul falangelor degetelor, mai rar la police;<\/p>\n

– Afecteaz\u0103 mai ales sexul feminin;<\/p>\n

– Patogenia este incert\u0103.<\/p>\n

c)<\/strong>LIMFEDEMUL PRIMAR**<\/p>\n

** – Caracterizat prin acumularea excesiv\u0103 de lichid limfatic \u015fi tumefierea \u0163esutului cutanat datorit\u0103 obstruc\u0163iei, distrugerii sau hiperplaziei vaselor limfatice;<\/p>\n

– Poate surveni la na\u015ftere, adolescen\u0163\u0103 sau mai t\u00e2rziu, pe parcursul vie\u0163ii;<\/p>\n

– Mai frecvent\u0103 la femei \u015fi de obicei unilateral;<\/p>\n

– Edem difuz cu deformarea membrului inferior sau superior \u00een fazele \u00eenaintate, f\u0103r\u0103 modific\u0103ri cutanate sau semene de insuficien\u0163\u0103 venoas\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRII FUNC\u0162IONALI<\/p>\n<\/td>\n

– Oscilometria;
\n– Ecografia intravascular\u0103;
\n– Examen Doppler;
\n– RMN;
\n– Angiografia cu substan\u0163a de contrast;
\n– Pletismografia prin impedan\u0163\u0103;
\nNB. 1. Evaluare \u00een func\u0163ie de gradul de ischemie periferic\u0103, modul de apari\u0163ie al claudica\u0163iei intermitente \u015fi intensitatea tulbur\u0103rilor ischemico-necrotice;
\n2. Evaluare dup\u0103 clasificarea Leriche-Fontaine.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Arteriopatie obliterant\u0103 std. II a \u015fi std. II b cu claudica\u0163ie intermitent\u0103 sau constric\u0163ia arterial\u0103 evaluat\u0103 prin metode de laborator (parametri func\u0163ionali).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

Arteriopatie obliterant\u0103 stadiul III cu claudica\u0163ie intermitent\u0103 \u00een repaus, dureri \u00een decubit.
\nArteriopatie obliteranta stadiul IV cu amputa\u0163ie gamb\u0103 unilateral protezat\u0103. BR cu crize vaso-spastice frecvente, cu dureri, cianoza degetelor m\u00e2inii \u015fi parestezii.
\nLimfedemul primar cu deformarea unilateral\u0103 global\u0103 a membrului inferior.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

Arteriopatie obliterant\u0103 stadiul IV cu:
\nAmputa\u0163ii de membre unilaterale sau bilaterale greu protezabile sau neprotezabile:
\n– Amputa\u0163ie de coaps\u0103 (bont mai mic de 6 cm.) greu protezabil\u0103, dezarticula\u0163ie coxo-femural\u0103;
\n– Amputa\u0163ie bilateral\u0103 a membrului pelvin de la nivelul gambelor;
\n– Amputa\u0163ie unilateral\u0103 asociat\u0103 cu anchiloze \u015fi calusuri vicioase contralateral.
\nArteriopatie obliterant\u0103 stadiul IV cu amputa\u0163ie gamb\u0103 unilateral neprotezat\u0103, cu tulbur\u0103ri trofice cutanate la membrul contralateral.
\nAngioneuropatiile primare (B.R.) forme avansate.
\nLimfedemul primar bilateral cu deformare globala a membrului inferior, cu tulbur\u0103ri de static\u0103 \u015fi mers.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

Arteriopatie obliterant\u0103 stadiul IV cu:
\n– Amputa\u0163ie a ambelor coapse (imposibilitatea realiz\u0103rii ortostatismului f\u0103r\u0103 c\u00e2rje);
\n– Lipsa prin dezarticula\u0163ie a unui membru pelvin, asociat\u0103 cu anchiloza membrului pelvin opus;
\n– Lipsa prin dezarticula\u0163ie a unui membru pelvin, asociat\u0103 cu amputa\u0163ie sau dezarticula\u0163ie de membru toracic;
\n– Amputa\u0163ia membrului toracic unilateral\u0103 cu reducerea prehensiunii contralateral;
\n– Amputa\u0163ie a ambelor membre toracice (de la diferite niveluri) cu redori str\u00e2nse ale articula\u0163iilor cu imposibilitatea realiz\u0103rii gestualit\u0103\u0163ii profesionale \u015fi uzuale.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
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 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Activit\u0103\u0163ile indicate \u015fi accesibile, ca \u015fi limit\u0103rile \u00een func\u0163ie de intensitatea deficien\u0163ei func\u0163ionale precum \u015fi restric\u0163iile \u015fi serviciile necesare pentru participare sunt prezentate la Cap 7, subcap. III – Evaluarea gradului de handicap \u00een afectarea func\u0163iilor motorii, a staticii \u015fi mobilit\u0103\u0163ii – locomo\u0163iei, sau\/\u015fi gestualit\u0103\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

SEC\u0162IUNEA 2: B. FUNC\u0162IILE SISTEMULUI HEMATOLOGIC<\/em><\/p>\n

\u00a0<\/p>\n

De re\u0163inut:<\/p>\n

– \u00cen afec\u0163iunile care evolueaz\u0103 \u00een pusee, evaluarea se va face \u00een perioadele de remisiune, lu\u00e2ndu-se \u00een considerare \u00eens\u0103, ca element important, frecven\u0163a \u015fi durata episoadelor acute (confirmate prin documente medicale).<\/p>\n

– Se va \u0163ine seama de posibilitatea tratamentului, durata acestuia, efectele produse \u015fi persisten\u0163a lor \u00een timp.<\/p>\n

– Evaluarea func\u0163ional\u0103 se face la 6 – 12 luni.<\/p>\n

– \u00cen situa\u0163ia aplic\u0103rii tratamentului citostatic, imuno-supresor \u015fi radioterapeutic, \u00een evaluare se vor avea \u00een vedere at\u00e2t efectele nefavorabile ale acestora c\u00e2t \u015fi tulb\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen psihiatric (aprecierea clinic\u0103 a intensit\u0103\u0163ii tulbur\u0103rii psihice \u015fi a prognosticului apropiat al afec\u0163iunii);<\/p>\n

– Examen psihologic: testarea a func\u0163iilor cognitive, afective, a comportamentului \u015fi a personalit\u0103\u0163ii (prin teste psihometrice \u015fi probe proiective);<\/p>\n

– Investiga\u0163ii sociale<\/p>\n<\/td>\n

\n

\u00cen forme clinice reziduale, stabilite cu pruden\u0163\u0103<\/p>\n<\/td>\n

\n

\u00cen remisiuni cu dispari\u0163ia fenomenelor delirante \u015fi halucinatorii permi\u0163\u00e2nd reluarea activit\u0103\u0163ii la un nivel inferior<\/p>\n<\/td>\n

\n

\u00cen formele catatonice, dezorganizate (hebrefrenice), paranoide, nediferen\u0163iate.<\/p>\n

NB \u00cen formele care au instituit\u0103 interdic\u0163ia, handicap grav<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie progredient\u0103 sever\u0103 a personalit\u0103\u0163ii \u015fi a comportamentului, cu poten\u0163ial antisocial<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB – De re\u0163inut:<\/p>\n

1.<\/strong>Debutul psihotic poate fi necaracteristic \u015fi, ulterior, se pune diagnosticul de afec\u0163iune psihic\u0103 major\u0103. Debutul este reprezentat de prima consulta\u0163ie avut\u0103 de pacient la un serviciu de psihiatrie (fi\u015fa de consulta\u0163ie este util\u0103).<\/p>\n

2.<\/strong>Schizofrenia, \u00een faza activ\u0103 (productiv\u0103), este caracterizat\u0103 prin:<\/p>\n

a)<\/strong>idei delirante, halucina\u0163ii, incoeren\u0163\u0103, autism, catatonie, afect plat sau evident inadecvat (discordant);<\/p>\n

b)<\/strong>idei delirante, bizare;<\/p>\n

c)<\/strong>halucina\u0163ii proeminente;<\/p>\n

d)<\/strong>\u00een timpul puseului – munca, rela\u0163iile sociale \u015fi auto\u00eengrijirea sunt afectate major;<\/p>\n

e)<\/strong>nu poate fi stabilit un factor organic care a ini\u0163iat sau men\u0163inut tulburarea.<\/p>\n

3.<\/strong>La evaluarea gradului de handicap \u00een schizofrenie se vor avea \u00een vedere:<\/p>\n

a)<\/strong>forma clinic\u0103: catatonic\u0103, hebefrenic\u0103, paranoid\u0103, nediferen\u0163iat\u0103, rezidual\u0103, simpl\u0103 \u015fi depresia post schizofrenic\u0103. Primele patru forme sunt cele mai severe \u015fi au un poten\u0163ial handicapant major;<\/p>\n

b)<\/strong>tipul de evolu\u0163ie:<\/p>\n

– subcronic\u0103 sau cronic\u0103, cu sau f\u0103r\u0103 episoade de acutizare;<\/p>\n

– \u00een remisiune (c\u00e2nd o persoan\u0103 cu schizofrenie nu mai prezint\u0103 nici un semn de tulburare);<\/p>\n

c)<\/strong>cooperarea la monitorizarea medical\u0103 \u015fi eficien\u0163a ac\u0163iunilor psihoterapeutice;<\/p>\n

d)<\/strong>climatul familial \u015fi socioprofesional.<\/p>\n

4.<\/strong>La evaluarea gradului de handicap \u00een psihozele afective se va avea \u00een vedere:<\/p>\n

– mania cronicizat\u0103, formele bipolare, ciclotimia rapid\u0103, depresia sever\u0103 cronic\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Pot presta activit\u0103\u0163i \u00een condi\u0163ii de confort psihic \u015fi fizic din punct de vedere al ambian\u0163ei rela\u0163ionale \u015fi materiale.<\/p>\n

– Sunt contraindicate activit\u0103\u0163ile care implic\u0103 suprasolicitare psihica, stresante \u015fi cu responsabilitate ridicat\u0103.<\/p>\n<\/td>\n

\n

– Sprijin pentru men\u0163inerea \u00een activitate – activit\u0103\u0163i organizate, accesibile;<\/p>\n

– Monitorizarea medico-psihosocial\u0103 la serviciul teritorial de psihiatrie.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Pot desf\u0103\u015fura activit\u0103\u0163i, cu program integral sau par\u0163ial, \u00een acela\u015fi loc de munc\u0103. Schimbarea locului de munc\u0103 se va face numai dac\u0103 acesta este corespunz\u0103tor din punctele de vedere ale solicit\u0103rii psihice \u015fi al rela\u0163iilor interpersonale;<\/p>\n

– Evitarea profesiunilor cu risc de acutizare a tulbur\u0103rii.<\/p>\n<\/td>\n

\n

– Sprijin pentru men\u0163inere \u00een acela\u015fi loc de munc\u0103 sau pentru eventuala schimbare a locului de munc\u0103;<\/p>\n

– Facilitarea rela\u0163ion\u0103rii interpersonale \u00een colectivul de lucru;<\/p>\n

– Sprijin pentru monitorizarea medico-psiho-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Nu pot desf\u0103\u015fura activit\u0103\u0163i profesionale organizate, indiferent de natura \u015fi nivelul de solicitare;<\/p>\n

– Eventual activit\u0103\u0163i \u00een sec\u0163ii de ergoterapie-terapie ocupa\u0163ional\u0103, cu rol psihoterapeutic;<\/p>\n

– Au afectata par\u0163ial capacitatea de autodeterminare \u015fi autoservire;<\/p>\n

– Nu necesit\u0103 supraveghere permanent\u0103 din partea altei persoane.<\/p>\n<\/td>\n

\n

– Sprijin familial pentru respectarea tratamentului de specialitate, cooperare la activit\u0103\u0163ile de psihoterapie sau\/\u015fi terapie ocupa\u0163ional\u0103;<\/p>\n

– Asigurarea unui climat comunitar \u015fi familial de \u00een\u0163elegere, sprijin, f\u0103r\u0103 factori stresan\u0163i psihoafectivi.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Au pierdut\u0103 capacitatea de autodeterminare, autoservire, auto\u00eengrijire.<\/p>\n<\/td>\n

\n

– Monitorizare medico-psiho-social\u0103 permanent\u0103.<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n

– Necesit\u0103 servicii specializate.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/h3>\n

CAPITOLUL<\/strong>\u00a02:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0SENZORIALE<\/strong><\/p>\n

\u00a0<\/h5>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR VEDERII*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Acuitatea vizual\u0103<\/p>\n

(calitatea vederii) mono-binocular\u0103 (cu cea mai bun\u0103 corec\u0163ie, la ochiul cel mai bun)<\/p>\n

Refractrometrie ocular\u0103 (autorefractometru dioptron)<\/p>\n<\/td>\n

\n

1\/2 = 0,5 – 1\/3 = 0,3 (2\/3, 1\/2, 1\/3)<\/p>\n<\/td>\n

\n

VAO \u00eentre 1\/4 (0,25)-1\/10 (0,1)<\/p>\n<\/td>\n

\n

VAO \u00eentre 1\/12 = 0,08 (4m) – 1\/25 = 0,04 (2m)<\/p>\n<\/td>\n

\n

VAO sub 1\/25 < 0,04 (2m) cecitate relativ\u0103<\/p>\n

VAO = pmm pl, fpl = cecitate absolut\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

– C\u00e2mp vizual (manual) la ochiul cel mai bun<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Redus concentric \u00een jurul punctului de fixa\u0163ie la 30 -40 grade<\/p>\n<\/td>\n

\n

Redus concentric \u00een jurul punctului de fixa\u0163ie la 10 – 30 grade<\/p>\n<\/td>\n

\n

Tubular, \u00een jurul punctului de fixa\u0163ie (0 – 10 grade)<\/p>\n<\/td>\n<\/tr>\n

\n

– C\u00e2mp vizual computerizat **<\/p>\n<\/td>\n

\n

\u00cen func\u0163ie de structura ocular\u0103 afectat\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

– Percep\u0163ia luminii la stimuli vizuali***<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

– Poten\u0163iale vizuale evocate (PEV)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Poten\u0163iale modificate<\/p>\n<\/td>\n

\n

Lips\u0103 percep\u0163ie luminoas\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

– Electroretinograma (ERG)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

Retina \u00eenc\u0103 func\u0163ional\u0103<\/p>\n<\/td>\n

\n

Traseu stins (retina nefunc\u0163ional\u0103)<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen afec\u0163iunile cronice primar \u015fi secundar oculare, inflamatorii, heredodegenerative, degenerative, traumatice, tumorale, vasculare cu evolu\u0163ie cronic\u0103-progresiv\u0103 sub tratament specific sau cu sechele morfofunc\u0163ionale handicapante.<\/p>\n

Cataract\u0103 cu indica\u0163ie chirurgical\u0103 va fi evaluat\u0103 dup\u0103 interven\u0163ia operatorie.<\/p>\n

Vicii de refrac\u0163ie, de acomodare, nistagmusul.<\/p>\n

** C\u00e2mpul vizual computerizat ofer\u0103 rela\u0163ii privind sensibilitatea retinei cu modific\u0103ri specifice structurii func\u0163iilor vizuale afectate efectiv (are programe prestabilite \u00een func\u0163ie de diagnosticul clinic).<\/p>\n

*** PEV \u015fi ERG utilizate \u00een aprecierea st\u0103rii func\u0163ionale a retinei (teste obiective).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice profesie<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Profesiuni care nu comport\u0103 periclitate oculara sau suprasolicitare vizual\u0103.<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Limit\u0103ri \u00een orientarea spa\u0163ial\u0103, \u00een acomodarea la trecerea de la lumin\u0103 la \u00eentuneric \u015fi invers;<\/p>\n

– Profesiuni care nu comport\u0103 periclitate ocular\u0103 sau suprasolicitare ocular\u0103.<\/p>\n<\/td>\n

\n

– Asigurarea de lupe m\u0103ritoare pentru reperele prelucrate;<\/p>\n

– Afi\u015farea cu litere mari a instruc\u0163iunilor de munc\u0103 \u015fi de protec\u0163ia a muncii;<\/p>\n

– Iluminat mai puternic compensator.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Dificult\u0103\u0163i majore de orientare \u00een spa\u0163iu.<\/p>\n

– Pot desf\u0103\u015fura activit\u0103\u0163i lucrative<\/p>\n<\/td>\n

\n

– Marcarea drumului de acces spre locul de munc\u0103;<\/p>\n

– Schimbarea sistemului de alarm\u0103;<\/p>\n

– Ajustarea ambian\u0163ei luminoase;<\/p>\n

– Loc de munc\u0103 protejat pentru reg\u0103sirea materiei prime \u015fi a uneltelor, eventual cu jalonarea drumului m\u00e2inii;<\/p>\n

– Montarea de ap\u0103r\u0103toare \u00een zonele periculoase pentru munc\u0103;<\/p>\n

– Informarea \u00een munc\u0103 s\u0103 se fac\u0103 verbal sau \u00een Braille;<\/p>\n

– Necesit\u0103 ajutor regulat.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR AUZULUI*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI<\/p>\n

FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

F\u0102R\u0102 DEFICIEN\u0162\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

INFIRMITATE<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Audiometrie (subiectiv\u0103 – liminar\u0103 sau supraliminar\u0103 sau audiometrie vocal\u0103 \u015fi obiectiv\u0103 cu poten\u0163iale evocate), impedansmetrie \u015fi otoemisiuni acustice<\/p>\n<\/td>\n

\n

Sc\u0103derea sau abolirea unilateral\u0103 a auzului<\/p>\n

Tulbur\u0103ri de auz bilaterale cu pierdere \u00eentre 0 – 20 dB<\/p>\n<\/td>\n

\n

Pierdere auditiv\u0103 bilateral\u0103 \u00eentre 20 – 40 dB<\/p>\n<\/td>\n

\n

Pierdere auditiv\u0103 bilateral\u0103 \u00eentre 41 – 70 dB protezabil\u0103<\/p>\n<\/td>\n

\n

– Pierderea auditiv\u0103 peste 70 dB care se protezeaz\u0103 greu asociat\u0103 cu tulbur\u0103ri psihice \u015fi de limbaj;<\/p>\n

– Surditate congenital\u0103 sau dob\u00e2ndit\u0103 \u00eenaintea achizi\u0163ion\u0103rii limbajului \u00eenso\u0163it\u0103 de mutitate (surdocecitate cu demutizare slab\u0103\/nul\u0103), cu pierdere peste 90 dB (cofoz\u0103)<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen afec\u0163iunile cronice auditive de cauz\u0103 divers\u0103: inflamatorie, infec\u0163ioas\u0103, toxic\u0103, vascular\u0103, heredodegenerativ\u0103, traumatic\u0103, tumoral\u0103 – congenitale sau dob\u00e2ndite precoce (copil\u0103rie\/adolescen\u0163\u0103) \u00eenso\u0163ite de hipoacuzie (tip transmisie, neurosenzorial\u0103, mixt\u0103), protezabile sau neprotezabile sau cu surditate (cofoza), cu sau f\u0103r\u0103 tulbur\u0103ri de comunicare (surdomutitate-surdocecitate).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Acces la majoritatea locurilor de munc\u0103, cu condi\u0163ia evit\u0103rii activit\u0103\u0163ilor de comunicare cu publicul.<\/p>\n<\/td>\n

\n

Asigurarea unor sisteme optice de semnalizare \u00eenlocuindu-le pe cele sonore, at\u00e2t \u00een scopul protec\u0163iei muncii, c\u00e2t \u015fi de asigurare a unui flux tehnologic normal, cu preluarea sarcinilor de supraveghere.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

III.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR VESTIBULARE*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI<\/p>\n

FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV*<\/p>\n<\/td>\n<\/tr>\n

\n

Evaluarea reflexelor:<\/p>\n

– vestibulo-ocular (electronistagmografie);<\/p>\n

– vestibulo-spinal (posturo-grafie dinamic\u0103 computerizat\u0103 \u015fi cranio-corpo-grafie)<\/p>\n<\/td>\n

\n

Diferen\u0163e func\u0163ionale la probele provocate \u00eentre cele 2 vestibule de cel pu\u0163in 20%<\/p>\n

Hipo\/hiper excitabilitate vestibular\u0103 bilateral\u0103<\/p>\n<\/td>\n

\n

Diferen\u0163a \u00eentre cele doua vestibule la probele provocate dep\u0103\u015fe\u015fte 30% (nistagmus spontan sau devia\u0163ii nete)<\/p>\n<\/td>\n

\n

Ortostatismul este posibil dar dificil de men\u0163inut, nistagmus spontan, diferen\u0163a mare \u00eentre vestibule (tulbur\u0103ri calitative ale traseului electronistagmografic), tulbur\u0103ri func\u0163ionale echivalente cu 60-80%<\/p>\n<\/td>\n

\n

Ortostatismul este imposibil \u00een criz\u0103, \u00eenso\u0163it de tulbur\u0103ri vegetative.<\/p>\n

Probele spontane \u015fi provocate(dac\u0103 se pot practica) sunt net pozitive.<\/p>\n

Tulbur\u0103ri func\u0163ionale echivalente cu 80-100%*<\/p>\n

Pentru perioade limitate de 6-12 luni, \u00een func\u0163ie de durata \u015fi reversibilitatea tulbur\u0103rilor majore de echilibru la ac\u0163iunile de recuperare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen afec\u0163iunile cronice vestibulare, precum \u015fi a c\u0103ilor acestora, congenitale sau contractate precoce.<\/p>\n

NB: \u00cen general tulbur\u0103rile vestibulare periferice au un caracter pasager, tranzitoriu.<\/p>\n

Tulbur\u0103rile de echilibru survin c\u00e2nd exist\u0103 o diferen\u0163\u0103 func\u0163ional\u0103 mai mare de 20 – 30 % \u00eentre cele dou\u0103 vestibule.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

Restric\u0163ie pentru activit\u0103\u0163ile care se desf\u0103\u015foar\u0103 la \u00een\u0103l\u0163ime<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Locuri de munc\u0103 – f\u0103r\u0103 suprasolicitare postural\u0103 \u015fi deplas\u0103ri posturale de durat\u0103 sau care impun alternan\u0163a rapid\u0103 \u00een variantele posturale;<\/p>\n

– Sunt accesibile, \u00een general, muncile statice, activit\u0103\u0163ile de birou\/me\u015fte\u015fug\u0103re\u015fti.<\/p>\n<\/td>\n

\n

Adaptarea locului de munc\u0103, astfel \u00eenc\u00e2t s\u0103 nu fie suprasolicitat\u0103 postura ortostatic\u0103 sau s\u0103 o faciliteze prin mijloace suplimentare de sprijin, scaune adaptate, etc.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Sprijin pentru autoservire, \u00eengrijire \u015fi autogospod\u0103rire \u00een activit\u0103\u0163ile de baz\u0103 ale vie\u0163ii de zi cu zi.<\/p>\n

– Pentru perioada \u00een care ortostatismul \u015fi mobilizarea nu se pot realiza.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asisten\u0163\u0103 de specialitate.<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a03:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0FONATORII<\/strong>\u00a0\u015eI<\/strong>\u00a0DE<\/strong>\u00a0COMUNICARE<\/strong>\u00a0VERBAL\u0102<\/strong><\/p>\n

\u00a0<\/p>\n

EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA VOCII*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen ORL<\/p>\n

– Examen laringoscopic<\/p>\n

– Examen histopatologic<\/p>\n

– Probe ventilatori<\/p>\n

– Anchet\u0103<\/p>\n<\/td>\n

\n

– Disfonie izolat\u0103 (r\u0103gu\u015feal\u0103);<\/p>\n

– Voce bitonal\u0103 (parez\u0103 coard\u0103 vocal\u0103 – recuren\u0163ial\u0103, unilateral\u0103)<\/p>\n<\/td>\n

\n

Diplegie recuren\u0163ial\u0103 \u00een pozi\u0163ie de abduc\u0163ie sau aduc\u0163ie (cu p\u0103strarea vocii dar cu tulbur\u0103ri de respira\u0163ie), \u00een func\u0163ie \u015fi de specificul profesiunii (profesioni\u015fti ai vocii)<\/p>\n<\/td>\n

\n

– Traheostom\u0103 permanent\u0103 f\u0103r\u0103 laringectomie.<\/p>\n

– Traheostom\u0103 cu laringectomie, determinat\u0103 de procese maligne sau zdrobirea laringelui.<\/p>\n

– Abla\u0163ia laringelui cu traheostom\u0103 permanent\u0103 \u015fi lipsa crigmofonatiei, cu tulbur\u0103ri de vorbire, de ventila\u0163ie \u015fi, eventual, de nutri\u0163ie, \u0163in\u00e2nd seama de cauza care a determinat afectarea structural\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Se refer\u0103 la tulbur\u0103rile fonatorii determinate de afectarea laringelui, cauzate de:<\/p>\n

– stenoze post traumatice,<\/p>\n

– pareze sau paralizii (corzi vocale – n. recuren\u0163iali),<\/p>\n

– procese tumorale benigne, maligne,<\/p>\n

– procese inflamatorii cronice, trenante sau repetitive.<\/p>\n

Func\u0163ia fonatorie poate fi tulburat\u0103 \u00eencep\u00e2nd cu cavitatea bucal\u0103 (stomatolalie) \u015fi p\u00e2n\u0103 la organul fonator principal, laringele, sub form\u0103 de:<\/p>\n

– voce bitonal\u0103 \u00een paralizie recuren\u0163ial\u0103,<\/p>\n

– disfonie prin forma\u0163iuni tumorale,<\/p>\n

– afonie consecutiv\u0103 abla\u0163iei laringelui.<\/p>\n

Cuantificarea tulbur\u0103rilor fonatorii se face \u00een raport de inteligibilitatea vocii de la u\u015foar\u0103 \u015fi p\u00e2n\u0103 la accentuat\u0103, c\u00e2nd este vorba de afonie.<\/p>\n

\u00cen stabilirea gradului de handicap se vor avea \u00een vedere \u015fi:<\/p>\n

– specificul profesiei (profesioni\u015fti ai vocii),<\/p>\n

– efectul terapiei,<\/p>\n

– eventualele recidive (nodului corzi vocale, polipi – recidive tumorale benigne sau malign\u0103).<\/p>\n

NB Func\u0163iile mentale ale limbajului, de articulare, tulbur\u0103rile de limbaj vorbit – mutitatea, limbaj slab cu toate \u00eencerc\u0103rile de reeducare (labiolectura) sunt prev\u0103zute la capitolele respective.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI*<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I*<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 f\u0103r\u0103 suprasolicitare fizic\u0103 mare, \u00een condi\u0163ii de microclimat adecvat, f\u0103r\u0103 varia\u0163ii termice, mediu prea rece sau prea cald sau uscat, f\u0103r\u0103 curen\u0163i de aer, umezeal\u0103.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 cu solicitare redus\u0103, \u00een condi\u0163ii de microclimat, f\u0103r\u0103 varia\u0163ii termice, curen\u0163i de aer, prea umed.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 f\u0103r\u0103 suprasolicitare fizic\u0103 mare, \u00een condi\u0163ii de microclimat adecvat, f\u0103r\u0103 varia\u0163ii termice, mediu prea rece sau prea cald sau uscat, f\u0103r\u0103 curen\u0163i de aer, umezeal\u0103. Pentru profesioni\u015fti ai vocii (profesori, avoca\u0163i, soli\u015fti, c\u00e2nt\u0103re\u0163i vocali s.a.), schimbarea locului de munc\u0103 f\u0103r\u0103 solicitarea vocei, \u00een condi\u0163ii favorabile de microclimat – condi\u0163ii ambientale la locul de munc\u0103 sau profesiei.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 cu solicitare redus\u0103 \u00een condi\u0163ii de microclimat, f\u0103r\u0103 varia\u0163ii termice, curen\u0163i de aer, prea umed. Monitorizare medical\u0103 la serviciul de ORL, tratament adecvat.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Au capacitatea de autoservire \u015fi auto\u00eengrijire conservate.<\/p>\n<\/td>\n

\n

Monitorizare medico-psiho-social\u0103 la serviciul ORL, de logopedie, \u015fi psihologie teritorial\u0103. Sprijin familial \u015fi eventual comunitar pentru unele activit\u0103\u0163i (de autogospod\u0103rire).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen principiu, afectarea vocii pentru anumite profesii \u015fi locuri de munc\u0103 poate fi hot\u0103r\u00e2toare, \u00een timp ce, \u00een altele, unde nu exist\u0103 mesaj vorbit, munca se poate desf\u0103\u015fura normal.<\/p>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a04:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0SISTEMULUI<\/strong>\u00a0CARDIOVASCULAR,<\/strong>\u00a0HEMATOLOGIC,<\/strong>\u00a0IMUNITAR<\/strong>\u00a0\u015eI<\/strong>\u00a0RESPIRATOR<\/strong><\/p>\n

SEC\u0162IUNEA 1: A. FUNC\u0162IILE SISTEMULUI CARDIOVASCULAR<\/em><\/p>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR INIMII*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– EKG de repaus;<\/p>\n

– Test de toleran\u0163\u0103 la efort (TTE);<\/p>\n

– Ecografie bidimensional\u0103, ecografie Doppler;<\/p>\n

Cateterism cardiac, angiografie<\/p>\n

– Monitorizare tensiune arterial\u0103 (TA)<\/p>\n

– Examen fund de ochi (FO).<\/p>\n<\/td>\n

\n

IC Nyha I<\/p>\n<\/td>\n

\n

IC Nyha II<\/p>\n<\/td>\n

\n

IC Nyha III<\/p>\n<\/td>\n

\n

IC Nyha IV<\/p>\n<\/td>\n<\/tr>\n

\n

– Persoana este asimptomatic\u0103 \u00een timpul activit\u0103\u0163ii uzuale sau\/\u015fi profesionale;<\/p>\n

– Tulbur\u0103ri de ritm \u015fi conducere minore, influen\u0163ate de tratamentul specific.<\/p>\n<\/td>\n

\n

– Persoana este asimptomatic\u0103 \u00een condi\u0163ii de repaus, efectueaz\u0103 activit\u0103\u0163i zilnice uzuale, dar nu poate face eforturi fizice prelungite;<\/p>\n

– Tulbur\u0103ri de ritm sau\/\u015fi de conducere repetitive care necesit\u0103 tratament sus\u0163inut continuu la care toleran\u0163a de efort este limitat\u0103 de apari\u0163ia tulbur\u0103rilor func\u0163ionale la eforturi de intensitate mare sau medie.<\/p>\n<\/td>\n

\n

– Persoana prezint\u0103 simptome limitatoare de prestare a activit\u0103\u0163ii zilnice de \u00eentre\u0163inere, prezint\u0103 semne de ICC corectabile sub tratament;<\/p>\n

– Cardiostimulare eficient\u0103 cu tulbur\u0103ri func\u0163ionale la eforturi mici, chiar \u015fi \u00een repaus;<\/p>\n

– Aritmii ES ce nu pot fi controlate prin tratament \u015fi induc tulbur\u0103ri hemodinamice manifeste accentuate \u00een efort.<\/p>\n<\/td>\n

\n

– Persoana este simptomatic\u0103 \u00een repaus, apar semne de ICC, gradul de afectare cardiac\u0103 \u00eentre 85-100%, ireversibil\u0103 la tratament;<\/p>\n

– Tulbur\u0103ri de ritm \u015fi de conducere grave, neinfluen\u0163ate de tratament<\/p>\n

– Cardiostimulare ineficient\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*1.\u00cen afectarea primar\u0103 a func\u0163iei contractile a inimii:<\/p>\n

– Cardiomiopatiile primare, primitive sau idiopatice:<\/p>\n

– CMP dilatativ\u0103 sau congestive,<\/p>\n

– CMP hipertrofic\u0103 sau obstructive,<\/p>\n

– CMP restrictiv\u0103 sau obliterant\u0103,<\/p>\n

2.\u00cen afectarea secundara a func\u0163iei contractile a inimii:<\/p>\n

– Angiopatii congenitale cianogene sau necianogene operate sau neoperate cu insuficien\u0163\u0103 cardiac\u0103 cronic\u0103 clinic manifestat\u0103:<\/p>\n

– DSA, DSV, Coarcta\u0163ie aort\u0103 Stenoz\u0103 de aort\u0103, Stenoz\u0103 de arter\u0103 pulmonar\u0103 asociat\u0103 cu DSV,<\/p>\n

– Tetralogia Fallot, transpozi\u0163ii de vase mari,<\/p>\n

– Atrezia de tricuspid\u0103, anomalia Ebstein.<\/p>\n

– Valvulopatii: de etiologie divers\u0103, complicate sau decompensate neoperate sau operate (protezate), contractate precoce.<\/p>\n

3.\u00cen afectarea ritmului \u015fi conducerii cardiace:<\/p>\n

– Tulbur\u0103ri de ritm \u015fi de conducere persistente \u015fi severe contractate precoce<\/p>\n

(purt\u0103tor de pacemaker).<\/p>\n

4.Complica\u0163ii post-transplant cardiac.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 care nu necesit\u0103 efort fizic mare.<\/p>\n<\/td>\n

\n

Nu se pot adapta la efort fizic de intensitate mare \u015fi durat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Limitarea capacit\u0103\u0163ii de adaptare la efort fizic (profesional \u015fi casnic)<\/p>\n<\/td>\n

\n

M\u0103suri de adaptare a utilajelor pentru reducerea efortului fizic necesar, evitarea pozi\u0163iei for\u0163ate \u00een munc\u0103, deplas\u0103rii posturale pe distan\u0163e mari pe plan \u00eenclinat, urcarea de sc\u0103ri.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Limitare major\u0103 a capacit\u0103\u0163ii de auto\u00eengrijire \u015fi autogospod\u0103rire, de men\u0163inere a st\u0103rii de s\u0103n\u0103tate, de comunicare \u015fi participare la via\u0163a de familie.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Necesit\u0103 servicii specializate.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR ARTERELOR LEGATE DE FLUXUL SANGUIN<\/u><\/p>\n

a)<\/strong>CONSTRIC\u0162IA \u015eI\/SAU OBSTRUC\u0162IA ARTERIAL\u0102 (ARTERIOPATII OBLITERANTE – TROMBANGIOPATII OBLITERANTE – BOAL\u0102 BURGER<\/p>\n

b)<\/strong>ANGINEUROPATII PRIMARE (BOAL\u0102 RAYNAUD)*<\/p>\n

* – Caracterizate prin spasm al arteriolelor de la nivelul degetelor \u015fi, ocazional, al altor extremit\u0103\u0163i, prag sc\u0103zut pentru aplica\u0163ii reci sau orice cauz\u0103 care activeaz\u0103 simpaticul sau eliberarea de catecolamine;<\/p>\n

– \u00cen formele severe se pot forma tromboze ale articula\u0163iilor mici care pot favoriza apari\u0163ia de necroze cu amputa\u0163ii (pierderi tisulare) la nivelul falangelor degetelor, mai rar la police;<\/p>\n

– Afecteaz\u0103 mai ales sexul feminin;<\/p>\n

– Patogenia este incert\u0103.<\/p>\n

c)<\/strong>LIMFEDEMUL PRIMAR**<\/p>\n

** – Caracterizat prin acumularea excesiv\u0103 de lichid limfatic \u015fi tumefierea \u0163esutului cutanat datorit\u0103 obstruc\u0163iei, distrugerii sau hiperplaziei vaselor limfatice;<\/p>\n

– Poate surveni la na\u015ftere, adolescen\u0163\u0103 sau mai t\u00e2rziu, pe parcursul vie\u0163ii;<\/p>\n

– Mai frecvent\u0103 la femei \u015fi de obicei unilateral;<\/p>\n

– Edem difuz cu deformarea membrului inferior sau superior \u00een fazele \u00eenaintate, f\u0103r\u0103 modific\u0103ri cutanate sau semene de insuficien\u0163\u0103 venoas\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRII FUNC\u0162IONALI<\/p>\n<\/td>\n

– Oscilometria;
\n– Ecografia intravascular\u0103;
\n– Examen Doppler;
\n– RMN;
\n– Angiografia cu substan\u0163a de contrast;
\n– Pletismografia prin impedan\u0163\u0103;
\nNB. 1. Evaluare \u00een func\u0163ie de gradul de ischemie periferic\u0103, modul de apari\u0163ie al claudica\u0163iei intermitente \u015fi intensitatea tulbur\u0103rilor ischemico-necrotice;
\n2. Evaluare dup\u0103 clasificarea Leriche-Fontaine.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Arteriopatie obliterant\u0103 std. II a \u015fi std. II b cu claudica\u0163ie intermitent\u0103 sau constric\u0163ia arterial\u0103 evaluat\u0103 prin metode de laborator (parametri func\u0163ionali).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

Arteriopatie obliterant\u0103 stadiul III cu claudica\u0163ie intermitent\u0103 \u00een repaus, dureri \u00een decubit.
\nArteriopatie obliteranta stadiul IV cu amputa\u0163ie gamb\u0103 unilateral protezat\u0103. BR cu crize vaso-spastice frecvente, cu dureri, cianoza degetelor m\u00e2inii \u015fi parestezii.
\nLimfedemul primar cu deformarea unilateral\u0103 global\u0103 a membrului inferior.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

Arteriopatie obliterant\u0103 stadiul IV cu:
\nAmputa\u0163ii de membre unilaterale sau bilaterale greu protezabile sau neprotezabile:
\n– Amputa\u0163ie de coaps\u0103 (bont mai mic de 6 cm.) greu protezabil\u0103, dezarticula\u0163ie coxo-femural\u0103;
\n– Amputa\u0163ie bilateral\u0103 a membrului pelvin de la nivelul gambelor;
\n– Amputa\u0163ie unilateral\u0103 asociat\u0103 cu anchiloze \u015fi calusuri vicioase contralateral.
\nArteriopatie obliterant\u0103 stadiul IV cu amputa\u0163ie gamb\u0103 unilateral neprotezat\u0103, cu tulbur\u0103ri trofice cutanate la membrul contralateral.
\nAngioneuropatiile primare (B.R.) forme avansate.
\nLimfedemul primar bilateral cu deformare globala a membrului inferior, cu tulbur\u0103ri de static\u0103 \u015fi mers.<\/td>\n<\/tr>\n
\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

Arteriopatie obliterant\u0103 stadiul IV cu:
\n– Amputa\u0163ie a ambelor coapse (imposibilitatea realiz\u0103rii ortostatismului f\u0103r\u0103 c\u00e2rje);
\n– Lipsa prin dezarticula\u0163ie a unui membru pelvin, asociat\u0103 cu anchiloza membrului pelvin opus;
\n– Lipsa prin dezarticula\u0163ie a unui membru pelvin, asociat\u0103 cu amputa\u0163ie sau dezarticula\u0163ie de membru toracic;
\n– Amputa\u0163ia membrului toracic unilateral\u0103 cu reducerea prehensiunii contralateral;
\n– Amputa\u0163ie a ambelor membre toracice (de la diferite niveluri) cu redori str\u00e2nse ale articula\u0163iilor cu imposibilitatea realiz\u0103rii gestualit\u0103\u0163ii profesionale \u015fi uzuale.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Activit\u0103\u0163ile indicate \u015fi accesibile, ca \u015fi limit\u0103rile \u00een func\u0163ie de intensitatea deficien\u0163ei func\u0163ionale precum \u015fi restric\u0163iile \u015fi serviciile necesare pentru participare sunt prezentate la Cap 7, subcap. III – Evaluarea gradului de handicap \u00een afectarea func\u0163iilor motorii, a staticii \u015fi mobilit\u0103\u0163ii – locomo\u0163iei, sau\/\u015fi gestualit\u0103\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

SEC\u0162IUNEA 2: B. FUNC\u0162IILE SISTEMULUI HEMATOLOGIC<\/em><\/p>\n

\u00a0<\/p>\n

De re\u0163inut:<\/p>\n

– \u00cen afec\u0163iunile care evolueaz\u0103 \u00een pusee, evaluarea se va face \u00een perioadele de remisiune, lu\u00e2ndu-se \u00een considerare \u00eens\u0103, ca element important, frecven\u0163a \u015fi durata episoadelor acute (confirmate prin documente medicale).<\/p>\n

– Se va \u0163ine seama de posibilitatea tratamentului, durata acestuia, efectele produse \u015fi persisten\u0163a lor \u00een timp.<\/p>\n

– Evaluarea func\u0163ional\u0103 se face la 6 – 12 luni.<\/p>\n

– \u00cen situa\u0163ia aplic\u0103rii tratamentului citostatic, imuno-supresor \u015fi radioterapeutic, \u00een evaluare se vor avea \u00een vedere at\u00e2t efectele nefavorabile ale acestora c\u00e2t \u015fi tulbur\u0103rile func\u0163ionale determinate de afec\u0163iunea hematologic\u0103 propriu-zis\u0103.<\/p>\n

– \u00cen caz de transplant de m\u0103duv\u0103 osoas\u0103, evaluarea se va face la 6 luni de la realizarea transplantului.<\/p>\n

\u00a0<\/p>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN ANOMALII ALE CELULELOR HEMATOPOETICE (FUNC\u0162IILOR DE PRODUCERE A S\u00c2NGELUI \u015eI ALE M\u0102DUVEI OSOASE)*<\/u><\/p>\n

\u00a0<\/p>\n

*1.Leucemii acute<\/p>\n

2.Leucemia granulocitar\u0103 cronic\u0103<\/p>\n

3.Leucemia limfoid\u0103 cronic\u0103<\/p>\n

4.Policitemia vera (Boala Vaquez)<\/p>\n

5.Trombocitemia hemoragic\u0103<\/p>\n

6.Mielofibroza cu metaplazie medular\u0103<\/p>\n

7.Sindromul mielo-displazic<\/p>\n

8.Anemiile aplastice<\/p>\n

1.<\/strong>Leucemii acute**<\/p>\n

**a)Proliferare malign\u0103 a celulelor hematopoetice, caracterizat\u0103 prin oprirea lor \u00een diferen\u0163iere \u015fi matura\u0163ie, asociat\u0103 sau nu cu trecerea celulelor blastice \u00een s\u00e2ngele periferic.<\/p>\n

Caracterul esen\u0163ial (major) de diagnostic = prezen\u0163a de celule blastice peste 30% din totalul celulelor medulare la punc\u0163ie sau biopsie osoas\u0103.<\/p>\n

b)Intensitatea deficien\u0163ei func\u0163ionale este determinat\u0103 de caracterul malign al bolii, de anemia \u00eenso\u0163itoare, de hemoragii, de infec\u0163ii, precum \u015fi de alte complica\u0163ii ca: meningita leucemic\u0103, infiltrate craniene, pulmonare sau nefropatia uric\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– hemoleucograma complet\u0103<\/p>\n

– frotiu de s\u00e2nge periferic<\/p>\n

– mielogram\u0103<\/p>\n

– acid uric<\/p>\n

– creatinin\u0103<\/p>\n

– computer tomograf<\/p>\n

– lichid cefalorahidian (LCR)<\/p>\n

– transaminaze<\/p>\n<\/td>\n

\n

\u00cen remisiunile durabile de 4-5 ani, sub rezerva verific\u0103rilor func\u0163ionale, anual<\/p>\n<\/td>\n

\n

\u00cen remisiunile durabile sub 4-5 ani<\/p>\n<\/td>\n

\n

– Afec\u0163iune evolutiv\u0103 cu complica\u0163ii \u015fi r\u0103spuns nesatisf\u0103c\u0103tor la tratament.<\/p>\n

– Rec\u0103dere dup\u0103 3-4 ani (rec\u0103dere rezistent\u0103 la tratament).<\/p>\n<\/td>\n

\n

\u00cen formele accentuate care determin\u0103 imobilizarea \u015fi pierderea capacit\u0103\u0163ii de autoservire, prin complica\u0163ii grave, ireversibile<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Leucemia granulocitar\u0103 cronic\u0103*<\/p>\n

*a)Afec\u0163iune neoplazic\u0103 hematologic\u0103 din grupa bolilor mieloproliferative cronice, caracterizat\u0103 prin cre\u015fterea excesiv\u0103 a granulocitelor;<\/p>\n

b)Are o evolu\u0163ie medie de 4 ani, dar supravie\u0163uirea poate atinge 15-20 de ani;<\/p>\n

c)Remisiunile \u00een faza cronic\u0103 produse de tratament, au durate de luni \u015fi ani;<\/p>\n

d)Deficien\u0163a este determinat\u0103 de caracterul malign, de complica\u0163ii (hipersplenism, splin\u0103 tumoral\u0103 cu fenomene de compresiune abdominal\u0103, infarcte splenice, hemoragii, infec\u0163ii s.a.)<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Clinic:<\/p>\n

– splenomegalie;<\/p>\n

– hepatomegalie (u\u015foar\u0103);<\/p>\n

– dureri osoase.<\/p>\n

– Paraclinic:<\/p>\n

– hemoleucogram\u0103: leucocitoz\u0103 marcat\u0103 cu deviere la st\u00e2nga<\/p>\n

– anemie \u00een grad variabil;<\/p>\n

– mielogram\u0103: m\u0103duv\u0103 hiperplazic\u0103, predomin\u00e2nd granulocitar\u0103;<\/p>\n

– acid uric, creatinin\u0103;<\/p>\n

– ecografie renal\u0103 (abdominal\u0103)<\/p>\n

– examen citogenetic.<\/p>\n<\/td>\n

\n

\u00cen formele u\u015foare cu remisiuni de lung\u0103 durat\u0103, clinice \u015fi citologice.<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie lent\u0103, cu remisiuni trec\u0103toare dar repetate, cu complica\u0163ii moderate (litiaz\u0103 renal\u0103)<\/p>\n<\/td>\n

\n

\u00cen faze accentuate \u015fi de metamorfozare blastic\u0103 cu complica\u0163ii severe, leucocitoz\u0103 care nu r\u0103spunde la tratament<\/p>\n<\/td>\n

\n

\u00cen faza blastic\u0103 (final\u0103) – ca \u00een leucemiile acute<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Leucemia limfatic\u0103 cronic\u0103*<\/p>\n

*Este o afec\u0163iune primar\u0103 a \u0163esutului limfatic \u00een care se produce acumularea \u015fi proliferarea unei clone maligne de limfocite blocate \u00een matura\u0163ie.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– Clinic:<\/p>\n

– transpira\u0163ii nocturne,<\/p>\n

– astenie fizic\u0103,<\/p>\n

– sc\u0103dere ponderal\u0103,<\/p>\n

– adenopatii,<\/p>\n

– hepato-splenomegalie.<\/p>\n

– Paraclinic:<\/p>\n

– hemoleucogram\u0103: limfocitoz\u0103 > 30.000 mmc<\/p>\n

– mielogram\u0103: infiltra\u0163ii limfocitare \u00een m\u0103duva osoas\u0103 ce dep\u0103\u015fesc 30% (criteriu major),<\/p>\n

– electroforeza proteine \u015fi test Coombs.<\/p>\n<\/td>\n

\n

\u00cen stadiul 0 sau I, c\u00e2nd apar adenopatii, evolu\u0163ie sta\u0163ionar\u0103 pe timp \u00eendelungat, r\u0103spuns favorabil la tratament.<\/p>\n<\/td>\n

\n

\u00cen stadiul II, c\u00e2nd apare hepatomegalia sau\/\u015fi splenomegalia cu remisiuni de minimum 3 ani sub tratament.<\/p>\n<\/td>\n

\n

\u00cen leucemia limfatic\u0103 cronic\u0103 stadiul III \u015fi IV cu anemie < 11 gr% Hb, hematocrit sub 33%, trombocitopenie (sub 100.000 mmc), cu r\u0103spuns terapeutic slab \u015fi prognostic nefavorabil.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Policitemia vera (Boala Vaquez)*<\/p>\n

*Este o afec\u0163iune hematologic\u0103 (din cadrul bolilor mieloproliferative) caracterizat\u0103 prin proliferarea excesiv\u0103 a celulelor din seria ro\u015fie<\/p>\n

Evolueaz\u0103 \u00een trei faze<\/p>\n

– faza policitemic\u0103 \u00een care sunt posibile remisiuni clinice \u015fi citologice p\u00e2n\u0103 la 20 ani,<\/p>\n

– faza de metaplazie mieloid\u0103 postpolicitemic\u0103,<\/p>\n

– faza de leucemie acut\u0103 postpolicitemic\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Clinic:<\/p>\n

– splenomegalie;<\/p>\n

– hepatomegalie;<\/p>\n

– HTA<\/p>\n

– examen neurologic<\/p>\n

– Paraclinic:<\/p>\n

– hemogram\u0103 complet\u0103:<\/p>\n

– nr. hematii<\/p>\n

– Hb gr. %<\/p>\n

– nr. leucocite<\/p>\n

– nr. trombocite<\/p>\n

– HT<\/p>\n

– mielogram\u0103 sau\/\u015fi<\/p>\n

– punc\u0163ie osoas\u0103<\/p>\n

– teste de coagulare<\/p>\n

– ecografie cardiac\u0103<\/p>\n

– satura\u0163ia cu O2<\/sub>\u00a0a Hb din s\u00e2ngele arterial (dac\u0103 este cazul)<\/p>\n

– eritropoietin\u0103 seric\u0103 sau urinar\u0103<\/p>\n<\/td>\n

\n

\u00cen faza policitemic\u0103 \u00een remisiune clinica \u015fi citologic\u0103, cu HT \u00eentre 40 – 45%, trombocite sub 400.000 mmc<\/p>\n<\/td>\n

\n

\u00cen faza policitemic\u0103 f\u0103r\u0103 remisiune, cu complica\u0163ii moderate (HTA, hemoragice sau tromboze reduse), cu HT de 50%, cu splenomegalie moderata, cu satura\u0163ie de HbO2<\/sub>\u00a0normal\u0103, cu trombocitoz\u0103 peste 400.000 mmc \u015fi leucocitoz\u0103 peste 12.000 mmc\/<\/p>\n<\/td>\n

\n

\u00cen faza policitemic\u0103 cu sechele persistente prin complica\u0163ii trombotice (neurologice, cardiace, hepatice) sau \u00een faza de metaplazie, postpolicitemic\u0103, cu splenomegalie tumoral\u0103, fibroz\u0103 medular\u0103 extins\u0103, tablou sangvin cu leucoeritroblasti, mas\u0103 eritrocitar\u0103 normal\u0103 sau sc\u0103zut\u0103.<\/p>\n<\/td>\n

\n

\u00cen metaplazia mieloid\u0103 postpolicitemic\u0103 \u015fi de leucemie acut\u0103 cu complica\u0163ii severe neurologice sau cardiace, care \u00eempiedica autoservirea.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Trombocitemie hemoragic\u0103 esen\u0163ial\u0103 sau primar\u0103*<\/p>\n

*a)Este o anomalie hematologic\u0103 (din bolile mieloproliferative cronice) caracterizat\u0103 prin proliferare megacariocitelor, ceea ce conduce la cre\u015fterea num\u0103rului de trombocite \u00een s\u00e2nge.<\/p>\n

b)Diagnosticul se pune pe:<\/p>\n

– trombocite > 600.000\/mmc<\/p>\n

– masa eritrocitar\u0103 normal\u0103, bazofilie prezent\u0103<\/p>\n

– splenomegalie<\/p>\n

Se pot ob\u0163ine, prin tratament, remisiuni pe durate variabile.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– nr. trombocite = crescute mai mult de 600.000\/mmc, f\u0103r\u0103 o cauz\u0103 identificabil\u0103 (infec\u0163ie, neoplasm sau hematologice);<\/p>\n

– mielograma = hipercelular\u0103 cu hiperplazie megacariocitar\u0103;<\/p>\n

– masa eritrocitar\u0103 normal\u0103 (sub 36 ml\/kg corp la B \u015fi sub 32 ml\/kg corp la F);<\/p>\n

– absen\u0163a fibrozei extinse a m\u0103duvei;<\/p>\n

– splenomegalie, \u00een evolu\u0163ie atrofie splenic\u0103;<\/p>\n

– agregate trombocitare.<\/p>\n<\/td>\n

\n

\u00cen faze de remisiune clinic\u0103 \u015fi hematologic\u0103 cu trombocite de 400.000 mmc.<\/p>\n<\/td>\n

\n

\u00cen formele cu complica\u0163ii trombotice \u015fi\/sau hemoragice remise \u015fi cu remisiune citologic\u0103 (trombocite 400.000 mmc) cu splenomegalie moderat\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu complica\u0163ii trombotice \u015fi\/sau hemoragice severe, cu sechele persistente, cu trombocitoz\u0103 peste 600.000 mmc, rezistente la tratament.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

6.<\/strong>Mielofibroz\u0103 cu metaplazie mieloid\u0103*<\/p>\n

*a)Este o afec\u0163iune neoplazic\u0103, hematologic\u0103 din grupa bolilor mieloproliferative cronice, caracterizat\u0103 prin:<\/p>\n

– Hiperproduc\u0163ie de celule hematopoetice;<\/p>\n

– Hiperproduc\u0163ie de celule stromale (fibrobla\u015fti).<\/p>\n

b)Supravie\u0163uirea este, \u00een medie, de 5-7 ani, cu limite \u00eentre 1-20 ani.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– splenomegalie moderat\u0103 sau gigant\u0103;<\/p>\n

– hemogram\u0103 (Hb sc\u0103zut\u0103, Ht sc\u0103zut, reticulocitoz\u0103, nr. leucocite normal sau sc\u0103zut, formula leucocitar\u0103 deviat\u0103 la st\u00e2ng\u0103 \u015fi bazofilie) frotiu s\u00e2nge-hematii \u00ab\u00een pic\u0103tur\u0103\u00bb;<\/p>\n

– mielogram\u0103 (biopsie medular\u0103 din creasta iliac\u0103: tablou leucoeritroblastic \u015fi mielofibroz\u0103);<\/p>\n

– \u00cen fazele avansate = insuficien\u0163a medular\u0103 = pancitopenie cu:<\/p>\n

– – Sindrom anemic<\/p>\n

– – Sindrom infec\u0163ios<\/p>\n

– – Sindrom hemoragic.<\/p>\n

– Acid uric;<\/p>\n

– Creatinin\u0103;<\/p>\n

– Sideremie<\/p>\n<\/td>\n

\n

\u00cen faze proliferative f\u0103r\u0103 complica\u0163ii.<\/p>\n<\/td>\n

\n

\u00cen faza de insuficien\u0163\u0103 medular\u0103 cu pancitopenie, cu sindrom anemic, hemoragic \u015fi infec\u0163ios.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

7.<\/strong>Sindromul mielo-displazic*<\/p>\n

*a)Este forma de insuficien\u0163\u0103 medular\u0103 datorat\u0103 imposibilit\u0103\u0163ii matur\u0103rii celulare din seriile mieloide;<\/p>\n

b)Sunt incluse st\u0103ri preleucemice cu anemie refractar\u0103 simpl\u0103 sau cu siderobla\u015fti inelari sau cu exces de bla\u015fti \u015fi leucemia cronic\u0103 mielomonocitar\u0103;<\/p>\n

c)Durata de via\u0163\u0103 1-3 ani.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Anemie cu semne de hipoxie anemic\u0103 \u015fi cu modific\u0103ri morfologice cu macrocitoz\u0103, poichilocitoz\u0103, siderocite \u00een s\u00e2ngele periferic;<\/p>\n

– Megaloblastoz\u0103, siderobla\u015fti patologici multinuclea\u0163i \u00een m\u0103duva osoas\u0103.<\/p>\n

– Mielograma cu colora\u0163ii speciale.<\/p>\n<\/td>\n

\n

\u00cen remisiuni complete, clinice \u015fi citologice, \u00een anemii simple, refractare.<\/p>\n<\/td>\n

\n

\u00cen remisiuni par\u0163iale, de durat\u0103 medie, cu rezultate favorabile la tratament, \u00een anemiile refractare, \u00een leucemia mielomonocitar\u0103 cronic\u0103, \u00een faze cronice f\u0103r\u0103 complica\u0163ii.<\/p>\n<\/td>\n

\n

– \u00cen anemie refractar\u0103 simpl\u0103 sau cu exces de bla\u015fti, cu Hb sub 8 gr\/dl, cu tratament ineficient;<\/p>\n

– \u00cen anemii cu exces de bla\u015fti \u00een transformare care preced leucemia acut\u0103;<\/p>\n

– \u00cen leucemia mielomonocitar\u0103 cronic\u0103 \u00een perioada de acutizare a afec\u0163iunii.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

8.<\/strong>Anemiile aplastice*<\/p>\n

*a)Caracterizate prin citopenie periferic\u0103 \u015fi medular\u0103 cu hipo sau acelularitate.<\/p>\n

b)Pot avea aspect de:<\/p>\n

– Anemie eritroid\u0103 pur\u0103 (eritroblastopenie) cu reticulocite < 1%<\/p>\n

– Aplazie granulocitar\u0103 (agranulocitoz\u0103) \u00een care granulocitele sunt < 500\/ml<\/p>\n

– Aplazie megacariocitar\u0103 \u00een care trombocitele sunt sub 20. 000\/ml<\/p>\n

c)Complica\u0163ii: infec\u0163ii, hemoragii, mielodisplazie, leucemie acut\u0103 \u00een fazele tardive<\/p>\n

d)Remisiunile sunt rare, dar pot fi par\u0163iale sau totale.<\/p>\n

e)\u00cen formele severe mortalitate este > 80%, din care peste 50% mor \u00een primul an de evolu\u0163ie.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Hemograma complet\u0103<\/p>\n

– Hematocrit (HT)<\/p>\n

– Hemoglobina (Hb)<\/p>\n

– Num\u0103r trombocite<\/p>\n

– Mielogram\u0103 sau punc\u0163ie osoas\u0103, biopsie<\/p>\n

– Sideremie<\/p>\n

– Glicemie<\/p>\n

– Probe de insuficient\u0103 hepatic\u0103<\/p>\n<\/td>\n

\n

\u00cen forme u\u015foare sau remisiuni totale ale acestora.<\/p>\n<\/td>\n

\n

\u00cen formele medii, f\u0103r\u0103 tendin\u0163e evolutive, f\u0103r\u0103 complica\u0163ii sau \u00een fazele de remisiune par\u0163ial\u0103.<\/p>\n<\/td>\n

\n

– \u00cen forme cronice care necesit\u0103 transfuzii repetate, cu hemosideroz\u0103, ciroz\u0103 hepatic\u0103 \u015fi cu diabet zaharat;<\/p>\n

– \u00cen formele severe cu complica\u0163ii grave;<\/p>\n

– \u00cen forme ce necesit\u0103 transfuzii repetate, at\u00e2t \u00een perioade acute c\u00e2t \u015fi 2 ani dup\u0103 ob\u0163inerea unei remisiuni.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA CAPACIT\u0102\u0162II S\u00c2NGELUI DE A TRANSPORTA OXIGEN<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ANEMIE FERIPRIV\u0102*<\/p>\n<\/td>\n

\n

ANEMIE MEGALOBLASTIC\u0102**<\/p>\n<\/td>\n

\n

ANEMII HEMOLITICE***<\/p>\n<\/td>\n<\/tr>\n

\n

PARAMETRII FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

– Hb + HT sc\u0103zute;<\/p>\n

– CHEM < 30%;<\/p>\n

– VEM < 80 microni;<\/p>\n

– Sideremie < 50 micrograme la 100 ml;<\/p>\n

– Mielogram\u0103: absen\u0163a hemosiderinei medulare \u015fi a siderobla\u015ftilor.<\/p>\n

– Investiga\u0163ii pentru determinarea cauzei<\/p>\n<\/td>\n

\n

– Hb + HT sc\u0103zute;<\/p>\n

– Trombo-leucopenie;<\/p>\n

– Scad reticulocitele;<\/p>\n

– \u00cen frotiu macrocite;<\/p>\n

– Mielogram\u0103: modific\u0103ri de tip megaloblastic pe toate seriile.<\/p>\n

Alte semne:<\/p>\n

– Glosita Hunter,<\/p>\n

– Manifest\u0103ri neurologice,<\/p>\n

– Anaclorhidrie histamino-rezistent\u0103,<\/p>\n

– Gastrit\u0103 atrofic\u0103,<\/p>\n

– Test Schilling cu valori sc\u0103zute (normal 8-25%),<\/p>\n

– Vitamina B12 \u00een s\u00e2nge < 100 mg %.<\/p>\n

– Acid folic – dozare<\/p>\n<\/td>\n

\n

Clinic:<\/p>\n

– Paloare;<\/p>\n

– Subicter conjunctival sau\/\u015fi tegumentar;<\/p>\n

– Splenomegalie cu\/f\u0103r\u0103 hepatomegalie.<\/p>\n

Paraclinic:<\/p>\n

-CENTER Hb + HT sc\u0103zute;<\/p>\n

– Reticulocite crescute;<\/p>\n

– Mielograma arat\u0103 hiperplazie eritroblastic\u0103 cu inversarea raportului G\/E;<\/p>\n

– Bilirubinemie crescut\u0103, \u00een special indirect\u0103;<\/p>\n

– Urobilinogen prezent;<\/p>\n

– Teste de hemoliz\u0103<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Este o anemie hipocrom\u0103 microcitar\u0103 \u00een care tulburarea de baz\u0103 o reprezint\u0103 sc\u0103derea cantit\u0103\u0163ii de fier din hematii.<\/p>\n

** Este o anemie datorata tulbur\u0103rii diviziunii celulare prin sc\u0103derea sintezei ADN urmare unui deficit de vitamin\u0103 B12\/de acid folic.<\/p>\n

*** a)Se produc prin liza excesiv\u0103 a eritrocitelor;<\/p>\n

b)Durata de via\u0163\u0103 a eritrocitelor scade la 80-90 zile \u00een hemolize u\u015foare, p\u00e2n\u0103 la 5-10 zile \u00een hemolize severe;<\/p>\n

c)Forme de anemie hemolitic\u0103:<\/p>\n

– sferocitoz\u0103 ereditar\u0103,<\/p>\n

– eliptocitoz\u0103 ereditar\u0103,<\/p>\n

– hemoglobinuria paroxistic\u0103 nocturn\u0103,<\/p>\n

– hemoglobinopatii (talazemia major\u0103 \u015fi minor\u0103),<\/p>\n

– enzimopatii,<\/p>\n

– autoimune,<\/p>\n

– methemoglobinopatii.<\/p>\n

De re\u0163inut:<\/p>\n

a)Anemiile reprezint\u0103 bolile sistemului eritocitar determinate de sc\u0103derea hemoglobinei \u015fi\/sau a masei eritrocitare totale care, prin sc\u0103derea capacit\u0103\u0163ii de transport a O2<\/sub>\u00a0de c\u0103tre s\u00e2nge, determin\u0103 diferite grade de hipoxie tisular\u0103 sau celular\u0103.<\/p>\n

b)Dac\u0103 se ia ca parametru valoarea hemoglobinei, se consider\u0103:<\/p>\n

– Valori normale = 14 g\/dl (\u00b12) la b\u0103rba\u0163i; 13 g\/dl (\u00b12) la femei (valorile variaz\u0103 \u00een func\u0163ie de v\u00e2rst\u0103)<\/p>\n

– Anemie u\u015foar\u0103 la Hb \u00eentre 10-12 g\/dl;<\/p>\n

– Anemie medie la Hb \u00eentre 8-10 g\/dl;<\/p>\n

– Anemie sever\u0103 la Hb sub 8 g\/dl.<\/p>\n

c)\u00cen aprecierea deficien\u0163ei func\u0163ionale se \u0163ine seama de:<\/p>\n

– Severitatea anemiei;<\/p>\n

– Necesitatea transfuziilor repetate;<\/p>\n

– R\u0103spunsul la tratament \u015fi caracteristicile bolii primare care a generat anemia.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

ANEMII<\/p>\n<\/td>\n

\n

Forme u\u015foare cu Hb \u00eentre 10-12 gr%, cu r\u0103spuns imediat \u015fi persistent la tratament corespunz\u0103tor.<\/p>\n<\/td>\n

\n

Forme moderate cu Hb \u00eentre 8 – 10 gr % cu r\u0103spuns favorabil la tratament, f\u0103r\u0103 complica\u0163ii.<\/p>\n<\/td>\n

\n

– Anemie sever\u0103 cu Hb sub 8 gr%;<\/p>\n

– Forme cu complica\u0163ii, tromboze, hemoragii repetate, mielodisplazie;<\/p>\n

– Forme care necesit\u0103 transfuzii frecvente.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

III.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA SISTEMULUI LIMFOID*<\/u><\/p>\n

\u00a0<\/p>\n

*Se refer\u0103 la:<\/p>\n

1.B. Hodgkin<\/p>\n

2.Limfoame Nonhodgkiniene<\/p>\n

3.Mielomul multiplu<\/p>\n

4.B. Waldenstrom (macroglobulinemia)<\/p>\n

1.<\/strong>Boala Hodgkin**<\/p>\n

**a)Este determinat\u0103 de proliferarea malign\u0103 a unei clone celulare, probabil din seria limfoid\u0103 cu forme de celule gigante tip STENBERG REED, paralele cu dezvoltarea unei reac\u0163ii celulare polimorfe granulomatoase.<\/p>\n

b)Post terapeutic pot apare remisiuni de lung\u0103 durat\u0103, care pot fi complete (dispari\u0163ia ganglionilor \u015fi a semnelor biologice) sau incomplete (dispari\u0163ia sau reducerea adenopatiilor cu VSH \u015fi fibrinogen crescute).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– adenopatii periferice \u015fi\/sau pofunde;<\/p>\n

– hepatosplenomegalie;<\/p>\n

– febr\u0103;<\/p>\n

– prurit;<\/p>\n

– sc\u0103dere ponderal\u0103;<\/p>\n

Paraclinic:<\/p>\n

– biopsie ganglionar\u0103 (criteriu major);<\/p>\n

– electroforez\u0103-imunelectroforez\u0103;<\/p>\n

– hemoleucogram\u0103; num\u0103r de trombocite;<\/p>\n

– VSH;<\/p>\n

– Fibrinogenemie.<\/p>\n

– CT pentru stadializare.<\/p>\n<\/td>\n

\n

Formele \u00een remisiune complet\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu remisiune incomplet\u0103.<\/p>\n<\/td>\n

\n

– Formele \u00een evolu\u0163ie \u00een perioadele de acutizare (cel pu\u0163in 6 luni de la ini\u0163ierea tratamentului fazei acute);<\/p>\n

– \u00cen formele cu complica\u0163ii viscerale.<\/p>\n<\/td>\n

\n

\u00cen formele diseminate cu casexie neoplazic\u0103 care \u00eempiedic\u0103 autoservirea, auto\u00eengrijirea \u015fi autogospod\u0103rirea<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

N.B. Evolu\u0163ia cuprinde 4 stadii:<\/p>\n

– Stadiul I (1E) = afectarea unei singure grupe ganglionare sau a unui organ visceral prin contiguitate;<\/p>\n

– Stadiul II (2E) = afectarea a dou\u0103 grupe ganglionare de aceea\u015fi parte a diafragmului cu\/f\u0103r\u0103 afectarea unui organ visceral prin contiguitate;<\/p>\n

– Stadiul III (3E) = afectarea de grupe ganglionare supra \u015fi subdiafragmatice;<\/p>\n

– Stadiul IV (4E) = determin\u0103ri viscerale (examen: m\u0103duv\u0103 osoas\u0103, ficat etc.) produse prin diseminare hematogen\u0103.<\/p>\n

2.<\/strong>Limfoame Nonhodgkiniene (LNH)*<\/p>\n

*Anomalie neoplazic\u0103 cu proliferarea unei clone maligne de celule apar\u0163in\u00e2nd sistemului imunitar.<\/p>\n

Face parte din sindromul limfoproliferativ cronic.<\/p>\n

Evolu\u0163ie \u00een patru stadii (vezi B. Hodgkin).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Febr\u0103;<\/p>\n

– Pierdere ponderal\u0103; – Adenopatii (70% din cazuri);<\/p>\n

– Splenomegalie (30% din cazuri);<\/p>\n

– Hepatomegalie (30-50% din cazuri).<\/p>\n

Paraclinic:<\/p>\n

– Examen histologic (criteriu major):<\/p>\n

– – LNH cu limfocite mici cu evolu\u0163ie lent\u0103 de c\u00e2\u0163iva ani,<\/p>\n

– – LNH cu malignitate medie,<\/p>\n

– – LNH cu malignitate mare, cu prognostic sumbru.<\/p>\n

– VSH;<\/p>\n

– Fibrinogenemie; – Electroforez\u0103-imunoelectroforez\u0103;<\/p>\n

– Hemoleucogram\u0103;<\/p>\n

– Num\u0103r trombocite;<\/p>\n

– Examen neurologic;<\/p>\n

– RMN;<\/p>\n

– Computer tomograf;<\/p>\n

– Ecografie hepatic\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu celule mici, cu remisiune de durat\u0103 crescut\u0103.<\/p>\n<\/td>\n

\n

\u00cen remisiuni incomplete \u015fi de durate mai scurte, mai ales \u00een formele cu malignitate medie.<\/p>\n<\/td>\n

\n

– \u00cen formele cu remisiuni incomplete, de scurt\u0103 durat\u0103;<\/p>\n

– Cele rapid evolutive (\u00een special LNH cu malignitate mare); – \u00cen determin\u0103rile viscerale.<\/p>\n<\/td>\n

\n

\u00cen formele cu invazie medular\u0103, hepatic\u0103, sistem nervos central – care \u00eempiedic\u0103 autoservirea, auto\u00eengrijirea \u015fi autogospod\u0103rirea<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Mielomul multiplu*<\/p>\n

*a)Produs\u0103 de proliferarea malign\u0103 a celulelor plasmocitare, caracterizat\u0103 prin leziuni osoase, tulbur\u0103ri \u00een metabolismul imunoglobulinelor, insuficien\u0163\u0103 medular\u0103 \u015fi insuficien\u0163\u0103 renal\u0103.<\/p>\n

b)Fracturi patologice, sindrom de compresiune medular\u0103, insuficien\u0163\u0103 renal\u0103, infec\u0163ii, sindrom hemoragipar, sindrom de hipercalcemie, sindrom de hipervascozitate.<\/p>\n

c)Durata medie de via\u0163\u0103 informele netratate este de peste 7 luni, la cei trata\u0163i, peste 30 de luni.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Criterii majore:<\/p>\n

– Plasmocitoz\u0103 tisular\u0103;<\/p>\n

– Plasmocitoz\u0103 medular\u0103 peste 30%;<\/p>\n

– Componenta M (IgG > 3,5 gr%, IgA > 2gr%, eliminare de proteina Bence Jons (BJ) > 2gr\/24h).<\/p>\n

Criterii minore:<\/p>\n

– Plasmocitoz\u0103 medular\u0103 \u00eentre 10-30%;<\/p>\n

– Component\u0103 M cu valori mai sc\u0103zute dec\u00e2t \u00een criteriile majore;<\/p>\n

– Leziuni osoase;<\/p>\n

– Sc\u0103derea imunoglobulinelor normale.<\/p>\n

– Hemoleucogram\u0103,calcemie, creatinin\u0103, ac. uric.<\/p>\n<\/td>\n

\n

\u00cen stadiul I, \u00een remisiune, dup\u0103 tratament.<\/p>\n<\/td>\n

\n

\u00cen stadiul II, cu fracturi consolidate corect, cu anemie u\u015foar\u0103, cu afectare renal\u0103 incipient\u0103.<\/p>\n<\/td>\n

\n

\u00cen stadiul III, cu complica\u0163ii osoase, renale, infec\u0163ioase etc.<\/p>\n<\/td>\n

\n

\u00cen formele cu sindrom de compresiune medular\u0103 sau paralizii sau insuficien\u0163\u0103 renal\u0103 grav\u0103, ceea ce conduce la pierderea capacit\u0103\u0163ii de autoservire, a capacit\u0103\u0163ii de auto\u00eengrijire \u015fi a capacit\u0103\u0163ii de autogospod\u0103rire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB \u00cen remisiuni:<\/p>\n

– scade componen\u0163a monoclonal\u0103 cu 50 – 75% \u015fi eliminarea proteinei BJ \u00een urin\u0103 cu 90%,<\/p>\n

– se stabilizeaz\u0103 leziunile osoase \u015fi<\/p>\n

– se normalizeaz\u0103 calciul seric.<\/p>\n

Evolu\u0163ie stadial\u0103 (trei stadii):<\/p>\n

I.Hb > 12 gr %<\/p>\n

a)Ca seric normal<\/p>\n

b)Leziuni osoase absente<\/p>\n

c)IgG sub 5 gr %, IgA sub 3 gr %<\/p>\n

d)Proteina BJ \u00een urin\u0103 sub 4 gr\/24 h<\/p>\n

II.Intermediar \u00eentre I – III<\/p>\n

III.Hb < 8 gr%<\/p>\n

Ca seric peste 12 mg %<\/p>\n

Complica\u0163ii specifice.<\/p>\n

4.<\/strong>Boala Waldenstrom (macroglobulinemia)*<\/p>\n

*a)Este produs\u0103 prin proliferarea maligna a seriei limfo-plasmocitare \u015fi se exprim\u0103 prin hiperplazia organelor limfoide, cre\u015fterea monoclonal\u0103 de IgM \u015fi fenomene de hipervascozitate sangvin\u0103;<\/p>\n

b)Apare de obicei la v\u00e2rstnici;<\/p>\n

c)Durata supravie\u0163uirii este variabil\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Adenopatii;<\/p>\n

– Hepatosplenomegalie;<\/p>\n

– Fenomene hemoragipare cutaneo-mucoase;<\/p>\n

– Sindrom de hipervascozitate sanguin\u0103;<\/p>\n

– Tulbur\u0103ri de memorie \u015fi orientare;<\/p>\n

– Somnolen\u0163\u0103.<\/p>\n

Paraclinic:<\/p>\n

– Anemie cu prezen\u0163a de rulouri de hematii pe frotiu;<\/p>\n

– Cre\u015ftere mare a proteinemiei<\/p>\n

– Electroforez\u0103 proteine<\/p>\n

– Cre\u015fte VSH;<\/p>\n

– Cre\u015fterea IgM \u015fi a v\u00e2scozit\u0103\u0163ii serice;<\/p>\n

– Teste psihologice (cognitive);<\/p>\n

– Uree, creatinin\u0103, acid uric;<\/p>\n

– Medulogram\u0103;<\/p>\n

– PBO<\/p>\n<\/td>\n

\n

– \u00cen perioada de remisiune;<\/p>\n

– \u00cen forme cu anemie moderat\u0103;<\/p>\n

– \u00cen formele cu determin\u0103ri viscerale reduse.<\/p>\n<\/td>\n

\n

– \u00cen forme avansate cu sindrom hemoragic ce duce la anemii pronun\u0163ate;<\/p>\n

– \u00cen forme complicate cu insuficien\u0163\u0103 cardiac\u0103 sau insuficien\u0163\u0103 renal\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

IV.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR DE COAGULARE*<\/u><\/p>\n

\u00a0<\/p>\n

* Se refer\u0103 la:<\/p>\n

1)Purpura trombocitopenic\u0103 idiopatic\u0103 (PTI)<\/p>\n

2)Sindroame hemoragice prin deficit de factori plasmatici ai coagul\u0103rii<\/p>\n

Hemofilia A \u015fi B<\/p>\n

3)Alte sindroame hemoragice prin deficit de factori plasmatici ai coagul\u0103rii<\/p>\n

4)B. Von Willebrand<\/p>\n

5)Trombofilii ereditare (primare)<\/p>\n

1.<\/strong>Purpura trombocitopenic\u0103 idiopatic\u0103 (PTI)**<\/p>\n

** a)Este un sindrom hemoragic produs prin trombocitopenie imun\u0103 datorat\u0103 anticorpilor antitrombocit\u0103ri, ceea ce produce distrugerea prematur\u0103 a trombocitelor \u00een sistemul macrofagic.<\/p>\n

b)Durata de via\u0163\u0103, \u00een majoritatea cazurilor, este normal\u0103, mortalitatea fiind mai mic\u0103 de 10%.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– S\u00e2nger\u0103ri cutaneo-mucoase;<\/p>\n

– Absen\u0163a splenomegaliei.<\/p>\n

Paraclinic:<\/p>\n

– Num\u0103r trombocite \u00een s\u00e2ngur\u0103rile func\u0163ionale determinate de afec\u0163iunea hematologic\u0103 propriu-zis\u0103.<\/p>\n

– \u00cen caz de transplant de m\u0103duv\u0103 osoas\u0103, evaluarea se va face la 6 luni de la realizarea transplantului.<\/p>\n

\u00a0<\/p>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN ANOMALII ALE CELULELOR HEMATOPOETICE (FUNC\u0162IILOR DE PRODUCERE A S\u00c2NGELUI \u015eI ALE M\u0102DUVEI OSOASE)*<\/u><\/p>\n

\u00a0<\/p>\n

*1.Leucemii acute<\/p>\n

2.Leucemia granulocitar\u0103 cronic\u0103<\/p>\n

3.Leucemia limfoid\u0103 cronic\u0103<\/p>\n

4.Policitemia vera (Boala Vaquez)<\/p>\n

5.Trombocitemia hemoragic\u0103<\/p>\n

6.Mielofibroza cu metaplazie medular\u0103<\/p>\n

7.Sindromul mielo-displazic<\/p>\n

8.Anemiile aplastice<\/p>\n

1.<\/strong>Leucemii acute**<\/p>\n

**a)Proliferare malign\u0103 a celulelor hematopoetice, caracterizat\u0103 prin oprirea lor \u00een diferen\u0163iere \u015fi matura\u0163ie, asociat\u0103 sau nu cu trecerea celulelor blastice \u00een s\u00e2ngele periferic.<\/p>\n

Caracterul esen\u0163ial (major) de diagnostic = prezen\u0163a de celule blastice peste 30% din totalul celulelor medulare la punc\u0163ie sau biopsie osoas\u0103.<\/p>\n

b)Intensitatea deficien\u0163ei func\u0163ionale este determinat\u0103 de caracterul malign al bolii, de anemia \u00eenso\u0163itoare, de hemoragii, de infec\u0163ii, precum \u015fi de alte complica\u0163ii ca: meningita leucemic\u0103, infiltrate craniene, pulmonare sau nefropatia uric\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– hemoleucograma complet\u0103<\/p>\n

– frotiu de s\u00e2nge periferic<\/p>\n

– mielogram\u0103<\/p>\n

– acid uric<\/p>\n

– creatinin\u0103<\/p>\n

– computer tomograf<\/p>\n

– lichid cefalorahidian (LCR)<\/p>\n

– transaminaze<\/p>\n<\/td>\n

\n

\u00cen remisiunile durabile de 4-5 ani, sub rezerva verific\u0103rilor func\u0163ionale, anual<\/p>\n<\/td>\n

\n

\u00cen remisiunile durabile sub 4-5 ani<\/p>\n<\/td>\n

\n

– Afec\u0163iune evolutiv\u0103 cu complica\u0163ii \u015fi r\u0103spuns nesatisf\u0103c\u0103tor la tratament.<\/p>\n

– Rec\u0103dere dup\u0103 3-4 ani (rec\u0103dere rezistent\u0103 la tratament).<\/p>\n<\/td>\n

\n

\u00cen formele accentuate care determin\u0103 imobilizarea \u015fi pierderea capacit\u0103\u0163ii de autoservire, prin complica\u0163ii grave, ireversibile<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Leucemia granulocitar\u0103 cronic\u0103*<\/p>\n

*a)Afec\u0163iune neoplazic\u0103 hematologic\u0103 din grupa bolilor mieloproliferative cronice, caracterizat\u0103 prin cre\u015fterea excesiv\u0103 a granulocitelor;<\/p>\n

b)Are o evolu\u0163ie medie de 4 ani, dar supravie\u0163uirea poate atinge 15-20 de ani;<\/p>\n

c)Remisiunile \u00een faza cronic\u0103 produse de tratament, au durate de luni \u015fi ani;<\/p>\n

d)Deficien\u0163a este determinat\u0103 de caracterul malign, de complica\u0163ii (hipersplenism, splin\u0103 tumoral\u0103 cu fenomene de compresiune abdominal\u0103, infarcte splenice, hemoragii, infec\u0163ii s.a.)<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Clinic:<\/p>\n

– splenomegalie;<\/p>\n

– hepatomegalie (u\u015foar\u0103);<\/p>\n

– dureri osoase.<\/p>\n

– Paraclinic:<\/p>\n

– hemoleucogram\u0103: leucocitoz\u0103 marcat\u0103 cu deviere la st\u00e2nga<\/p>\n

– anemie \u00een grad variabil;<\/p>\n

– mielogram\u0103: m\u0103duv\u0103 hiperplazic\u0103, predomin\u00e2nd granulocitar\u0103;<\/p>\n

– acid uric, creatinin\u0103;<\/p>\n

– ecografie renal\u0103 (abdominal\u0103)<\/p>\n

– examen citogenetic.<\/p>\n<\/td>\n

\n

\u00cen formele u\u015foare cu remisiuni de lung\u0103 durat\u0103, clinice \u015fi citologice.<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie lent\u0103, cu remisiuni trec\u0103toare dar repetate, cu complica\u0163ii moderate (litiaz\u0103 renal\u0103)<\/p>\n<\/td>\n

\n

\u00cen faze accentuate \u015fi de metamorfozare blastic\u0103 cu complica\u0163ii severe, leucocitoz\u0103 care nu r\u0103spunde la tratament<\/p>\n<\/td>\n

\n

\u00cen faza blastic\u0103 (final\u0103) – ca \u00een leucemiile acute<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Leucemia limfatic\u0103 cronic\u0103*<\/p>\n

*Este o afec\u0163iune primar\u0103 a \u0163esutului limfatic \u00een care se produce acumularea \u015fi proliferarea unei clone maligne de limfocite blocate \u00een matura\u0163ie.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– Clinic:<\/p>\n

– transpira\u0163ii nocturne,<\/p>\n

– astenie fizic\u0103,<\/p>\n

– sc\u0103dere ponderal\u0103,<\/p>\n

– adenopatii,<\/p>\n

– hepato-splenomegalie.<\/p>\n

– Paraclinic:<\/p>\n

– hemoleucogram\u0103: limfocitoz\u0103 > 30.000 mmc<\/p>\n

– mielogram\u0103: infiltra\u0163ii limfocitare \u00een m\u0103duva osoas\u0103 ce dep\u0103\u015fesc 30% (criteriu major),<\/p>\n

– electroforeza proteine \u015fi test Coombs.<\/p>\n<\/td>\n

\n

\u00cen stadiul 0 sau I, c\u00e2nd apar adenopatii, evolu\u0163ie sta\u0163ionar\u0103 pe timp \u00eendelungat, r\u0103spuns favorabil la tratament.<\/p>\n<\/td>\n

\n

\u00cen stadiul II, c\u00e2nd apare hepatomegalia sau\/\u015fi splenomegalia cu remisiuni de minimum 3 ani sub tratament.<\/p>\n<\/td>\n

\n

\u00cen leucemia limfatic\u0103 cronic\u0103 stadiul III \u015fi IV cu anemie < 11 gr% Hb, hematocrit sub 33%, trombocitopenie (sub 100.000 mmc), cu r\u0103spuns terapeutic slab \u015fi prognostic nefavorabil.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Policitemia vera (Boala Vaquez)*<\/p>\n

*Este o afec\u0163iune hematologic\u0103 (din cadrul bolilor mieloproliferative) caracterizat\u0103 prin proliferarea excesiv\u0103 a celulelor din seria ro\u015fie<\/p>\n

Evolueaz\u0103 \u00een trei faze<\/p>\n

– faza policitemic\u0103 \u00een care sunt posibile remisiuni clinice \u015fi citologice p\u00e2n\u0103 la 20 ani,<\/p>\n

– faza de metaplazie mieloid\u0103 postpolicitemic\u0103,<\/p>\n

– faza de leucemie acut\u0103 postpolicitemic\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Clinic:<\/p>\n

– splenomegalie;<\/p>\n

– hepatomegalie;<\/p>\n

– HTA<\/p>\n

– examen neurologic<\/p>\n

– Paraclinic:<\/p>\n

– hemogram\u0103 complet\u0103:<\/p>\n

– nr. hematii<\/p>\n

– Hb gr. %<\/p>\n

– nr. leucocite<\/p>\n

– nr. trombocite<\/p>\n

– HT<\/p>\n

– mielogram\u0103 sau\/\u015fi<\/p>\n

– punc\u0163ie osoas\u0103<\/p>\n

– teste de coagulare<\/p>\n

– ecografie cardiac\u0103<\/p>\n

– satura\u0163ia cu O2<\/sub>\u00a0a Hb din s\u00e2ngele arterial (dac\u0103 este cazul)<\/p>\n

– eritropoietin\u0103 seric\u0103 sau urinar\u0103<\/p>\n<\/td>\n

\n

\u00cen faza policitemic\u0103 \u00een remisiune clinica \u015fi citologic\u0103, cu HT \u00eentre 40 – 45%, trombocite sub 400.000 mmc<\/p>\n<\/td>\n

\n

\u00cen faza policitemic\u0103 f\u0103r\u0103 remisiune, cu complica\u0163ii moderate (HTA, hemoragice sau tromboze reduse), cu HT de 50%, cu splenomegalie moderata, cu satura\u0163ie de HbO2<\/sub>\u00a0normal\u0103, cu trombocitoz\u0103 peste 400.000 mmc \u015fi leucocitoz\u0103 peste 12.000 mmc\/<\/p>\n<\/td>\n

\n

\u00cen faza policitemic\u0103 cu sechele persistente prin complica\u0163ii trombotice (neurologice, cardiace, hepatice) sau \u00een faza de metaplazie, postpolicitemic\u0103, cu splenomegalie tumoral\u0103, fibroz\u0103 medular\u0103 extins\u0103, tablou sangvin cu leucoeritroblasti, mas\u0103 eritrocitar\u0103 normal\u0103 sau sc\u0103zut\u0103.<\/p>\n<\/td>\n

\n

\u00cen metaplazia mieloid\u0103 postpolicitemic\u0103 \u015fi de leucemie acut\u0103 cu complica\u0163ii severe neurologice sau cardiace, care \u00eempiedica autoservirea.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Trombocitemie hemoragic\u0103 esen\u0163ial\u0103 sau primar\u0103*<\/p>\n

*a)Este o anomalie hematologic\u0103 (din bolile mieloproliferative cronice) caracterizat\u0103 prin proliferare megacariocitelor, ceea ce conduce la cre\u015fterea num\u0103rului de trombocite \u00een s\u00e2nge.<\/p>\n

b)Diagnosticul se pune pe:<\/p>\n

– trombocite > 600.000\/mmc<\/p>\n

– masa eritrocitar\u0103 normal\u0103, bazofilie prezent\u0103<\/p>\n

– splenomegalie<\/p>\n

Se pot ob\u0163ine, prin tratament, remisiuni pe durate variabile.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– nr. trombocite = crescute mai mult de 600.000\/mmc, f\u0103r\u0103 o cauz\u0103 identificabil\u0103 (infec\u0163ie, neoplasm sau hematologice);<\/p>\n

– mielograma = hipercelular\u0103 cu hiperplazie megacariocitar\u0103;<\/p>\n

– masa eritrocitar\u0103 normal\u0103 (sub 36 ml\/kg corp la B \u015fi sub 32 ml\/kg corp la F);<\/p>\n

– absen\u0163a fibrozei extinse a m\u0103duvei;<\/p>\n

– splenomegalie, \u00een evolu\u0163ie atrofie splenic\u0103;<\/p>\n

– agregate trombocitare.<\/p>\n<\/td>\n

\n

\u00cen faze de remisiune clinic\u0103 \u015fi hematologic\u0103 cu trombocite de 400.000 mmc.<\/p>\n<\/td>\n

\n

\u00cen formele cu complica\u0163ii trombotice \u015fi\/sau hemoragice remise \u015fi cu remisiune citologic\u0103 (trombocite 400.000 mmc) cu splenomegalie moderat\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu complica\u0163ii trombotice \u015fi\/sau hemoragice severe, cu sechele persistente, cu trombocitoz\u0103 peste 600.000 mmc, rezistente la tratament.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

6.<\/strong>Mielofibroz\u0103 cu metaplazie mieloid\u0103*<\/p>\n

*a)Este o afec\u0163iune neoplazic\u0103, hematologic\u0103 din grupa bolilor mieloproliferative cronice, caracterizat\u0103 prin:<\/p>\n

– Hiperproduc\u0163ie de celule hematopoetice;<\/p>\n

– Hiperproduc\u0163ie de celule stromale (fibrobla\u015fti).<\/p>\n

b)Supravie\u0163uirea este, \u00een medie, de 5-7 ani, cu limite \u00eentre 1-20 ani.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– splenomegalie moderat\u0103 sau gigant\u0103;<\/p>\n

– hemogram\u0103 (Hb sc\u0103zut\u0103, Ht sc\u0103zut, reticulocitoz\u0103, nr. leucocite normal sau sc\u0103zut, formula leucocitar\u0103 deviat\u0103 la st\u00e2ng\u0103 \u015fi bazofilie) frotiu s\u00e2nge-hematii \u00ab\u00een pic\u0103tur\u0103\u00bb;<\/p>\n

– mielogram\u0103 (biopsie medular\u0103 din creasta iliac\u0103: tablou leucoeritroblastic \u015fi mielofibroz\u0103);<\/p>\n

– \u00cen fazele avansate = insuficien\u0163a medular\u0103 = pancitopenie cu:<\/p>\n

– – Sindrom anemic<\/p>\n

– – Sindrom infec\u0163ios<\/p>\n

– – Sindrom hemoragic.<\/p>\n

– Acid uric;<\/p>\n

– Creatinin\u0103;<\/p>\n

– Sideremie<\/p>\n<\/td>\n

\n

\u00cen faze proliferative f\u0103r\u0103 complica\u0163ii.<\/p>\n<\/td>\n

\n

\u00cen faza de insuficien\u0163\u0103 medular\u0103 cu pancitopenie, cu sindrom anemic, hemoragic \u015fi infec\u0163ios.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

7.<\/strong>Sindromul mielo-displazic*<\/p>\n

*a)Este forma de insuficien\u0163\u0103 medular\u0103 datorat\u0103 imposibilit\u0103\u0163ii matur\u0103rii celulare din seriile mieloide;<\/p>\n

b)Sunt incluse st\u0103ri preleucemice cu anemie refractar\u0103 simpl\u0103 sau cu siderobla\u015fti inelari sau cu exces de bla\u015fti \u015fi leucemia cronic\u0103 mielomonocitar\u0103;<\/p>\n

c)Durata de via\u0163\u0103 1-3 ani.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Anemie cu semne de hipoxie anemic\u0103 \u015fi cu modific\u0103ri morfologice cu macrocitoz\u0103, poichilocitoz\u0103, siderocite \u00een s\u00e2ngele periferic;<\/p>\n

– Megaloblastoz\u0103, siderobla\u015fti patologici multinuclea\u0163i \u00een m\u0103duva osoas\u0103.<\/p>\n

– Mielograma cu colora\u0163ii speciale.<\/p>\n<\/td>\n

\n

\u00cen remisiuni complete, clinice \u015fi citologice, \u00een anemii simple, refractare.<\/p>\n<\/td>\n

\n

\u00cen remisiuni par\u0163iale, de durat\u0103 medie, cu rezultate favorabile la tratament, \u00een anemiile refractare, \u00een leucemia mielomonocitar\u0103 cronic\u0103, \u00een faze cronice f\u0103r\u0103 complica\u0163ii.<\/p>\n<\/td>\n

\n

– \u00cen anemie refractar\u0103 simpl\u0103 sau cu exces de bla\u015fti, cu Hb sub 8 gr\/dl, cu tratament ineficient;<\/p>\n

– \u00cen anemii cu exces de bla\u015fti \u00een transformare care preced leucemia acut\u0103;<\/p>\n

– \u00cen leucemia mielomonocitar\u0103 cronic\u0103 \u00een perioada de acutizare a afec\u0163iunii.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

8.<\/strong>Anemiile aplastice*<\/p>\n

*a)Caracterizate prin citopenie periferic\u0103 \u015fi medular\u0103 cu hipo sau acelularitate.<\/p>\n

b)Pot avea aspect de:<\/p>\n

– Anemie eritroid\u0103 pur\u0103 (eritroblastopenie) cu reticulocite < 1%<\/p>\n

– Aplazie granulocitar\u0103 (agranulocitoz\u0103) \u00een care granulocitele sunt < 500\/ml<\/p>\n

– Aplazie megacariocitar\u0103 \u00een care trombocitele sunt sub 20. 000\/ml<\/p>\n

c)Complica\u0163ii: infec\u0163ii, hemoragii, mielodisplazie, leucemie acut\u0103 \u00een fazele tardive<\/p>\n

d)Remisiunile sunt rare, dar pot fi par\u0163iale sau totale.<\/p>\n

e)\u00cen formele severe mortalitate este > 80%, din care peste 50% mor \u00een primul an de evolu\u0163ie.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Hemograma complet\u0103<\/p>\n

– Hematocrit (HT)<\/p>\n

– Hemoglobina (Hb)<\/p>\n

– Num\u0103r trombocite<\/p>\n

– Mielogram\u0103 sau punc\u0163ie osoas\u0103, biopsie<\/p>\n

– Sideremie<\/p>\n

– Glicemie<\/p>\n

– Probe de insuficient\u0103 hepatic\u0103<\/p>\n<\/td>\n

\n

\u00cen forme u\u015foare sau remisiuni totale ale acestora.<\/p>\n<\/td>\n

\n

\u00cen formele medii, f\u0103r\u0103 tendin\u0163e evolutive, f\u0103r\u0103 complica\u0163ii sau \u00een fazele de remisiune par\u0163ial\u0103.<\/p>\n<\/td>\n

\n

– \u00cen forme cronice care necesit\u0103 transfuzii repetate, cu hemosideroz\u0103, ciroz\u0103 hepatic\u0103 \u015fi cu diabet zaharat;<\/p>\n

– \u00cen formele severe cu complica\u0163ii grave;<\/p>\n

– \u00cen forme ce necesit\u0103 transfuzii repetate, at\u00e2t \u00een perioade acute c\u00e2t \u015fi 2 ani dup\u0103 ob\u0163inerea unei remisiuni.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA CAPACIT\u0102\u0162II S\u00c2NGELUI DE A TRANSPORTA OXIGEN<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ANEMIE FERIPRIV\u0102*<\/p>\n<\/td>\n

\n

ANEMIE MEGALOBLASTIC\u0102**<\/p>\n<\/td>\n

\n

ANEMII HEMOLITICE***<\/p>\n<\/td>\n<\/tr>\n

\n

PARAMETRII FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

– Hb + HT sc\u0103zute;<\/p>\n

– CHEM < 30%;<\/p>\n

– VEM < 80 microni;<\/p>\n

– Sideremie < 50 micrograme la 100 ml;<\/p>\n

– Mielogram\u0103: absen\u0163a hemosiderinei medulare \u015fi a siderobla\u015ftilor.<\/p>\n

– Investiga\u0163ii pentru determinarea cauzei<\/p>\n<\/td>\n

\n

– Hb + HT sc\u0103zute;<\/p>\n

– Trombo-leucopenie;<\/p>\n

– Scad reticulocitele;<\/p>\n

– \u00cen frotiu macrocite;<\/p>\n

– Mielogram\u0103: modific\u0103ri de tip megaloblastic pe toate seriile.<\/p>\n

Alte semne:<\/p>\n

– Glosita Hunter,<\/p>\n

– Manifest\u0103ri neurologice,<\/p>\n

– Anaclorhidrie histamino-rezistent\u0103,<\/p>\n

– Gastrit\u0103 atrofic\u0103,<\/p>\n

– Test Schilling cu valori sc\u0103zute (normal 8-25%),<\/p>\n

– Vitamina B12 \u00een s\u00e2nge < 100 mg %.<\/p>\n

– Acid folic – dozare<\/p>\n<\/td>\n

\n

Clinic:<\/p>\n

– Paloare;<\/p>\n

– Subicter conjunctival sau\/\u015fi tegumentar;<\/p>\n

– Splenomegalie cu\/f\u0103r\u0103 hepatomegalie.<\/p>\n

Paraclinic:<\/p>\n

-CENTER Hb + HT sc\u0103zute;<\/p>\n

– Reticulocite crescute;<\/p>\n

– Mielograma arat\u0103 hiperplazie eritroblastic\u0103 cu inversarea raportului G\/E;<\/p>\n

– Bilirubinemie crescut\u0103, \u00een special indirect\u0103;<\/p>\n

– Urobilinogen prezent;<\/p>\n

– Teste de hemoliz\u0103<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Este o anemie hipocrom\u0103 microcitar\u0103 \u00een care tulburarea de baz\u0103 o reprezint\u0103 sc\u0103derea cantit\u0103\u0163ii de fier din hematii.<\/p>\n

** Este o anemie datorata tulbur\u0103rii diviziunii celulare prin sc\u0103derea sintezei ADN urmare unui deficit de vitamin\u0103 B12\/de acid folic.<\/p>\n

*** a)Se produc prin liza excesiv\u0103 a eritrocitelor;<\/p>\n

b)Durata de via\u0163\u0103 a eritrocitelor scade la 80-90 zile \u00een hemolize u\u015foare, p\u00e2n\u0103 la 5-10 zile \u00een hemolize severe;<\/p>\n

c)Forme de anemie hemolitic\u0103:<\/p>\n

– sferocitoz\u0103 ereditar\u0103,<\/p>\n

– eliptocitoz\u0103 ereditar\u0103,<\/p>\n

– hemoglobinuria paroxistic\u0103 nocturn\u0103,<\/p>\n

– hemoglobinopatii (talazemia major\u0103 \u015fi minor\u0103),<\/p>\n

– enzimopatii,<\/p>\n

– autoimune,<\/p>\n

– methemoglobinopatii.<\/p>\n

De re\u0163inut:<\/p>\n

a)Anemiile reprezint\u0103 bolile sistemului eritocitar determinate de sc\u0103derea hemoglobinei \u015fi\/sau a masei eritrocitare totale care, prin sc\u0103derea capacit\u0103\u0163ii de transport a O2<\/sub>\u00a0de c\u0103tre s\u00e2nge, determin\u0103 diferite grade de hipoxie tisular\u0103 sau celular\u0103.<\/p>\n

b)Dac\u0103 se ia ca parametru valoarea hemoglobinei, se consider\u0103:<\/p>\n

– Valori normale = 14 g\/dl (\u00b12) la b\u0103rba\u0163i; 13 g\/dl (\u00b12) la femei (valorile variaz\u0103 \u00een func\u0163ie de v\u00e2rst\u0103)<\/p>\n

– Anemie u\u015foar\u0103 la Hb \u00eentre 10-12 g\/dl;<\/p>\n

– Anemie medie la Hb \u00eentre 8-10 g\/dl;<\/p>\n

– Anemie sever\u0103 la Hb sub 8 g\/dl.<\/p>\n

c)\u00cen aprecierea deficien\u0163ei func\u0163ionale se \u0163ine seama de:<\/p>\n

– Severitatea anemiei;<\/p>\n

– Necesitatea transfuziilor repetate;<\/p>\n

– R\u0103spunsul la tratament \u015fi caracteristicile bolii primare care a generat anemia.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

ANEMII<\/p>\n<\/td>\n

\n

Forme u\u015foare cu Hb \u00eentre 10-12 gr%, cu r\u0103spuns imediat \u015fi persistent la tratament corespunz\u0103tor.<\/p>\n<\/td>\n

\n

Forme moderate cu Hb \u00eentre 8 – 10 gr % cu r\u0103spuns favorabil la tratament, f\u0103r\u0103 complica\u0163ii.<\/p>\n<\/td>\n

\n

– Anemie sever\u0103 cu Hb sub 8 gr%;<\/p>\n

– Forme cu complica\u0163ii, tromboze, hemoragii repetate, mielodisplazie;<\/p>\n

– Forme care necesit\u0103 transfuzii frecvente.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

III.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA SISTEMULUI LIMFOID*<\/u><\/p>\n

\u00a0<\/p>\n

*Se refer\u0103 la:<\/p>\n

1.B. Hodgkin<\/p>\n

2.Limfoame Nonhodgkiniene<\/p>\n

3.Mielomul multiplu<\/p>\n

4.B. Waldenstrom (macroglobulinemia)<\/p>\n

1.<\/strong>Boala Hodgkin**<\/p>\n

**a)Este determinat\u0103 de proliferarea malign\u0103 a unei clone celulare, probabil din seria limfoid\u0103 cu forme de celule gigante tip STENBERG REED, paralele cu dezvoltarea unei reac\u0163ii celulare polimorfe granulomatoase.<\/p>\n

b)Post terapeutic pot apare remisiuni de lung\u0103 durat\u0103, care pot fi complete (dispari\u0163ia ganglionilor \u015fi a semnelor biologice) sau incomplete (dispari\u0163ia sau reducerea adenopatiilor cu VSH \u015fi fibrinogen crescute).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– adenopatii periferice \u015fi\/sau pofunde;<\/p>\n

– hepatosplenomegalie;<\/p>\n

– febr\u0103;<\/p>\n

– prurit;<\/p>\n

– sc\u0103dere ponderal\u0103;<\/p>\n

Paraclinic:<\/p>\n

– biopsie ganglionar\u0103 (criteriu major);<\/p>\n

– electroforez\u0103-imunelectroforez\u0103;<\/p>\n

– hemoleucogram\u0103; num\u0103r de trombocite;<\/p>\n

– VSH;<\/p>\n

– Fibrinogenemie.<\/p>\n

– CT pentru stadializare.<\/p>\n<\/td>\n

\n

Formele \u00een remisiune complet\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu remisiune incomplet\u0103.<\/p>\n<\/td>\n

\n

– Formele \u00een evolu\u0163ie \u00een perioadele de acutizare (cel pu\u0163in 6 luni de la ini\u0163ierea tratamentului fazei acute);<\/p>\n

– \u00cen formele cu complica\u0163ii viscerale.<\/p>\n<\/td>\n

\n

\u00cen formele diseminate cu casexie neoplazic\u0103 care \u00eempiedic\u0103 autoservirea, auto\u00eengrijirea \u015fi autogospod\u0103rirea<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

N.B. Evolu\u0163ia cuprinde 4 stadii:<\/p>\n

– Stadiul I (1E) = afectarea unei singure grupe ganglionare sau a unui organ visceral prin contiguitate;<\/p>\n

– Stadiul II (2E) = afectarea a dou\u0103 grupe ganglionare de aceea\u015fi parte a diafragmului cu\/f\u0103r\u0103 afectarea unui organ visceral prin contiguitate;<\/p>\n

– Stadiul III (3E) = afectarea de grupe ganglionare supra \u015fi subdiafragmatice;<\/p>\n

– Stadiul IV (4E) = determin\u0103ri viscerale (examen: m\u0103duv\u0103 osoas\u0103, ficat etc.) produse prin diseminare hematogen\u0103.<\/p>\n

2.<\/strong>Limfoame Nonhodgkiniene (LNH)*<\/p>\n

*Anomalie neoplazic\u0103 cu proliferarea unei clone maligne de celule apar\u0163in\u00e2nd sistemului imunitar.<\/p>\n

Face parte din sindromul limfoproliferativ cronic.<\/p>\n

Evolu\u0163ie \u00een patru stadii (vezi B. Hodgkin).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Febr\u0103;<\/p>\n

– Pierdere ponderal\u0103; – Adenopatii (70% din cazuri);<\/p>\n

– Splenomegalie (30% din cazuri);<\/p>\n

– Hepatomegalie (30-50% din cazuri).<\/p>\n

Paraclinic:<\/p>\n

– Examen histologic (criteriu major):<\/p>\n

– – LNH cu limfocite mici cu evolu\u0163ie lent\u0103 de c\u00e2\u0163iva ani,<\/p>\n

– – LNH cu malignitate medie,<\/p>\n

– – LNH cu malignitate mare, cu prognostic sumbru.<\/p>\n

– VSH;<\/p>\n

– Fibrinogenemie; – Electroforez\u0103-imunoelectroforez\u0103;<\/p>\n

– Hemoleucogram\u0103;<\/p>\n

– Num\u0103r trombocite;<\/p>\n

– Examen neurologic;<\/p>\n

– RMN;<\/p>\n

– Computer tomograf;<\/p>\n

– Ecografie hepatic\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu celule mici, cu remisiune de durat\u0103 crescut\u0103.<\/p>\n<\/td>\n

\n

\u00cen remisiuni incomplete \u015fi de durate mai scurte, mai ales \u00een formele cu malignitate medie.<\/p>\n<\/td>\n

\n

– \u00cen formele cu remisiuni incomplete, de scurt\u0103 durat\u0103;<\/p>\n

– Cele rapid evolutive (\u00een special LNH cu malignitate mare); – \u00cen determin\u0103rile viscerale.<\/p>\n<\/td>\n

\n

\u00cen formele cu invazie medular\u0103, hepatic\u0103, sistem nervos central – care \u00eempiedic\u0103 autoservirea, auto\u00eengrijirea \u015fi autogospod\u0103rirea<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Mielomul multiplu*<\/p>\n

*a)Produs\u0103 de proliferarea malign\u0103 a celulelor plasmocitare, caracterizat\u0103 prin leziuni osoase, tulbur\u0103ri \u00een metabolismul imunoglobulinelor, insuficien\u0163\u0103 medular\u0103 \u015fi insuficien\u0163\u0103 renal\u0103.<\/p>\n

b)Fracturi patologice, sindrom de compresiune medular\u0103, insuficien\u0163\u0103 renal\u0103, infec\u0163ii, sindrom hemoragipar, sindrom de hipercalcemie, sindrom de hipervascozitate.<\/p>\n

c)Durata medie de via\u0163\u0103 informele netratate este de peste 7 luni, la cei trata\u0163i, peste 30 de luni.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Criterii majore:<\/p>\n

– Plasmocitoz\u0103 tisular\u0103;<\/p>\n

– Plasmocitoz\u0103 medular\u0103 peste 30%;<\/p>\n

– Componenta M (IgG > 3,5 gr%, IgA > 2gr%, eliminare de proteina Bence Jons (BJ) > 2gr\/24h).<\/p>\n

Criterii minore:<\/p>\n

– Plasmocitoz\u0103 medular\u0103 \u00eentre 10-30%;<\/p>\n

– Component\u0103 M cu valori mai sc\u0103zute dec\u00e2t \u00een criteriile majore;<\/p>\n

– Leziuni osoase;<\/p>\n

– Sc\u0103derea imunoglobulinelor normale.<\/p>\n

– Hemoleucogram\u0103,calcemie, creatinin\u0103, ac. uric.<\/p>\n<\/td>\n

\n

\u00cen stadiul I, \u00een remisiune, dup\u0103 tratament.<\/p>\n<\/td>\n

\n

\u00cen stadiul II, cu fracturi consolidate corect, cu anemie u\u015foar\u0103, cu afectare renal\u0103 incipient\u0103.<\/p>\n<\/td>\n

\n

\u00cen stadiul III, cu complica\u0163ii osoase, renale, infec\u0163ioase etc.<\/p>\n<\/td>\n

\n

\u00cen formele cu sindrom de compresiune medular\u0103 sau paralizii sau insuficien\u0163\u0103 renal\u0103 grav\u0103, ceea ce conduce la pierderea capacit\u0103\u0163ii de autoservire, a capacit\u0103\u0163ii de auto\u00eengrijire \u015fi a capacit\u0103\u0163ii de autogospod\u0103rire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB \u00cen remisiuni:<\/p>\n

– scade componen\u0163a monoclonal\u0103 cu 50 – 75% \u015fi eliminarea proteinei BJ \u00een urin\u0103 cu 90%,<\/p>\n

– se stabilizeaz\u0103 leziunile osoase \u015fi<\/p>\n

– se normalizeaz\u0103 calciul seric.<\/p>\n

Evolu\u0163ie stadial\u0103 (trei stadii):<\/p>\n

I.Hb > 12 gr %<\/p>\n

a)Ca seric normal<\/p>\n

b)Leziuni osoase absente<\/p>\n

c)IgG sub 5 gr %, IgA sub 3 gr %<\/p>\n

d)Proteina BJ \u00een urin\u0103 sub 4 gr\/24 h<\/p>\n

II.Intermediar \u00eentre I – III<\/p>\n

III.Hb < 8 gr%<\/p>\n

Ca seric peste 12 mg %<\/p>\n

Complica\u0163ii specifice.<\/p>\n

4.<\/strong>Boala Waldenstrom (macroglobulinemia)*<\/p>\n

*a)Este produs\u0103 prin proliferarea maligna a seriei limfo-plasmocitare \u015fi se exprim\u0103 prin hiperplazia organelor limfoide, cre\u015fterea monoclonal\u0103 de IgM \u015fi fenomene de hipervascozitate sangvin\u0103;<\/p>\n

b)Apare de obicei la v\u00e2rstnici;<\/p>\n

c)Durata supravie\u0163uirii este variabil\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Adenopatii;<\/p>\n

– Hepatosplenomegalie;<\/p>\n

– Fenomene hemoragipare cutaneo-mucoase;<\/p>\n

– Sindrom de hipervascozitate sanguin\u0103;<\/p>\n

– Tulbur\u0103ri de memorie \u015fi orientare;<\/p>\n

– Somnolen\u0163\u0103.<\/p>\n

Paraclinic:<\/p>\n

– Anemie cu prezen\u0163a de rulouri de hematii pe frotiu;<\/p>\n

– Cre\u015ftere mare a proteinemiei<\/p>\n

– Electroforez\u0103 proteine<\/p>\n

– Cre\u015fte VSH;<\/p>\n

– Cre\u015fterea IgM \u015fi a v\u00e2scozit\u0103\u0163ii serice;<\/p>\n

– Teste psihologice (cognitive);<\/p>\n

– Uree, creatinin\u0103, acid uric;<\/p>\n

– Medulogram\u0103;<\/p>\n

– PBO<\/p>\n<\/td>\n

\n

– \u00cen perioada de remisiune;<\/p>\n

– \u00cen forme cu anemie moderat\u0103;<\/p>\n

– \u00cen formele cu determin\u0103ri viscerale reduse.<\/p>\n<\/td>\n

\n

– \u00cen forme avansate cu sindrom hemoragic ce duce la anemii pronun\u0163ate;<\/p>\n

– \u00cen forme complicate cu insuficien\u0163\u0103 cardiac\u0103 sau insuficien\u0163\u0103 renal\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

IV.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR DE COAGULARE*<\/u><\/p>\n

\u00a0<\/p>\n

* Se refer\u0103 la:<\/p>\n

1)Purpura trombocitopenic\u0103 idiopatic\u0103 (PTI)<\/p>\n

2)Sindroame hemoragice prin deficit de factori plasmatici ai coagul\u0103rii<\/p>\n

Hemofilia A \u015fi B<\/p>\n

3)Alte sindroame hemoragice prin deficit de factori plasmatici ai coagul\u0103rii<\/p>\n

4)B. Von Willebrand<\/p>\n

5)Trombofilii ereditare (primare)<\/p>\n

1.<\/strong>Purpura trombocitopenic\u0103 idiopatic\u0103 (PTI)**<\/p>\n

** a)Este un sindrom hemoragic produs prin trombocitopenie imun\u0103 datorat\u0103 anticorpilor antitrombocit\u0103ri, ceea ce produce distrugerea prematur\u0103 a trombocitelor \u00een sistemul macrofagic.<\/p>\n

b)Durata de via\u0163\u0103, \u00een majoritatea cazurilor, este normal\u0103, mortalitatea fiind mai mic\u0103 de 10%.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– S\u00e2nger\u0103ri cutaneo-mucoase;<\/p>\n

– Absen\u0163a splenomegaliei.<\/p>\n

Paraclinic:<\/p>\n

– Num\u0103r trombocite \u00een s\u00e2ngele periferic:<\/p>\n

trombocitopenie cu num\u0103r mai mare de megacariocite;<\/p>\n

– Mielograma (punc\u0163ie osoas\u0103): megacariocite normale sau crescute \u00een m\u0103duva osoas\u0103;<\/p>\n

– Determinare de anticorpi antitrombocitari;<\/p>\n

– Teste de coagulare – s\u00e2ngerare.<\/p>\n<\/td>\n

\n

Forme \u00een remisiuni cu trombocite mai mult de 150.000\/mmc.<\/p>\n<\/td>\n

\n

Forme \u00een remisiune incomplet\u0103 cu trombocite \u00eentre 70.000-150.000\/mmc.<\/p>\n<\/td>\n

\n

\u00cen formele severe cu trombocite sub 50.000\/mmc, cu s\u00e2nger\u0103ri la traume minime sau spontan.<\/p>\n<\/td>\n

\n

\u00cen formele severe cu s\u00e2nger\u0103ri \u00een SNC, cu deficit motor de tip paretic sau plegic.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

De re\u0163inut:<\/p>\n

a)la un num\u0103r de trombocite mai mare de 100.000\/mmc nu apar s\u00e2nger\u0103ri,<\/p>\n

b)\u00eentre 30.000 – 50.000\/mmc apar s\u00e2nger\u0103ri la traume minime,<\/p>\n

c)trombocite sub 30.000\/mmc – apar s\u00e2nger\u0103ri cutaneo-mucoase,<\/p>\n

d)trombocite sub 10.000\/mmc – se constituie sindromul hemoragic generalizat cu risc crescut de hemoragii \u00een SNC.<\/p>\n

2.<\/strong>Sindroame hemoragice prin deficit de factori plasmatici ai coagul\u0103rii<\/p>\n

Hemofilia A \u015fi B prin deficit de factor VIII \u015fi IX ai coagul\u0103rii<\/p>\n

A fost tratat\u0103 la Cap. 7 – Evaluarea afect\u0103rii func\u0163iilor de static\u0103, locomo\u0163ie sau\/\u015fi gestualitate – prin care devin handicapante<\/p>\n

3.<\/strong>Alte sindroame hemoragice prin deficit de factorii plasmatici ai coagul\u0103rii<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

SINDROAME HEMORAGICE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Deficit de factor I (hipo sau afibrogenemia) \u015fi deficit de factor II (hipoprotrombinemie), au de obicei o evolu\u0163ie benign\u0103;<\/p>\n

– Sindrom Owren (hipoproaccelerinemie) \u00een general benign;<\/p>\n

– Parahemofilie Alexander cu hemoragii articulare mici, pu\u0163in importante;<\/p>\n

– Deficit de factor XIII, \u00een general benign dar pot apare hemoragii intracraniene.<\/p>\n<\/td>\n

\n

\u00cen formele f\u0103r\u0103 complica\u0163ii hemoragice.<\/p>\n<\/td>\n

\n

\u00cen formele medii f\u0103r\u0103 limitarea ortostatismului, locomo\u0163iei sau\/\u015fi gestualit\u0103\u0163ii.<\/p>\n<\/td>\n

\n

\u00cen situa\u0163ia hemoragiilor intracraniene, \u00een raport de intensitatea \u015fi sechelele motorii de tip paretic sau plegic.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Boala Von Willebrand (BvW)*<\/p>\n

*a)Este o deficien\u0163a ereditar\u0103 a factorului vW cu transmitere de tip autosomal \u015fi expresie fenotipic\u0103 variabil\u0103 chiar \u015fi \u00eentre membrii acelea\u015fi familii.<\/p>\n

b)Factorul vW asigur\u0103 adeziunea plachetelor la colagenul subendotelial dezgolit, transportul \u015fi stabilitatea \u00een plasm\u0103 a factorului VIII al coagul\u0103rii (VIII C).<\/p>\n

c)Tratamentul se instituie odat\u0103 cu instalarea accidentelor hemoragice sau, profilactic, \u00een cazul unor explor\u0103ri invazive, de extrac\u0163ii dentare sau interven\u0163ii chirurgicale.<\/p>\n

d)Hemoragiile pot fi stopate prin tratament medicamentos. \u00cen cele severe se recurge la substitu\u0163ie (plasma proasp\u0103t\u0103 congelat\u0103, crioprecipitate concentrate de F VIII C \u015fi FvW).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– TS alungit;<\/p>\n

– Sc\u0103derea nivelului factorului VIII C \u015fi a factorului vW(Ag);<\/p>\n

– Deficien\u0163a agreg\u0103rii plachetare.<\/p>\n

Clinic:<\/p>\n

– evenimente hemoragice diverse cutaneo-mucoase, \u00een forme u\u015foare ale bolii;<\/p>\n

– hemartroze sau hematoame profunde, \u00een formele severe;<\/p>\n

– hemoragii severe dup\u0103 traumatisme, interven\u0163ii chirurgicale sau extrac\u0163ii dentare.<\/p>\n

NB. Intensitatea manifest\u0103rilor hemoragice poate sc\u0103dea cu v\u00e2rsta sau \u00een cursul sarcinii. Sunt \u015fi cazuri asimptomatice. Deficien\u0163a func\u0163ional\u0103 este determinat\u0103 de:<\/p>\n

– Frecven\u0163a \u015fi gravitatea manifest\u0103rilor hemoragice,<\/p>\n

– Sechelele pe care le produc,<\/p>\n

– R\u0103spunsul la tratament.<\/p>\n<\/td>\n

\n

\u00cen cazuri asimptomatice cu modific\u0103ri hematologice de mic\u0103 intensitate sau \u00een situa\u0163ia unor evenimente hemoragice muco-cutanate ce survin rar \u015fi r\u0103spund prompt la tratament.<\/p>\n<\/td>\n

\n

\u00cen formele \u00een care episoadele hemoragice survin relativ frecvent dar r\u0103spund favorabil la tratament.<\/p>\n<\/td>\n

\n

\u00cen formele cu hemoragii severe ce survin dup\u0103 traumatisme minore, \u00een hemartroze sau hematoame profunde, care necesit\u0103 tratamente substitutive prelungite.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Trombofilii ereditare (primare)*<\/p>\n

* Deficien\u0163a func\u0163ional\u0103 este determinat\u0103 de:<\/p>\n

– frecven\u0163a \u015fi intensitatea accidentului trombotic,<\/p>\n

– teritoriile venoase afectate,<\/p>\n

– manifest\u0103rile clinice specifice,<\/p>\n

– tratamentul anticoagulant de fond ce predispune la evenimente hemoragice,<\/p>\n

– sechelele induse de accidentele trombotice.<\/p>\n

\u00a0<\/p>\n

Tromboze unice sau recurente (venoase sau\/\u015fi arteriale) sau predispozi\u0163ii pentru accidente trombotice generate de o stare latent\u0103 \u015fi permanent\u0103 de hipercuagulabilitate plasmatic\u0103 de cauz\u0103 ereditar\u0103. Muta\u0163iile genetice implic\u0103:<\/p>\n

– Anomalii ale unor factori de coagulare (muta\u0163ia genei protrombinei \u015fi a genei factorului V \u015fi rezisten\u0163a la proteina C activat\u0103),<\/p>\n

– Deficien\u0163a inhibitorilor naturali ai coagul\u0103rii (proteina C, proteina S, antitrombina III s.a.), Anomalii ale lizei cheagului (disfibrinogenemia, deficien\u0163a plasmogenului \u015fi a inhibitorului s\u0103u),<\/p>\n

– Hiperhomocisteinemia.<\/p>\n

Studii popula\u0163ionale au eviden\u0163iat frecven\u0163a ridicat\u0103 a anomaliilor protrombinei, a factorilor V, a hiperhormocisteinemiei \u015fi a inhibitorilor proteinei C, proteinei S \u015fi a antitrombinei III.<\/p>\n

Transmiterea este de tip autosomal.<\/p>\n

Accidentele trombotice pot s\u0103 apar\u0103 din mic\u0103 copil\u0103rie sau la adul\u0163ii tineri.<\/p>\n

Sunt mai frecvente la hemozigo\u0163i sau la dublu heterozigo\u0163i.<\/p>\n

Pot afecta preponderent teritorii venoase profunde (cava inferioar\u0103, mezenteric\u0103, cerebrale, renale, hepatice).<\/p>\n

Factori predispozan\u0163i pentru precipitarea accidentelor vasculare sunt: sarcina, l\u0103uzia, contraceptivele orale, traumatismele sau manevrele chirurgicale laborioase.<\/p>\n

Dup\u0103 diagnostic, pacien\u0163ii trebuie anticoagula\u0163i toat\u0103 via\u0163a.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

\u00cen formele cu tromboze de intensitate redus\u0103, unice sau recurente, care nu las\u0103 sechele durabile.<\/p>\n<\/td>\n

\n

\u00cen formele cu accidente trombotice repetate, \u00een care se implic\u0103 teritorii venoase profunde, \u00een formele cu necroz\u0103 cutanat\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu accidente trombotice cu sechele durabile, \u00een special cerebrale care \u00eempiedic\u0103 autoservirea, auto\u00eengrijirea \u015fi autogospod\u0103rirea.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

V.<\/strong>EVALUAREA GRADULUI DE HANDICAP LA PERSOANELE CU TRANSPLANT MEDULAR (Status post transplant – auto sau allo transplant)<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

La formele f\u0103r\u0103 complica\u0163ii (apreciate de medicul curant).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Status post auto sau allo transplant de celule Stem hematopoetice \u00een care hematopoeza post transplant este cu deficit (grefare cu deficit). Se eviden\u0163iaz\u0103:<\/p>\n

– Trombocitopenie (u\u015foar\u0103-moderat\u0103),<\/p>\n

– Leucopenie (u\u015foar\u0103-moderat\u0103),<\/p>\n

– Anemie (u\u015foar\u0103-moderat\u0103) – care nu necesit\u0103 tratament substitutiv \u00een condi\u0163ii bazale prin hipoplazie medular\u0103 datorat\u0103 unei grefe insuficiente \u00een ceea ce prive\u015fte cantitatea de celule Stem con\u0163inute.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Status post auto sau allo transplant de celule Stem hematopoetice \u00een care exist\u0103 complica\u0163ii legate de regimul de condi\u0163ionare:<\/p>\n

– cataract\u0103 secundar\u0103 corticoterapiei \u015fi\/sau iradierii corporale totale;<\/p>\n

– complica\u0163ii neurologice tardive, secundare iradierii craniene, chimioterapiei sau neurotoxicit\u0103\u0163ii unor medicamente;<\/p>\n

– disfunc\u0163ii pulmonare, cardiace, hepatice \u015fi\/sau renale, considerate a fi secundare procedurii (tratament \u015fi\/sau regimului de condi\u0163ionare);<\/p>\n

– boala malign\u0103 a c\u0103rei apari\u0163ie poate fi legat\u0103 de procedura de transplantare (iradiere corporal\u0103 total\u0103, deficien\u0163\u0103 imun\u0103 secundar\u0103 transplantului, infec\u0163iilor, medica\u0163iei imunosupresoare);<\/p>\n

– existen\u0163a bolii de gref\u0103 contragazd\u0103, indiferent de forma \u015fi\/sau \u00eentinderea sa (organele interesate) \u00een cazul allo transplantului;<\/p>\n

– hematopoez\u0103 post transplant cu defect (grefare cu defect) cu bi- sau pancitopenie moderat\u0103\/sever\u0103 (trombocitopenie, leucopenie sau anemie) care necesit\u0103 tratament substitutiv lunar, prin hipoplazie medular\u0103 datorit\u0103 unei grefe insuficiente \u00een ceea ce prive\u015fte cantitatea de celule Stem con\u0163inute.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I*<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Locuri de munca cu solicit\u0103ri energetice de intensitate redus\u0103 \u015fi medie.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii cu condi\u0163ia monitoriz\u0103rii medicale \u015fi administr\u0103rii tratamentului adecvat alter\u0103rii sistemului hematologic.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i cu solicit\u0103ri de intensitate redus\u0103 \u015fi medie, cu program normal sau redus, f\u0103r\u0103 expunere la toxice cu ac\u0163iune pe sistemul hematopoetic, f\u0103r\u0103 risc de traumatizare fizic\u0103, f\u0103r\u0103 expunere la factori fizici nefavorabili de mediu;<\/p>\n

– Capacitatea de adaptare la efort este limitat\u0103 par\u0163ial;<\/p>\n

– Se recomand\u0103 evitarea suprasolicit\u0103rii cu activit\u0103\u0163i suplimentare la locul de munc\u0103.<\/p>\n<\/td>\n

\n

– M\u0103suri de reducere a efortului fizic prin utilizarea unor auxiliare tehnico-mecanice de ridicare \u015fi transport a greut\u0103\u0163ilor;<\/p>\n

– Adaptarea utilajului de lucru pentru a reduce solicitarea postural\u0103, gestual\u0103 \u015fi pozi\u0163ia for\u0163at\u0103 \u00een munc\u0103;<\/p>\n

– Ajustarea mediului fizic ambiant pentru a se evita expunere la un microclimat cu substan\u0163e toxice cu ac\u0163iune pe sistemul hematopoetic, cu risc de traumatizare, accidentare;<\/p>\n

– Asigurarea unui loc de munc\u0103 f\u0103r\u0103 regim impus cu posibilitatea alimenta\u0163iei frac\u0163ionate (mese mici \u015fi repetate);<\/p>\n

– Sprijin pentru monitorizarea medical\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Au \u00een general limitat\u0103 capacitatea de efectuare a unor activit\u0103\u0163i organizate datorit\u0103 capacit\u0103\u0163ii reduse de adaptare la efort;<\/p>\n

– Conservarea, \u00een cea mai mare parte, a capacit\u0103\u0163ii de autoservire \u015fi auto\u00eengrijire.<\/p>\n<\/td>\n

\n

– Sprijin pentru posibilitatea efectu\u0103rii unor activit\u0103\u0163i de colaborare pentru profesiunile cu preg\u0103tire superioar\u0103, cu rol psihoterapeutic, dup\u0103 principiul \u00abcum \u015fi c\u00e2t poate \u00bb;<\/p>\n

– Sprijin pentru monitorizarea medical\u0103 \u015fi asigurarea tratamentului, \u00een func\u0163ie de tulbur\u0103rile morfofunc\u0163ionale.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Lipsa capacit\u0103\u0163ii de a presta orice activitate profesional\u0103, indiferent de nivel de solicitare \u015fi condi\u0163iile de desf\u0103\u015furare;<\/p>\n

– Lipsa capacit\u0103\u0163ii de auto\u00eengrijire autoservire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Sprijin familial \u015fi comunitar pentru cooperarea la monitorizarea medical\u0103, la serviciile de specialitate, ambulatorii sau spitalice\u015fti;<\/p>\n

– Sprijin pentru asigurarea tratamentului substitutiv corespunz\u0103tor \u015fi urm\u0103rirea eficien\u0163ei.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Elemente valabile \u00een toate afect\u0103rile func\u0163iilor sistemului hematologic (indiferent de structura afectat\u0103)<\/p>\n

\u00a0<\/p>\n

SEC\u0162IUNEA 3: C. FUNC\u0162IILE SISTEMULUI IMUNITAR<\/em><\/p>\n

\u00a0<\/p>\n

EVALUAREA GRADULUI DE HANDICAP \u00ceN SINDROMUL IMUNODEFICITAR CRONIC DOB\u00c2NDIT*<\/u><\/p>\n

\u00a0<\/p>\n

* Se refer\u0103 la sindromul imunodeficitar cronic dob\u00e2ndit = infec\u0163ia HIV-SIDA<\/p>\n

Evaluarea deficien\u0163ei globale \u00een sindromul prin deficit imunitar dob\u00e2ndit se face dup\u0103 ultimile criterii clinico-imunologice emise de CDC (Centrul de Control al Bolilor), de la Atlanta \u00een anul 1993, pentru adul\u0163i, \u015fi \u00een anul 1994 pentru copii<\/p>\n

\u00cen evaluare trebuie avute \u00een vedere:<\/p>\n

a)stadiul clinico-imunologic al infec\u0163iei HIV-SIDA (intensitatea supresiei imunologice)<\/p>\n

b)infec\u0163iile specifice bolii SIDA – intensitatea tulbur\u0103rilor func\u0163ionale<\/p>\n

c)infec\u0163iile oportuniste grefate pe organisme f\u0103r\u0103 ap\u0103rare (rezistent\u0103 foarte sc\u0103zut\u0103 sau absent\u0103)<\/p>\n

SIDA este o problem\u0103 cu prec\u0103dere medical\u0103 \u00een ultimele faze, care timp de ani devine o problem\u0103 social\u0103, educativ\u0103, comunitar\u0103, cu largi implica\u0163ii economice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Testul infec\u0163iei HIV pozitiv (Ac anti-HIV);<\/p>\n

– Stabilirea categoriei imunologice bazat\u0103 pe num\u0103rul de limfocite CD4<\/sub>\u00a0\u015fi pe procentul acestora din totalul limfocitelor (CDC-Atlanta\/1994)<\/p>\n

– Categorii, dup\u0103 celule CD4<\/sub>\u00a0\u00b1 \/l<\/p>\n

1. = >= 500<\/p>\n

2. = 200 – 499<\/p>\n

3. = < 200 indicator celular de SIDA;<\/p>\n

– Investiga\u0163ii variate \u00een func\u0163ie de modific\u0103rile structurale specifice infec\u0163iei HIV \u015fi celor oportuniste;<\/p>\n

– Investiga\u0163ii sociale.<\/p>\n<\/td>\n

\n

\u00cen infec\u0163ia HIV asimptomatic\u0103 cu test HIV pozitiv (pentru Ac anti-HIV). Categoria A1<\/p>\n<\/td>\n

\n

\u00cen stadiul clinico-imunologic A2, infec\u0163ie HIV simptomatic\u0103 (categoria B1 \u015fi A2) cu manifest\u0103ri clinice datorit\u0103 infec\u0163iei sau sc\u0103derii imunit\u0103\u0163ii celulare, de ex:<\/p>\n

– Angiomatoz\u0103,<\/p>\n

– Candidoz\u0103 oro-faringian\u0103,<\/p>\n

– Candidoz\u0103 vulvo-vaginal\u0103,<\/p>\n

– Herpes Zoster,<\/p>\n

– Trombocitopenie idiopatic\u0103,<\/p>\n

– Boli inflamatorii pelvine.<\/p>\n<\/td>\n

\n

Formele cu deficien\u0163\u0103 global\u0103 accentuat\u0103, cu manifest\u0103ri diverse datorit\u0103 imuno-depresiei (de exemplu: candidoz\u0103, febr\u0103 mai mult de o lun\u0103 \u015fi repetat\u0103, herpes Zoster recidivant, neuropatii periferice, inflama\u0163ii sau abcese pelvine, pneumonii recurente) care se coreleaz\u0103 cu stadiile clinico-imunologice A2, B1 \u015fi B2 la adul\u0163i + confirmare de c\u0103tre laborator a infec\u0163iei HIV.<\/p>\n<\/td>\n

\n

\u00cen formele cu deficien\u0163\u0103 global\u0103 grav\u0103, cu manifest\u0103ri variate \u015fi cu evolu\u0163ie progresiv\u0103 (de exemplu:<\/p>\n

leucoencefalopatie multifocal\u0103, septicemii recurente cu salmonella netifoidic\u0103, toxoplasmoz\u0103 cerebral\u0103, sindromul de emaciere HIV, febr\u0103 continu\u0103, diaree cronic\u0103), corespunde stadiilor clinico-imunologice A3, B3, C1, C2 \u015fi C3 la adult, suprapun\u00e2ndu-se cu diagnosticul de SIDA.<\/p>\n

Este obligatorie confirmarea de c\u0103tre laborator a infec\u0163iei HIV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

NB \u00cen SIDA stadiul clinico-imunologic C3, indiferent de complica\u0163iile specifice \u015fi infec\u0163iile oportuniste este necesar\u0103 recomandarea asistentului personal sau a indemniza\u0163iei de \u00eenso\u0163itor.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Orice activitate profesional\u0103, f\u0103r\u0103 limit\u0103ri.<\/p>\n

– Capacitatea de presta\u0163ie profesional\u0103 p\u0103strat\u0103.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu necesitatea de monitorizare medical\u0103 la Serviciul de boli infec\u0163ioase pentru testare \u015fi tratament adecvat, dac\u0103 este cazul.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i profesionale cu solicitare redus\u0103, cu norm\u0103 \u00eentreag\u0103 sau jum\u0103tate de norm\u0103, \u00een condi\u0163ii de confort.<\/p>\n<\/td>\n

\n

Participare cu condi\u0163ia:<\/p>\n

– asigur\u0103rii unui loc de munc\u0103 cu solicitare redus\u0103,<\/p>\n

– dispensariz\u0103rii pentru tratament specific antiretroviral \u015fi particularizat manifest\u0103rilor.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Dupa recuperarea episodului acut sub tratament antiretroviral, activit\u0103\u0163i profesionale cu solicitare redus\u0103, cu norm\u0103 \u00eentreag\u0103 sau jum\u0103tate de norm\u0103, \u00een condi\u0163ii de confort.<\/p>\n

– Sunt accesibile, \u00een general, muncile statice, activit\u0103\u0163ile de birou\/me\u015fte\u015fug\u0103re\u015fti.<\/p>\n<\/td>\n

\n

Participare cu condi\u0163ia:<\/p>\n

– asigur\u0103rii unui loc de munc\u0103 cu solicitare redus\u0103,<\/p>\n

– dispensariz\u0103rii pentru tratament specific antiretroviral \u015fi particularizat manifest\u0103rilor.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen stadiile A3, B3, C1, C2:<\/p>\n

– dup\u0103 recuperarea episodului acut sub tratament antiretroviral \u015fi specific activit\u0103\u0163i profesionale cu solicitare redus\u0103, cu norm\u0103 \u00eentreag\u0103 sau jum\u0103tate de norm\u0103, \u00een condi\u0163ii de confort;<\/p>\n

– sunt accesibile, \u00een general, muncile statice, activit\u0103\u0163ile de birou\/me\u015fte\u015fug\u0103re\u015fti.<\/p>\n

La persoanele cu SIDA stadiul C3 – pierderea total\u0103 a capacit\u0103\u0163ii de a efectua activit\u0103\u0163i de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire din cauza tulbur\u0103rilor func\u0163ionale severe \u015fi progresive.<\/p>\n<\/td>\n

\n

\u00cen stadiile A3, B3, C1, C2: Participare cu condi\u0163ia:<\/p>\n

– asigur\u0103rii unui loc de munc\u0103 cu solicitare redus\u0103,<\/p>\n

– dispensariz\u0103rii pentru tratament specific antiretroviral \u015fi particularizat manifest\u0103rilor.<\/p>\n

Necesit\u0103 asistent personal.<\/p>\n

Supraveghere medical\u0103 permanent\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

SEC\u0162IUNEA 4: D. FUNC\u0162IILE SISTEMULUI RESPIRATOR<\/em><\/p>\n

\u00a0<\/p>\n

EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR SISTEMULUI RESPIRATOR*<\/u><\/p>\n

* 1.\u00cen afec\u0163iunile respiratorii cronice,contractate precoce (copil\u0103rie,adolescen\u0163\u0103 p\u00e2n\u0103 26 ani), care determin\u0103 tulbur\u0103ri func\u0163ionale permanente sau care risc\u0103 s\u0103 devin\u0103 permanente, de exemplu: astmul bron\u015fic, anomalii congenitale, agenezie pulmonar\u0103 par\u0163ial\u0103, BPOC, pneumopatii intersti\u0163iale fibrozante difuze, bron\u015fiectazii supura\u0163ii bronhopulmonare, tuberculoz\u0103 pulmonar\u0103 activ\u0103, tuberculoz\u0103 pulmonar\u0103 operat\u0103, sindromul post tuberculos;<\/p>\n

2.Cancerul bronho-pulmonar;<\/p>\n

3.Transplantul pulmonar.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Evaluarea ventila\u0163iei pulmonare (metoda spirografic\u0103 \u015fi pneumotahografic\u0103) = severitatea disfunc\u0163iei ventilatorii (reducere VEMS fa\u0163\u0103 de valoarea teoretic\u0103 sau sc\u0103derea ventila\u0163iei maxime);<\/p>\n

– Evaluarea global\u0103 a schimburilor gazoase (gazanaliza s\u00e2ngelui arterial, \u00een repaos \u015fi eventual \u00een condi\u0163ii de efort)**;<\/p>\n

– Aprecierea adapt\u0103rii la efort (teste de efort) = capacitatea maxim\u0103 de presta\u0163ie***;<\/p>\n

– Mecanic\u0103 pulmonar\u0103;<\/p>\n

– Pletismografie – determinarea rezisten\u0163ei la flux<\/p>\n

– Examen radiologic;<\/p>\n

– EKG;<\/p>\n

– CT,RMN (dac\u0103 este cazul);<\/p>\n

– Examen histologic (dac\u0103 este cazul).<\/p>\n<\/td>\n

\n

VEMS >= 60 %<\/p>\n

PaO2<\/sub>\u00a0<= 70 mmHg (hipoxie u\u015foar\u0103).<\/p>\n<\/td>\n

\n

VEMS 59 – 40 %<\/p>\n

PaO2<\/sub>\u00a0= 69 – 60 mmHg (hipoxie medie).<\/p>\n<\/td>\n

\n

VEMS = 40 – 30 %<\/p>\n

PaO2<\/sub>\u00a0= 59-45 mmHg<\/p>\n

PaO2<\/sub>\u00a0= 44 – 35 mmHg<\/p>\n

(sever\u0103)<\/p>\n

(hipoxie accentuat\u0103\/sever\u0103).<\/p>\n<\/td>\n

\n

VEMS = < 30 %<\/p>\n

Pa O2<\/sub>\u00a0< 35 mmHg<\/p>\n

PaCO2<\/sub>\u00a0> 70 mmHg<\/p>\n

(hipoxie grav\u0103)<\/p>\n

Hipercapnie ICC dreapt\u0103 (CPC).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Se poate determina:<\/p>\n

– presiunea par\u0163iala a O2<\/sub>\u00a0\u00een s\u00e2ngele arterial sistemic (Pa O2<\/sub>) – Valori normale: 78 – 100mmHg<\/p>\n

– presiunea par\u0163ial\u0103 a CO2<\/sub>\u00a0\u00een s\u00e2ngele arterial sistemic (Pa CO2<\/sub>) – Valori normale: 35 – 45 (\u00een medie 40 mm Hg)<\/p>\n

– satura\u0163ia O2<\/sub>\u00a0a Hb \u00een s\u00e2ngele arterial sistemic (Sa O2<\/sub>)- Valori normale = 95%<\/p>\n

*** – reducere u\u015foar\u0103 150 – 110 w<\/p>\n

– reducere medie 110 – 80 w<\/p>\n

– reducere accentuat\u0103 80 – 35 w<\/p>\n

– reducere grav\u0103 < 35w<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Se vor evita activit\u0103\u0163ile cu solicit\u0103ri energetice excesive, \u00een mediu cu varia\u0163ii termice \u015fi noxe respiratorii.<\/p>\n<\/td>\n

\n

Asigurarea unor condi\u0163ii de micro \u015fi macroclimat adecvat \u00een scopul prevenirii manifest\u0103rilor spastice bron\u015fice – agrav\u0103rii tulbur\u0103rilor func\u0163ionale \u00een func\u0163ie de structura anatomic\u0103 afectat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Capacitate redus\u0103 de adaptare la efort. Sunt indicate activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103, \u00een mediu de confort, f\u0103r\u0103 expunere la intemperii, noxe respiratorii (praf-pulberi), de exemplu: activit\u0103\u0163i de birou cu preg\u0103tire superioar\u0103 sau medie sau activit\u0103\u0163i me\u015fte\u015fug\u0103re\u015fti.<\/p>\n<\/td>\n

\n

– M\u0103suri de adaptare a locului de munc\u0103 pentru a reduce efortul fizic necesar;<\/p>\n

– Preocupare pentru ameliorarea microclimatului profesional \u00een cazul existen\u0163ei unor factori nefavorabili la locul de munc\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Sunt indicate activit\u0103\u0163i statice cu solicitare fizic\u0103 redus\u0103.<\/p>\n

– Este limitat\u0103 major capacitatea de adaptare la efort fizic datorit\u0103 hipoxiei.<\/p>\n

– Se vor evita expunerea la micro sau macroclimat necorespunz\u0103tor, deplas\u0103rile posturale pe distan\u0163e mari sau urcarea de trepte, care implic\u0103 efort \u015fi agraveaz\u0103 insuficien\u0163a respiratorie.<\/p>\n<\/td>\n

\n

Este necesar\u0103:<\/p>\n

– diminuarea efortului fizic prin mijloace auxiliare tehnico-mecanice de ridicare \u015fi transportare a greut\u0103\u0163ilor;<\/p>\n

– asigurarea unor condi\u0163ii de micro \u015fi macroclimat corespunz\u0103tor, f\u0103r\u0103 noxe respiratorii – mediu uscat, umed, rece, cu varia\u0163ii termice, cu praf (pulberi nocive bronho-pulmonare);<\/p>\n

– sprijin, din partea agen\u0163ilor economici, pentru monitorizare medical\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Lipse\u015fte \u00een totalitate sau aproape \u00een totalitate capacitatea de autoservire \u015fi auto\u00eengrijire din cauza insuficien\u0163ei respiratorii manifeste\/severe \u015fi complica\u0163iilor secundare (CPC), neinfluen\u0163ate de ac\u0163iunile recuperatorii particularizate structurii respiratorii afectate.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Trebuie s\u0103 se asigure oxigenoterapia permanent\u0103 (dac\u0103 este cazul).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a05:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0SISTEMULUI<\/strong>\u00a0DIGESTIV,<\/strong>\u00a0METABOLIC<\/strong>\u00a0\u015eI<\/strong>\u00a0ENDOCRIN<\/strong><\/p>\n

I.<\/strong>_<\/p>\n

a)<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA UNOR FUNC\u0162II ALE SISTEMULUI DIGESTIV (DE DIGESTIE, SECRE\u0162IE, ABSORB\u0162IE-ASIMILA\u0162IE)*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

– unele tumori maligne ale tubului digestiv, operabile sau neoperabile:<\/p>\n

Gastrectomie larg\u0103 pentru ADK cu gastrostom\u0103;<\/p>\n

TM oro-faringo-esofago-gastrice sau ale unor segmente intestinale inoperabile sau \u00een faze de generalizare.<\/p>\n

Rezec\u0163ia unor segmente intestinale pentru TM cu colostom\u0103, anus iliac, sigma anus sau anus contra lateralis (definitive),<\/p>\n

– pancreatectomie par\u0163ial\u0103 sau total\u0103 pentru TM,<\/p>\n

– stenoze esofagiene str\u00e2nse, de cauz\u0103 divers\u0103, care necesit\u0103 dilata\u0163ii, esofagoplastii, protezare, gastrostom\u0103 pentru alimenta\u0163ie.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Indicele ponderal (starea de nutri\u0163ie)***;<\/p>\n

– Hemograma (Hb gr%);<\/p>\n

– Evaluarea malabsorb\u0163iei:<\/p>\n

– Proteinemie,<\/p>\n

– Ionograma,<\/p>\n

– Glicemie,<\/p>\n

– Amilazemie,<\/p>\n

– Amilazurie;<\/p>\n

– Ecografie abdominal\u0103;<\/p>\n

– Examen radiologic gastro-duodeno-intestinal;<\/p>\n

– Endoscopie eso-gastro-jejunala (eventual cu biopsie ecoghidat\u0103);<\/p>\n

– Colonosigmoidoscopie;<\/p>\n

– Rectoscopie;<\/p>\n

– Irigografie;<\/p>\n

– CT-RMN;<\/p>\n

– Examen histopatologic.<\/p>\n<\/td>\n

\n

– Denutri\u0163ie cu deficit ponderal \u00eentre 20-25%;<\/p>\n

– Anemie u\u015foar\u0103.<\/p>\n<\/td>\n

\n

– Sindrom de malabsorb\u0163ie cu deficit ponderal \u00eentre 25-30%;<\/p>\n

– Anemie cu Hb \u00eentre 7-10 gr%.<\/p>\n<\/td>\n

\n

– Anemie sever\u0103 (sub 7 gr%Hb);<\/p>\n

– Deregl\u0103ri severe de resorb\u0163ie, malabsorb\u0163ie-malasimila\u0163ie, cu denutri\u0163ie peste 30%;<\/p>\n<\/td>\n

\n

– Anemie sever\u0103 (sub 7 gr. Hb %) rezisten\u0163\u0103 la tratament;<\/p>\n

– Stare de casexie (malabsorb\u0163ie \u015fi malasimila\u0163ie progresiv\u0103 \u015fi sever\u0103).<\/p>\n<\/td>\n<\/tr>\n

\n

\u00cen stenozele esofagiene confirmate radiologic, cu manifest\u0103rile de mai sus care nu se remit complet la tratament (dilata\u0163ii) \u015fi necesit\u0103 tratament chirurgical.<\/p>\n

Pentru perioade limitate, p\u00e2n\u0103 la recuperare cu restabilirea tulbur\u0103rilor de nutri\u0163ie.<\/p>\n<\/td>\n

\n

\u00cen stenozele esofagiene str\u00e2nse cu gastrostrom\u0103; TM gastrice cu gastrostrom\u0103 pentru alimenta\u0163ie;<\/p>\n

TM de colon, rect, sigmoid \u015fi alte segmente intestinale cu colostom\u0103;<\/p>\n

Cancerul pancreatic cu rezec\u0163ii par\u0163iale sau totale, \u00een tratament de substitu\u0163ie.<\/p>\n<\/td>\n

\n

\u00cen tumorile maligne inoperabile sau operabile cu recidive loco-regionale sau \u00een faze de generalizare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Parametrii func\u0163ionali se vor selecta \u00een raport de segmentul de tub digestiv afectat, modific\u0103rile morfologice \u015fi biochimice induse, precum \u015fi de datele antropometrice \u00een func\u0163ie de care se stabile\u015fte echilibrul ponderal.<\/p>\n

*** Indicele ponderal ideal se stabile\u015fte dup\u0103 formula Lorencz: X = A cm – 100 – (Acm – 150)\/4, unde Acm = \u00een\u0103l\u0163imea individului \u00een cm.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Independen\u0163a \u00een exercitarea activit\u0103\u0163ilor profesionale<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i f\u0103r\u0103 efort fizic mare, \u00een mediu f\u0103r\u0103 varia\u0163ii de temperatur\u0103 precum \u015fi f\u0103r\u0103 substan\u0163e toxice digestive, \u00een ritm liber.<\/p>\n<\/td>\n

\n

– Asigurarea unor locuri de munc\u0103 f\u0103r\u0103 efort fizic mare, f\u0103r\u0103 expuneri la un micro sau macroclimat necorespunz\u0103tor;<\/p>\n

– Asigurarea unor pauze pentru hr\u0103nire.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 efort fizic, \u00een mediu f\u0103r\u0103 varia\u0163ii de temperatur\u0103, precum \u015fi f\u0103r\u0103 substan\u0163e toxice digestive, \u00een ritm liber;<\/p>\n

– Activit\u0103\u0163i care nu impun deplas\u0103ri posturale, mers pe plan \u00eenclinat.<\/p>\n<\/td>\n

\n

– M\u0103suri de reducere a efortului fizic \u015fi de evitare a activit\u0103\u0163ii \u00een mediu nefavorabil, \u00een scopul prevenirii agrav\u0103rilor;<\/p>\n

– M\u0103suri pentru ajustarea mediului ambiant fizic;<\/p>\n

– Regim de munc\u0103 adecvat pentru asigurarea meselor frac\u0163ionate;<\/p>\n

– M\u0103suri igienico-sanitare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Necesit\u0103 ajutor periodic pentru igiena corporal\u0103, autoservire \u015fi pentru activit\u0103\u0163ile de zi cu zi.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Ajutor pentru activit\u0103\u0163ile cotidiene (autogospod\u0103rire) pentru perioade variabile, \u00een func\u0163ie de evolu\u0163ie, agravarea structurilor afectate, r\u0103spunsul la tratament, cooperarea la ac\u0163iunile medico-sociale de recuperare;<\/p>\n

– Asigurarea de pungi speciale pentru persoanele cu gastrostom\u0103, colostom\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR HEPATICE*<\/p>\n

* Se refer\u0103 la: afec\u0163iuni cronice hepatice indiferent de etiologie:<\/p>\n

– hepatite cronice \u015fi ciroze hepatice – contractate precoce (copil\u0103rie adolescen\u0163\u0103 p\u00e2n\u0103 la 26 ani)<\/p>\n

– cancer hepatic primar sau secundar,<\/p>\n

– transplant hepatic total sau par\u0163ial.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Anamnez\u0103;<\/p>\n

– Examen clinic;<\/p>\n

– Ecografie abdominal\u0103; – (Ex radiologic esofagian);<\/p>\n

– Ex endoscopic;<\/p>\n

– CT-RMN;<\/p>\n

– Punc\u0163ie bioptic\u0103 hepatic\u0103;<\/p>\n

– Ex histopatologic;<\/p>\n

– Hemogram\u0103 complet\u0103;<\/p>\n

– Indice de protrombin\u0103; – Electroforez\u0103, imunelectroforez\u0103, prezen\u0163a de anticorpi,ele periferic:<\/p>\n

trombocitopenie cu num\u0103r mai mare de megacariocite;<\/p>\n

– Mielograma (punc\u0163ie osoas\u0103): megacariocite normale sau crescute \u00een m\u0103duva osoas\u0103;<\/p>\n

– Determinare de anticorpi antitrombocitari;<\/p>\n

– Teste de coagulare – s\u00e2ngerare.<\/p>\n<\/td>\n

\n

Forme \u00een remisiuni cu trombocite mai mult de 150.000\/mmc.<\/p>\n<\/td>\n

\n

Forme \u00een remisiune incomplet\u0103 cu trombocite \u00eentre 70.000-150.000\/mmc.<\/p>\n<\/td>\n

\n

\u00cen formele severe cu trombocite sub 50.000\/mmc, cu s\u00e2nger\u0103ri la traume minime sau spontan.<\/p>\n<\/td>\n

\n

\u00cen formele severe cu s\u00e2nger\u0103ri \u00een SNC, cu deficit motor de tip paretic sau plegic.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

De re\u0163inut:<\/p>\n

a)la un num\u0103r de trombocite mai mare de 100.000\/mmc nu apar s\u00e2nger\u0103ri,<\/p>\n

b)\u00eentre 30.000 – 50.000\/mmc apar s\u00e2nger\u0103ri la traume minime,<\/p>\n

c)trombocite sub 30.000\/mmc – apar s\u00e2nger\u0103ri cutaneo-mucoase,<\/p>\n

d)trombocite sub 10.000\/mmc – se constituie sindromul hemoragic generalizat cu risc crescut de hemoragii \u00een SNC.<\/p>\n

2.<\/strong>Sindroame hemoragice prin deficit de factori plasmatici ai coagul\u0103rii<\/p>\n

Hemofilia A \u015fi B prin deficit de factor VIII \u015fi IX ai coagul\u0103rii<\/p>\n

A fost tratat\u0103 la Cap. 7 – Evaluarea afect\u0103rii func\u0163iilor de static\u0103, locomo\u0163ie sau\/\u015fi gestualitate – prin care devin handicapante<\/p>\n

3.<\/strong>Alte sindroame hemoragice prin deficit de factorii plasmatici ai coagul\u0103rii<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

SINDROAME HEMORAGICE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Deficit de factor I (hipo sau afibrogenemia) \u015fi deficit de factor II (hipoprotrombinemie), au de obicei o evolu\u0163ie benign\u0103;<\/p>\n

– Sindrom Owren (hipoproaccelerinemie) \u00een general benign;<\/p>\n

– Parahemofilie Alexander cu hemoragii articulare mici, pu\u0163in importante;<\/p>\n

– Deficit de factor XIII, \u00een general benign dar pot apare hemoragii intracraniene.<\/p>\n<\/td>\n

\n

\u00cen formele f\u0103r\u0103 complica\u0163ii hemoragice.<\/p>\n<\/td>\n

\n

\u00cen formele medii f\u0103r\u0103 limitarea ortostatismului, locomo\u0163iei sau\/\u015fi gestualit\u0103\u0163ii.<\/p>\n<\/td>\n

\n

\u00cen situa\u0163ia hemoragiilor intracraniene, \u00een raport de intensitatea \u015fi sechelele motorii de tip paretic sau plegic.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Boala Von Willebrand (BvW)*<\/p>\n

*a)Este o deficien\u0163a ereditar\u0103 a factorului vW cu transmitere de tip autosomal \u015fi expresie fenotipic\u0103 variabil\u0103 chiar \u015fi \u00eentre membrii acelea\u015fi familii.<\/p>\n

b)Factorul vW asigur\u0103 adeziunea plachetelor la colagenul subendotelial dezgolit, transportul \u015fi stabilitatea \u00een plasm\u0103 a factorului VIII al coagul\u0103rii (VIII C).<\/p>\n

c)Tratamentul se instituie odat\u0103 cu instalarea accidentelor hemoragice sau, profilactic, \u00een cazul unor explor\u0103ri invazive, de extrac\u0163ii dentare sau interven\u0163ii chirurgicale.<\/p>\n

d)Hemoragiile pot fi stopate prin tratament medicamentos. \u00cen cele severe se recurge la substitu\u0163ie (plasma proasp\u0103t\u0103 congelat\u0103, crioprecipitate concentrate de F VIII C \u015fi FvW).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

– TS alungit;<\/p>\n

– Sc\u0103derea nivelului factorului VIII C \u015fi a factorului vW(Ag);<\/p>\n

– Deficien\u0163a agreg\u0103rii plachetare.<\/p>\n

Clinic:<\/p>\n

– evenimente hemoragice diverse cutaneo-mucoase, \u00een forme u\u015foare ale bolii;<\/p>\n

– hemartroze sau hematoame profunde, \u00een formele severe;<\/p>\n

– hemoragii severe dup\u0103 traumatisme, interven\u0163ii chirurgicale sau extrac\u0163ii dentare.<\/p>\n

NB. Intensitatea manifest\u0103rilor hemoragice poate sc\u0103dea cu v\u00e2rsta sau \u00een cursul sarcinii. Sunt \u015fi cazuri asimptomatice. Deficien\u0163a func\u0163ional\u0103 este determinat\u0103 de:<\/p>\n

– Frecven\u0163a \u015fi gravitatea manifest\u0103rilor hemoragice,<\/p>\n

– Sechelele pe care le produc,<\/p>\n

– R\u0103spunsul la tratament.<\/p>\n<\/td>\n

\n

\u00cen cazuri asimptomatice cu modific\u0103ri hematologice de mic\u0103 intensitate sau \u00een situa\u0163ia unor evenimente hemoragice muco-cutanate ce survin rar \u015fi r\u0103spund prompt la tratament.<\/p>\n<\/td>\n

\n

\u00cen formele \u00een care episoadele hemoragice survin relativ frecvent dar r\u0103spund favorabil la tratament.<\/p>\n<\/td>\n

\n

\u00cen formele cu hemoragii severe ce survin dup\u0103 traumatisme minore, \u00een hemartroze sau hematoame profunde, care necesit\u0103 tratamente substitutive prelungite.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Trombofilii ereditare (primare)*<\/p>\n

* Deficien\u0163a func\u0163ional\u0103 este determinat\u0103 de:<\/p>\n

– frecven\u0163a \u015fi intensitatea accidentului trombotic,<\/p>\n

– teritoriile venoase afectate,<\/p>\n

– manifest\u0103rile clinice specifice,<\/p>\n

– tratamentul anticoagulant de fond ce predispune la evenimente hemoragice,<\/p>\n

– sechelele induse de accidentele trombotice.<\/p>\n

\u00a0<\/p>\n

Tromboze unice sau recurente (venoase sau\/\u015fi arteriale) sau predispozi\u0163ii pentru accidente trombotice generate de o stare latent\u0103 \u015fi permanent\u0103 de hipercuagulabilitate plasmatic\u0103 de cauz\u0103 ereditar\u0103. Muta\u0163iile genetice implic\u0103:<\/p>\n

– Anomalii ale unor factori de coagulare (muta\u0163ia genei protrombinei \u015fi a genei factorului V \u015fi rezisten\u0163a la proteina C activat\u0103),<\/p>\n

– Deficien\u0163a inhibitorilor naturali ai coagul\u0103rii (proteina C, proteina S, antitrombina III s.a.), Anomalii ale lizei cheagului (disfibrinogenemia, deficien\u0163a plasmogenului \u015fi a inhibitorului s\u0103u),<\/p>\n

– Hiperhomocisteinemia.<\/p>\n

Studii popula\u0163ionale au eviden\u0163iat frecven\u0163a ridicat\u0103 a anomaliilor protrombinei, a factorilor V, a hiperhormocisteinemiei \u015fi a inhibitorilor proteinei C, proteinei S \u015fi a antitrombinei III.<\/p>\n

Transmiterea este de tip autosomal.<\/p>\n

Accidentele trombotice pot s\u0103 apar\u0103 din mic\u0103 copil\u0103rie sau la adul\u0163ii tineri.<\/p>\n

Sunt mai frecvente la hemozigo\u0163i sau la dublu heterozigo\u0163i.<\/p>\n

Pot afecta preponderent teritorii venoase profunde (cava inferioar\u0103, mezenteric\u0103, cerebrale, renale, hepatice).<\/p>\n

Factori predispozan\u0163i pentru precipitarea accidentelor vasculare sunt: sarcina, l\u0103uzia, contraceptivele orale, traumatismele sau manevrele chirurgicale laborioase.<\/p>\n

Dup\u0103 diagnostic, pacien\u0163ii trebuie anticoagula\u0163i toat\u0103 via\u0163a.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

\u00cen formele cu tromboze de intensitate redus\u0103, unice sau recurente, care nu las\u0103 sechele durabile.<\/p>\n<\/td>\n

\n

\u00cen formele cu accidente trombotice repetate, \u00een care se implic\u0103 teritorii venoase profunde, \u00een formele cu necroz\u0103 cutanat\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cu accidente trombotice cu sechele durabile, \u00een special cerebrale care \u00eempiedic\u0103 autoservirea, auto\u00eengrijirea \u015fi autogospod\u0103rirea.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

V.<\/strong>EVALUAREA GRADULUI DE HANDICAP LA PERSOANELE CU TRANSPLANT MEDULAR (Status post transplant – auto sau allo transplant)<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

La formele f\u0103r\u0103 complica\u0163ii (apreciate de medicul curant).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Status post auto sau allo transplant de celule Stem hematopoetice \u00een care hematopoeza post transplant este cu deficit (grefare cu deficit). Se eviden\u0163iaz\u0103:<\/p>\n

– Trombocitopenie (u\u015foar\u0103-moderat\u0103),<\/p>\n

– Leucopenie (u\u015foar\u0103-moderat\u0103),<\/p>\n

– Anemie (u\u015foar\u0103-moderat\u0103) – care nu necesit\u0103 tratament substitutiv \u00een condi\u0163ii bazale prin hipoplazie medular\u0103 datorat\u0103 unei grefe insuficiente \u00een ceea ce prive\u015fte cantitatea de celule Stem con\u0163inute.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Status post auto sau allo transplant de celule Stem hematopoetice \u00een care exist\u0103 complica\u0163ii legate de regimul de condi\u0163ionare:<\/p>\n

– cataract\u0103 secundar\u0103 corticoterapiei \u015fi\/sau iradierii corporale totale;<\/p>\n

– complica\u0163ii neurologice tardive, secundare iradierii craniene, chimioterapiei sau neurotoxicit\u0103\u0163ii unor medicamente;<\/p>\n

– disfunc\u0163ii pulmonare, cardiace, hepatice \u015fi\/sau renale, considerate a fi secundare procedurii (tratament \u015fi\/sau regimului de condi\u0163ionare);<\/p>\n

– boala malign\u0103 a c\u0103rei apari\u0163ie poate fi legat\u0103 de procedura de transplantare (iradiere corporal\u0103 total\u0103, deficien\u0163\u0103 imun\u0103 secundar\u0103 transplantului, infec\u0163iilor, medica\u0163iei imunosupresoare);<\/p>\n

– existen\u0163a bolii de gref\u0103 contragazd\u0103, indiferent de forma \u015fi\/sau \u00eentinderea sa (organele interesate) \u00een cazul allo transplantului;<\/p>\n

– hematopoez\u0103 post transplant cu defect (grefare cu defect) cu bi- sau pancitopenie moderat\u0103\/sever\u0103 (trombocitopenie, leucopenie sau anemie) care necesit\u0103 tratament substitutiv lunar, prin hipoplazie medular\u0103 datorit\u0103 unei grefe insuficiente \u00een ceea ce prive\u015fte cantitatea de celule Stem con\u0163inute.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I*<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Locuri de munca cu solicit\u0103ri energetice de intensitate redus\u0103 \u015fi medie.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii cu condi\u0163ia monitoriz\u0103rii medicale \u015fi administr\u0103rii tratamentului adecvat alter\u0103rii sistemului hematologic.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i cu solicit\u0103ri de intensitate redus\u0103 \u015fi medie, cu program normal sau redus, f\u0103r\u0103 expunere la toxice cu ac\u0163iune pe sistemul hematopoetic, f\u0103r\u0103 risc de traumatizare fizic\u0103, f\u0103r\u0103 expunere la factori fizici nefavorabili de mediu;<\/p>\n

– Capacitatea de adaptare la efort este limitat\u0103 par\u0163ial;<\/p>\n

– Se recomand\u0103 evitarea suprasolicit\u0103rii cu activit\u0103\u0163i suplimentare la locul de munc\u0103.<\/p>\n<\/td>\n

\n

– M\u0103suri de reducere a efortului fizic prin utilizarea unor auxiliare tehnico-mecanice de ridicare \u015fi transport a greut\u0103\u0163ilor;<\/p>\n

– Adaptarea utilajului de lucru pentru a reduce solicitarea postural\u0103, gestual\u0103 \u015fi pozi\u0163ia for\u0163at\u0103 \u00een munc\u0103;<\/p>\n

– Ajustarea mediului fizic ambiant pentru a se evita expunere la un microclimat cu substan\u0163e toxice cu ac\u0163iune pe sistemul hematopoetic, cu risc de traumatizare, accidentare;<\/p>\n

– Asigurarea unui loc de munc\u0103 f\u0103r\u0103 regim impus cu posibilitatea alimenta\u0163iei frac\u0163ionate (mese mici \u015fi repetate);<\/p>\n

– Sprijin pentru monitorizarea medical\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Au \u00een general limitat\u0103 capacitatea de efectuare a unor activit\u0103\u0163i organizate datorit\u0103 capacit\u0103\u0163ii reduse de adaptare la efort;<\/p>\n

– Conservarea, \u00een cea mai mare parte, a capacit\u0103\u0163ii de autoservire \u015fi auto\u00eengrijire.<\/p>\n<\/td>\n

\n

– Sprijin pentru posibilitatea efectu\u0103rii unor activit\u0103\u0163i de colaborare pentru profesiunile cu preg\u0103tire superioar\u0103, cu rol psihoterapeutic, dup\u0103 principiul \u00abcum \u015fi c\u00e2t poate \u00bb;<\/p>\n

– Sprijin pentru monitorizarea medical\u0103 \u015fi asigurarea tratamentului, \u00een func\u0163ie de tulbur\u0103rile morfofunc\u0163ionale.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Lipsa capacit\u0103\u0163ii de a presta orice activitate profesional\u0103, indiferent de nivel de solicitare \u015fi condi\u0163iile de desf\u0103\u015furare;<\/p>\n

– Lipsa capacit\u0103\u0163ii de auto\u00eengrijire autoservire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Sprijin familial \u015fi comunitar pentru cooperarea la monitorizarea medical\u0103, la serviciile de specialitate, ambulatorii sau spitalice\u015fti;<\/p>\n

– Sprijin pentru asigurarea tratamentului substitutiv corespunz\u0103tor \u015fi urm\u0103rirea eficien\u0163ei.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Elemente valabile \u00een toate afect\u0103rile func\u0163iilor sistemului hematologic (indiferent de structura afectat\u0103)<\/p>\n

\u00a0<\/p>\n

SEC\u0162IUNEA 3: C. FUNC\u0162IILE SISTEMULUI IMUNITAR<\/em><\/p>\n

\u00a0<\/p>\n

EVALUAREA GRADULUI DE HANDICAP \u00ceN SINDROMUL IMUNODEFICITAR CRONIC DOB\u00c2NDIT*<\/u><\/p>\n

\u00a0<\/p>\n

* Se refer\u0103 la sindromul imunodeficitar cronic dob\u00e2ndit = infec\u0163ia HIV-SIDA<\/p>\n

Evaluarea deficien\u0163ei globale \u00een sindromul prin deficit imunitar dob\u00e2ndit se face dup\u0103 ultimile criterii clinico-imunologice emise de CDC (Centrul de Control al Bolilor), de la Atlanta \u00een anul 1993, pentru adul\u0163i, \u015fi \u00een anul 1994 pentru copii<\/p>\n

\u00cen evaluare trebuie avute \u00een vedere:<\/p>\n

a)stadiul clinico-imunologic al infec\u0163iei HIV-SIDA (intensitatea supresiei imunologice)<\/p>\n

b)infec\u0163iile specifice bolii SIDA – intensitatea tulbur\u0103rilor func\u0163ionale<\/p>\n

c)infec\u0163iile oportuniste grefate pe organisme f\u0103r\u0103 ap\u0103rare (rezistent\u0103 foarte sc\u0103zut\u0103 sau absent\u0103)<\/p>\n

SIDA este o problem\u0103 cu prec\u0103dere medical\u0103 \u00een ultimele faze, care timp de ani devine o problem\u0103 social\u0103, educativ\u0103, comunitar\u0103, cu largi implica\u0163ii economice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Testul infec\u0163iei HIV pozitiv (Ac anti-HIV);<\/p>\n

– Stabilirea categoriei imunologice bazat\u0103 pe num\u0103rul de limfocite CD4<\/sub>\u00a0\u015fi pe procentul acestora din totalul limfocitelor (CDC-Atlanta\/1994)<\/p>\n

– Categorii, dup\u0103 celule CD4<\/sub>\u00a0\u00b1 \/l<\/p>\n

1. = >= 500<\/p>\n

2. = 200 – 499<\/p>\n

3. = < 200 indicator celular de SIDA;<\/p>\n

– Investiga\u0163ii variate \u00een func\u0163ie de modific\u0103rile structurale specifice infec\u0163iei HIV \u015fi celor oportuniste;<\/p>\n

– Investiga\u0163ii sociale.<\/p>\n<\/td>\n

\n

\u00cen infec\u0163ia HIV asimptomatic\u0103 cu test HIV pozitiv (pentru Ac anti-HIV). Categoria A1<\/p>\n<\/td>\n

\n

\u00cen stadiul clinico-imunologic A2, infec\u0163ie HIV simptomatic\u0103 (categoria B1 \u015fi A2) cu manifest\u0103ri clinice datorit\u0103 infec\u0163iei sau sc\u0103derii imunit\u0103\u0163ii celulare, de ex:<\/p>\n

– Angiomatoz\u0103,<\/p>\n

– Candidoz\u0103 oro-faringian\u0103,<\/p>\n

– Candidoz\u0103 vulvo-vaginal\u0103,<\/p>\n

– Herpes Zoster,<\/p>\n

– Trombocitopenie idiopatic\u0103,<\/p>\n

– Boli inflamatorii pelvine.<\/p>\n<\/td>\n

\n

Formele cu deficien\u0163\u0103 global\u0103 accentuat\u0103, cu manifest\u0103ri diverse datorit\u0103 imuno-depresiei (de exemplu: candidoz\u0103, febr\u0103 mai mult de o lun\u0103 \u015fi repetat\u0103, herpes Zoster recidivant, neuropatii periferice, inflama\u0163ii sau abcese pelvine, pneumonii recurente) care se coreleaz\u0103 cu stadiile clinico-imunologice A2, B1 \u015fi B2 la adul\u0163i + confirmare de c\u0103tre laborator a infec\u0163iei HIV.<\/p>\n<\/td>\n

\n

\u00cen formele cu deficien\u0163\u0103 global\u0103 grav\u0103, cu manifest\u0103ri variate \u015fi cu evolu\u0163ie progresiv\u0103 (de exemplu:<\/p>\n

leucoencefalopatie multifocal\u0103, septicemii recurente cu salmonella netifoidic\u0103, toxoplasmoz\u0103 cerebral\u0103, sindromul de emaciere HIV, febr\u0103 continu\u0103, diaree cronic\u0103), corespunde stadiilor clinico-imunologice A3, B3, C1, C2 \u015fi C3 la adult, suprapun\u00e2ndu-se cu diagnosticul de SIDA.<\/p>\n

Este obligatorie confirmarea de c\u0103tre laborator a infec\u0163iei HIV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

NB \u00cen SIDA stadiul clinico-imunologic C3, indiferent de complica\u0163iile specifice \u015fi infec\u0163iile oportuniste este necesar\u0103 recomandarea asistentului personal sau a indemniza\u0163iei de \u00eenso\u0163itor.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Orice activitate profesional\u0103, f\u0103r\u0103 limit\u0103ri.<\/p>\n

– Capacitatea de presta\u0163ie profesional\u0103 p\u0103strat\u0103.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu necesitatea de monitorizare medical\u0103 la Serviciul de boli infec\u0163ioase pentru testare \u015fi tratament adecvat, dac\u0103 este cazul.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i profesionale cu solicitare redus\u0103, cu norm\u0103 \u00eentreag\u0103 sau jum\u0103tate de norm\u0103, \u00een condi\u0163ii de confort.<\/p>\n<\/td>\n

\n

Participare cu condi\u0163ia:<\/p>\n

– asigur\u0103rii unui loc de munc\u0103 cu solicitare redus\u0103,<\/p>\n

– dispensariz\u0103rii pentru tratament specific antiretroviral \u015fi particularizat manifest\u0103rilor.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Dupa recuperarea episodului acut sub tratament antiretroviral, activit\u0103\u0163i profesionale cu solicitare redus\u0103, cu norm\u0103 \u00eentreag\u0103 sau jum\u0103tate de norm\u0103, \u00een condi\u0163ii de confort.<\/p>\n

– Sunt accesibile, \u00een general, muncile statice, activit\u0103\u0163ile de birou\/me\u015fte\u015fug\u0103re\u015fti.<\/p>\n<\/td>\n

\n

Participare cu condi\u0163ia:<\/p>\n

– asigur\u0103rii unui loc de munc\u0103 cu solicitare redus\u0103,<\/p>\n

– dispensariz\u0103rii pentru tratament specific antiretroviral \u015fi particularizat manifest\u0103rilor.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen stadiile A3, B3, C1, C2:<\/p>\n

– dup\u0103 recuperarea episodului acut sub tratament antiretroviral \u015fi specific activit\u0103\u0163i profesionale cu solicitare redus\u0103, cu norm\u0103 \u00eentreag\u0103 sau jum\u0103tate de norm\u0103, \u00een condi\u0163ii de confort;<\/p>\n

– sunt accesibile, \u00een general, muncile statice, activit\u0103\u0163ile de birou\/me\u015fte\u015fug\u0103re\u015fti.<\/p>\n

La persoanele cu SIDA stadiul C3 – pierderea total\u0103 a capacit\u0103\u0163ii de a efectua activit\u0103\u0163i de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire din cauza tulbur\u0103rilor func\u0163ionale severe \u015fi progresive.<\/p>\n<\/td>\n

\n

\u00cen stadiile A3, B3, C1, C2: Participare cu condi\u0163ia:<\/p>\n

– asigur\u0103rii unui loc de munc\u0103 cu solicitare redus\u0103,<\/p>\n

– dispensariz\u0103rii pentru tratament specific antiretroviral \u015fi particularizat manifest\u0103rilor.<\/p>\n

Necesit\u0103 asistent personal.<\/p>\n

Supraveghere medical\u0103 permanent\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

SEC\u0162IUNEA 4: D. FUNC\u0162IILE SISTEMULUI RESPIRATOR<\/em><\/p>\n

\u00a0<\/p>\n

EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR SISTEMULUI RESPIRATOR*<\/u><\/p>\n

* 1.\u00cen afec\u0163iunile respiratorii cronice,contractate precoce (copil\u0103rie,adolescen\u0163\u0103 p\u00e2n\u0103 26 ani), care determin\u0103 tulbur\u0103ri func\u0163ionale permanente sau care risc\u0103 s\u0103 devin\u0103 permanente, de exemplu: astmul bron\u015fic, anomalii congenitale, agenezie pulmonar\u0103 par\u0163ial\u0103, BPOC, pneumopatii intersti\u0163iale fibrozante difuze, bron\u015fiectazii supura\u0163ii bronhopulmonare, tuberculoz\u0103 pulmonar\u0103 activ\u0103, tuberculoz\u0103 pulmonar\u0103 operat\u0103, sindromul post tuberculos;<\/p>\n

2.Cancerul bronho-pulmonar;<\/p>\n

3.Transplantul pulmonar.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Evaluarea ventila\u0163iei pulmonare (metoda spirografic\u0103 \u015fi pneumotahografic\u0103) = severitatea disfunc\u0163iei ventilatorii (reducere VEMS fa\u0163\u0103 de valoarea teoretic\u0103 sau sc\u0103derea ventila\u0163iei maxime);<\/p>\n

– Evaluarea global\u0103 a schimburilor gazoase (gazanaliza s\u00e2ngelui arterial, \u00een repaos \u015fi eventual \u00een condi\u0163ii de efort)**;<\/p>\n

– Aprecierea adapt\u0103rii la efort (teste de efort) = capacitatea maxim\u0103 de presta\u0163ie***;<\/p>\n

– Mecanic\u0103 pulmonar\u0103;<\/p>\n

– Pletismografie – determinarea rezisten\u0163ei la flux<\/p>\n

– Examen radiologic;<\/p>\n

– EKG;<\/p>\n

– CT,RMN (dac\u0103 este cazul);<\/p>\n

– Examen histologic (dac\u0103 este cazul).<\/p>\n<\/td>\n

\n

VEMS >= 60 %<\/p>\n

PaO2<\/sub>\u00a0<= 70 mmHg (hipoxie u\u015foar\u0103).<\/p>\n<\/td>\n

\n

VEMS 59 – 40 %<\/p>\n

PaO2<\/sub>\u00a0= 69 – 60 mmHg (hipoxie medie).<\/p>\n<\/td>\n

\n

VEMS = 40 – 30 %<\/p>\n

PaO2<\/sub>\u00a0= 59-45 mmHg<\/p>\n

PaO2<\/sub>\u00a0= 44 – 35 mmHg<\/p>\n

(sever\u0103)<\/p>\n

(hipoxie accentuat\u0103\/sever\u0103).<\/p>\n<\/td>\n

\n

VEMS = < 30 %<\/p>\n

Pa O2<\/sub>\u00a0< 35 mmHg<\/p>\n

PaCO2<\/sub>\u00a0> 70 mmHg<\/p>\n

(hipoxie grav\u0103)<\/p>\n

Hipercapnie ICC dreapt\u0103 (CPC).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Se poate determina:<\/p>\n

– presiunea par\u0163iala a O2<\/sub>\u00a0\u00een s\u00e2ngele arterial sistemic (Pa O2<\/sub>) – Valori normale: 78 – 100mmHg<\/p>\n

– presiunea par\u0163ial\u0103 a CO2<\/sub>\u00a0\u00een s\u00e2ngele arterial sistemic (Pa CO2<\/sub>) – Valori normale: 35 – 45 (\u00een medie 40 mm Hg)<\/p>\n

– satura\u0163ia O2<\/sub>\u00a0a Hb \u00een s\u00e2ngele arterial sistemic (Sa O2<\/sub>)- Valori normale = 95%<\/p>\n

*** – reducere u\u015foar\u0103 150 – 110 w<\/p>\n

– reducere medie 110 – 80 w<\/p>\n

– reducere accentuat\u0103 80 – 35 w<\/p>\n

– reducere grav\u0103 < 35w<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Se vor evita activit\u0103\u0163ile cu solicit\u0103ri energetice excesive, \u00een mediu cu varia\u0163ii termice \u015fi noxe respiratorii.<\/p>\n<\/td>\n

\n

Asigurarea unor condi\u0163ii de micro \u015fi macroclimat adecvat \u00een scopul prevenirii manifest\u0103rilor spastice bron\u015fice – agrav\u0103rii tulbur\u0103rilor func\u0163ionale \u00een func\u0163ie de structura anatomic\u0103 afectat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Capacitate redus\u0103 de adaptare la efort. Sunt indicate activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103, \u00een mediu de confort, f\u0103r\u0103 expunere la intemperii, noxe respiratorii (praf-pulberi), de exemplu: activit\u0103\u0163i de birou cu preg\u0103tire superioar\u0103 sau medie sau activit\u0103\u0163i me\u015fte\u015fug\u0103re\u015fti.<\/p>\n<\/td>\n

\n

– M\u0103suri de adaptare a locului de munc\u0103 pentru a reduce efortul fizic necesar;<\/p>\n

– Preocupare pentru ameliorarea microclimatului profesional \u00een cazul existen\u0163ei unor factori nefavorabili la locul de munc\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Sunt indicate activit\u0103\u0163i statice cu solicitare fizic\u0103 redus\u0103.<\/p>\n

– Este limitat\u0103 major capacitatea de adaptare la efort fizic datorit\u0103 hipoxiei.<\/p>\n

– Se vor evita expunerea la micro sau macroclimat necorespunz\u0103tor, deplas\u0103rile posturale pe distan\u0163e mari sau urcarea de trepte, care implic\u0103 efort \u015fi agraveaz\u0103 insuficien\u0163a respiratorie.<\/p>\n<\/td>\n

\n

Este necesar\u0103:<\/p>\n

– diminuarea efortului fizic prin mijloace auxiliare tehnico-mecanice de ridicare \u015fi transportare a greut\u0103\u0163ilor;<\/p>\n

– asigurarea unor condi\u0163ii de micro \u015fi macroclimat corespunz\u0103tor, f\u0103r\u0103 noxe respiratorii – mediu uscat, umed, rece, cu varia\u0163ii termice, cu praf (pulberi nocive bronho-pulmonare);<\/p>\n

– sprijin, din partea agen\u0163ilor economici, pentru monitorizare medical\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Lipse\u015fte \u00een totalitate sau aproape \u00een totalitate capacitatea de autoservire \u015fi auto\u00eengrijire din cauza insuficien\u0163ei respiratorii manifeste\/severe \u015fi complica\u0163iilor secundare (CPC), neinfluen\u0163ate de ac\u0163iunile recuperatorii particularizate structurii respiratorii afectate.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Trebuie s\u0103 se asigure oxigenoterapia permanent\u0103 (dac\u0103 este cazul).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a05:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0SISTEMULUI<\/strong>\u00a0DIGESTIV,<\/strong>\u00a0METABOLIC<\/strong>\u00a0\u015eI<\/strong>\u00a0ENDOCRIN<\/strong><\/p>\n

I.<\/strong>_<\/p>\n

a)<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA UNOR FUNC\u0162II ALE SISTEMULUI DIGESTIV (DE DIGESTIE, SECRE\u0162IE, ABSORB\u0162IE-ASIMILA\u0162IE)*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

– unele tumori maligne ale tubului digestiv, operabile sau neoperabile:<\/p>\n

Gastrectomie larg\u0103 pentru ADK cu gastrostom\u0103;<\/p>\n

TM oro-faringo-esofago-gastrice sau ale unor segmente intestinale inoperabile sau \u00een faze de generalizare.<\/p>\n

Rezec\u0163ia unor segmente intestinale pentru TM cu colostom\u0103, anus iliac, sigma anus sau anus contra lateralis (definitive),<\/p>\n

– pancreatectomie par\u0163ial\u0103 sau total\u0103 pentru TM,<\/p>\n

– stenoze esofagiene str\u00e2nse, de cauz\u0103 divers\u0103, care necesit\u0103 dilata\u0163ii, esofagoplastii, protezare, gastrostom\u0103 pentru alimenta\u0163ie.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Indicele ponderal (starea de nutri\u0163ie)***;<\/p>\n

– Hemograma (Hb gr%);<\/p>\n

– Evaluarea malabsorb\u0163iei:<\/p>\n

– Proteinemie,<\/p>\n

– Ionograma,<\/p>\n

– Glicemie,<\/p>\n

– Amilazemie,<\/p>\n

– Amilazurie;<\/p>\n

– Ecografie abdominal\u0103;<\/p>\n

– Examen radiologic gastro-duodeno-intestinal;<\/p>\n

– Endoscopie eso-gastro-jejunala (eventual cu biopsie ecoghidat\u0103);<\/p>\n

– Colonosigmoidoscopie;<\/p>\n

– Rectoscopie;<\/p>\n

– Irigografie;<\/p>\n

– CT-RMN;<\/p>\n

– Examen histopatologic.<\/p>\n<\/td>\n

\n

– Denutri\u0163ie cu deficit ponderal \u00eentre 20-25%;<\/p>\n

– Anemie u\u015foar\u0103.<\/p>\n<\/td>\n

\n

– Sindrom de malabsorb\u0163ie cu deficit ponderal \u00eentre 25-30%;<\/p>\n

– Anemie cu Hb \u00eentre 7-10 gr%.<\/p>\n<\/td>\n

\n

– Anemie sever\u0103 (sub 7 gr%Hb);<\/p>\n

– Deregl\u0103ri severe de resorb\u0163ie, malabsorb\u0163ie-malasimila\u0163ie, cu denutri\u0163ie peste 30%;<\/p>\n<\/td>\n

\n

– Anemie sever\u0103 (sub 7 gr. Hb %) rezisten\u0163\u0103 la tratament;<\/p>\n

– Stare de casexie (malabsorb\u0163ie \u015fi malasimila\u0163ie progresiv\u0103 \u015fi sever\u0103).<\/p>\n<\/td>\n<\/tr>\n

\n

\u00cen stenozele esofagiene confirmate radiologic, cu manifest\u0103rile de mai sus care nu se remit complet la tratament (dilata\u0163ii) \u015fi necesit\u0103 tratament chirurgical.<\/p>\n

Pentru perioade limitate, p\u00e2n\u0103 la recuperare cu restabilirea tulbur\u0103rilor de nutri\u0163ie.<\/p>\n<\/td>\n

\n

\u00cen stenozele esofagiene str\u00e2nse cu gastrostrom\u0103; TM gastrice cu gastrostrom\u0103 pentru alimenta\u0163ie;<\/p>\n

TM de colon, rect, sigmoid \u015fi alte segmente intestinale cu colostom\u0103;<\/p>\n

Cancerul pancreatic cu rezec\u0163ii par\u0163iale sau totale, \u00een tratament de substitu\u0163ie.<\/p>\n<\/td>\n

\n

\u00cen tumorile maligne inoperabile sau operabile cu recidive loco-regionale sau \u00een faze de generalizare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Parametrii func\u0163ionali se vor selecta \u00een raport de segmentul de tub digestiv afectat, modific\u0103rile morfologice \u015fi biochimice induse, precum \u015fi de datele antropometrice \u00een func\u0163ie de care se stabile\u015fte echilibrul ponderal.<\/p>\n

*** Indicele ponderal ideal se stabile\u015fte dup\u0103 formula Lorencz: X = A cm – 100 – (Acm – 150)\/4, unde Acm = \u00een\u0103l\u0163imea individului \u00een cm.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Independen\u0163a \u00een exercitarea activit\u0103\u0163ilor profesionale<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i f\u0103r\u0103 efort fizic mare, \u00een mediu f\u0103r\u0103 varia\u0163ii de temperatur\u0103 precum \u015fi f\u0103r\u0103 substan\u0163e toxice digestive, \u00een ritm liber.<\/p>\n<\/td>\n

\n

– Asigurarea unor locuri de munc\u0103 f\u0103r\u0103 efort fizic mare, f\u0103r\u0103 expuneri la un micro sau macroclimat necorespunz\u0103tor;<\/p>\n

– Asigurarea unor pauze pentru hr\u0103nire.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 efort fizic, \u00een mediu f\u0103r\u0103 varia\u0163ii de temperatur\u0103, precum \u015fi f\u0103r\u0103 substan\u0163e toxice digestive, \u00een ritm liber;<\/p>\n

– Activit\u0103\u0163i care nu impun deplas\u0103ri posturale, mers pe plan \u00eenclinat.<\/p>\n<\/td>\n

\n

– M\u0103suri de reducere a efortului fizic \u015fi de evitare a activit\u0103\u0163ii \u00een mediu nefavorabil, \u00een scopul prevenirii agrav\u0103rilor;<\/p>\n

– M\u0103suri pentru ajustarea mediului ambiant fizic;<\/p>\n

– Regim de munc\u0103 adecvat pentru asigurarea meselor frac\u0163ionate;<\/p>\n

– M\u0103suri igienico-sanitare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Necesit\u0103 ajutor periodic pentru igiena corporal\u0103, autoservire \u015fi pentru activit\u0103\u0163ile de zi cu zi.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Ajutor pentru activit\u0103\u0163ile cotidiene (autogospod\u0103rire) pentru perioade variabile, \u00een func\u0163ie de evolu\u0163ie, agravarea structurilor afectate, r\u0103spunsul la tratament, cooperarea la ac\u0163iunile medico-sociale de recuperare;<\/p>\n

– Asigurarea de pungi speciale pentru persoanele cu gastrostom\u0103, colostom\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR HEPATICE*<\/p>\n

* Se refer\u0103 la: afec\u0163iuni cronice hepatice indiferent de etiologie:<\/p>\n

– hepatite cronice \u015fi ciroze hepatice – contractate precoce (copil\u0103rie adolescen\u0163\u0103 p\u00e2n\u0103 la 26 ani)<\/p>\n

– cancer hepatic primar sau secundar,<\/p>\n

– transplant hepatic total sau par\u0163ial.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Anamnez\u0103;<\/p>\n

– Examen clinic;<\/p>\n

– Ecografie abdominal\u0103; – (Ex radiologic esofagian);<\/p>\n

– Ex endoscopic;<\/p>\n

– CT-RMN;<\/p>\n

– Punc\u0163ie bioptic\u0103 hepatic\u0103;<\/p>\n

– Ex histopatologic;<\/p>\n

– Hemogram\u0103 complet\u0103;<\/p>\n

– Indice de protrombin\u0103; – Electroforez\u0103, imunelectroforez\u0103, prezen\u0163a de anticorpi,<\/p>\n

– Enzimogram\u0103;<\/p>\n

– Bilirubinemie, glicemie, creatininemie;<\/p>\n

– Determinare AcHVC \u00een ser;<\/p>\n

– Determinare AgHBs \u00een ser;<\/p>\n

NB. 70 – 80% dintre hepatitele cronice \u015fi 40% dintre ciroze au drept cauze VHC.<\/p>\n<\/td>\n

\n

\u00cen formele stabilizate sau persistente,<\/p>\n

neevolutive, cu hepato-splenomegalie moderat\u0103, f\u0103r\u0103 semne de insuficien\u0163\u0103 hepatic\u0103 (teste biologice \u00een limite normale sau slab pozitive, dominant de activitate mezenchimal\u0103).<\/p>\n<\/td>\n

\n

– \u00cen formele moderat active sau ciroze hepatice compensate, (Child Pugh A) f\u0103r\u0103 fenomene de hipertensiune portal\u0103;<\/p>\n

– Teste paraclinice alterate la nivel mediu;<\/p>\n

– Purt\u0103tor de AgHBs sau AcHVC.<\/p>\n<\/td>\n

\n

– \u00cen formele active<\/p>\n

de hepatite cronice, cu semnele clinice specifice (ficat mare\/mic, indurat, sau\/\u015fi splenomegalie) cu fenomene de hipersplenism, ecografie cu modific\u0103ri imagistice caracteristice \u015fi teste biologice alterate semnificativ; purt\u0103tor de AgHBs sau AcHVC, r\u0103spuns par\u0163ial sau f\u0103r\u0103 r\u0103spuns la ac\u0163iunile de recuperare.<\/p>\n

– Ciroze hepatice, decompensate parenchimatos sau\/\u015fi vascular, cu varice esofagiene (radiologic sau endoscopic) cu semne de hipertensiune portal\u0103 (circula\u0163ie colateral\u0103 sau\/\u015fi ascit\u0103) cu frecven\u0163\u0103 periodic\u0103, reductibil\u0103, (clasa Child Pugh B \u015fi C)<\/p>\n<\/td>\n

\n

– Ciroze hepatice<\/p>\n

(clasa Child Pugh C) cu hipertensiune portal\u0103 ireductibil\u0103, hemoragii digestive repetate (rupere de varice esofagiene sau prin tulbur\u0103ri de craz\u0103 sanguin\u0103), cu fenomene de encefalopatie hepatic\u0103, cu episoade de insuficien\u0163\u0103 hepatic\u0103 acut\u0103 \u015fi insuficien\u0163\u0103 hepato-renal\u0103;<\/p>\n

– Adenocarcinom hepatic sau cancere primitive hepatice cu agravare progresiv\u0103 \u015fi pierdere ponderal\u0103 continu\u0103.<\/p>\n

Au pierdut\u0103 capacitatea de autoservire \u015fi necesit\u0103 \u00eengrijire permanent\u0103 din partea altor persoane.<\/p>\n

NB. \u00cen transplantul hepatic (total sau par\u0163ial) \u00een primele 12 luni, apoi \u00een func\u0163ie de bilan\u0163ul clinic \u015fi parclinic postoperator \u00een dinamic\u0103, de eventualele fenomene de respingere \u015fi complica\u0163ii postoperatorii<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Parametrii func\u0163ionali se vor selecta \u00een raport de structurile \u015fi func\u0163iile hepatice afectate \u015fi de natura afec\u0163iunii.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Pot desf\u0103\u015fura orice activitate profesional\u0103 cu evitarea locurilor de munc\u0103 care impun efort fizic mare \u015fi contact cu substan\u0163e hepatotoxice.<\/p>\n<\/td>\n

\n

– Participare f\u0103r\u0103 restric\u0163ie cu evitarea locurilor de munc\u0103 cu solicit\u0103ri fizice mari;<\/p>\n

– Asigurarea unor condi\u0163ii de microclimat profesional corespunz\u0103tor, f\u0103r\u0103 factori nocivi (substan\u0163e hepatotoxice).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Vor fi orienta\u0163i sau \u00eendruma\u0163i profesional spre locuri de munc\u0103 adecvate, f\u0103r\u0103 solicit\u0103ri fizice \u015fi psihice mari, sarcini suplimentare, munc\u0103 \u00een ture, munc\u0103 de noapte, \u00een ritm impus, precum \u015fi \u00eentr-un mediu inadecvat, cu factori toxici.<\/p>\n<\/td>\n

\n

Preocupare pentru orientarea profesional\u0103 sau \u00eendrumarea spre locuri de munc\u0103 f\u0103r\u0103 solicitare fizic\u0103 \u015fi psihic\u0103 mare, ritm liber, f\u0103r\u0103 ture de noapte, \u00eentr-un microclimat f\u0103r\u0103 factori nocivi (hepatotoxici).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Tulbur\u0103rile func\u0163ionale de intensitate accentuat\u0103 contraindic\u0103 prestarea oric\u0103rei activit\u0103\u0163i profesionale;<\/p>\n

– Au conservat\u0103 capacitatea de autoservire, auto\u00eengrijire \u015fi, \u00een mod limitat, pe cea de autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 sprijin pentru efectuarea activit\u0103\u0163ilor cotidiene care solicit\u0103 efort fizic \u015fi deplas\u0103ri posturale;<\/p>\n

– Sprijin pentru monitorizarea medico-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Lipse\u015fte capacitatea de prestare a unei activit\u0103\u0163i profesionale indiferent de nivelul de solicitare \u015fi condi\u0163iile de munc\u0103;<\/p>\n

– Lipse\u015fte capacitatea de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Sprijin pentru cooperare la monitorizare medical\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA UNOR FUNC\u0162II METABOLICE*<\/u><\/p>\n

* Se refer\u0103 la diabetul zaharat tip I, juvenil sau al adultului t\u00e2n\u0103r p\u00e2n\u0103 la 26 ani).<\/p>\n

NB. Diabetul zaharat tip I este o boal\u0103 metabolic\u0103, de cele mai multe ori determinat\u0103 genetic, cu evolu\u0163ie cronic\u0103 stadial\u0103, \u00een care lipsa sau sc\u0103derea insulinei eficiente determin\u0103 sc\u0103derea glucozei celulare urmat\u0103 de hiperglicemie care, dac\u0103 nu este corectat\u0103, antreneaz\u0103 perturb\u0103ri ale metabolismului lipidic, protidic \u015fi ale echilibrului hidro-electrolitic. Aceste perturb\u0103ri, dup\u0103 o perioad\u0103 variabil\u0103, \u00een func\u0163ie de o serie de factori favorizan\u0163i\/determinan\u0163i, medico-psiho-sociali, conduc la apari\u0163ia complica\u0163iilor metabolice, cardiovasculare, oftalmologice, renale, infec\u0163ioase.<\/p>\n

– Cu c\u00e2t diabetul este depistat la o v\u00e2rst\u0103 mai t\u00e2n\u0103r\u0103 (copil\u0103rie), cu at\u00e2t prognosticul este mai rezervat.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

1. Examene paraclinice:<\/p>\n

a. – glicemie a jeun, repetate, peste 130 mg\/dl;<\/p>\n

b. – glicemie venoas\u0103 dup\u0103 testul de toleran\u0163\u0103 la glucoz\u0103 (dac\u0103 este cazul) de cel pu\u0163in 170 mg\/dl (s\u0103geat\u0103 hiperglicemic\u0103) sau 130mg\/dl dup\u0103 2 ore;<\/p>\n

c. – glicozurie de minimum 5 gr \u2030 \u00een urin\u0103 din 24 de ore;<\/p>\n

– examen sumar urin\u0103 (densitate, albumin\u0103, corpi cetonici);<\/p>\n

– dozare albumin\u0103 \u00een urin\u0103 (dac\u0103 este cazul);<\/p>\n

– creatinin\u0103, uree, acid uric;<\/p>\n

– examen oftalmologic (FO, AV, c\u00e2mp vizual);<\/p>\n

– examen neurologic;<\/p>\n

– oscilometrie – eco Dopller – indice oscilometric membre inferiore<\/p>\n

2. Examen clinic<\/p>\n<\/td>\n

\n

– \u00cen formele cu echilibru glicemic cu profil glicemic convenabil, f\u0103r\u0103 complica\u0163ii (func\u0163ia renal\u0103 normal\u0103, FO normal, examen neurologic normal, indici oscilometrici normali);<\/p>\n

– Necesar de insulina administrat \u00een dou\u0103 prize.<\/p>\n<\/td>\n

\n

– \u00cen formele care se pot echilibra din punct de vedere glicemic<\/p>\n

– Cu tulbur\u0103ri de reglare simpaticoparsimpatic<\/p>\n

– Hipotensiune ortostatic\u0103;<\/p>\n

– Cu complica\u0163ii incipiente microangiopatice, cu modific\u0103ri nesemnificative microalbuminurie \u00een repaos dozabil\u0103 la efort)<\/p>\n

– Necesar de insulin\u0103 repartizat \u00een trei prize.<\/p>\n<\/td>\n

\n

– \u00cen formele dezechilibrate metabolic, instabile, cu\/f\u0103r\u0103 fenomene de decompensare metabolic\u0103 (tip hipoglicemic-cetocetonic), necomplicate, pentru perioada necesar\u0103 echilibr\u0103rii.<\/p>\n<\/td>\n

\n

– \u00cen formele cu complica\u0163ii specifice (microangiopatice) manifeste pe un organ \u0163int\u0103 sau pe mai multe organe predilecte sau cu microangiopatie periferic\u0103 (artropatia Charcot – picior diabetic)- \u00een func\u0163ie de intensitatea tulbur\u0103rilor morfofunc\u0163ionale.<\/p>\n

NB. Pentru evaluare vezi criteriile stabilite pentru afectarea func\u0163iei respective (func\u0163iei vizuale, urinare, de mobilitate, static\u0103 \u015fi locomo\u0163ie).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Vor fi selectate \u015fi aprofundate investiga\u0163iile paraclinice \u00een func\u0163ie de echilibrul metabolic \u015fi decelarea complica\u0163iilor specifice (microangiopatii cu localizare ocular\u0103, renal\u0103 \u015fi pl\u0103cut\u0103 neuro-motorie)<\/p>\n

NB. – Examenele paraclinice de la pct. 1, lit. a, b \u015fi c au importan\u0163\u0103 major\u0103 pentru controlul terapeutic.<\/p>\n

– Examenul clinic \u00een diabetul tip I necomplicat are importan\u0163\u0103 minor\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Loc de munc\u0103 corespunz\u0103tor, cu solicitare energetic\u0103 redus\u0103 \u015fi psihic\u0103 medie, \u00een condi\u0163ii ambientale corespunz\u0103toare;<\/p>\n

– Evitarea activit\u0103\u0163ii \u00een ture, munca de noapte, la \u00een\u0103l\u0163ime, l\u00e2ng\u0103 foc, unelte \u00een mi\u015fcare, siguran\u0163a circula\u0163iei;<\/p>\n

– Ritm liber cu pauze de mas\u0103 pentru administrarea insulinei.<\/p>\n<\/td>\n

\n

– Asigurarea unui loc de munc\u0103 adecvat, \u00een aceea\u015fi profesie sau \u00eendrumare profesional\u0103 spre activit\u0103\u0163i care nu se desf\u0103\u015foar\u0103 la \u00een\u0103l\u0163ime, l\u00e2ng\u0103 foc, unelte \u00een mi\u015fcare \u015fi care nu impun suprasolicitare vizual\u0103;<\/p>\n

– Sunt contraindicate activit\u0103\u0163ile care pot periclita siguran\u0163a circula\u0163iei;<\/p>\n

– Asigurarea pauzei de mas\u0103 pentru mese frac\u0163ionate \u015fi administrarea necesarului de insulin\u0103;<\/p>\n

– Monitorizarea medical\u0103 la Centrul Antidiabetic (CAD) pentru urm\u0103rirea echilibrului metabolic \u015fi prevenirea apari\u0163iei complica\u0163iilor specifice.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

NB. Pentru adolescen\u0163i, orientarea \u015fi formarea profesional\u0103 pentru profesiuni care:<\/p>\n

– nu impun suprasolicitarea analizatorului vizual (activit\u0103\u0163i de precizie)<\/p>\n

– impun activit\u0103\u0163i \u00een mediu cald,<\/p>\n

– se desf\u0103\u015foar\u0103 la \u00een\u0103l\u0163ime,<\/p>\n

– impun deplas\u0103ri posturale frecvente,<\/p>\n

– necesit\u0103 solicitare fizic\u0103 \u015fi psihic\u0103 intens\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Incapacitate tranzitorie de desf\u0103\u015furare a oric\u0103rei activit\u0103\u0163i profesionale pe perioada necesar\u0103 echilibr\u0103rii metabolice, stabilirii necesarului de insulin\u0103 \u015fi de hidra\u0163i de carbon (regim igienodietetic).<\/p>\n<\/td>\n

\n

– Necesit\u0103 ajutor din partea familiei pentru respectarea regimului alimentar \u015fi administrarea la timp a cantit\u0103\u0163ii de insulina;<\/p>\n

– Monitorizare la CAD pentru echilibrare \u015fi prevenirea complica\u0163iilor specifice.<\/p>\n

NB. Dup\u0103 echilibrarea homeostaziei glicemice, \u00eendrumarea sau orientarea profesional\u0103 spre locuri de munc\u0103 sau profesiuni compatibile cu respectarea indica\u0163iilor \u015fi contraindica\u0163iilor prev\u0103zute pentru persoanele cu handicap u\u015for \u015fi mediu.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Stabilite pentru afectarea func\u0163iilor: vederii, urinare, mobilit\u0103\u0163ii, staticii \u015fi locomo\u0163iei.<\/p>\n<\/td>\n

\n

– Vezi capitolele respective;<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

III.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR ENDOCRINE<\/u><\/p>\n

1.<\/strong>Evaluarea gradului de handicap \u00een hiperfunc\u0163ia hipofizar\u0103 (tumora hipofizar\u0103 secretant\u0103 de GH – hormon de cre\u015ftere)*<\/p>\n

* Se refer\u0103 la acromegalie – tumor\u0103 hipofizar\u0103 secretant\u0103 de GH (hormon de cre\u015ftere) la adult.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Examen endocrin:<\/p>\n

– modificarea fizionomiei;<\/p>\n

– cre\u015fterea de volum a extremit\u0103\u0163ilor;<\/p>\n

– visceromegalie;<\/p>\n

– sindrom clinic tumoral cerebral;<\/p>\n

– tulbur\u0103ri de metabolism glucidic (DZ tip II);<\/p>\n

– tulbur\u0103ri hormonale secundare paraclinic;<\/p>\n

– cre\u015ftere hormon GH \u00een ser \u015fi \u00een LCR;<\/p>\n

– CT, RMN \u015fi radiografie de \u015fea turceasc\u0103 -tumor\u0103 hipofizar\u0103 \u00een std. I-IV (Hardy);<\/p>\n

Examen oftalmologic:<\/p>\n

– Tulbur\u0103ri de c\u00e2mp vizual,<\/p>\n

– Hemianopsie,<\/p>\n

– Scotoame;<\/p>\n

Examen neurologic: semne de hipertensiune intracranian\u0103;<\/p>\n

EEG;<\/p>\n

Examen histopatologic.<\/p>\n<\/td>\n

\n

\u00cencadrare \u00een tablou clinic \u015fi paraclinic incomplet, \u00een tratament simptomatic.<\/p>\n<\/td>\n

\n

– Tumor\u0103 hipofizar\u0103 oprit\u0103 \u00een evolu\u0163ie, spontan sau dup\u0103 tratament specific (Roentgen terapie, hormonoterapie antisecretorie sau interven\u0163ie chirurgical\u0103);<\/p>\n

– F\u0103r\u0103 semne neurologice sau oftalmologice;<\/p>\n

– Tulbur\u0103ri echilibrate prin tratament hormonal substitutiv.<\/p>\n<\/td>\n

\n

– Tumor\u0103 hipofizar\u0103 evolutiv\u0103, aflat\u0103 \u00een tratament antihormonal complex sau<\/p>\n

– Tumor\u0103 hipofizar\u0103 recent stabilizat\u0103 cu tulbur\u0103ri hormonale secundare, par\u0163ial echilibrate prin tratament substitutiv sau<\/p>\n

– Tumor\u0103 hipofizar\u0103 oprit\u0103 \u00een evolu\u0163ie dup\u0103 tratament sau spontan, \u00eens\u0103 cu sechele neurologice, oftalmologice sau endocrine accentuate sau<\/p>\n

– Tumor\u0103 hipofizar\u0103 cu examen histopatologic de malignitate, \u00een tratament specific.<\/p>\n<\/td>\n

\n

Tumor\u0103 hipofizar\u0103 cu:<\/p>\n

– sechele oftalmologice grave (cecitate practic\u0103 sau absolut\u0103) sau<\/p>\n

– tulbur\u0103ri neurologice grave sau<\/p>\n

– tulbur\u0103ri metabolice grave (casexie hipofizara) care necesit\u0103 \u00eengrijire permanent\u0103 din partea altei persoane.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Evaluarea gradului de handicap \u00een hipofunc\u0163ia hipofizar\u0103<\/p>\n

a)<\/strong>Nanismul hipofizar*<\/p>\n

* Se refer\u0103 la insuficien\u0163a hipofizar\u0103 de GH (hormon de cre\u015ftere) sau tulbur\u0103ri la nivelul receptorilor periferici prin GH insuficient \u00een perioada de cre\u015ftere somatic\u0103 cu hipotrofie statural\u0103 armonioas\u0103, prezent\u00e2nd un deficit statural mai mare de 3 deriva\u0163ii standard (3DS) fa\u0163\u0103 de media de \u00een\u0103l\u0163ime pentru genera\u0163ia respectiv\u0103 de v\u00e2rst\u0103, uneori asocieri de insuficien\u0163\u0103 hipofizar\u0103 pluritrop\u0103 (panhipopituitarism).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic \u015fi paraclinic:<\/p>\n

– hipotrofie statural\u0103;<\/p>\n

– antropometrie armonioas\u0103;<\/p>\n

– schelet gracil;<\/p>\n

– musculatur\u0103 hipotrofic\u0103;<\/p>\n

– facies infantil;<\/p>\n

– doz\u0103ri hormonale (hormon GH, gonadotropi, tiroidieni, corticotropi);<\/p>\n

– m\u0103sur\u0103toarea taliei;<\/p>\n

– teste psihologice (QI);<\/p>\n

– EKG, tensiune arterial\u0103.<\/p>\n<\/td>\n

\n

– Tulbur\u0103ri de gestualitate \u015fi locomo\u0163ie u\u015foare;<\/p>\n

– Talie 1,49-1,40 m;<\/p>\n

– Performan\u0163e intelectuale normale.<\/p>\n<\/td>\n

\n

– Tulbur\u0103ri de gestualitate – locomotorii de intensitate medie;<\/p>\n

– Talie 1,39-1,30 m;<\/p>\n

– Performan\u0163e intelectuale normale.<\/p>\n<\/td>\n

\n

– Tulbur\u0103ri de gestualitate \u015fi locomotorii accentuate;<\/p>\n

– Talie sub 1,29 m;<\/p>\n

– Performan\u0163e intelectuale normale;<\/p>\n

– Deficit al hormonilor hipofizari:<\/p>\n

– Gonadotropi = infantilism sexual,<\/p>\n

– Tireoptropi = mixedem secundar,<\/p>\n

– Corticotropi = hipotensiune arterial\u0103 = performan\u0163\u0103 de efort sc\u0103zut\u0103.<\/p>\n

NB. Intensitatea tulbur\u0103rilor hormonale asociate se cuantific\u0103 dup\u0103 criteriile stabilite pentru afectarea func\u0163iei respective.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>Condrodisplazia*<\/p>\n

* Hipotrofie statural\u0103 disarmonic\u0103 prin lipsa receptorilor pentru GH la nivelul cartilajelor de cre\u015ftere ale extremit\u0103\u0163ilor toracale \u015fi pelviene, cu artropatii secundare.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Examen clinic:<\/p>\n

– Hipotrofie statural\u0103;<\/p>\n

– Antropometrie dizarmonic\u0103;<\/p>\n

– Hipotrofia extremit\u0103\u0163ilor toracale \u015fi pelviene;<\/p>\n

– Mobilitatea articula\u0163iilor scapulohumerale-coxofemurale limitate prin artropatii secundare;<\/p>\n

Examene paraclinice: – prezentate la nanismul hipofizar.<\/p>\n<\/td>\n

\n

\u00cen evaluarea deficien\u0163ei func\u0163ionale \u015fi a gradului de handicap se vor avea \u00een vedere:<\/p>\n

– criteriile stabilite pentru afectarea mobilit\u0103\u0163ii articulare, (artropatia condrodisplazic\u0103 determina tulbur\u0103ri de realizare a variantelor posturale \u015fi a gestualit\u0103\u0163ii),<\/p>\n

– criteriile de \u00een\u0103l\u0163ime prezentate \u00een insuficien\u0163a hipofizar\u0103 (nanismul hipofizar).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

c)<\/strong>Sindrom Sheehan*<\/p>\n

* Se refer\u0103 la insuficien\u0163a hipofizar\u0103 primar\u0103 (sindrom Sheehan) – afec\u0163iune uni sau, mai frecvent, pluritrop\u0103, exprimat\u0103 prin tulbur\u0103ri clinice \u015fi hormonale.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Examen endocrin:<\/p>\n

– semne de hipotiroidie;<\/p>\n

– semne de hipogonadism, hipogonadotropi;<\/p>\n

– insuficien\u0163\u0103 cortico-suprarenal\u0103 cronic\u0103;<\/p>\n

– hipoanabolism care poate merge p\u00e2n\u0103 la casexie;<\/p>\n

Doz\u0103ri hormonale specifice; Examen neurologic; EKG;<\/p>\n

Examen psihic.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 ne\u00eenso\u0163it\u0103 de complica\u0163ii.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 cu complica\u0163ii compensate cu tratament hormonal substitutiv.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 cu tulbur\u0103ri endocrino-metabolice accentuate, necompensate clinic \u015fi biologic sub tratament substitutiv complex, asociat cu complica\u0163ii metabolice (pierdere ponderal\u0103 progresiv\u0103), cardiovasculare \u015fi neuropsihice.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 sever\u0103 cu tulbur\u0103ri endocrine \u015fi metabolice grave \u015fi complica\u0163ii cardiovasculare \u015fi neuropsihice care conduc la pierderea ctdExamen clinic:apacit\u0103\u0163ii de auto\u00eengrijire, autoservire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Evaluarea gradului de handicap \u00een insuficien\u0163a hipofizar\u0103 posterioar\u0103, prin deficit total\/par\u0163ial de vasopresin\u0103 (AVP)*<\/p>\n

* Sindrom clinic de poliurie, polidipsie cu densitate urinar\u0103 sub 1010 prin deficit total\/par\u0163ial de vasopresin\u0103 (AVP) sau lipsa ac\u0163iunii tisulare a AVP.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

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Clinic \u015fi paraclinic:<\/p>\n

– Diureza = 3 l\/24 h;<\/p>\n

– densitate urinar\u0103 sub 1010;<\/p>\n

– subizostenurie-osmolaritate urinar\u0103 < 300 mEq\/l<\/p>\n

– -Clearence-ul apei libere pozitiv;<\/p>\n

– proba de sete cu test la vasopresin\u0103 (adiuretin) pozitiv – \u00een etiologia tumoral\u0103;<\/p>\n

– investiga\u0163ii hormonale;<\/p>\n

– CT, RMN.<\/p>\n<\/td>\n

\n

\u00cen formele care r\u0103spund la tratamentul cu vasopresin\u0103 sau analogi.<\/p>\n<\/td>\n

\n

\u00cen diabetul insipid lezional sau tumoral, compensat \u00een tratament substitutiv cu vasopresin\u0103 (adiuretin).<\/p>\n<\/td>\n

\n

Post tumoral sau postoperator, rezistente la tratament cu vasopresin\u0103 sau analogi, asociate cu complica\u0163ii neurologice \u015fi hormonale secundare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Evaluarea gradului de handicap \u00een insuficien\u0163a tiroidian\u0103*<\/p>\n

* Se refer\u0103 la:<\/p>\n

– mixedemul primar cu visceralizare;<\/p>\n

– mixedemul congenital (disgenezie tiroidian\u0103).<\/p>\n

Sindrom clinic determinat de sc\u0103derea cantit\u0103\u0163ii de hormoni tiroidieni la nivelul receptorilor celulari ceea ce determin\u0103 infiltrarea \u0163esuturilor cu consecin\u0163ele respective, handicapante.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n

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HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

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Clinic:<\/p>\n

– Metabolic: cre\u015ftere ponderal\u0103, infiltrarea tegumentelor, anemie secundar\u0103;<\/p>\n

– Neuropsihic: lentoare psihic\u0103, frilozitate;<\/p>\n

– Cardiovascular:<\/p>\n

cardiomiopatie mixedematoas\u0103, insuficien\u0163\u0103 cardiac\u0103;<\/p>\n

– Nanism dizarmonic cu \u00eent\u00e2rziere mental\u0103 (mixedem congenital), doz\u0103ri hormonale specifice \u00b1 gu\u015f\u0103; Paraclinic:<\/p>\n

– T3<\/sub>, T4<\/sub>\u00a0sc\u0103zute, PBI sc\u0103zut;<\/p>\n

– TSH crescut (mixedemul primar);<\/p>\n

– Scintigrama tiroidian\u0103 (lipsa tiroidei \u00een disgenezia tiroidian\u0103, imagine neomogen\u0103 \u00een gu\u015fa multinodular\u0103);<\/p>\n

– RIC sc\u0103zut sau absent;<\/p>\n

– EKG (tulbur\u0103ri de conducere, bradicardie, microvoltaj);<\/p>\n

– Ecografie cardiac\u0103 (cord m\u0103rit);<\/p>\n

– Hb, HT sc\u0103zute (anemie secundar\u0103);<\/p>\n

– Radiografie cord-pl\u0103m\u00e2n (indice cardio-toracic crescut);<\/p>\n

– Biochimie:<\/p>\n

– Hiperlipoproteinemie,<\/p>\n

– Hipercolesterolemie;<\/p>\n<\/td>\n

\n

Hipotiroidismul subclinic, eviden\u0163iat prin doz\u0103ri hormonale (TSH crescut) f\u0103r\u0103 expresie clinic\u0103 manifest\u0103 sau oligosimptomatic, forme u\u015foare cu r\u0103spuns la substitu\u0163ia hormonal\u0103, \u00een doze minime.<\/p>\n<\/td>\n

\n

Insuficien\u0163a tiroidian\u0103 clinic manifest\u0103, \u00een tratament hormonal substitutiv, cu complica\u0163ii cardiovasculare \u015fi metabolice echilibrabile.<\/p>\n<\/td>\n

\n

Insuficien\u0163a tiroidian\u0103 cu complica\u0163ii persistente (cardiovasculare \u015fi metabolice) sau leziuni degenerative nervoase \u015fi osteoarticulare neechilibrate sau sechelare, decompensate la tratament specific.<\/p>\n<\/td>\n

\n

Insuficien\u0163a tiroidian\u0103 sever\u0103 cu visceraliz\u0103ri – cu complica\u0163ii cardiovasculare \u015fi neurologice grave, insuficien\u0163\u0103 cardiac\u0103 congestiv\u0103 ireductibil\u0103, poliserozite, encefalopatie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Evaluarea gradului de handicap \u00een afectarea func\u0163iei paratiroidei<\/p>\n

a)<\/strong>Hiperfunc\u0163ie paratiroidian\u0103*<\/p>\n

* Se refer\u0103 la hiperparatiroidismul primar (boala Recklighausen), caracterizat prin: secre\u0163ie excesiv\u0103 \u015fi autonom\u0103 de parthormon (PTH) de c\u00e2tre una sau mai multe glande paratiroide (de obicei tumorale), adenoame, care produc:<\/p>\n

– hipercalcemie seric\u0103,<\/p>\n

– hipofosfatemie,<\/p>\n

– rezorb\u0163ie osoas\u0103 excesiv\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n

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HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Leziuni scheletale (osoase), oase lungi \u015fi vertebre:<\/p>\n

– Fracturi spontane,<\/p>\n

– Osteoporoz\u0103 cu arii de demineralizare \u015fi<\/p>\n

– Formarea de chisturi osoase;<\/p>\n

– Tulbur\u0103ri renale: poliurie, litiaz\u0103;<\/p>\n

– Tulbur\u0103ri gastro-intestinale;<\/p>\n

– Tulbur\u0103ri neuropsihice;<\/p>\n

Paraclinic:<\/p>\n

– Calcemie peste 11 mg % (repetat\u0103);<\/p>\n

– Calciurie peste 400 mg %\/24 h;<\/p>\n

– Fosfatemie sc\u0103zut\u0103 (sub 2,5 mg%);<\/p>\n

– Fosfataz\u0103 alcalin\u0103 crescut\u0103 (\u00een leziuni osoase);<\/p>\n

– PTH seric (imunodozare) cu nivel crescut \u00een condi\u0163iile calcemiei crescute sau normale;<\/p>\n

– EKG: scurtare interval QT;<\/p>\n

– Examen radiologic:<\/p>\n

– Geode osoase sau\/\u015fi lacune diseminate;<\/p>\n

– Fracturi, calusuri;<\/p>\n

– Osteoporoz\u0103 generalizat\u0103;<\/p>\n

– Litiaz\u0103 renal\u0103 (nefrocalcinoz\u0103);<\/p>\n

– Ulcer gastric.<\/p>\n<\/td>\n

\n

Hipercalcemie seric\u0103 asimptomatic\u0103 sau cu tablou clinic oligosimptomatic.<\/p>\n<\/td>\n

\n

Hiperparatiroidism operat, cu sechele osoase sau renale neevolutive, cu tulbur\u0103ri de locomo\u0163ie \u015fi excre\u0163ie medie.<\/p>\n<\/td>\n

\n

Hiperparatiroidism operat, forma osteodistrofic\u0103 cu tulbur\u0103ri locomotorii accentuate prin deform\u0103ri osoase \u015fi forma nefrolitiazic\u0103 moderat\u0103 cu IRC stadiul de RAF.<\/p>\n<\/td>\n

\n

Hiperparatiroidism cu fracturi multiple \u015fi deform\u0103ri osoase cu deficien\u0163\u0103 locomotori grav\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Pentru evaluarea gradului de handicap mediu, accentuat \u015fi grav vezi criteriile stabilite \u00een afectarea func\u0163iilor osteo-musculo-articulare \u015fi ale mi\u015fc\u0103rilor aferente precum \u015fi a func\u0163iilor urinare.<\/p>\n

b)<\/strong>Hipofunc\u0163ie paratiroidian\u0103*<\/p>\n

*Se refer\u0103 la: hipoparatiroidismul primar (tetanie), caracterizat prin sc\u0103derea nivelului sangvin de parathormon (PTH) \u00een urma lez\u0103rii primitive a glandelor paratiroide.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Hiperexcitabilitate neuro-muscular\u0103;<\/p>\n

– Crize spontane de contractur\u0103 muscular\u0103, localizate pe grupuri musculare sau generalizate;<\/p>\n

– Crize de contractur\u0103 muscular\u0103 provocate de hiperpnee;<\/p>\n

– Semne mecanice de hiperexcitabilitate neuromuscular\u0103 (semnul Chwostek \u015fi Weiss pozitive);<\/p>\n

– Tulbur\u0103ri trofice (cataract\u0103 \u00een formele cronice, \u00eendelungate)<\/p>\n

Paraclinic:<\/p>\n

– Ca total \u015fi\/sau ionic sc\u0103zut;<\/p>\n

– Mg total \u015fi\/sau ionic sc\u0103zut;<\/p>\n

– EMG pozitiv.<\/p>\n<\/td>\n

\n

Tetanie latent\u0103 (spasmofilie) \u00een tratament specific cu manifest\u0103ri sporadice.<\/p>\n<\/td>\n

\n

Tetanie cronic\u0103 cu manifest\u0103ri clinice \u015fi crize relativ frecvente sub tratament specific.<\/p>\n<\/td>\n

\n

Tetanie cronic\u0103 cu crize acute frecvente, neinfluen\u0163ate de tratament.<\/p>\n

NB. Manifest\u0103ri mai rar \u00eent\u00e2lnite \u00een afectarea primitiv\u0103 a glandelor paratiroide.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

6.<\/strong>Evaluarea gradului de handicap \u00een afectarea glandei suprarenale<\/p>\n

– Insuficien\u0163a corticosuprarenal\u0103 cronic\u0103, primar\u0103 (Boala Addison)*<\/p>\n

* Se refer\u0103 la insuficien\u0163a corticosuprarenal\u0103 primar\u0103 cronic\u0103 (CSR), datorit\u0103 distrugerii ambelor corticosuprarenale (peste 80%), care determin\u0103:<\/p>\n

– sc\u0103dere hormoni glucocorticoizi;<\/p>\n

– sc\u0103dere hormoni mineralocorticoizi;<\/p>\n

– sc\u0103dere hormoni androgeni adrenali.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Astenie, adinamie, fatigabilitate;<\/p>\n

– Gre\u0163uri, v\u0103rs\u0103turi, dureri musculare;<\/p>\n

– Sc\u0103dere ponderal\u0103, deshidratare;<\/p>\n

– Melanodermie;<\/p>\n

– Hipotensiune arterial\u0103.<\/p>\n

Paraclinic:<\/p>\n

– Doz\u0103ri hormonale specifice;<\/p>\n

– Ionogram\u0103:<\/p>\n

– Na+<\/sup>\u00a0sc\u0103zut,<\/p>\n

– K+<\/sup>\u00a0crescut,<\/p>\n

– Glicemie: hipoglicemie seric\u0103;<\/p>\n

– Test stimulare cu ACTH (cortrosyn) negativ.<\/p>\n<\/td>\n

\n

\u00cen forma compensat\u0103 clinic \u015fi hormonal, sub tratament substitutiv.<\/p>\n<\/td>\n

\n

– Insuficien\u0163\u0103 CSR cronic\u0103 cu decompens\u0103ri repetate sau<\/p>\n

– Insuficien\u0163\u0103 CSR cronic\u0103 cu rezerve hormonale labile, par\u0163ial echilibrate sub tratament sau<\/p>\n

– Insuficien\u0163\u0103 CSR cronic\u0103 uni sau bilateral operat\u0103, \u00een tratament substitutiv continuu, p\u00e2n\u0103 la echilibrare.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 CSR cronic\u0103 decompensat\u0103, rezistent\u0103 la tratament, care necesit\u0103 \u00eengrijire permanent\u0103 din partea altei persoane.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

7.<\/strong>Evaluarea gradului de handicap \u00een insuficien\u0163a gonadic\u0103<\/p>\n

a)<\/strong>Insuficien\u0163a gonadic\u0103 primar\u0103 (primitiv\u0103)*<\/p>\n

* Se refer\u0103 la: insuficien\u0163a gonadic\u0103 primitiv\u0103, disginezii gonadale (mai frecvent) cu simptomatologie variabil\u0103, \u00een func\u0163ie de:<\/p>\n

– tipul gonadic;<\/p>\n

– v\u00e2rsta instal\u0103rii;<\/p>\n

– intensitatea insuficien\u0163ei gonadice;<\/p>\n

– cauza insuficien\u0163ei gonadice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

Sindrom clinic caracterizat prin formarea deficitar\u0103 a testiculelor datorit\u0103 unor defec\u0163iuni cromozomiale;<\/p>\n

Disgenezie a tubilor seminiferi determinate de anomalii ale formulei cromozomiale.<\/p>\n

Tablou clinic:<\/p>\n

– Fenotip masculin;<\/p>\n

– Aspect enucoid;<\/p>\n

– Aspect infantil\/normal;<\/p>\n

– Testicule mici;<\/p>\n

– Ginecomastie;<\/p>\n

– Obezitate \u00b1;<\/p>\n

– Deficit intelectual de intensitate variabil\u0103<\/p>\n

Paraclinic:<\/p>\n

– Spermatograma – azoospermie;<\/p>\n

– H. gornadotropi serici crescu\u0163i;<\/p>\n

– Testosteron plasmatic sc\u0103zut.<\/p>\n<\/td>\n

\n

Forme clinice cu tablou oligosimptomatic, compensat prin substitu\u0163ie cu hormoni sexoizi, f\u0103r\u0103 sc\u0103derea capacit\u0103\u0163ii de efort fizic sau f\u0103r\u0103 tulbur\u0103ri psihice handicapante.<\/p>\n<\/td>\n

\n

Formele clinice cu tulbur\u0103ri de dezvoltare musculara \u015fi osteoporoz\u0103 sexoiodopriv\u0103 cu sc\u0103derea capacit\u0103\u0163ii de efort fizic \u015fi prin tulbur\u0103ri neuropsihice de intensitate medie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>Insuficien\u0163a gonadic\u0103 prin disgenezii gonadale cu fenotip feminin (Sindromul Turner)*<\/p>\n

* Afec\u0163iune determinat\u0103 de un deficit al cromozomului X cu cariotip 45Xa, – sindromul Turner (digenezii gonadale cu fenotip feminin).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n
\n

PARAM<\/p>\n

– Enzimogram\u0103;<\/p>\n

– Bilirubinemie, glicemie, creatininemie;<\/p>\n

– Determinare AcHVC \u00een ser;<\/p>\n

– Determinare AgHBs \u00een ser;<\/p>\n

NB. 70 – 80% dintre hepatitele cronice \u015fi 40% dintre ciroze au drept cauze VHC.<\/p>\n<\/td>\n

\n

\u00cen formele stabilizate sau persistente,<\/p>\n

neevolutive, cu hepato-splenomegalie moderat\u0103, f\u0103r\u0103 semne de insuficien\u0163\u0103 hepatic\u0103 (teste biologice \u00een limite normale sau slab pozitive, dominant de activitate mezenchimal\u0103).<\/p>\n<\/td>\n

\n

– \u00cen formele moderat active sau ciroze hepatice compensate, (Child Pugh A) f\u0103r\u0103 fenomene de hipertensiune portal\u0103;<\/p>\n

– Teste paraclinice alterate la nivel mediu;<\/p>\n

– Purt\u0103tor de AgHBs sau AcHVC.<\/p>\n<\/td>\n

\n

– \u00cen formele active<\/p>\n

de hepatite cronice, cu semnele clinice specifice (ficat mare\/mic, indurat, sau\/\u015fi splenomegalie) cu fenomene de hipersplenism, ecografie cu modific\u0103ri imagistice caracteristice \u015fi teste biologice alterate semnificativ; purt\u0103tor de AgHBs sau AcHVC, r\u0103spuns par\u0163ial sau f\u0103r\u0103 r\u0103spuns la ac\u0163iunile de recuperare.<\/p>\n

– Ciroze hepatice, decompensate parenchimatos sau\/\u015fi vascular, cu varice esofagiene (radiologic sau endoscopic) cu semne de hipertensiune portal\u0103 (circula\u0163ie colateral\u0103 sau\/\u015fi ascit\u0103) cu frecven\u0163\u0103 periodic\u0103, reductibil\u0103, (clasa Child Pugh B \u015fi C)<\/p>\n<\/td>\n

\n

– Ciroze hepatice<\/p>\n

(clasa Child Pugh C) cu hipertensiune portal\u0103 ireductibil\u0103, hemoragii digestive repetate (rupere de varice esofagiene sau prin tulbur\u0103ri de craz\u0103 sanguin\u0103), cu fenomene de encefalopatie hepatic\u0103, cu episoade de insuficien\u0163\u0103 hepatic\u0103 acut\u0103 \u015fi insuficien\u0163\u0103 hepato-renal\u0103;<\/p>\n

– Adenocarcinom hepatic sau cancere primitive hepatice cu agravare progresiv\u0103 \u015fi pierdere ponderal\u0103 continu\u0103.<\/p>\n

Au pierdut\u0103 capacitatea de autoservire \u015fi necesit\u0103 \u00eengrijire permanent\u0103 din partea altor persoane.<\/p>\n

NB. \u00cen transplantul hepatic (total sau par\u0163ial) \u00een primele 12 luni, apoi \u00een func\u0163ie de bilan\u0163ul clinic \u015fi parclinic postoperator \u00een dinamic\u0103, de eventualele fenomene de respingere \u015fi complica\u0163ii postoperatorii<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Parametrii func\u0163ionali se vor selecta \u00een raport de structurile \u015fi func\u0163iile hepatice afectate \u015fi de natura afec\u0163iunii.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Pot desf\u0103\u015fura orice activitate profesional\u0103 cu evitarea locurilor de munc\u0103 care impun efort fizic mare \u015fi contact cu substan\u0163e hepatotoxice.<\/p>\n<\/td>\n

\n

– Participare f\u0103r\u0103 restric\u0163ie cu evitarea locurilor de munc\u0103 cu solicit\u0103ri fizice mari;<\/p>\n

– Asigurarea unor condi\u0163ii de microclimat profesional corespunz\u0103tor, f\u0103r\u0103 factori nocivi (substan\u0163e hepatotoxice).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Vor fi orienta\u0163i sau \u00eendruma\u0163i profesional spre locuri de munc\u0103 adecvate, f\u0103r\u0103 solicit\u0103ri fizice \u015fi psihice mari, sarcini suplimentare, munc\u0103 \u00een ture, munc\u0103 de noapte, \u00een ritm impus, precum \u015fi \u00eentr-un mediu inadecvat, cu factori toxici.<\/p>\n<\/td>\n

\n

Preocupare pentru orientarea profesional\u0103 sau \u00eendrumarea spre locuri de munc\u0103 f\u0103r\u0103 solicitare fizic\u0103 \u015fi psihic\u0103 mare, ritm liber, f\u0103r\u0103 ture de noapte, \u00eentr-un microclimat f\u0103r\u0103 factori nocivi (hepatotoxici).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Tulbur\u0103rile func\u0163ionale de intensitate accentuat\u0103 contraindic\u0103 prestarea oric\u0103rei activit\u0103\u0163i profesionale;<\/p>\n

– Au conservat\u0103 capacitatea de autoservire, auto\u00eengrijire \u015fi, \u00een mod limitat, pe cea de autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 sprijin pentru efectuarea activit\u0103\u0163ilor cotidiene care solicit\u0103 efort fizic \u015fi deplas\u0103ri posturale;<\/p>\n

– Sprijin pentru monitorizarea medico-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Lipse\u015fte capacitatea de prestare a unei activit\u0103\u0163i profesionale indiferent de nivelul de solicitare \u015fi condi\u0163iile de munc\u0103;<\/p>\n

– Lipse\u015fte capacitatea de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n

– Sprijin pentru cooperare la monitorizare medical\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA UNOR FUNC\u0162II METABOLICE*<\/u><\/p>\n

* Se refer\u0103 la diabetul zaharat tip I, juvenil sau al adultului t\u00e2n\u0103r p\u00e2n\u0103 la 26 ani).<\/p>\n

NB. Diabetul zaharat tip I este o boal\u0103 metabolic\u0103, de cele mai multe ori determinat\u0103 genetic, cu evolu\u0163ie cronic\u0103 stadial\u0103, \u00een care lipsa sau sc\u0103derea insulinei eficiente determin\u0103 sc\u0103derea glucozei celulare urmat\u0103 de hiperglicemie care, dac\u0103 nu este corectat\u0103, antreneaz\u0103 perturb\u0103ri ale metabolismului lipidic, protidic \u015fi ale echilibrului hidro-electrolitic. Aceste perturb\u0103ri, dup\u0103 o perioad\u0103 variabil\u0103, \u00een func\u0163ie de o serie de factori favorizan\u0163i\/determinan\u0163i, medico-psiho-sociali, conduc la apari\u0163ia complica\u0163iilor metabolice, cardiovasculare, oftalmologice, renale, infec\u0163ioase.<\/p>\n

– Cu c\u00e2t diabetul este depistat la o v\u00e2rst\u0103 mai t\u00e2n\u0103r\u0103 (copil\u0103rie), cu at\u00e2t prognosticul este mai rezervat.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

1. Examene paraclinice:<\/p>\n

a. – glicemie a jeun, repetate, peste 130 mg\/dl;<\/p>\n

b. – glicemie venoas\u0103 dup\u0103 testul de toleran\u0163\u0103 la glucoz\u0103 (dac\u0103 este cazul) de cel pu\u0163in 170 mg\/dl (s\u0103geat\u0103 hiperglicemic\u0103) sau 130mg\/dl dup\u0103 2 ore;<\/p>\n

c. – glicozurie de minimum 5 gr \u2030 \u00een urin\u0103 din 24 de ore;<\/p>\n

– examen sumar urin\u0103 (densitate, albumin\u0103, corpi cetonici);<\/p>\n

– dozare albumin\u0103 \u00een urin\u0103 (dac\u0103 este cazul);<\/p>\n

– creatinin\u0103, uree, acid uric;<\/p>\n

– examen oftalmologic (FO, AV, c\u00e2mp vizual);<\/p>\n

– examen neurologic;<\/p>\n

– oscilometrie – eco Dopller – indice oscilometric membre inferiore<\/p>\n

2. Examen clinic<\/p>\n<\/td>\n

\n

– \u00cen formele cu echilibru glicemic cu profil glicemic convenabil, f\u0103r\u0103 complica\u0163ii (func\u0163ia renal\u0103 normal\u0103, FO normal, examen neurologic normal, indici oscilometrici normali);<\/p>\n

– Necesar de insulina administrat \u00een dou\u0103 prize.<\/p>\n<\/td>\n

\n

– \u00cen formele care se pot echilibra din punct de vedere glicemic<\/p>\n

– Cu tulbur\u0103ri de reglare simpaticoparsimpatic<\/p>\n

– Hipotensiune ortostatic\u0103;<\/p>\n

– Cu complica\u0163ii incipiente microangiopatice, cu modific\u0103ri nesemnificative microalbuminurie \u00een repaos dozabil\u0103 la efort)<\/p>\n

– Necesar de insulin\u0103 repartizat \u00een trei prize.<\/p>\n<\/td>\n

\n

– \u00cen formele dezechilibrate metabolic, instabile, cu\/f\u0103r\u0103 fenomene de decompensare metabolic\u0103 (tip hipoglicemic-cetocetonic), necomplicate, pentru perioada necesar\u0103 echilibr\u0103rii.<\/p>\n<\/td>\n

\n

– \u00cen formele cu complica\u0163ii specifice (microangiopatice) manifeste pe un organ \u0163int\u0103 sau pe mai multe organe predilecte sau cu microangiopatie periferic\u0103 (artropatia Charcot – picior diabetic)- \u00een func\u0163ie de intensitatea tulbur\u0103rilor morfofunc\u0163ionale.<\/p>\n

NB. Pentru evaluare vezi criteriile stabilite pentru afectarea func\u0163iei respective (func\u0163iei vizuale, urinare, de mobilitate, static\u0103 \u015fi locomo\u0163ie).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Vor fi selectate \u015fi aprofundate investiga\u0163iile paraclinice \u00een func\u0163ie de echilibrul metabolic \u015fi decelarea complica\u0163iilor specifice (microangiopatii cu localizare ocular\u0103, renal\u0103 \u015fi pl\u0103cut\u0103 neuro-motorie)<\/p>\n

NB. – Examenele paraclinice de la pct. 1, lit. a, b \u015fi c au importan\u0163\u0103 major\u0103 pentru controlul terapeutic.<\/p>\n

– Examenul clinic \u00een diabetul tip I necomplicat are importan\u0163\u0103 minor\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Loc de munc\u0103 corespunz\u0103tor, cu solicitare energetic\u0103 redus\u0103 \u015fi psihic\u0103 medie, \u00een condi\u0163ii ambientale corespunz\u0103toare;<\/p>\n

– Evitarea activit\u0103\u0163ii \u00een ture, munca de noapte, la \u00een\u0103l\u0163ime, l\u00e2ng\u0103 foc, unelte \u00een mi\u015fcare, siguran\u0163a circula\u0163iei;<\/p>\n

– Ritm liber cu pauze de mas\u0103 pentru administrarea insulinei.<\/p>\n<\/td>\n

\n

– Asigurarea unui loc de munc\u0103 adecvat, \u00een aceea\u015fi profesie sau \u00eendrumare profesional\u0103 spre activit\u0103\u0163i care nu se desf\u0103\u015foar\u0103 la \u00een\u0103l\u0163ime, l\u00e2ng\u0103 foc, unelte \u00een mi\u015fcare \u015fi care nu impun suprasolicitare vizual\u0103;<\/p>\n

– Sunt contraindicate activit\u0103\u0163ile care pot periclita siguran\u0163a circula\u0163iei;<\/p>\n

– Asigurarea pauzei de mas\u0103 pentru mese frac\u0163ionate \u015fi administrarea necesarului de insulin\u0103;<\/p>\n

– Monitorizarea medical\u0103 la Centrul Antidiabetic (CAD) pentru urm\u0103rirea echilibrului metabolic \u015fi prevenirea apari\u0163iei complica\u0163iilor specifice.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

NB. Pentru adolescen\u0163i, orientarea \u015fi formarea profesional\u0103 pentru profesiuni care:<\/p>\n

– nu impun suprasolicitarea analizatorului vizual (activit\u0103\u0163i de precizie)<\/p>\n

– impun activit\u0103\u0163i \u00een mediu cald,<\/p>\n

– se desf\u0103\u015foar\u0103 la \u00een\u0103l\u0163ime,<\/p>\n

– impun deplas\u0103ri posturale frecvente,<\/p>\n

– necesit\u0103 solicitare fizic\u0103 \u015fi psihic\u0103 intens\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Incapacitate tranzitorie de desf\u0103\u015furare a oric\u0103rei activit\u0103\u0163i profesionale pe perioada necesar\u0103 echilibr\u0103rii metabolice, stabilirii necesarului de insulin\u0103 \u015fi de hidra\u0163i de carbon (regim igienodietetic).<\/p>\n<\/td>\n

\n

– Necesit\u0103 ajutor din partea familiei pentru respectarea regimului alimentar \u015fi administrarea la timp a cantit\u0103\u0163ii de insulina;<\/p>\n

– Monitorizare la CAD pentru echilibrare \u015fi prevenirea complica\u0163iilor specifice.<\/p>\n

NB. Dup\u0103 echilibrarea homeostaziei glicemice, \u00eendrumarea sau orientarea profesional\u0103 spre locuri de munc\u0103 sau profesiuni compatibile cu respectarea indica\u0163iilor \u015fi contraindica\u0163iilor prev\u0103zute pentru persoanele cu handicap u\u015for \u015fi mediu.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Stabilite pentru afectarea func\u0163iilor: vederii, urinare, mobilit\u0103\u0163ii, staticii \u015fi locomo\u0163iei.<\/p>\n<\/td>\n

\n

– Vezi capitolele respective;<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

III.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR ENDOCRINE<\/u><\/p>\n

1.<\/strong>Evaluarea gradului de handicap \u00een hiperfunc\u0163ia hipofizar\u0103 (tumora hipofizar\u0103 secretant\u0103 de GH – hormon de cre\u015ftere)*<\/p>\n

* Se refer\u0103 la acromegalie – tumor\u0103 hipofizar\u0103 secretant\u0103 de GH (hormon de cre\u015ftere) la adult.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Examen endocrin:<\/p>\n

– modificarea fizionomiei;<\/p>\n

– cre\u015fterea de volum a extremit\u0103\u0163ilor;<\/p>\n

– visceromegalie;<\/p>\n

– sindrom clinic tumoral cerebral;<\/p>\n

– tulbur\u0103ri de metabolism glucidic (DZ tip II);<\/p>\n

– tulbur\u0103ri hormonale secundare paraclinic;<\/p>\n

– cre\u015ftere hormon GH \u00een ser \u015fi \u00een LCR;<\/p>\n

– CT, RMN \u015fi radiografie de \u015fea turceasc\u0103 -tumor\u0103 hipofizar\u0103 \u00een std. I-IV (Hardy);<\/p>\n

Examen oftalmologic:<\/p>\n

– Tulbur\u0103ri de c\u00e2mp vizual,<\/p>\n

– Hemianopsie,<\/p>\n

– Scotoame;<\/p>\n

Examen neurologic: semne de hipertensiune intracranian\u0103;<\/p>\n

EEG;<\/p>\n

Examen histopatologic.<\/p>\n<\/td>\n

\n

\u00cencadrare \u00een tablou clinic \u015fi paraclinic incomplet, \u00een tratament simptomatic.<\/p>\n<\/td>\n

\n

– Tumor\u0103 hipofizar\u0103 oprit\u0103 \u00een evolu\u0163ie, spontan sau dup\u0103 tratament specific (Roentgen terapie, hormonoterapie antisecretorie sau interven\u0163ie chirurgical\u0103);<\/p>\n

– F\u0103r\u0103 semne neurologice sau oftalmologice;<\/p>\n

– Tulbur\u0103ri echilibrate prin tratament hormonal substitutiv.<\/p>\n<\/td>\n

\n

– Tumor\u0103 hipofizar\u0103 evolutiv\u0103, aflat\u0103 \u00een tratament antihormonal complex sau<\/p>\n

– Tumor\u0103 hipofizar\u0103 recent stabilizat\u0103 cu tulbur\u0103ri hormonale secundare, par\u0163ial echilibrate prin tratament substitutiv sau<\/p>\n

– Tumor\u0103 hipofizar\u0103 oprit\u0103 \u00een evolu\u0163ie dup\u0103 tratament sau spontan, \u00eens\u0103 cu sechele neurologice, oftalmologice sau endocrine accentuate sau<\/p>\n

– Tumor\u0103 hipofizar\u0103 cu examen histopatologic de malignitate, \u00een tratament specific.<\/p>\n<\/td>\n

\n

Tumor\u0103 hipofizar\u0103 cu:<\/p>\n

– sechele oftalmologice grave (cecitate practic\u0103 sau absolut\u0103) sau<\/p>\n

– tulbur\u0103ri neurologice grave sau<\/p>\n

– tulbur\u0103ri metabolice grave (casexie hipofizara) care necesit\u0103 \u00eengrijire permanent\u0103 din partea altei persoane.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Evaluarea gradului de handicap \u00een hipofunc\u0163ia hipofizar\u0103<\/p>\n

a)<\/strong>Nanismul hipofizar*<\/p>\n

* Se refer\u0103 la insuficien\u0163a hipofizar\u0103 de GH (hormon de cre\u015ftere) sau tulbur\u0103ri la nivelul receptorilor periferici prin GH insuficient \u00een perioada de cre\u015ftere somatic\u0103 cu hipotrofie statural\u0103 armonioas\u0103, prezent\u00e2nd un deficit statural mai mare de 3 deriva\u0163ii standard (3DS) fa\u0163\u0103 de media de \u00een\u0103l\u0163ime pentru genera\u0163ia respectiv\u0103 de v\u00e2rst\u0103, uneori asocieri de insuficien\u0163\u0103 hipofizar\u0103 pluritrop\u0103 (panhipopituitarism).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic \u015fi paraclinic:<\/p>\n

– hipotrofie statural\u0103;<\/p>\n

– antropometrie armonioas\u0103;<\/p>\n

– schelet gracil;<\/p>\n

– musculatur\u0103 hipotrofic\u0103;<\/p>\n

– facies infantil;<\/p>\n

– doz\u0103ri hormonale (hormon GH, gonadotropi, tiroidieni, corticotropi);<\/p>\n

– m\u0103sur\u0103toarea taliei;<\/p>\n

– teste psihologice (QI);<\/p>\n

– EKG, tensiune arterial\u0103.<\/p>\n<\/td>\n

\n

– Tulbur\u0103ri de gestualitate \u015fi locomo\u0163ie u\u015foare;<\/p>\n

– Talie 1,49-1,40 m;<\/p>\n

– Performan\u0163e intelectuale normale.<\/p>\n<\/td>\n

\n

– Tulbur\u0103ri de gestualitate – locomotorii de intensitate medie;<\/p>\n

– Talie 1,39-1,30 m;<\/p>\n

– Performan\u0163e intelectuale normale.<\/p>\n<\/td>\n

\n

– Tulbur\u0103ri de gestualitate \u015fi locomotorii accentuate;<\/p>\n

– Talie sub 1,29 m;<\/p>\n

– Performan\u0163e intelectuale normale;<\/p>\n

– Deficit al hormonilor hipofizari:<\/p>\n

– Gonadotropi = infantilism sexual,<\/p>\n

– Tireoptropi = mixedem secundar,<\/p>\n

– Corticotropi = hipotensiune arterial\u0103 = performan\u0163\u0103 de efort sc\u0103zut\u0103.<\/p>\n

NB. Intensitatea tulbur\u0103rilor hormonale asociate se cuantific\u0103 dup\u0103 criteriile stabilite pentru afectarea func\u0163iei respective.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>Condrodisplazia*<\/p>\n

* Hipotrofie statural\u0103 disarmonic\u0103 prin lipsa receptorilor pentru GH la nivelul cartilajelor de cre\u015ftere ale extremit\u0103\u0163ilor toracale \u015fi pelviene, cu artropatii secundare.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

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Examen clinic:<\/p>\n

– Hipotrofie statural\u0103;<\/p>\n

– Antropometrie dizarmonic\u0103;<\/p>\n

– Hipotrofia extremit\u0103\u0163ilor toracale \u015fi pelviene;<\/p>\n

– Mobilitatea articula\u0163iilor scapulohumerale-coxofemurale limitate prin artropatii secundare;<\/p>\n

Examene paraclinice: – prezentate la nanismul hipofizar.<\/p>\n<\/td>\n

\n

\u00cen evaluarea deficien\u0163ei func\u0163ionale \u015fi a gradului de handicap se vor avea \u00een vedere:<\/p>\n

– criteriile stabilite pentru afectarea mobilit\u0103\u0163ii articulare, (artropatia condrodisplazic\u0103 determina tulbur\u0103ri de realizare a variantelor posturale \u015fi a gestualit\u0103\u0163ii),<\/p>\n

– criteriile de \u00een\u0103l\u0163ime prezentate \u00een insuficien\u0163a hipofizar\u0103 (nanismul hipofizar).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

c)<\/strong>Sindrom Sheehan*<\/p>\n

* Se refer\u0103 la insuficien\u0163a hipofizar\u0103 primar\u0103 (sindrom Sheehan) – afec\u0163iune uni sau, mai frecvent, pluritrop\u0103, exprimat\u0103 prin tulbur\u0103ri clinice \u015fi hormonale.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n

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HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Examen endocrin:<\/p>\n

– semne de hipotiroidie;<\/p>\n

– semne de hipogonadism, hipogonadotropi;<\/p>\n

– insuficien\u0163\u0103 cortico-suprarenal\u0103 cronic\u0103;<\/p>\n

– hipoanabolism care poate merge p\u00e2n\u0103 la casexie;<\/p>\n

Doz\u0103ri hormonale specifice; Examen neurologic; EKG;<\/p>\n

Examen psihic.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 ne\u00eenso\u0163it\u0103 de complica\u0163ii.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 cu complica\u0163ii compensate cu tratament hormonal substitutiv.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 cu tulbur\u0103ri endocrino-metabolice accentuate, necompensate clinic \u015fi biologic sub tratament substitutiv complex, asociat cu complica\u0163ii metabolice (pierdere ponderal\u0103 progresiv\u0103), cardiovasculare \u015fi neuropsihice.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 hipofizar\u0103 sever\u0103 cu tulbur\u0103ri endocrine \u015fi metabolice grave \u015fi complica\u0163ii cardiovasculare \u015fi neuropsihice care conduc la pierderea ctdExamen clinic:apacit\u0103\u0163ii de auto\u00eengrijire, autoservire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Evaluarea gradului de handicap \u00een insuficien\u0163a hipofizar\u0103 posterioar\u0103, prin deficit total\/par\u0163ial de vasopresin\u0103 (AVP)*<\/p>\n

* Sindrom clinic de poliurie, polidipsie cu densitate urinar\u0103 sub 1010 prin deficit total\/par\u0163ial de vasopresin\u0103 (AVP) sau lipsa ac\u0163iunii tisulare a AVP.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

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Clinic \u015fi paraclinic:<\/p>\n

– Diureza = 3 l\/24 h;<\/p>\n

– densitate urinar\u0103 sub 1010;<\/p>\n

– subizostenurie-osmolaritate urinar\u0103 < 300 mEq\/l<\/p>\n

– -Clearence-ul apei libere pozitiv;<\/p>\n

– proba de sete cu test la vasopresin\u0103 (adiuretin) pozitiv – \u00een etiologia tumoral\u0103;<\/p>\n

– investiga\u0163ii hormonale;<\/p>\n

– CT, RMN.<\/p>\n<\/td>\n

\n

\u00cen formele care r\u0103spund la tratamentul cu vasopresin\u0103 sau analogi.<\/p>\n<\/td>\n

\n

\u00cen diabetul insipid lezional sau tumoral, compensat \u00een tratament substitutiv cu vasopresin\u0103 (adiuretin).<\/p>\n<\/td>\n

\n

Post tumoral sau postoperator, rezistente la tratament cu vasopresin\u0103 sau analogi, asociate cu complica\u0163ii neurologice \u015fi hormonale secundare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Evaluarea gradului de handicap \u00een insuficien\u0163a tiroidian\u0103*<\/p>\n

* Se refer\u0103 la:<\/p>\n

– mixedemul primar cu visceralizare;<\/p>\n

– mixedemul congenital (disgenezie tiroidian\u0103).<\/p>\n

Sindrom clinic determinat de sc\u0103derea cantit\u0103\u0163ii de hormoni tiroidieni la nivelul receptorilor celulari ceea ce determin\u0103 infiltrarea \u0163esuturilor cu consecin\u0163ele respective, handicapante.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n

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HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

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Clinic:<\/p>\n

– Metabolic: cre\u015ftere ponderal\u0103, infiltrarea tegumentelor, anemie secundar\u0103;<\/p>\n

– Neuropsihic: lentoare psihic\u0103, frilozitate;<\/p>\n

– Cardiovascular:<\/p>\n

cardiomiopatie mixedematoas\u0103, insuficien\u0163\u0103 cardiac\u0103;<\/p>\n

– Nanism dizarmonic cu \u00eent\u00e2rziere mental\u0103 (mixedem congenital), doz\u0103ri hormonale specifice \u00b1 gu\u015f\u0103; Paraclinic:<\/p>\n

– T3<\/sub>, T4<\/sub>\u00a0sc\u0103zute, PBI sc\u0103zut;<\/p>\n

– TSH crescut (mixedemul primar);<\/p>\n

– Scintigrama tiroidian\u0103 (lipsa tiroidei \u00een disgenezia tiroidian\u0103, imagine neomogen\u0103 \u00een gu\u015fa multinodular\u0103);<\/p>\n

– RIC sc\u0103zut sau absent;<\/p>\n

– EKG (tulbur\u0103ri de conducere, bradicardie, microvoltaj);<\/p>\n

– Ecografie cardiac\u0103 (cord m\u0103rit);<\/p>\n

– Hb, HT sc\u0103zute (anemie secundar\u0103);<\/p>\n

– Radiografie cord-pl\u0103m\u00e2n (indice cardio-toracic crescut);<\/p>\n

– Biochimie:<\/p>\n

– Hiperlipoproteinemie,<\/p>\n

– Hipercolesterolemie;<\/p>\n<\/td>\n

\n

Hipotiroidismul subclinic, eviden\u0163iat prin doz\u0103ri hormonale (TSH crescut) f\u0103r\u0103 expresie clinic\u0103 manifest\u0103 sau oligosimptomatic, forme u\u015foare cu r\u0103spuns la substitu\u0163ia hormonal\u0103, \u00een doze minime.<\/p>\n<\/td>\n

\n

Insuficien\u0163a tiroidian\u0103 clinic manifest\u0103, \u00een tratament hormonal substitutiv, cu complica\u0163ii cardiovasculare \u015fi metabolice echilibrabile.<\/p>\n<\/td>\n

\n

Insuficien\u0163a tiroidian\u0103 cu complica\u0163ii persistente (cardiovasculare \u015fi metabolice) sau leziuni degenerative nervoase \u015fi osteoarticulare neechilibrate sau sechelare, decompensate la tratament specific.<\/p>\n<\/td>\n

\n

Insuficien\u0163a tiroidian\u0103 sever\u0103 cu visceraliz\u0103ri – cu complica\u0163ii cardiovasculare \u015fi neurologice grave, insuficien\u0163\u0103 cardiac\u0103 congestiv\u0103 ireductibil\u0103, poliserozite, encefalopatie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Evaluarea gradului de handicap \u00een afectarea func\u0163iei paratiroidei<\/p>\n

a)<\/strong>Hiperfunc\u0163ie paratiroidian\u0103*<\/p>\n

* Se refer\u0103 la hiperparatiroidismul primar (boala Recklighausen), caracterizat prin: secre\u0163ie excesiv\u0103 \u015fi autonom\u0103 de parthormon (PTH) de c\u00e2tre una sau mai multe glande paratiroide (de obicei tumorale), adenoame, care produc:<\/p>\n

– hipercalcemie seric\u0103,<\/p>\n

– hipofosfatemie,<\/p>\n

– rezorb\u0163ie osoas\u0103 excesiv\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
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PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

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DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

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HANDICAP U\u015eOR<\/p>\n<\/td>\n

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HANDICAP MEDIU<\/p>\n<\/td>\n

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HANDICAP ACCENTUAT<\/p>\n<\/td>\n

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HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

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Clinic:<\/p>\n

– Leziuni scheletale (osoase), oase lungi \u015fi vertebre:<\/p>\n

– Fracturi spontane,<\/p>\n

– Osteoporoz\u0103 cu arii de demineralizare \u015fi<\/p>\n

– Formarea de chisturi osoase;<\/p>\n

– Tulbur\u0103ri renale: poliurie, litiaz\u0103;<\/p>\n

– Tulbur\u0103ri gastro-intestinale;<\/p>\n

– Tulbur\u0103ri neuropsihice;<\/p>\n

Paraclinic:<\/p>\n

– Calcemie peste 11 mg % (repetat\u0103);<\/p>\n

– Calciurie peste 400 mg %\/24 h;<\/p>\n

– Fosfatemie sc\u0103zut\u0103 (sub 2,5 mg%);<\/p>\n

– Fosfataz\u0103 alcalin\u0103 crescut\u0103 (\u00een leziuni osoase);<\/p>\n

– PTH seric (imunodozare) cu nivel crescut \u00een condi\u0163iile calcemiei crescute sau normale;<\/p>\n

– EKG: scurtare interval QT;<\/p>\n

– Examen radiologic:<\/p>\n

– Geode osoase sau\/\u015fi lacune diseminate;<\/p>\n

– Fracturi, calusuri;<\/p>\n

– Osteoporoz\u0103 generalizat\u0103;<\/p>\n

– Litiaz\u0103 renal\u0103 (nefrocalcinoz\u0103);<\/p>\n

– Ulcer gastric.<\/p>\n<\/td>\n

\n

Hipercalcemie seric\u0103 asimptomatic\u0103 sau cu tablou clinic oligosimptomatic.<\/p>\n<\/td>\n

\n

Hiperparatiroidism operat, cu sechele osoase sau renale neevolutive, cu tulbur\u0103ri de locomo\u0163ie \u015fi excre\u0163ie medie.<\/p>\n<\/td>\n

\n

Hiperparatiroidism operat, forma osteodistrofic\u0103 cu tulbur\u0103ri locomotorii accentuate prin deform\u0103ri osoase \u015fi forma nefrolitiazic\u0103 moderat\u0103 cu IRC stadiul de RAF.<\/p>\n<\/td>\n

\n

Hiperparatiroidism cu fracturi multiple \u015fi deform\u0103ri osoase cu deficien\u0163\u0103 locomotori grav\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Pentru evaluarea gradului de handicap mediu, accentuat \u015fi grav vezi criteriile stabilite \u00een afectarea func\u0163iilor osteo-musculo-articulare \u015fi ale mi\u015fc\u0103rilor aferente precum \u015fi a func\u0163iilor urinare.<\/p>\n

b)<\/strong>Hipofunc\u0163ie paratiroidian\u0103*<\/p>\n

*Se refer\u0103 la: hipoparatiroidismul primar (tetanie), caracterizat prin sc\u0103derea nivelului sangvin de parathormon (PTH) \u00een urma lez\u0103rii primitive a glandelor paratiroide.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Hiperexcitabilitate neuro-muscular\u0103;<\/p>\n

– Crize spontane de contractur\u0103 muscular\u0103, localizate pe grupuri musculare sau generalizate;<\/p>\n

– Crize de contractur\u0103 muscular\u0103 provocate de hiperpnee;<\/p>\n

– Semne mecanice de hiperexcitabilitate neuromuscular\u0103 (semnul Chwostek \u015fi Weiss pozitive);<\/p>\n

– Tulbur\u0103ri trofice (cataract\u0103 \u00een formele cronice, \u00eendelungate)<\/p>\n

Paraclinic:<\/p>\n

– Ca total \u015fi\/sau ionic sc\u0103zut;<\/p>\n

– Mg total \u015fi\/sau ionic sc\u0103zut;<\/p>\n

– EMG pozitiv.<\/p>\n<\/td>\n

\n

Tetanie latent\u0103 (spasmofilie) \u00een tratament specific cu manifest\u0103ri sporadice.<\/p>\n<\/td>\n

\n

Tetanie cronic\u0103 cu manifest\u0103ri clinice \u015fi crize relativ frecvente sub tratament specific.<\/p>\n<\/td>\n

\n

Tetanie cronic\u0103 cu crize acute frecvente, neinfluen\u0163ate de tratament.<\/p>\n

NB. Manifest\u0103ri mai rar \u00eent\u00e2lnite \u00een afectarea primitiv\u0103 a glandelor paratiroide.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

6.<\/strong>Evaluarea gradului de handicap \u00een afectarea glandei suprarenale<\/p>\n

– Insuficien\u0163a corticosuprarenal\u0103 cronic\u0103, primar\u0103 (Boala Addison)*<\/p>\n

* Se refer\u0103 la insuficien\u0163a corticosuprarenal\u0103 primar\u0103 cronic\u0103 (CSR), datorit\u0103 distrugerii ambelor corticosuprarenale (peste 80%), care determin\u0103:<\/p>\n

– sc\u0103dere hormoni glucocorticoizi;<\/p>\n

– sc\u0103dere hormoni mineralocorticoizi;<\/p>\n

– sc\u0103dere hormoni androgeni adrenali.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Astenie, adinamie, fatigabilitate;<\/p>\n

– Gre\u0163uri, v\u0103rs\u0103turi, dureri musculare;<\/p>\n

– Sc\u0103dere ponderal\u0103, deshidratare;<\/p>\n

– Melanodermie;<\/p>\n

– Hipotensiune arterial\u0103.<\/p>\n

Paraclinic:<\/p>\n

– Doz\u0103ri hormonale specifice;<\/p>\n

– Ionogram\u0103:<\/p>\n

– Na+<\/sup>\u00a0sc\u0103zut,<\/p>\n

– K+<\/sup>\u00a0crescut,<\/p>\n

– Glicemie: hipoglicemie seric\u0103;<\/p>\n

– Test stimulare cu ACTH (cortrosyn) negativ.<\/p>\n<\/td>\n

\n

\u00cen forma compensat\u0103 clinic \u015fi hormonal, sub tratament substitutiv.<\/p>\n<\/td>\n

\n

– Insuficien\u0163\u0103 CSR cronic\u0103 cu decompens\u0103ri repetate sau<\/p>\n

– Insuficien\u0163\u0103 CSR cronic\u0103 cu rezerve hormonale labile, par\u0163ial echilibrate sub tratament sau<\/p>\n

– Insuficien\u0163\u0103 CSR cronic\u0103 uni sau bilateral operat\u0103, \u00een tratament substitutiv continuu, p\u00e2n\u0103 la echilibrare.<\/p>\n<\/td>\n

\n

Insuficien\u0163\u0103 CSR cronic\u0103 decompensat\u0103, rezistent\u0103 la tratament, care necesit\u0103 \u00eengrijire permanent\u0103 din partea altei persoane.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

7.<\/strong>Evaluarea gradului de handicap \u00een insuficien\u0163a gonadic\u0103<\/p>\n

a)<\/strong>Insuficien\u0163a gonadic\u0103 primar\u0103 (primitiv\u0103)*<\/p>\n

* Se refer\u0103 la: insuficien\u0163a gonadic\u0103 primitiv\u0103, disginezii gonadale (mai frecvent) cu simptomatologie variabil\u0103, \u00een func\u0163ie de:<\/p>\n

– tipul gonadic;<\/p>\n

– v\u00e2rsta instal\u0103rii;<\/p>\n

– intensitatea insuficien\u0163ei gonadice;<\/p>\n

– cauza insuficien\u0163ei gonadice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

Sindrom clinic caracterizat prin formarea deficitar\u0103 a testiculelor datorit\u0103 unor defec\u0163iuni cromozomiale;<\/p>\n

Disgenezie a tubilor seminiferi determinate de anomalii ale formulei cromozomiale.<\/p>\n

Tablou clinic:<\/p>\n

– Fenotip masculin;<\/p>\n

– Aspect enucoid;<\/p>\n

– Aspect infantil\/normal;<\/p>\n

– Testicule mici;<\/p>\n

– Ginecomastie;<\/p>\n

– Obezitate \u00b1;<\/p>\n

– Deficit intelectual de intensitate variabil\u0103<\/p>\n

Paraclinic:<\/p>\n

– Spermatograma – azoospermie;<\/p>\n

– H. gornadotropi serici crescu\u0163i;<\/p>\n

– Testosteron plasmatic sc\u0103zut.<\/p>\n<\/td>\n

\n

Forme clinice cu tablou oligosimptomatic, compensat prin substitu\u0163ie cu hormoni sexoizi, f\u0103r\u0103 sc\u0103derea capacit\u0103\u0163ii de efort fizic sau f\u0103r\u0103 tulbur\u0103ri psihice handicapante.<\/p>\n<\/td>\n

\n

Formele clinice cu tulbur\u0103ri de dezvoltare musculara \u015fi osteoporoz\u0103 sexoiodopriv\u0103 cu sc\u0103derea capacit\u0103\u0163ii de efort fizic \u015fi prin tulbur\u0103ri neuropsihice de intensitate medie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>Insuficien\u0163a gonadic\u0103 prin disgenezii gonadale cu fenotip feminin (Sindromul Turner)*<\/p>\n

* Afec\u0163iune determinat\u0103 de un deficit al cromozomului X cu cariotip 45Xa, – sindromul Turner (digenezii gonadale cu fenotip feminin).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Tablou clinic:<\/p>\n

– Hipotrofie statural\u0103 disarmonic\u0103;<\/p>\n

– Facies caracteristic;<\/p>\n

– Organe genitale externe infantile;<\/p>\n

– Infertilitate;<\/p>\n

– Malforma\u0163ii somatice: cardiace, renale, surditate;<\/p>\n

– Semne de hipotiroidie.<\/p>\n

Tablou paraclinic:<\/p>\n

– Doz\u0103ri hormonale specifice;<\/p>\n

– Estradiol plasmatic sc\u0103zut;<\/p>\n

– Hormoni gonadotropi crescu\u0163i;<\/p>\n

– Glicemie: tulbur\u0103ri de glicoreglare;<\/p>\n

– Examen psihologic: QI (cel pu\u0163in intelect liminar);<\/p>\n

– Audiogram\u0103 (hipoacuzie\/surditate).<\/p>\n<\/td>\n

\n

– Forme clinice cu hipotrofie statural\u0103 \u00eentre 140-149 cm.;<\/p>\n

– Forme f\u0103r\u0103 malforma\u0163ii somatice handicapante.<\/p>\n<\/td>\n

\n

– Forme cu hipotrofie statural\u0103 \u00eentre 130-139 cm. cu tulb locomotorii, de realizare a variantelor posturale \u015fi de prehensiune (gestualitate) de intensitate medie;<\/p>\n

– Forme cu tulbur\u0103ri func\u0163ionale somatice (cardiovasculare, renale) \u015fi tulbur\u0103ri psihice de intensitate medie.<\/p>\n<\/td>\n

\n

– Forme clinice cu hipotrofie statural\u0103 sub 120 cm, malforma\u0163ii cardiovasculare, sc\u0103derea accentuat\u0103 a capacit\u0103\u0163ii de presta\u0163ie fizic\u0103 sau prin tulbur\u0103ri neuropsihice accentuate.<\/p>\n<\/td>\n<\/tr>\n

\n

NB: \u00cen evaluarea gradului de handicap se vor avea \u00een vedere \u015fi:<\/p>\n

– Criteriile de la insuficien\u0163a hipofizar\u0103 (antehipofizar\u0103);<\/p>\n

– Criteriile de la nanismul hipofizar;<\/p>\n

– Criteriile de la insuficien\u0163a tiroidian\u0103;<\/p>\n

– Criteriile prev\u0103zute la afectarea fibrei miocardice;<\/p>\n

– Criteriile prev\u0103zute la afectarea func\u0163iilor mentale (nedezvoltarea global\u0103 a func\u0163iilor mentale);<\/p>\n

– Criteriile prev\u0103zute la afectarea func\u0163iilor urinare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

8.<\/strong>Evaluarea gradului de handicap \u00een afectarea func\u0163iei tiroidiene din prolifer\u0103rile maligne*<\/p>\n

* Se refer\u0103 la:<\/p>\n

– cancerul tiroidian operat recent sau cu sechele metabolice sau pulmonare, dezechilibrate, sub tratament continuu,<\/p>\n

– formele inoperabile sau\/\u015fi tratate chirurgical sau\/\u015fi izotopic \u00een faze de diseminare.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Glanda tiroid\u0103 m\u0103rit\u0103, dur\u0103, cu\/f\u0103r\u0103 adenopatii sau nodul ferm, tiroidian;<\/p>\n

– Ganglioni laterocervicali (palpabili);<\/p>\n

– Tablou metabolic consumptiv.<\/p>\n

Paraclinic:<\/p>\n

– Scintigrama tiroidian\u0103 (imagini neomogene sau lacunare);<\/p>\n

– RIC – hipocaptare sau valori normale;<\/p>\n

– Doz\u0103ri hormonale complementare (hiperfunc\u0163ionalitate);<\/p>\n

– Punc\u0163ie bioptic\u0103 tiroid\u0103 – examen histopatologic;<\/p>\n

– Examen radiografic pulmonar \u015fi osos pentru formele metastatice.<\/p>\n<\/td>\n

\n

– \u00cen timpul tratamentului complex, chirurgical \u015fi radioizotopic;<\/p>\n

– \u00cen formele operate cu recidive locale sau cu sechele dezechilibrate sub tratament continuu.<\/p>\n<\/td>\n

\n

– \u00cen formele inoperabile sau<\/p>\n

– Tratate chirurgical sau\/\u015fi izotopic, \u00een faze de diseminare cu metastaze (pulmonare, osoase etc.).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Pot desf\u0103\u015fura activit\u0103\u0163i cu solicit\u0103ri fizice de intensitate redus\u0103, \u00een pozi\u0163ie predominant \u015fez\u00e2nd, care nu necesit\u0103 variante posturale, deplas\u0103ri posturale, \u00eentr-un micro\/macro-climat de confort organic.<\/p>\n<\/td>\n

\n

Au redus\u0103 capacitatea de adaptare la efort. Este necesar s\u0103 se diminueze efortul fizic prin:<\/p>\n

– m\u0103suri de adaptare a utilajelor la locul de munc\u0103,<\/p>\n

– ajustarea mediului ambiental fizic,<\/p>\n

– m\u0103suri tehnico-mecanice de ridicare \u015fi transport al greut\u0103\u0163ilor,<\/p>\n

– m\u0103suri pentru evitarea pozi\u0163iei for\u0163ate \u00een munc\u0103 sau deplas\u0103rilor posturale pe distan\u0163e mari, pe plan \u00eenclinat sau urcare pe sc\u0103ri. \u00cen aceste situa\u0163ii trebuie s\u0103 se asigure un mijloc de transport adecvat.<\/p>\n

– evitarea sarcinilor suplimentare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Au limitat\u0103 par\u0163ial sau total capacitatea de a efectua activit\u0103\u0163i profesionale.<\/p>\n<\/td>\n

\n

– Sprijin pentru compensarea pierderii par\u0163iale sau totale a capacit\u0103\u0163ii de auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n

– Necesit\u0103 asistent personal;<\/p>\n

– Monitorizare medical\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Pentru func\u0163iile care, pe l\u00e2ng\u0103 limitarea capacit\u0103\u0163ii de adaptare la efort au \u015fi alte disfunc\u0163ii, de obicei complexe, vezi:<\/p>\n

Criteriile de la afectarea mobilit\u0103\u0163ii-locomo\u0163iei,<\/p>\n

Criteriile de la afectarea func\u0163iilor mentale, pentru cazurile cu deficien\u0163e prin nedezvoltarea global\u0103 intelectual\u0103 (pot executa sarcini \u00een raport de nivelul lor de integrare \u015fi comportamentul adoptat de familie \u015fi comunitate).<\/p>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a06:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0UROGENITALE<\/strong><\/p>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR DE FILTRARE \u015eI SECRE\u0162IE RENAL\u0102, DE COLECTARE \u015eI STOCARE A URINEI \u00ceN VEZICA URINAR\u0102*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE\/ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR (IRC Std. I)<\/p>\n<\/td>\n

\n

HANDICAP MEDIU (IRC Std. II faza a)<\/p>\n<\/td>\n

\n

HANDICAP MEDIU\/ACCENTUAT (IRC Std. II faza b)<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT (IRC Std. III preuremic)<\/p>\n<\/td>\n

\n

HANDICAP GRAV (IRC Std. IV de uremie terminal\u0103)<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV (IRC Std. V de uremie dep\u0103\u015fit\u0103)**<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

\u00cen func\u0163ie de toleran\u0163a individual\u0103 a IRC \u015fi simptomatologia clinic\u0103<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Densitate urinar\u0103<\/p>\n<\/td>\n

\n

< 1025<\/p>\n<\/td>\n

\n

<= 1022<\/p>\n<\/td>\n

\n

< 1017<\/p>\n<\/td>\n

\n

1010-1011<\/p>\n<\/td>\n

\n

<= 1010<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Uree sanguin\u0103 (mg\/dl)<\/p>\n<\/td>\n

\n

< 50<\/p>\n<\/td>\n

\n

< 50<\/p>\n<\/td>\n

\n

50-100<\/p>\n<\/td>\n

\n

> 100<\/p>\n<\/td>\n

\n

300-500<\/p>\n<\/td>\n

\n

< 500<\/p>\n<\/td>\n<\/tr>\n

\n

Creatinin\u0103 sanguin\u0103(mg\/dl)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

1.5 – 2.5<\/p>\n<\/td>\n

\n

3 – 4<\/p>\n<\/td>\n

\n

> 4.5<\/p>\n<\/td>\n

\n

> 6<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Hb gr\/dl<\/p>\n<\/td>\n

\n

12 – 15<\/p>\n<\/td>\n

\n

12-13<\/p>\n<\/td>\n

\n

10 – 12<\/p>\n<\/td>\n

\n

8 – 10<\/p>\n<\/td>\n

\n

8<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Cl uree (ml\/min)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

70 – 26<\/p>\n<\/td>\n

\n

26-20<\/p>\n<\/td>\n

\n

20 – 2.5<\/p>\n<\/td>\n

\n

7.5-1.2<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Cl creatinin\u0103 (ml\/min)<\/p>\n<\/td>\n

\n

120 – 70<\/p>\n<\/td>\n

\n

70 – 40<\/p>\n<\/td>\n

\n

40-30<\/p>\n<\/td>\n

\n

40 – 12<\/p>\n<\/td>\n

\n

< 7.5<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Nr. nefroni func\u0163ionali (%)<\/p>\n<\/td>\n

\n

100 – 50<\/p>\n<\/td>\n

\n

50 – 35<\/p>\n<\/td>\n

\n

35 – 25<\/p>\n<\/td>\n

\n

25-10<\/p>\n<\/td>\n

\n

< 10<\/p>\n<\/td>\n

\n

< 10<\/p>\n<\/td>\n<\/tr>\n

\n

Sumar urin\u0103;<\/p>\n

Dozare albumin\u0103 \u00een urin\u0103 CT, RMN, cistoscopie;<\/p>\n

Ex histopatologic<\/p>\n<\/td>\n

\n

Dac\u0103 este cazul<\/p>\n

\u00cen func\u0163ie de structura afectat\u0103<\/p>\n

\u00cen func\u0163ie de structura afectat\u0103<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*Se refer\u0103 la:<\/p>\n

1.Toate afec\u0163iunile cronice renale, congenitale sau dob\u00e2ndite, de etiologie multipl\u0103, cu afectare primar\u0103 sau secundar\u0103 renal\u0103, localizate la ambii rinichi sau \u00eentr-unul singur, \u00een caz de rinichi unic congenital sau dob\u00e2ndit.<\/p>\n

De exemplu:<\/p>\n

Cauze malformative (agenezie renal\u0103 unilateral\u0103, hipoplazii renale, rinichi polichistic, rinichi \u00een potcoav\u0103, duplicare ureteral\u0103, hidronefroz\u0103 etc.);<\/p>\n

Cauze tumorale;<\/p>\n

Hipertensiune arterial\u0103 renovascular\u0103;<\/p>\n

Boli renale sau pielonefrit\u0103 pe rinichi unic congenital sau chirurgical cu fenomene de IRC.<\/p>\n

Afec\u0163iuni renale cu evolu\u0163ie progresiv\u0103, care au ca expresie func\u0163ional\u0103 insuficien\u0163a renal\u0103 cronic\u0103.<\/p>\n

2.Rezec\u0163ia total\u0103 a vezicii urinare pentru cancer, cu implantare de uretere (indiferent unde este implantul) – pierderea func\u0163iei de colectare \u015fi stocare a urinei de c\u0103tre vezica urinar\u0103.<\/p>\n

Insuficien\u0163a renal\u0103 cronic\u0103 evolueaz\u0103 stadial, indiferent de structura afectat\u0103 \u015fi de cauzele ei \u00een 5 stadii.<\/p>\n

\u00a0<\/p>\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

Stadii<\/p>\n<\/td>\n

\n

Insuficienta func\u0163ional\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Std. I<\/p>\n

– de deplin\u0103 compensare<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 normal\u0103 \u00een repaos, u\u015for alterat\u0103 \u00een condi\u0163ii de suprasolicitare;<\/p>\n

– Homeostazie hidroelectrolitic\u0103 \u015fi acido-bazic\u0103 normal\u0103;<\/p>\n

– Probe func\u0163ionale renale normale;<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 120-70 ml\/min<\/p>\n

– Nu exist\u0103 anemie.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. II<\/p>\n

– insuficien\u0163a renal\u0103 compensat\u0103<\/p>\n

a. faza poliuric\u0103<\/p>\n

b. faza RAF<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 normal\u0103 \u00een repaos prin interven\u0163ia mecanismelor compensatorii (hipertrofia func\u0163ional\u0103 a nefronilor restan\u0163i, hipertensiune, poliurie compensatorie, reten\u0163ie azotat\u0103);<\/p>\n

– Probe func\u0163ionale renale pu\u0163in sau moderat modificate;<\/p>\n

– Homeostazie modificat\u0103 moderat (in faza b);<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 69-40 ml\/min<\/p>\n

– Anemie u\u015foar\u0103 sau moderat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. III<\/p>\n

IRC decompensat\u0103 (preuremie)<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 afectat\u0103 \u00een repaos;<\/p>\n

– Homeostazie constant alterat\u0103;<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 39-24 ml\/min<\/p>\n

– Anemie moderat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. IV<\/p>\n

– de uremie terminal\u0103<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 grav alterat\u0103;<\/p>\n

– Homeostazie grav alterat\u0103 prin cre\u015fterea semnificativ\u0103 a produ\u015filor de reten\u0163ie azotat\u0103;<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 24 – 12 ml\/min<\/p>\n

– Anemie medie sau sever\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. V*<\/p>\n

– de uremie dep\u0103\u015fit\u0103<\/p>\n<\/td>\n

\n

Supravie\u0163uirea este asigurat\u0103 prin mijloace de substitu\u0163ie a func\u0163iei renale.<\/p>\n

Constantele statice \u015fi dinamice renale sunt variabile \u00een func\u0163ie de metoda de epurare extrarenal\u0103:<\/p>\n

– hemodializa (epurare extracorporeal\u0103);<\/p>\n

– dializa peritoneal\u0103 (epurare intracorporeal\u0103) sau<\/p>\n

– transplantul renal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Gradul de handicap \u00een stadiul V (uremie dep\u0103\u015fit\u0103) este variabil.<\/p>\n

\u00cen evaluare se vor avea \u00een vedere:<\/p>\n

– eficien\u0163a metodelor de epurare extrarenal\u0103 (grad IRC);<\/p>\n

– apari\u0163ia de complica\u0163ii specifice nefropatiei de fond;<\/p>\n

– patologia indus\u0103 de tehnica de epurare extrarenal\u0103.<\/p>\n

\u00cen st\u0103rile post transplant de rinichi:<\/p>\n

– Handicap grav \u00een primele 12 luni, datorit\u0103 posibilit\u0103\u0163ii de apari\u0163ie a fenomenelor de respingere, cu reluarea programului de hemodializ\u0103;<\/p>\n

– Ulterior evaluarea gradului de handicap se face \u00een func\u0163ie de gradul de restabilire a func\u0163iei renale.<\/p>\n

\u00cen evaluare se va \u0163ine seama \u015fi de efectul tratamentului imunosupresor, psihicului \u015fi cooperarea pacientului.<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR UROGENITALE<\/p>\n

1.<\/strong>Neoplasme urogenitale operate cu recidive locoregionale sau la distan\u0163\u0103 sau inoperabile, \u00een faze de generalizare.<\/p>\n

2.<\/strong>Neoplasme mamare inoperabile \u00een faza de generalizare, sau operate cu recidive locale sau\/\u015fi la distant\u0103.<\/p>\n

\u00a0<\/p>\n\n\n<\/colgroup>\n\n\n\n\n
\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/<\/p>\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT\/<\/p>\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

\u00cen func\u0163ie de apari\u0163ia recidivelor locoregionale sau determin\u0103rilor la distan\u0163\u0103, precum \u015fi de starea de nutri\u0163ie – obligatorie ancheta social\u0103 cu obiective precizate de comisie<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103, \u00eentr-un microclimat f\u0103r\u0103 varia\u0163ii termice (temperaturi extreme), umiditate, toxice renale, trepida\u0163ii.<\/p>\n<\/td>\n

\n

Sprijin pentru:<\/p>\n

– asigurarea condi\u0163iilor de munc\u0103 (microclimat) adecvate;<\/p>\n

– activitate pe acela\u015fi loc de munc\u0103 sau, eventual, schimbarea locului de munc\u0103;<\/p>\n

\u00cen IRC IV \u015fi IRC V sprijin pentru:<\/p>\n

– activit\u0103\u0163ile cotidiene, ale vie\u0163ii de zi cu zi;<\/p>\n

– transport la \u015fi de la centrul de hemodializ\u0103;<\/p>\n

– transportul materialelor de epurare intracorporeal\u0103 (de la unitatea sanitar\u0103 la domiciliu);<\/p>\n

– suplinirea capacit\u0103\u0163ii de autoservire sau auto\u00eengrijire \u00een cazul complica\u0163iilor induse de procedura de epurare sau de agravarea structurilor de fond.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

\u00cen general activit\u0103\u0163i intelectuale, munci de birou, statice sau de colaborare (activit\u0103\u0163i la domiciliu).<\/p>\n

– Cu condi\u0163ia respect\u0103rii<\/p>\n

programului de hemodializ\u0103\/dializ\u0103 peritoneal\u0103 sau\/\u015fi<\/p>\n

– Cu asigurarea monitoriz\u0103rii<\/p>\n

clinice, paraclinice \u015fi terapeutice la centrul care a efectuat transplantul renal sau la unit\u0103\u0163ile sanitare la care sunt \u00een eviden\u0163\u0103 persoanele cu dializ\u0103 peritoneal\u0103 \u015fi hemodializ\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen cazul existen\u0163ei unor complica\u0163ii secundare, ineficien\u0163ei metodei de epurare extrarenal\u0103 sau transplant renal nefunc\u0163ional – lipse\u015fte capacitatea de realizare a unor activit\u0103\u0163i aduc\u0103toare de venit \u015fi chiar a activit\u0103\u0163ilor cotidiene de auto\u00eengrijire – autogospod\u0103rire.<\/p>\n

Idem pentru persoanele cu rezec\u0163ie total\u0103 de vezic\u0103, cu tumori maligne uro-genitale cu recidive loco-regionale sau determin\u0103ri la distant\u0103.<\/p>\n<\/td>\n

\n

La persoanele cu rezec\u0163ii totale de vezic\u0103 urinar\u0103: sprijin pentru asigurarea pungilor de colectare a urinei \u015fi pentru schimbarea lor \u00een condi\u0163ii aseptice<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a07:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0NEURO-MUSCULO-SCHELETICE<\/strong>\u00a0\u015eI<\/strong>\u00a0ALE<\/strong>\u00a0MI\u015eC\u0102RILOR<\/strong>\u00a0AFERENTE<\/strong><\/p>\n

I.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA MOBILIT\u0102\u0162II ARTICULA\u0162IILOR \u015eI OASELOR*<\/u><\/p>\n

* Se refer\u0103 la anomalii \u015fi structuri afectate, respectiv la:<\/p>\n

1.- bolile constitu\u0163ionale ale oaselor (de ex. acondrodisplazia);<\/p>\n

– malforma\u0163ii (de ex. amielia unui membru, total\u0103 sau par\u0163ial\u0103, toracal sau pelvin, sindactilie);<\/p>\n

– deform\u0103ri rahitice cu tulbur\u0103ri de postur\u0103;<\/p>\n

– luxa\u0163ie congenital\u0103 de \u015fold (unilateral sau bilateral) cu coxartroz\u0103 secundar\u0103 \u015fi\/sau modific\u0103ri ale coloanei vertebrale;<\/p>\n

– redori \u015fi anchiloze congenitale post traumatice sau dup\u0103 osteoartrit\u0103 TBC, redori str\u00e2nse mono sau bilaterale de \u015fold, genunchi sau combinate, \u00een pozi\u0163ii vicioase, asociate sau nu cu paralizii nervoase;<\/p>\n

– lipsa policelui sau a patru degete, bilateral;<\/p>\n

– anchiloze ale pumnului, coatelor sau umerilor;<\/p>\n

– pseudartroze (gamb\u0103, coaps\u0103, antebra\u0163, bra\u0163 – neoperabile)<\/p>\n

2.Hemofilia A \u015fi B, boal\u0103 congenital\u0103 care apare la sexul masculin prin deficit de factor VIII (Hemofilia A) \u015fi factor IX (Hemofilia B), \u00een formele cu modific\u0103ri ale mecanicii articulare sau \u00een formele cu anchiloze \u00een pozi\u0163ii vicioase \u015fi amiotrofii care \u00eempiedic\u0103 mobilizarea (locomo\u0163ia) sau\/\u015fi autoservirea.<\/p>\n

3.Colagenoze:<\/p>\n

a)poliartrit\u0103 reumatoid\u0103 (PR): boal\u0103 imunoinflamatorie cronic\u0103 progresiv\u0103 care afecteaz\u0103, cu predilec\u0163ie, articula\u0163iile mici ale membrelor, simetric \u015fi distructiv;<\/p>\n

b)sclerodermia: cu tulbur\u0103ri cutanate specifice, care reduce gestualitatea datorit\u0103 sclerodactiliei;<\/p>\n

c)dermatomiozita.<\/p>\n

d)lupusul eritematos sistemic.<\/p>\n

1.<\/strong>Afec\u0163iuni osteo-articulare congenitale sau contractate precoce<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen ortopedic;<\/p>\n

– Examene radiografice, segment afectat \u015fi, eventual, contralateral, \u00een func\u0163ie de limitarea func\u0163ional\u0103 secundar\u0103 (articula\u0163ii, coloan\u0103 vertebral\u0103);<\/p>\n

– CT (eventual – \u00een func\u0163ie de structura afectat\u0103);<\/p>\n

– Test\u0103ri biometrice;<\/p>\n

– Testarea mobilit\u0103\u0163ii articulare;<\/p>\n

– Examen oscilometric;<\/p>\n

– Examen eco – Doppler;<\/p>\n

– Spirometrie.<\/p>\n<\/td>\n

\n

\u00cencadrarea \u00een grad de handicap u\u015for, mediu, accentuat sau grav se realizeaz\u0103 particularizat \u00een func\u0163ie de:<\/p>\n

– intensitatea tulbur\u0103rilor de postura sau\/\u015fi gestualitate;<\/p>\n

– localizarea unilateral\u0103 sau bilateral\u0103 a deterior\u0103rii (anomaliei);<\/p>\n

– membrul sau membrele afectate;<\/p>\n

– consecin\u0163ele secundare (la articula\u0163iile suprajacentei, coloana vertebral\u0103);<\/p>\n

– capacitatea respiratorie afectat\u0103 secundar;<\/p>\n

– existen\u0163a tulbur\u0103rilor neurologice secundare de tip paretic\/plegic;<\/p>\n

– \u00een raport de gestualitatea \u015fi deservirea necesar\u0103;<\/p>\n

– capacitatea de mobilizare cu mijloace protetice, ortetice, mijloace speciale de deplasare;<\/p>\n

– limitarea prehensiunii \u015fi manipula\u0163iei;<\/p>\n

– capacitatea de autoservire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Selectarea se face \u00een func\u0163ie de anomalie, structura afectat\u0103 \u015fi cauzele care le-au determinat (etiologia lor).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Locuri de munc\u0103 f\u0103r\u0103 solicitare postural\u0103 sau\/si gestual\u0103, f\u0103r\u0103 deplas\u0103ri \u00een teren, \u00een func\u0163ie de structura\/structurile afectate cu limit\u0103rile func\u0163ionale secundare.<\/p>\n<\/td>\n

\n

– Asigurare de mijloace compensatorii (protetice, ortetice etc.), adaptate \u00een raport de secven\u0163ele muncii (pense, c\u00e2rlige etc.) \u00een raport de membrul sau membrele afectate;<\/p>\n

– Mijloace speciale de deplasare (baston, cadru, scaun rulant, ma\u015fini adaptate etc.);<\/p>\n

– Reorganizarea procesului de produc\u0163ie, adaptarea locuin\u0163ei pentru a facilita integrarea social\u0103;<\/p>\n

– Sprijin pentru activit\u0103\u0163ile cotidiene – instrumentale \u00een cazul persoanelor cu deficien\u0163e grave.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Hemofilia A \u015fi B*<\/p>\n

* Sindrom hemoragic produs prin deficit de factori plasmatici ai coagul\u0103rii.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen ortopedic;<\/p>\n

– Examen radiografic, segment afectat \u015fi, eventual, contralateral, \u00een func\u0163ie de limitarea func\u0163ional\u0103 secundar\u0103 (articula\u0163ii, coloan\u0103 vertebral\u0103);<\/p>\n

– CT (eventual – \u00een func\u0163ie de structura afectat\u0103);<\/p>\n

– RMN;<\/p>\n

– Test\u0103ri biometrice;<\/p>\n

– Testarea mobilit\u0103\u0163ii articulare;<\/p>\n

– Examen oscilometric;<\/p>\n

– Examen eco – Doppler;<\/p>\n

– Spirometrie;<\/p>\n

– Determinarea factorilor plasmatici ai coagul\u0103rii:<\/p>\n

– factorul VIII,<\/p>\n

– factorul IX.<\/p>\n<\/td>\n

\n

\u00cen formele u\u015foare, f\u0103r\u0103 tulbur\u0103ri hemoragice.<\/p>\n<\/td>\n

\n

– \u00cen formele medii cu s\u00e2nger\u0103ri minore, f\u0103r\u0103 determin\u0103ri articulare sau<\/p>\n

– \u00cen formele cu artropatii necomplicate care necesit\u0103 tratament antihemofilic periodic.<\/p>\n<\/td>\n

\n

– \u00cen formele severe cu artropatii cronice, cu modific\u0103ri reversibile ale mecanicii articulare, are necesit\u0103 administr\u0103ri repetate de preparate antihemofilice \u015fi transfuzii frecvente.<\/p>\n<\/td>\n

\n

– \u00cen formele severe cu anchiloze \u00een pozi\u0163ii vicioase, cu amiotrofii care \u00eempiedic\u0103 autoservirea \u015fi mobilizarea.<\/p>\n<\/td>\n<\/tr>\n

\n

NB. \u00cen evaluare se va \u0163ine seama \u015fi de afectarea altor structuri care predispun la s\u00e2ngerare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 \u00eentr-un loc de munc\u0103 f\u0103r\u0103 risc de traumatism fizic.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu condi\u0163ia evit\u0103rii riscului de accidentare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 \u00eentr-un loc de munc\u0103 f\u0103r\u0103 risc de traumatism fizic.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu condi\u0163ia evit\u0103rii riscului de accidentare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 solicitare fizic\u0103 mare sau cu risc de traumatizare indiferent de intensitate \u015fi cauze.<\/p>\n

– Sunt limitate activit\u0103\u0163ile care suprasolicit\u0103 postura ortostatic\u0103, deplas\u0103rile posturale prelungite, men\u0163inerea for\u0163at\u0103 a unei variante posturale \u015fi cele \u00een mediu cu trepida\u0163ii.<\/p>\n<\/td>\n

\n

Sprijin pentru:<\/p>\n

– asigurarea unui loc de munc\u0103 adecvat care s\u0103 previn\u0103 traumatizarea fizic\u0103, activarea hemartrozei \u015fi croniciz\u0103rii artropatiei specifice,<\/p>\n

– facilitarea mobiliz\u0103rii (baston, cadru, orteze etc.),<\/p>\n

– monitorizarea activit\u0103\u0163ii medicale (dispensar, administrarea de produse antihemofilice, efectuarea de transfuzii – \u00een func\u0163ie de situa\u0163ie).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Intensitatea tulbur\u0103rilor func\u0163iei locomotorii, ireversibil\u0103, neinfluen\u0163at\u0103 de tratamentul specific limiteaz\u0103 total sau aproape total capacitatea de mobilizare, autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Sprijin permanent din cauza pierderii capacit\u0103\u0163ii de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire;<\/p>\n

– Sprijin pentru pierderea autonomiei – capacitatea de mobilizare;<\/p>\n

– Sprijin pentru facilitarea deplas\u0103rii \u00een interiorul sau\/\u015fi exteriorul locuin\u0163ei \u00een func\u0163ie de necesit\u0103\u0163i.<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Colagenoze<\/p>\n

a)<\/strong>Poliartrit\u0103 reumatoid\u0103 (PR)*<\/p>\n

* Diagnosticul se stabile\u015fte atunci c\u00e2nd sunt satisf\u0103cute patru din cele \u015fapte criterii ale Asocia\u0163iei de Reumatologie Americane (ARA):<\/p>\n

– redori matinale,<\/p>\n

– artrite la trei sau mai multe articula\u0163ii,<\/p>\n

– artrita m\u00e2inilor,<\/p>\n

– artrita simetric\u0103 a m\u00e2inilor,<\/p>\n

– noduli reumatoizi,<\/p>\n

– factori reumatoizi \u00een ser,<\/p>\n

– semnele radiologice caracteristice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– VSH crescut;<\/p>\n

– Proteina C reactiv\u0103 crescut\u0103;<\/p>\n

– Fibrinogen seric crescut;<\/p>\n

– Electroforeza:<\/p>\n

hipergamaglobulinemie;<\/p>\n

– IGM \u015fi IGG mult crescute;<\/p>\n

– Factor reumatoizi prezen\u0163i:<\/p>\n

– Waler Rose pozitiv,<\/p>\n

– Latex: pozitiv;<\/p>\n

– Ex radiologic;<\/p>\n

– CT-RMN.<\/p>\n<\/td>\n

\n

\u00cen PR la debut:<\/p>\n

– redori matinale la nivelul articula\u0163iilor periferice;<\/p>\n

– mobilizarea articula\u0163iilor periferice f\u0103r\u0103 dureri;<\/p>\n

– f\u0103r\u0103 semne obiective patologice;<\/p>\n

– testarea mobilit\u0103\u0163ii articulare (mobilitate normal\u0103).<\/p>\n<\/td>\n

\n

\u00cen PR stadiul I, II\/III<\/p>\n

– moderat active:<\/p>\n

– redori matinale;<\/p>\n

– dureri la mobilizarea articula\u0163iilor periferice \u015fi \u00een repaos;<\/p>\n

– for\u0163a de prehensiune redus\u0103;<\/p>\n

– reducerea medie a mobilit\u0103\u0163ii articulare;<\/p>\n

– testele de activitate (evolu\u0163ie) pozitive, dar nu obligatoriu.<\/p>\n<\/td>\n

\n

\u00cen PR forme severe stadiul III \u015fi III\/IV:<\/p>\n

leziuni distructive cartilaginoase sau osoase; deform\u0103ri ale degetelor;<\/p>\n

subluxa\u0163ii;<\/p>\n

deriva\u0163ii axiale (cubitale ale m\u00e2inilor); atrofia mu\u015fchilor cu afectarea prehensiunii;<\/p>\n

semne radiologice caracteristice \u015fi de laborator specifice; capacitate func\u0163ional\u0103 limitat\u0103;<\/p>\n

autoservire par\u0163ial afectat\u0103.<\/p>\n<\/td>\n

\n

\u00cen PR grav\u0103 stadiul V:<\/p>\n

leziuni osteoarticulare cu deform\u0103ri \u015fi anchiloze (degete, pumni, coate, \u015folduri, genunchi \u00een semiflexie, tibiotarisene cu deformarea antepiciorului); limitarea aproape total\u0103 sau total\u0103 a gestualit\u0103\u0163ii sau\/\u015fi a posturii \u015fi deplas\u0103rilor posturale; capacitatea de autoservire pierdut\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

NB. Clasa func\u0163ional\u0103 I (Steinbrocker) – capacitatea func\u0163ional\u0103 complet\u0103 (capacitate normal\u0103 de a-\u015fi executa profesiunea).<\/p>\n<\/td>\n

\n

NB. Clasa func\u0163ional\u0103 II (Steinbrocker) – capacitatea func\u0163ional\u0103 normal\u0103 cu excep\u0163ia handicapului durerii \u015fi redorii la una sau mai multe articula\u0163ii.<\/p>\n<\/td>\n

\n

NB. Clasa func\u0163ional\u0103 III Steinbrocker) – permite numai o mic\u0103 parte din ocupa\u0163iile casnice \u015fi autoservire.<\/p>\n<\/td>\n

\n

NB. Clasa Func\u0163ional\u0103 IV Steinbrocker) – infirmitate important\u0103 – persoana imobilizat\u0103 la pat sau \u00een fotoliu, care nu se poate ocupa de propria \u00eengrijire sau o face cu foarte mare dificultate.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>Sclerodermia (afec\u0163iunea \u0163esutului conjunctiv)<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI*<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Fenomene de tip Raynaud;<\/p>\n

– Infiltra\u0163ii dure ale fe\u0163ei, trunchiului, membrelor;<\/p>\n

– Teste circulatorii periferice;<\/p>\n

– Teste func\u0163ionale renale;<\/p>\n

– Teste ventilatorii;<\/p>\n

– Biopsie muscular\u0103.<\/p>\n<\/td>\n

\n

Evaluarea gradului de handicap se face \u00een func\u0163ie de forma clinic\u0103, respectiv de intensitatea tulbur\u0103rilor de gestualitate, renale, respiratorii \u015fi de nutri\u0163ie, prev\u0103zute pentru afectarea structurilor, prezentate la capitolele \u00een cauz\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen func\u0163ie de forma clinic\u0103:<\/p>\n

– Progresiv\u0103 cu sindactilie,<\/p>\n

– Progresiv\u0103 cu tulbur\u0103ri viscerale,<\/p>\n

– Progresiv\u0103 edematoas\u0103.<\/p>\n

c)<\/strong>Dermatomiozit\u0103**<\/p>\n

** Afec\u0163iune \u00een cadrul larg al miopatiilor inflamatorii ideopatice, cu etiologie multifactorial\u0103 (infec\u0163ioas\u0103, autoimun\u0103 \u015fi vasculo-ischemic\u0103-vasculitic\u0103).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

DETERMINAREA PARAMETRILOR FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

\u00a0<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

Tablou clinic:<\/p>\n

– Hipotrofie statural\u0103 disarmonic\u0103;<\/p>\n

– Facies caracteristic;<\/p>\n

– Organe genitale externe infantile;<\/p>\n

– Infertilitate;<\/p>\n

– Malforma\u0163ii somatice: cardiace, renale, surditate;<\/p>\n

– Semne de hipotiroidie.<\/p>\n

Tablou paraclinic:<\/p>\n

– Doz\u0103ri hormonale specifice;<\/p>\n

– Estradiol plasmatic sc\u0103zut;<\/p>\n

– Hormoni gonadotropi crescu\u0163i;<\/p>\n

– Glicemie: tulbur\u0103ri de glicoreglare;<\/p>\n

– Examen psihologic: QI (cel pu\u0163in intelect liminar);<\/p>\n

– Audiogram\u0103 (hipoacuzie\/surditate).<\/p>\n<\/td>\n

\n

– Forme clinice cu hipotrofie statural\u0103 \u00eentre 140-149 cm.;<\/p>\n

– Forme f\u0103r\u0103 malforma\u0163ii somatice handicapante.<\/p>\n<\/td>\n

\n

– Forme cu hipotrofie statural\u0103 \u00eentre 130-139 cm. cu tulb locomotorii, de realizare a variantelor posturale \u015fi de prehensiune (gestualitate) de intensitate medie;<\/p>\n

– Forme cu tulbur\u0103ri func\u0163ionale somatice (cardiovasculare, renale) \u015fi tulbur\u0103ri psihice de intensitate medie.<\/p>\n<\/td>\n

\n

– Forme clinice cu hipotrofie statural\u0103 sub 120 cm, malforma\u0163ii cardiovasculare, sc\u0103derea accentuat\u0103 a capacit\u0103\u0163ii de presta\u0163ie fizic\u0103 sau prin tulbur\u0103ri neuropsihice accentuate.<\/p>\n<\/td>\n<\/tr>\n

\n

NB: \u00cen evaluarea gradului de handicap se vor avea \u00een vedere \u015fi:<\/p>\n

– Criteriile de la insuficien\u0163a hipofizar\u0103 (antehipofizar\u0103);<\/p>\n

– Criteriile de la nanismul hipofizar;<\/p>\n

– Criteriile de la insuficien\u0163a tiroidian\u0103;<\/p>\n

– Criteriile prev\u0103zute la afectarea fibrei miocardice;<\/p>\n

– Criteriile prev\u0103zute la afectarea func\u0163iilor mentale (nedezvoltarea global\u0103 a func\u0163iilor mentale);<\/p>\n

– Criteriile prev\u0103zute la afectarea func\u0163iilor urinare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

8.<\/strong>Evaluarea gradului de handicap \u00een afectarea func\u0163iei tiroidiene din prolifer\u0103rile maligne*<\/p>\n

* Se refer\u0103 la:<\/p>\n

– cancerul tiroidian operat recent sau cu sechele metabolice sau pulmonare, dezechilibrate, sub tratament continuu,<\/p>\n

– formele inoperabile sau\/\u015fi tratate chirurgical sau\/\u015fi izotopic \u00een faze de diseminare.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Clinic:<\/p>\n

– Glanda tiroid\u0103 m\u0103rit\u0103, dur\u0103, cu\/f\u0103r\u0103 adenopatii sau nodul ferm, tiroidian;<\/p>\n

– Ganglioni laterocervicali (palpabili);<\/p>\n

– Tablou metabolic consumptiv.<\/p>\n

Paraclinic:<\/p>\n

– Scintigrama tiroidian\u0103 (imagini neomogene sau lacunare);<\/p>\n

– RIC – hipocaptare sau valori normale;<\/p>\n

– Doz\u0103ri hormonale complementare (hiperfunc\u0163ionalitate);<\/p>\n

– Punc\u0163ie bioptic\u0103 tiroid\u0103 – examen histopatologic;<\/p>\n

– Examen radiografic pulmonar \u015fi osos pentru formele metastatice.<\/p>\n<\/td>\n

\n

– \u00cen timpul tratamentului complex, chirurgical \u015fi radioizotopic;<\/p>\n

– \u00cen formele operate cu recidive locale sau cu sechele dezechilibrate sub tratament continuu.<\/p>\n<\/td>\n

\n

– \u00cen formele inoperabile sau<\/p>\n

– Tratate chirurgical sau\/\u015fi izotopic, \u00een faze de diseminare cu metastaze (pulmonare, osoase etc.).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Pot desf\u0103\u015fura activit\u0103\u0163i cu solicit\u0103ri fizice de intensitate redus\u0103, \u00een pozi\u0163ie predominant \u015fez\u00e2nd, care nu necesit\u0103 variante posturale, deplas\u0103ri posturale, \u00eentr-un micro\/macro-climat de confort organic.<\/p>\n<\/td>\n

\n

Au redus\u0103 capacitatea de adaptare la efort. Este necesar s\u0103 se diminueze efortul fizic prin:<\/p>\n

– m\u0103suri de adaptare a utilajelor la locul de munc\u0103,<\/p>\n

– ajustarea mediului ambiental fizic,<\/p>\n

– m\u0103suri tehnico-mecanice de ridicare \u015fi transport al greut\u0103\u0163ilor,<\/p>\n

– m\u0103suri pentru evitarea pozi\u0163iei for\u0163ate \u00een munc\u0103 sau deplas\u0103rilor posturale pe distan\u0163e mari, pe plan \u00eenclinat sau urcare pe sc\u0103ri. \u00cen aceste situa\u0163ii trebuie s\u0103 se asigure un mijloc de transport adecvat.<\/p>\n

– evitarea sarcinilor suplimentare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Au limitat\u0103 par\u0163ial sau total capacitatea de a efectua activit\u0103\u0163i profesionale.<\/p>\n<\/td>\n

\n

– Sprijin pentru compensarea pierderii par\u0163iale sau totale a capacit\u0103\u0163ii de auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n

– Necesit\u0103 asistent personal;<\/p>\n

– Monitorizare medical\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Pentru func\u0163iile care, pe l\u00e2ng\u0103 limitarea capacit\u0103\u0163ii de adaptare la efort au \u015fi alte disfunc\u0163ii, de obicei complexe, vezi:<\/p>\n

Criteriile de la afectarea mobilit\u0103\u0163ii-locomo\u0163iei,<\/p>\n

Criteriile de la afectarea func\u0163iilor mentale, pentru cazurile cu deficien\u0163e prin nedezvoltarea global\u0103 intelectual\u0103 (pot executa sarcini \u00een raport de nivelul lor de integrare \u015fi comportamentul adoptat de familie \u015fi comunitate).<\/p>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a06:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0UROGENITALE<\/strong><\/p>\n

I.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR DE FILTRARE \u015eI SECRE\u0162IE RENAL\u0102, DE COLECTARE \u015eI STOCARE A URINEI \u00ceN VEZICA URINAR\u0102*<\/u><\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A MEDIE\/ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A GRAV\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162A ACCENTUAT\u0102\/GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR (IRC Std. I)<\/p>\n<\/td>\n

\n

HANDICAP MEDIU (IRC Std. II faza a)<\/p>\n<\/td>\n

\n

HANDICAP MEDIU\/ACCENTUAT (IRC Std. II faza b)<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT (IRC Std. III preuremic)<\/p>\n<\/td>\n

\n

HANDICAP GRAV (IRC Std. IV de uremie terminal\u0103)<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT\/GRAV (IRC Std. V de uremie dep\u0103\u015fit\u0103)**<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

\u00cen func\u0163ie de toleran\u0163a individual\u0103 a IRC \u015fi simptomatologia clinic\u0103<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Densitate urinar\u0103<\/p>\n<\/td>\n

\n

< 1025<\/p>\n<\/td>\n

\n

<= 1022<\/p>\n<\/td>\n

\n

< 1017<\/p>\n<\/td>\n

\n

1010-1011<\/p>\n<\/td>\n

\n

<= 1010<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Uree sanguin\u0103 (mg\/dl)<\/p>\n<\/td>\n

\n

< 50<\/p>\n<\/td>\n

\n

< 50<\/p>\n<\/td>\n

\n

50-100<\/p>\n<\/td>\n

\n

> 100<\/p>\n<\/td>\n

\n

300-500<\/p>\n<\/td>\n

\n

< 500<\/p>\n<\/td>\n<\/tr>\n

\n

Creatinin\u0103 sanguin\u0103(mg\/dl)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

1.5 – 2.5<\/p>\n<\/td>\n

\n

3 – 4<\/p>\n<\/td>\n

\n

> 4.5<\/p>\n<\/td>\n

\n

> 6<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Hb gr\/dl<\/p>\n<\/td>\n

\n

12 – 15<\/p>\n<\/td>\n

\n

12-13<\/p>\n<\/td>\n

\n

10 – 12<\/p>\n<\/td>\n

\n

8 – 10<\/p>\n<\/td>\n

\n

8<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Cl uree (ml\/min)<\/p>\n<\/td>\n

\n

Normal<\/p>\n<\/td>\n

\n

70 – 26<\/p>\n<\/td>\n

\n

26-20<\/p>\n<\/td>\n

\n

20 – 2.5<\/p>\n<\/td>\n

\n

7.5-1.2<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Cl creatinin\u0103 (ml\/min)<\/p>\n<\/td>\n

\n

120 – 70<\/p>\n<\/td>\n

\n

70 – 40<\/p>\n<\/td>\n

\n

40-30<\/p>\n<\/td>\n

\n

40 – 12<\/p>\n<\/td>\n

\n

< 7.5<\/p>\n<\/td>\n

\n

Variabil\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Nr. nefroni func\u0163ionali (%)<\/p>\n<\/td>\n

\n

100 – 50<\/p>\n<\/td>\n

\n

50 – 35<\/p>\n<\/td>\n

\n

35 – 25<\/p>\n<\/td>\n

\n

25-10<\/p>\n<\/td>\n

\n

< 10<\/p>\n<\/td>\n

\n

< 10<\/p>\n<\/td>\n<\/tr>\n

\n

Sumar urin\u0103;<\/p>\n

Dozare albumin\u0103 \u00een urin\u0103 CT, RMN, cistoscopie;<\/p>\n

Ex histopatologic<\/p>\n<\/td>\n

\n

Dac\u0103 este cazul<\/p>\n

\u00cen func\u0163ie de structura afectat\u0103<\/p>\n

\u00cen func\u0163ie de structura afectat\u0103<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*Se refer\u0103 la:<\/p>\n

1.Toate afec\u0163iunile cronice renale, congenitale sau dob\u00e2ndite, de etiologie multipl\u0103, cu afectare primar\u0103 sau secundar\u0103 renal\u0103, localizate la ambii rinichi sau \u00eentr-unul singur, \u00een caz de rinichi unic congenital sau dob\u00e2ndit.<\/p>\n

De exemplu:<\/p>\n

Cauze malformative (agenezie renal\u0103 unilateral\u0103, hipoplazii renale, rinichi polichistic, rinichi \u00een potcoav\u0103, duplicare ureteral\u0103, hidronefroz\u0103 etc.);<\/p>\n

Cauze tumorale;<\/p>\n

Hipertensiune arterial\u0103 renovascular\u0103;<\/p>\n

Boli renale sau pielonefrit\u0103 pe rinichi unic congenital sau chirurgical cu fenomene de IRC.<\/p>\n

Afec\u0163iuni renale cu evolu\u0163ie progresiv\u0103, care au ca expresie func\u0163ional\u0103 insuficien\u0163a renal\u0103 cronic\u0103.<\/p>\n

2.Rezec\u0163ia total\u0103 a vezicii urinare pentru cancer, cu implantare de uretere (indiferent unde este implantul) – pierderea func\u0163iei de colectare \u015fi stocare a urinei de c\u0103tre vezica urinar\u0103.<\/p>\n

Insuficien\u0163a renal\u0103 cronic\u0103 evolueaz\u0103 stadial, indiferent de structura afectat\u0103 \u015fi de cauzele ei \u00een 5 stadii.<\/p>\n

\u00a0<\/p>\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

Stadii<\/p>\n<\/td>\n

\n

Insuficienta func\u0163ional\u0103<\/p>\n<\/td>\n<\/tr>\n

\n

Std. I<\/p>\n

– de deplin\u0103 compensare<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 normal\u0103 \u00een repaos, u\u015for alterat\u0103 \u00een condi\u0163ii de suprasolicitare;<\/p>\n

– Homeostazie hidroelectrolitic\u0103 \u015fi acido-bazic\u0103 normal\u0103;<\/p>\n

– Probe func\u0163ionale renale normale;<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 120-70 ml\/min<\/p>\n

– Nu exist\u0103 anemie.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. II<\/p>\n

– insuficien\u0163a renal\u0103 compensat\u0103<\/p>\n

a. faza poliuric\u0103<\/p>\n

b. faza RAF<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 normal\u0103 \u00een repaos prin interven\u0163ia mecanismelor compensatorii (hipertrofia func\u0163ional\u0103 a nefronilor restan\u0163i, hipertensiune, poliurie compensatorie, reten\u0163ie azotat\u0103);<\/p>\n

– Probe func\u0163ionale renale pu\u0163in sau moderat modificate;<\/p>\n

– Homeostazie modificat\u0103 moderat (in faza b);<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 69-40 ml\/min<\/p>\n

– Anemie u\u015foar\u0103 sau moderat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. III<\/p>\n

IRC decompensat\u0103 (preuremie)<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 afectat\u0103 \u00een repaos;<\/p>\n

– Homeostazie constant alterat\u0103;<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 39-24 ml\/min<\/p>\n

– Anemie moderat\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. IV<\/p>\n

– de uremie terminal\u0103<\/p>\n<\/td>\n

\n

– Func\u0163ia renal\u0103 grav alterat\u0103;<\/p>\n

– Homeostazie grav alterat\u0103 prin cre\u015fterea semnificativ\u0103 a produ\u015filor de reten\u0163ie azotat\u0103;<\/p>\n

– Rata de filtrare glomerular\u0103 (Clearance-ul creatininei endogene) = 24 – 12 ml\/min<\/p>\n

– Anemie medie sau sever\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

Std. V*<\/p>\n

– de uremie dep\u0103\u015fit\u0103<\/p>\n<\/td>\n

\n

Supravie\u0163uirea este asigurat\u0103 prin mijloace de substitu\u0163ie a func\u0163iei renale.<\/p>\n

Constantele statice \u015fi dinamice renale sunt variabile \u00een func\u0163ie de metoda de epurare extrarenal\u0103:<\/p>\n

– hemodializa (epurare extracorporeal\u0103);<\/p>\n

– dializa peritoneal\u0103 (epurare intracorporeal\u0103) sau<\/p>\n

– transplantul renal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Gradul de handicap \u00een stadiul V (uremie dep\u0103\u015fit\u0103) este variabil.<\/p>\n

\u00cen evaluare se vor avea \u00een vedere:<\/p>\n

– eficien\u0163a metodelor de epurare extrarenal\u0103 (grad IRC);<\/p>\n

– apari\u0163ia de complica\u0163ii specifice nefropatiei de fond;<\/p>\n

– patologia indus\u0103 de tehnica de epurare extrarenal\u0103.<\/p>\n

\u00cen st\u0103rile post transplant de rinichi:<\/p>\n

– Handicap grav \u00een primele 12 luni, datorit\u0103 posibilit\u0103\u0163ii de apari\u0163ie a fenomenelor de respingere, cu reluarea programului de hemodializ\u0103;<\/p>\n

– Ulterior evaluarea gradului de handicap se face \u00een func\u0163ie de gradul de restabilire a func\u0163iei renale.<\/p>\n

\u00cen evaluare se va \u0163ine seama \u015fi de efectul tratamentului imunosupresor, psihicului \u015fi cooperarea pacientului.<\/p>\n

II.<\/strong>EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR UROGENITALE<\/p>\n

1.<\/strong>Neoplasme urogenitale operate cu recidive locoregionale sau la distan\u0163\u0103 sau inoperabile, \u00een faze de generalizare.<\/p>\n

2.<\/strong>Neoplasme mamare inoperabile \u00een faza de generalizare, sau operate cu recidive locale sau\/\u015fi la distant\u0103.<\/p>\n

\u00a0<\/p>\n\n\n<\/colgroup>\n\n\n\n\n
\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102\/<\/p>\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT\/<\/p>\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

\u00cen func\u0163ie de apari\u0163ia recidivelor locoregionale sau determin\u0103rilor la distan\u0163\u0103, precum \u015fi de starea de nutri\u0163ie – obligatorie ancheta social\u0103 cu obiective precizate de comisie<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103, \u00eentr-un microclimat f\u0103r\u0103 varia\u0163ii termice (temperaturi extreme), umiditate, toxice renale, trepida\u0163ii.<\/p>\n<\/td>\n

\n

Sprijin pentru:<\/p>\n

– asigurarea condi\u0163iilor de munc\u0103 (microclimat) adecvate;<\/p>\n

– activitate pe acela\u015fi loc de munc\u0103 sau, eventual, schimbarea locului de munc\u0103;<\/p>\n

\u00cen IRC IV \u015fi IRC V sprijin pentru:<\/p>\n

– activit\u0103\u0163ile cotidiene, ale vie\u0163ii de zi cu zi;<\/p>\n

– transport la \u015fi de la centrul de hemodializ\u0103;<\/p>\n

– transportul materialelor de epurare intracorporeal\u0103 (de la unitatea sanitar\u0103 la domiciliu);<\/p>\n

– suplinirea capacit\u0103\u0163ii de autoservire sau auto\u00eengrijire \u00een cazul complica\u0163iilor induse de procedura de epurare sau de agravarea structurilor de fond.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

\u00cen general activit\u0103\u0163i intelectuale, munci de birou, statice sau de colaborare (activit\u0103\u0163i la domiciliu).<\/p>\n

– Cu condi\u0163ia respect\u0103rii<\/p>\n

programului de hemodializ\u0103\/dializ\u0103 peritoneal\u0103 sau\/\u015fi<\/p>\n

– Cu asigurarea monitoriz\u0103rii<\/p>\n

clinice, paraclinice \u015fi terapeutice la centrul care a efectuat transplantul renal sau la unit\u0103\u0163ile sanitare la care sunt \u00een eviden\u0163\u0103 persoanele cu dializ\u0103 peritoneal\u0103 \u015fi hemodializ\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen cazul existen\u0163ei unor complica\u0163ii secundare, ineficien\u0163ei metodei de epurare extrarenal\u0103 sau transplant renal nefunc\u0163ional – lipse\u015fte capacitatea de realizare a unor activit\u0103\u0163i aduc\u0103toare de venit \u015fi chiar a activit\u0103\u0163ilor cotidiene de auto\u00eengrijire – autogospod\u0103rire.<\/p>\n

Idem pentru persoanele cu rezec\u0163ie total\u0103 de vezic\u0103, cu tumori maligne uro-genitale cu recidive loco-regionale sau determin\u0103ri la distant\u0103.<\/p>\n<\/td>\n

\n

La persoanele cu rezec\u0163ii totale de vezic\u0103 urinar\u0103: sprijin pentru asigurarea pungilor de colectare a urinei \u015fi pentru schimbarea lor \u00een condi\u0163ii aseptice<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a07:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0NEURO-MUSCULO-SCHELETICE<\/strong>\u00a0\u015eI<\/strong>\u00a0ALE<\/strong>\u00a0MI\u015eC\u0102RILOR<\/strong>\u00a0AFERENTE<\/strong><\/p>\n

I.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA MOBILIT\u0102\u0162II ARTICULA\u0162IILOR \u015eI OASELOR*<\/u><\/p>\n

* Se refer\u0103 la anomalii \u015fi structuri afectate, respectiv la:<\/p>\n

1.- bolile constitu\u0163ionale ale oaselor (de ex. acondrodisplazia);<\/p>\n

– malforma\u0163ii (de ex. amielia unui membru, total\u0103 sau par\u0163ial\u0103, toracal sau pelvin, sindactilie);<\/p>\n

– deform\u0103ri rahitice cu tulbur\u0103ri de postur\u0103;<\/p>\n

– luxa\u0163ie congenital\u0103 de \u015fold (unilateral sau bilateral) cu coxartroz\u0103 secundar\u0103 \u015fi\/sau modific\u0103ri ale coloanei vertebrale;<\/p>\n

– redori \u015fi anchiloze congenitale post traumatice sau dup\u0103 osteoartrit\u0103 TBC, redori str\u00e2nse mono sau bilaterale de \u015fold, genunchi sau combinate, \u00een pozi\u0163ii vicioase, asociate sau nu cu paralizii nervoase;<\/p>\n

– lipsa policelui sau a patru degete, bilateral;<\/p>\n

– anchiloze ale pumnului, coatelor sau umerilor;<\/p>\n

– pseudartroze (gamb\u0103, coaps\u0103, antebra\u0163, bra\u0163 – neoperabile)<\/p>\n

2.Hemofilia A \u015fi B, boal\u0103 congenital\u0103 care apare la sexul masculin prin deficit de factor VIII (Hemofilia A) \u015fi factor IX (Hemofilia B), \u00een formele cu modific\u0103ri ale mecanicii articulare sau \u00een formele cu anchiloze \u00een pozi\u0163ii vicioase \u015fi amiotrofii care \u00eempiedic\u0103 mobilizarea (locomo\u0163ia) sau\/\u015fi autoservirea.<\/p>\n

3.Colagenoze:<\/p>\n

a)poliartrit\u0103 reumatoid\u0103 (PR): boal\u0103 imunoinflamatorie cronic\u0103 progresiv\u0103 care afecteaz\u0103, cu predilec\u0163ie, articula\u0163iile mici ale membrelor, simetric \u015fi distructiv;<\/p>\n

b)sclerodermia: cu tulbur\u0103ri cutanate specifice, care reduce gestualitatea datorit\u0103 sclerodactiliei;<\/p>\n

c)dermatomiozita.<\/p>\n

d)lupusul eritematos sistemic.<\/p>\n

1.<\/strong>Afec\u0163iuni osteo-articulare congenitale sau contractate precoce<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI**<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen ortopedic;<\/p>\n

– Examene radiografice, segment afectat \u015fi, eventual, contralateral, \u00een func\u0163ie de limitarea func\u0163ional\u0103 secundar\u0103 (articula\u0163ii, coloan\u0103 vertebral\u0103);<\/p>\n

– CT (eventual – \u00een func\u0163ie de structura afectat\u0103);<\/p>\n

– Test\u0103ri biometrice;<\/p>\n

– Testarea mobilit\u0103\u0163ii articulare;<\/p>\n

– Examen oscilometric;<\/p>\n

– Examen eco – Doppler;<\/p>\n

– Spirometrie.<\/p>\n<\/td>\n

\n

\u00cencadrarea \u00een grad de handicap u\u015for, mediu, accentuat sau grav se realizeaz\u0103 particularizat \u00een func\u0163ie de:<\/p>\n

– intensitatea tulbur\u0103rilor de postura sau\/\u015fi gestualitate;<\/p>\n

– localizarea unilateral\u0103 sau bilateral\u0103 a deterior\u0103rii (anomaliei);<\/p>\n

– membrul sau membrele afectate;<\/p>\n

– consecin\u0163ele secundare (la articula\u0163iile suprajacentei, coloana vertebral\u0103);<\/p>\n

– capacitatea respiratorie afectat\u0103 secundar;<\/p>\n

– existen\u0163a tulbur\u0103rilor neurologice secundare de tip paretic\/plegic;<\/p>\n

– \u00een raport de gestualitatea \u015fi deservirea necesar\u0103;<\/p>\n

– capacitatea de mobilizare cu mijloace protetice, ortetice, mijloace speciale de deplasare;<\/p>\n

– limitarea prehensiunii \u015fi manipula\u0163iei;<\/p>\n

– capacitatea de autoservire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Selectarea se face \u00een func\u0163ie de anomalie, structura afectat\u0103 \u015fi cauzele care le-au determinat (etiologia lor).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Locuri de munc\u0103 f\u0103r\u0103 solicitare postural\u0103 sau\/si gestual\u0103, f\u0103r\u0103 deplas\u0103ri \u00een teren, \u00een func\u0163ie de structura\/structurile afectate cu limit\u0103rile func\u0163ionale secundare.<\/p>\n<\/td>\n

\n

– Asigurare de mijloace compensatorii (protetice, ortetice etc.), adaptate \u00een raport de secven\u0163ele muncii (pense, c\u00e2rlige etc.) \u00een raport de membrul sau membrele afectate;<\/p>\n

– Mijloace speciale de deplasare (baston, cadru, scaun rulant, ma\u015fini adaptate etc.);<\/p>\n

– Reorganizarea procesului de produc\u0163ie, adaptarea locuin\u0163ei pentru a facilita integrarea social\u0103;<\/p>\n

– Sprijin pentru activit\u0103\u0163ile cotidiene – instrumentale \u00een cazul persoanelor cu deficien\u0163e grave.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Hemofilia A \u015fi B*<\/p>\n

* Sindrom hemoragic produs prin deficit de factori plasmatici ai coagul\u0103rii.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen ortopedic;<\/p>\n

– Examen radiografic, segment afectat \u015fi, eventual, contralateral, \u00een func\u0163ie de limitarea func\u0163ional\u0103 secundar\u0103 (articula\u0163ii, coloan\u0103 vertebral\u0103);<\/p>\n

– CT (eventual – \u00een func\u0163ie de structura afectat\u0103);<\/p>\n

– RMN;<\/p>\n

– Test\u0103ri biometrice;<\/p>\n

– Testarea mobilit\u0103\u0163ii articulare;<\/p>\n

– Examen oscilometric;<\/p>\n

– Examen eco – Doppler;<\/p>\n

– Spirometrie;<\/p>\n

– Determinarea factorilor plasmatici ai coagul\u0103rii:<\/p>\n

– factorul VIII,<\/p>\n

– factorul IX.<\/p>\n<\/td>\n

\n

\u00cen formele u\u015foare, f\u0103r\u0103 tulbur\u0103ri hemoragice.<\/p>\n<\/td>\n

\n

– \u00cen formele medii cu s\u00e2nger\u0103ri minore, f\u0103r\u0103 determin\u0103ri articulare sau<\/p>\n

– \u00cen formele cu artropatii necomplicate care necesit\u0103 tratament antihemofilic periodic.<\/p>\n<\/td>\n

\n

– \u00cen formele severe cu artropatii cronice, cu modific\u0103ri reversibile ale mecanicii articulare, are necesit\u0103 administr\u0103ri repetate de preparate antihemofilice \u015fi transfuzii frecvente.<\/p>\n<\/td>\n

\n

– \u00cen formele severe cu anchiloze \u00een pozi\u0163ii vicioase, cu amiotrofii care \u00eempiedic\u0103 autoservirea \u015fi mobilizarea.<\/p>\n<\/td>\n<\/tr>\n

\n

NB. \u00cen evaluare se va \u0163ine seama \u015fi de afectarea altor structuri care predispun la s\u00e2ngerare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 \u00eentr-un loc de munc\u0103 f\u0103r\u0103 risc de traumatism fizic.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu condi\u0163ia evit\u0103rii riscului de accidentare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 \u00eentr-un loc de munc\u0103 f\u0103r\u0103 risc de traumatism fizic.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu condi\u0163ia evit\u0103rii riscului de accidentare.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 solicitare fizic\u0103 mare sau cu risc de traumatizare indiferent de intensitate \u015fi cauze.<\/p>\n

– Sunt limitate activit\u0103\u0163ile care suprasolicit\u0103 postura ortostatic\u0103, deplas\u0103rile posturale prelungite, men\u0163inerea for\u0163at\u0103 a unei variante posturale \u015fi cele \u00een mediu cu trepida\u0163ii.<\/p>\n<\/td>\n

\n

Sprijin pentru:<\/p>\n

– asigurarea unui loc de munc\u0103 adecvat care s\u0103 previn\u0103 traumatizarea fizic\u0103, activarea hemartrozei \u015fi croniciz\u0103rii artropatiei specifice,<\/p>\n

– facilitarea mobiliz\u0103rii (baston, cadru, orteze etc.),<\/p>\n

– monitorizarea activit\u0103\u0163ii medicale (dispensar, administrarea de produse antihemofilice, efectuarea de transfuzii – \u00een func\u0163ie de situa\u0163ie).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Intensitatea tulbur\u0103rilor func\u0163iei locomotorii, ireversibil\u0103, neinfluen\u0163at\u0103 de tratamentul specific limiteaz\u0103 total sau aproape total capacitatea de mobilizare, autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n

\n

– Sprijin permanent din cauza pierderii capacit\u0103\u0163ii de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire;<\/p>\n

– Sprijin pentru pierderea autonomiei – capacitatea de mobilizare;<\/p>\n

– Sprijin pentru facilitarea deplas\u0103rii \u00een interiorul sau\/\u015fi exteriorul locuin\u0163ei \u00een func\u0163ie de necesit\u0103\u0163i.<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Colagenoze<\/p>\n

a)<\/strong>Poliartrit\u0103 reumatoid\u0103 (PR)*<\/p>\n

* Diagnosticul se stabile\u015fte atunci c\u00e2nd sunt satisf\u0103cute patru din cele \u015fapte criterii ale Asocia\u0163iei de Reumatologie Americane (ARA):<\/p>\n

– redori matinale,<\/p>\n

– artrite la trei sau mai multe articula\u0163ii,<\/p>\n

– artrita m\u00e2inilor,<\/p>\n

– artrita simetric\u0103 a m\u00e2inilor,<\/p>\n

– noduli reumatoizi,<\/p>\n

– factori reumatoizi \u00een ser,<\/p>\n

– semnele radiologice caracteristice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– VSH crescut;<\/p>\n

– Proteina C reactiv\u0103 crescut\u0103;<\/p>\n

– Fibrinogen seric crescut;<\/p>\n

– Electroforeza:<\/p>\n

hipergamaglobulinemie;<\/p>\n

– IGM \u015fi IGG mult crescute;<\/p>\n

– Factor reumatoizi prezen\u0163i:<\/p>\n

– Waler Rose pozitiv,<\/p>\n

– Latex: pozitiv;<\/p>\n

– Ex radiologic;<\/p>\n

– CT-RMN.<\/p>\n<\/td>\n

\n

\u00cen PR la debut:<\/p>\n

– redori matinale la nivelul articula\u0163iilor periferice;<\/p>\n

– mobilizarea articula\u0163iilor periferice f\u0103r\u0103 dureri;<\/p>\n

– f\u0103r\u0103 semne obiective patologice;<\/p>\n

– testarea mobilit\u0103\u0163ii articulare (mobilitate normal\u0103).<\/p>\n<\/td>\n

\n

\u00cen PR stadiul I, II\/III<\/p>\n

– moderat active:<\/p>\n

– redori matinale;<\/p>\n

– dureri la mobilizarea articula\u0163iilor periferice \u015fi \u00een repaos;<\/p>\n

– for\u0163a de prehensiune redus\u0103;<\/p>\n

– reducerea medie a mobilit\u0103\u0163ii articulare;<\/p>\n

– testele de activitate (evolu\u0163ie) pozitive, dar nu obligatoriu.<\/p>\n<\/td>\n

\n

\u00cen PR forme severe stadiul III \u015fi III\/IV:<\/p>\n

leziuni distructive cartilaginoase sau osoase; deform\u0103ri ale degetelor;<\/p>\n

subluxa\u0163ii;<\/p>\n

deriva\u0163ii axiale (cubitale ale m\u00e2inilor); atrofia mu\u015fchilor cu afectarea prehensiunii;<\/p>\n

semne radiologice caracteristice \u015fi de laborator specifice; capacitate func\u0163ional\u0103 limitat\u0103;<\/p>\n

autoservire par\u0163ial afectat\u0103.<\/p>\n<\/td>\n

\n

\u00cen PR grav\u0103 stadiul V:<\/p>\n

leziuni osteoarticulare cu deform\u0103ri \u015fi anchiloze (degete, pumni, coate, \u015folduri, genunchi \u00een semiflexie, tibiotarisene cu deformarea antepiciorului); limitarea aproape total\u0103 sau total\u0103 a gestualit\u0103\u0163ii sau\/\u015fi a posturii \u015fi deplas\u0103rilor posturale; capacitatea de autoservire pierdut\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

NB. Clasa func\u0163ional\u0103 I (Steinbrocker) – capacitatea func\u0163ional\u0103 complet\u0103 (capacitate normal\u0103 de a-\u015fi executa profesiunea).<\/p>\n<\/td>\n

\n

NB. Clasa func\u0163ional\u0103 II (Steinbrocker) – capacitatea func\u0163ional\u0103 normal\u0103 cu excep\u0163ia handicapului durerii \u015fi redorii la una sau mai multe articula\u0163ii.<\/p>\n<\/td>\n

\n

NB. Clasa func\u0163ional\u0103 III Steinbrocker) – permite numai o mic\u0103 parte din ocupa\u0163iile casnice \u015fi autoservire.<\/p>\n<\/td>\n

\n

NB. Clasa Func\u0163ional\u0103 IV Steinbrocker) – infirmitate important\u0103 – persoana imobilizat\u0103 la pat sau \u00een fotoliu, care nu se poate ocupa de propria \u00eengrijire sau o face cu foarte mare dificultate.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

b)<\/strong>Sclerodermia (afec\u0163iunea \u0163esutului conjunctiv)<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI*<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOARA<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Fenomene de tip Raynaud;<\/p>\n

– Infiltra\u0163ii dure ale fe\u0163ei, trunchiului, membrelor;<\/p>\n

– Teste circulatorii periferice;<\/p>\n

– Teste func\u0163ionale renale;<\/p>\n

– Teste ventilatorii;<\/p>\n

– Biopsie muscular\u0103.<\/p>\n<\/td>\n

\n

Evaluarea gradului de handicap se face \u00een func\u0163ie de forma clinic\u0103, respectiv de intensitatea tulbur\u0103rilor de gestualitate, renale, respiratorii \u015fi de nutri\u0163ie, prev\u0103zute pentru afectarea structurilor, prezentate la capitolele \u00een cauz\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* \u00cen func\u0163ie de forma clinic\u0103:<\/p>\n

– Progresiv\u0103 cu sindactilie,<\/p>\n

– Progresiv\u0103 cu tulbur\u0103ri viscerale,<\/p>\n

– Progresiv\u0103 edematoas\u0103.<\/p>\n

c)<\/strong>Dermatomiozit\u0103**<\/p>\n

** Afec\u0163iune \u00een cadrul larg al miopatiilor inflamatorii ideopatice, cu etiologie multifactorial\u0103 (infec\u0163ioas\u0103, autoimun\u0103 \u015fi vasculo-ischemic\u0103-vasculitic\u0103).<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

DETERMINAREA PARAMETRILOR FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Edem \u00een 1\/2 superioar\u0103 a fe\u0163ei;<\/p>\n

– Deficit muscular de grade diferite (de la fatigabilitate p\u00e2n\u0103 la incapacitatea de a ridica bra\u0163ul \u015fi coapsele);<\/p>\n

– Teste enzimatice (transaminaza, creatinfosfokinaza, lactico-dehidrogenaza);<\/p>\n

– Traseu EMG caracteristic pentru afectare fibrelor musculare;<\/p>\n

– Biopsia – necroze focale.<\/p>\n<\/td>\n

\n

\u00cen conformitatea cu criteriile prezentate la Cap. 4: evaluarea gradului de handicap \u00een afectarea func\u0163iei mu\u015fchilor.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Capacitate func\u0163ional\u0103 complet\u0103 cu posibilitatea de a executa normal profesiunea.<\/p>\n<\/td>\n

\n

– Sunt necesare m\u0103suri profilactice:<\/p>\n

evitarea frigului, umezelii, curen\u0163ilor de aer la locul de munc\u0103;<\/p>\n

– Dispensarizare la medicul de familie sau reumatologie, ambulatorii de specialitate pentru controale periodice;<\/p>\n

– Profilaxia infec\u0163iilor acute \u015fi tratarea infec\u0163iilor cronice pentru a preveni progresiunea alter\u0103rilor func\u0163ionale.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Capacitate func\u0163ional\u0103 normal\u0103 cu excep\u0163ia handicapului durerii \u015fi redorii la una sau mai multe articula\u0163ii;<\/p>\n

– Limitarea gestualit\u0103\u0163ii profesionale \u015fi a mersului;<\/p>\n

– Activit\u0103\u0163i cu solicit\u0103ri fizice reduse f\u0103r\u0103 deplas\u0103ri posturale pe distan\u0163e mari, f\u0103r\u0103 ridicarea de greut\u0103\u0163i, urcat-cobor\u00e2t sc\u0103ri;<\/p>\n

– Unele limit\u0103ri \u00een activit\u0103\u0163ile cotidiene, casnice.<\/p>\n<\/td>\n

\n

– Sunt necesare m\u0103suri profilactice: evitarea frigului, umezelii, curen\u0163ilor de aer la locul de munc\u0103;<\/p>\n

– Dispensarizare la medicul de familie sau reumatologie, ambulatorii de specialitate pentru controale periodice;<\/p>\n

– Profilaxia infec\u0163iilor acute \u015fi tratarea infec\u0163iilor cronice pentru a preveni progresiunea alter\u0103rilor func\u0163ionale;<\/p>\n

– M\u0103suri pentru asigurarea unui loc de munc\u0103 f\u0103r\u0103 solicitare fizic\u0103\/trepida\u0163ii, \u00een condi\u0163ii de microclimat corespunz\u0103tor sau<\/p>\n

schimbarea locului de munc\u0103, recalificare profesional\u0103 dup\u0103 caz, \u00een func\u0163ie de v\u00e2rst\u0103, procesele evolutive \u015fi r\u0103spunsul la tratamentul aplicat.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Capacitate func\u0163ional\u0103 limitat\u0103 permi\u0163\u00e2nd numai o parte din activit\u0103\u0163ile casnice \u015fi autoservirea;<\/p>\n

– Imposibilitatea efectu\u0103rii unor activit\u0103\u0163i profesionale \u00een sistem organizat;<\/p>\n

– Eventuale activit\u0103\u0163i de colaborare \u00een func\u0163ie de deficitul de prehensiune;<\/p>\n

– Se va avea \u00een vedere faptul c\u0103:<\/p>\n

– – se ridic\u0103 cu greutate de pe scaun, chiar \u015fi cu sprijin,<\/p>\n

– – nu poate ridica \u015fi transporta greut\u0103\u0163i,<\/p>\n

– – dexteritatea se realizeaz\u0103 cu dificultate.<\/p>\n<\/td>\n

\n

– \u00cen general afectarea accentuat\u0103 a posturii, a deplas\u0103rilor posturale (mobilizarea), alternant\u0103 postural\u0103, gestualitatea – prehensiunea \u015fi manipula\u0163ia – fac imposibil\u0103 participarea la activit\u0103\u0163i profesionale;<\/p>\n

– Necesit\u0103 sprijin pentru facilitarea mobiliz\u0103rii (baston, scaun rulant);<\/p>\n

– Monitorizare periodic\u0103 medical\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Infirmitate important\u0103 – persoana cu handicap imobilizat\u0103 la pat sau \u00een fotoliu;<\/p>\n

– Nu se poate ocupa de propria sa \u00eengrijire sau o face cu foarte mult\u0103 dificultate;<\/p>\n

– Necesit\u0103 \u00eengrijire \u015fi supraveghere permanent\u0103, nu poate sta confortabil pe scaun, nu se poate ridica din pozi\u0163ia \u015fez\u00e2nd \u00een cea ortostatic\u0103;<\/p>\n

– Nu pot p\u0103stra ortostatismul nesprijinit \u015fi f\u0103r\u0103 ajutor;<\/p>\n

– Nu se pot \u00eembr\u0103ca, dezbr\u0103ca, nu-\u015fi pot t\u0103ia alimentele;<\/p>\n

– Capacitatea de autoservire \u015fi auto\u00eengrijire este afectat\u0103 major.<\/p>\n<\/td>\n

\n

– Suplinirea pierderii \u00een totalitate a capacit\u0103\u0163ii de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire;<\/p>\n

– Dependen\u0163a social\u0103 permanent\u0103;<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA MOBILIT\u0102\u0162II COLOANEI VERTEBRALE*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

1.Spondilita anchilozant\u0103 (SA), forma central\u0103, periferic\u0103 sau mixt\u0103 (central\u0103 \u015fi periferic\u0103) – afec\u0163iune inflamatori cronic\u0103 care afecteaz\u0103 preponderent coloana vertebral\u0103, procesul inflamator debut\u00e2nd frecvent la nivelul articula\u0163iilor sacro-iliace \u015fi progreseaz\u0103 ascendent.<\/p>\n

2.Cifoscolioze \u015fi scolioze deformante – idiopatice, cu grad mare de curbur\u0103, operate sau nu, care \u00eempiedic\u0103 capacitatea respiratorie normal\u0103 \u015fi\/sau cu tulbur\u0103ri neurologice (parapareze, paraplegii)<\/p>\n

1.<\/strong>Spondilit\u0103 anchilozant\u0103 (SA)<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

– Examen radiologic**:<\/p>\n

– radiografie bazin,<\/p>\n

– radiografia altor zone interesate,<\/p>\n

– tomografie – TC, RMN<\/p>\n

– scintigram\u0103 osteo-articular\u0103;<\/p>\n

– Investiga\u0163ii biologice:<\/p>\n

– VSH crescut\u0103,<\/p>\n

– electroforez\u0103 cu hiperalfaglobuline crescute \u015fi u\u015foar\u0103 hipergamaglobulinemie,<\/p>\n

– proteina C reactiv\u0103 pozitiv\u0103,<\/p>\n

– fibrinogen \u00een s\u00e2nge crescut,<\/p>\n

– imunelectroforez\u0103 serica IGA crescut\u0103,<\/p>\n

– factori reumatoizi negativi,<\/p>\n

– antigen HLA B27<\/sub>\u00a0*** prezent;<\/p>\n

– Probe paraclinice:<\/p>\n

– testarea mobilit\u0103\u0163ii coloanei vertebrale \u015fi a articula\u0163iilor mari,<\/p>\n

– spirometrie,<\/p>\n

– examen oftalmologic,<\/p>\n

– examen neurologic.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Sacroileit\u0103 gr. IV sau\/\u015fi pun\u0163i vertebrale \u00eentre dou\u0103 corpuri vertebrale;<\/p>\n

– F\u0103r\u0103 semne inflamatorii clinice;<\/p>\n

– Rectitudinea sau redoarea coloanei DL;<\/p>\n

– Mobilitatea coloanei CDL \u00een limite fiziologice sau o reducere cu 40% din valorile fiziologice ale flexiei, extensiei, \u00eenclin\u0103ri laterale dreapta \u015fi st\u00e2nga;<\/p>\n

– Semne biologice de inflama\u0163ie (\u00een puseele acute): VSH u\u015for crescut, fibrinogen u\u015for crescut, proteina C absent\u0103, antigen HLA B27<\/sub>\u00a0pozitiv,<\/p>\n

– F\u0103r\u0103 afectare ocular\u0103;<\/p>\n

– F\u0103r\u0103 disfunc\u0163ie respiratorie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Forma central\u0103:<\/p>\n

– generalizarea sindesmofitilor cu formare de pun\u0163i la un num\u0103r important de discuri vertebrale;<\/p>\n

– mobilitatea coloanei CDL: reducere cu 50% din valorile fiziologice ale flexiei, extensiei, \u00eenclin\u0103ri laterale, rota\u0163ii;<\/p>\n

– redoare matinal\u0103 coloan\u0103 CDL persistent\u0103;<\/p>\n

– deficien\u0163\u0103 ventilatorie restrictiv\u0103 u\u015foar\u0103;<\/p>\n

– f\u0103r\u0103 deficien\u0163\u0103 vizual\u0103 sau cu deficien\u0163\u0103 u\u015foar\u0103.<\/p>\n

Forma periferic\u0103:<\/p>\n

– articula\u0163ii periferice afectate de proces inflamator cronic, frecvent asimetric, cel mai des la genunchi;<\/p>\n

– tendinite, fascit\u0103 plantar\u0103,<\/p>\n

– mobilitatea articula\u0163iilor periferice redus\u0103 cu 30- 40% din valorile fiziologice;<\/p>\n

– semnele biologice moderat crescute;<\/p>\n

– antigen HLA B27 pozitiv.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Forma central\u0103:<\/p>\n

– cu prinderea coloanei CDL;<\/p>\n

– fixarea coloanei cervicale \u00een flexie \u00een mod ireversibil, \u00een puseele acute; – deficien\u0163\u0103 ventilatorie medie de tip restrictiv;<\/p>\n

– deficien\u0163\u0103 vizual\u0103 medie prin sechele de iridociclit\u0103;<\/p>\n

– afectarea mobilit\u0103\u0163ii coloanei vertebrale cu peste 70% din valorile fiziologice (urc\u0103 \u015fi coboar\u0103 sc\u0103rile dar cu dificultate)<\/p>\n

Forma mixt\u0103:<\/p>\n

– cu prinderea coloanei CDL;<\/p>\n

– cu prinderea centurilor scapulo-humerale \u015fi coxo-femurale, bilateral;<\/p>\n

– deficien\u0163\u0103 ventilatorie medie sau accentuat\u0103 de tip restrictiv;<\/p>\n

– deficien\u0163\u0103 vizual\u0103 medie prin afectare ocular\u0103 sechelar\u0103 iridociclitei;<\/p>\n

– afectarea func\u0163ionalit\u0103\u0163ii articula\u0163iilor periferice p\u00e2n\u0103 la 80% din valorile fiziologice (se deplaseaz\u0103 cu greutate cu baston sau c\u00e2rje \u015fi pe distan\u0163e mici); Forma periferic\u0103:<\/p>\n

– cu prinderea articula\u0163iilor mari: coxo-femurale, genunchi, articula\u0163ia coatelor, pumn \u015fi degete; – afectarea func\u0163iilor articula\u0163iilor periferice cu peste 80-85% din valorile fiziologice.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Forma central\u0103:<\/p>\n

– cu prinderea centurilor toracice \u015fi pelviene,<\/p>\n

– cu prinderea umerilor (anchiloza \u00een adduc\u0163ie),<\/p>\n

– cu prinderea coxo-femural\u0103 bilateral cu tendin\u0163\u0103 la anchiloze,<\/p>\n

– deficien\u0163\u0103 ventilatorie sever\u0103 de tip restrictiv.<\/p>\n

Forma periferic\u0103:<\/p>\n

– cu anchiloza pumnilor, coatelor – \u00een semiflexie, anchiloza tibio-tarsian\u0103 \u00een equin,<\/p>\n

– cu deformarea accentuat\u0103 a antepiciorului.<\/p>\n

Forma mixt\u0103:<\/p>\n

– forma sever\u0103 cu\/f\u0103r\u0103 afectarea grav\u0103 a acuit\u0103\u0163ii vizuale.<\/p>\n

NB.<\/p>\n

Persoanele cu SA stadiul IV se deplaseaz\u0103 cu mare dificultate \u015fi sprijinite. Sunt \u00een imposibilitatea realiz\u0103rii activit\u0103\u0163ilor vie\u0163ii zilnice de autoservire \u015fi \u00eengrijire. Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Principalul criteriu de diagnostic pozitiv poate consta, \u00een func\u0163ie de evolu\u0163ie, \u00een:<\/p>\n

– Sacroileit\u0103 gr. III (moderat\u0103): scleroz\u0103 \u015fi osteocondensare ale articula\u0163iilor;<\/p>\n

– sacroileit\u0103 grad IV: anchiloz\u0103 cu dispari\u0163ia spa\u0163iilor articulare;<\/p>\n

– apari\u0163ia de pun\u0163i intervertebrale (ini\u0163ial D11<\/sub>-D12,<\/sub>\u00a0L1<\/sub>-L2<\/sub>) – sindesmofite (osific\u0103ri interligamentare), ulterior se generalizeaz\u0103 – aspect „trestie de bambus”;<\/p>\n

– afectarea articula\u0163iilor interapofizare cu tendin\u0163\u0103 la pensare \u015fi anchiloze care pot lua aspect de „\u015fin\u0103 de tramvai”<\/p>\n

*** Antigenul HLA B27<\/sub>: are semnifica\u0163ie predispozant\u0103 pentru afec\u0163iune; este prezent la 80 – 90 % dintre persoane.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103.<\/p>\n

Pot desf\u0103\u015fura activit\u0103\u0163i fizice, nu au probleme cu mobilizarea, urcatul \u015fi cobor\u00e2tul de sc\u0103ri \u015fi ridicarea de greut\u0103\u0163i. Pot desf\u0103\u015fura activit\u0103\u0163i casnice (sociale \u015fi ale vie\u0163ii zilnice)<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ie, necesit\u0103:<\/p>\n

– monitorizare medical\u0103,<\/p>\n

– controale periodice,<\/p>\n

– cure balneare \u015fi<\/p>\n

– program de kinetoterapie.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu evitarea suprasolicit\u0103rilor gestuale, posturale – ortostatismul sau mersul prelungit, ridicarea de greut\u0103\u0163i, \u00eentr-un mediu adecvat, f\u0103r\u0103 curen\u0163i de aer, varia\u0163ii termice, trepida\u0163ii.<\/p>\n<\/td>\n

\n

– Asigurarea unui loc de munc\u0103 accesibil pentru prevenirea evolu\u0163iei spre stadii superioare;<\/p>\n

– Sprijin din partea angajatorilor \u015fi al familiei pentru aplicarea m\u0103surilor profilactice:<\/p>\n

– dispensarizare medic de familie sau serviciul de reumatologie,<\/p>\n

– program de kinetoterapie (gimnastic\u0103 medical\u0103),<\/p>\n

– eventual schimbarea locului de munc\u0103 pentru activit\u0103\u0163i f\u0103r\u0103 eforturi fizice, f\u0103r\u0103 ortostatism prelungit, \u00een mediu cu curen\u0163i de aer, umezeal\u0103, pozi\u0163ii vicioase – fixe \u00een timpul muncii.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare postural\u0103, f\u0103r\u0103 deplas\u0103ri prelungite sau care s\u0103 impun\u0103 variante posturale;<\/p>\n

– Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103 \u015fi vizual\u0103.<\/p>\n

\u00cen general au redus\u0103 capacitatea de efectuare a oric\u0103rei activit\u0103\u0163i profesionale organizate, cu program normal,<\/p>\n

– Au limitat\u0103 posibilitatea de a realiza majoritatea activit\u0103\u0163ilor necesare vie\u0163ii zilnice \u015fi pentru cele de autoservire (ex: aplecat, \u00eembr\u0103cat\/dezbr\u0103cat, transport greut\u0103\u0163i);<\/p>\n

– Au limitat\u0103 capacitatea de mobilizare (se deplaseaz\u0103 cu greutate cu baston) precum \u015fi posibilitatea de men\u0163inere \u00eendelungat\u0103 a pozi\u0163iei ortostatice sau \u015fez\u00e2nde \u015fi a variantelor posturale;<\/p>\n

– Capacitatea de efort fizic – redus\u0103.<\/p>\n<\/td>\n

\n

Participare \u00een condi\u0163ii de monitorizare medical\u0103 \u015fi profesional\u0103:<\/p>\n

– Internare \u00een sec\u0163ii de reumatologie \u00een puseele acute, pentru tratament particularizat \u015fi controlat;<\/p>\n

– Dispensarizare medic de familie sau specialist reumatolog pentru control periodic;<\/p>\n

– Program de kinetoterapie la domiciliu sau dispensar, ambulatoriu de specialitate;<\/p>\n

– Schimbarea locului de munc\u0103 sau orientare pentru munci f\u0103r\u0103 efort fizic, ortostatism prelungit, frig, curen\u0163i de aer, umezeal\u0103, pozi\u0163ii vicioase, suprasolicitarea vederii.<\/p>\n

\u00cen timpul muncii:<\/p>\n

– Sprijin din partea angajatorilor pentru asigurarea unui loc de munc\u0103 adaptat;<\/p>\n

– Ajutor din partea familiei pentru realizarea unor activit\u0103\u0163i necesare \u00eengrijirii \u015fi gospod\u0103ririi (vie\u0163ii cotidiene).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Pierderea total\u0103 a capacit\u0103\u0163ii de munc\u0103, de autoservire sau\/\u015fi de orientare spa\u0163ial\u0103;<\/p>\n

– Limitarea major\u0103 a capacit\u0103\u0163ii de mobilizare;<\/p>\n

– Limitarea major\u0103 a posibilit\u0103\u0163ii de realizare a activit\u0103\u0163ilor vie\u0163ii cotidiene, instrumentale \u015fi de auto\u00eengrijire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal;<\/p>\n

– Necesit\u0103 sprijin pentru ob\u0163inerea unor mijloace de deplasare (baston, fotoliu rulant etc.)<\/p>\n

– Asisten\u0163\u0103 medical\u0103 la domiciliu, particularizat\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Cifoscolioze idiopatice<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

DETERMINAREA PARAMETRILOR FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Radiografii coloan\u0103 vertebral\u0103, umeri \u015fi \u015fold, \u00een raport de consecin\u0163ele secundare;<\/p>\n

– Tomografie (TC), RMN;<\/p>\n

– Examen ortopedic;<\/p>\n

– Examen neurologic;<\/p>\n

– Testarea mobilit\u0103\u0163ii coloanei vertebrale;<\/p>\n

– Testarea mobilit\u0103\u0163ii articula\u0163iilor mari;<\/p>\n

– Probe ventilatorii.<\/p>\n<\/td>\n

\n

\u00cencadrarea \u00een grad de handicap se realizeaz\u0103 \u00een raport de existen\u0163a \u015fi intensitatea tulbur\u0103rilor de postur\u0103, locomotorii, respiratorii \u015fi motorii – conform criteriilor stabilite \u00een afectarea structurilor respective.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i accesibile \u015fi participare efectiv\u0103 \u00een func\u0163ie de intensitatea deficien\u0163ei func\u0163ionale \u015fi gradul de handicap prezentate \u00een afectarea func\u0163iilor motorii, statice \u015fi locomo\u0163iei.<\/p>\n

Orientarea profesional\u0103 a tinerilor spre locuri de munc\u0103 accesibile, concomitent cu monitorizarea medical\u0103 adecvat\u0103 pentru prevenirea consecin\u0163elor secundare.<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

III.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR MOTORII (A STATICII \u015eI MOBILIT\u0102\u0162II – LOCOMO\u0162IEI SAU\/\u015eI GESTUALIT\u0102\u0162II)<\/p>\n

1.<\/strong>Amputa\u0163ii*<\/p>\n

* Se refer\u0103 la:<\/p>\n

a)Amputa\u0163ii congenitale, contractate precoce (copil\u0103rie-adolescen\u0163\u0103), unilateral sau bilateral de membru inferior sau superior, indiferent de nivel, dezarticula\u0163ie membru pelvin, dezarticula\u0163ie membru toracal, protezabile, neprotezabile sau greu protezabile.<\/p>\n

b)Amputa\u0163ii de membru superior sau inferior, unilateral sau bilateral (protezabile, protezabile ineficient, greu protezabile, neprotezabile), indiferent de v\u00e2rst\u0103 \u015fi statut.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Examen ortopedic;<\/p>\n

Examen radiologic:<\/p>\n

– bont,<\/p>\n

– articula\u0163ia suprajacent\u0103, contralateral, coloan\u0103 vertebral\u0103, \u00een func\u0163ie de localizare, pentru evaluarea consecin\u0163elor handicapului locomotor;<\/p>\n

Testarea bontului;<\/p>\n

Testarea func\u0163ionalit\u0103\u0163ii protezei \u015fi a membrului\/membrelor;<\/p>\n

Indici oscilometrici;<\/p>\n

Test\u0103ri biometrice particularizate structurii afectate;<\/p>\n

Testarea mobilit\u0103\u0163ii articulare;<\/p>\n

Test\u0103ri musculare;<\/p>\n

Testarea mobilit\u0103\u0163ii coloanei vertebrale.<\/p>\n<\/td>\n<\/tr>\n

\n

F\u0103r\u0103 deficien\u0163e<\/p>\n<\/td>\n

\n

Infirmitate locomotorie<\/p>\n<\/td>\n

\n

Amputa\u0163ie total\u0103 sau par\u0163ial\u0103 a degetelor de la unul sau ambele picioare;<\/p>\n

Se va evalua \u00een func\u0163ie de tulbur\u0103rile secundare.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie u\u015foar\u0103:<\/p>\n

Amputa\u0163ie Lisfrank,<\/p>\n

Amputa\u0163ie Chopart,<\/p>\n

Deficien\u0163\u0103 de manipula\u0163ie u\u015foar\u0103:<\/p>\n

Lipsa prin amputa\u0163ie a 1-3 degete (\u00een afara policelui);<\/p>\n

Lipsa ultimilor falange de la toate degetele de la o m\u00e2n\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie medie:<\/p>\n

Amputa\u0163ie gamb\u0103 unilateral\u0103 (la orice nivel);<\/p>\n

Amputa\u0163ie coaps\u0103 – bont protezat, protez\u0103 func\u0163ional\u0103, f\u0103r\u0103 consecin\u0163e secundare.<\/p>\n

Deficien\u0163\u0103 de manipula\u0163ie medie:<\/p>\n

Lipsa degetelor de la o m\u00e2n\u0103;<\/p>\n

Dezarticula\u0163ie radio-carpian\u0103;<\/p>\n

Amputa\u0163ia membrului toracic: antebra\u0163-bra\u0163, de la diferite nivele, \u00een raport de v\u00e2rst\u0103, cauz\u0103 \u015fi cu gestualitatea \u015fi deservirea necesar\u0103.<\/p>\n

NB. Pentru perioade limitate, \u00een vederea adapt\u0103rii la unimanualitate, transfer gestualitate – handicap accentuat.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie accentuat\u0103:<\/p>\n

Amputa\u0163ie coapse – bont greu protezabil sau neprotezabil sau cu protez\u0103 nefunc\u0163ional\u0103;<\/p>\n

Dezarticula\u0163ie coxo-femural\u0103;<\/p>\n

Amputa\u0163ie bilateral\u0103 membru pelvin, de la nivelul gambelor – protezate, proteze func\u0163ionale;<\/p>\n

Deficien\u0163\u0103 de manipula\u0163ie accentuat\u0103:<\/p>\n

Dezarticula\u0163ie scapulo-humeral\u0103;<\/p>\n

Amputa\u0163ia membrului toracic unilateral\u0103 cu reducerea prehensiunii contralateral.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Imposibilitatea realiz\u0103rii ortostatismului – deficien\u0163\u0103 locomotorie grav\u0103:<\/p>\n

Lipsa prin amputa\u0163ie a ambelor coapse, protezate sau neprotezate;<\/p>\n

Lipsa prin dezarticula\u0163ie a unui membru pelvin asociat cu anchiloza membrului pelvin opus;<\/p>\n

Lipsa prin dezarticula\u0163ie sau prin amputa\u0163ie a unui membru pelvin, cu amputa\u0163ie sau dezarticula\u0163ie de membru toracal;<\/p>\n

Amputa\u0163ie bilateral\u0103 a membrelor pelvine de la nivelul gambelor – protezate ineficient sau neprotezate.<\/p>\n

NB. Pentru perioade limitate \u00een vederea protez\u0103rii \u015fi adapt\u0103rii la protez\u0103.<\/p>\n

Imposibilitatea realiz\u0103rii gestualit\u0103\u0163ii \u015fi manipula\u0163iei:<\/p>\n

Amputa\u0163ii ambele membre toracice de la diferite nivele cu\/f\u0103r\u0103 redori str\u00e2nse ale articula\u0163iilor.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Amputa\u0163ii cu dificult\u0103\u0163i de realizare a ortostatismului, mersului ori gestualit\u0103\u0163ii.<\/p>\n

\u00cen evaluarea deficien\u0163ei func\u0163ionale se vor avea \u00een vedere:<\/p>\n

Cauza care a condus la indica\u0163ia de amputa\u0163ie:<\/p>\n

a)distrugerea unui membru prin strivire,<\/p>\n

b)pierderea vasculariza\u0163iei,<\/p>\n

c)gangrene de cauze variate (arteriopatii, diabet zaharat, embolii),<\/p>\n

d)durere sever\u0103 de pcauz\u0103 circulatorie,<\/p>\n

e)tumori maligne,<\/p>\n

f)infec\u0163ie necontrolabil\u0103 terapeutic;<\/p>\n

Starea bontului: scurt; cu cicatrici vicioase; cu calus vicios; cu nevroame hiperalgice, cu leziuni trofice, fistule cronice; cu sechele complexe;<\/p>\n

Nivelul amputa\u0163iei, la membrul sau membrele afectate.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 f\u0103r\u0103 limit\u0103ri, cu excep\u0163ia celor care solicit\u0103 gestualitate fin\u0103, de precizie.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii.<\/p>\n

Necesit\u0103 schimbarea locului de munc\u0103 \u00een cazul unor profesiuni (ex: pianist, violonist s.a.).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice profesie cu excep\u0163ia celor care solicit\u0103:<\/p>\n

– ortostatism \u015fi deplas\u0103ri posturale prelungite,<\/p>\n

– bimanualitate.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 accesibil.<\/p>\n

Formare \u015fi \u00eendrumare profesional\u0103 \u00een func\u0163ie de v\u00e2rst\u0103 persoanelor care \u015fi-au pierdut bimanualitatea, cu referire la muncile manuale – necalificate.<\/p>\n

Asigurare cu proteze, orteze, proteze estetice diferen\u0163iate \u00een vederea activ\u0103rii \u00een via\u0163a social\u0103 f\u0103r\u0103 restric\u0163ii.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Locuri de munc\u0103 f\u0103r\u0103 solicitare fizic\u0103, f\u0103r\u0103 deplas\u0103ri \u015fi variante posturale sau\/\u015fi gestuale, \u00een func\u0163ie de deterior\u0103rile morfofunc\u0163ionale.<\/p>\n

NB. \u00cen elaborarea programelor de recuperare se vor avea \u00een vedere:<\/p>\n

– localizarea \u015fi nivelul amputa\u0163iei,<\/p>\n

– cauzele care au produs-o,<\/p>\n

– eficien\u0163a protez\u0103rii,<\/p>\n

– v\u00e2rsta,<\/p>\n

– preg\u0103tirea generala \u015fi profesional\u0103 – \u00een func\u0163ie de care se recomand\u0103:<\/p>\n

– schimbarea locului de munc\u0103 sau – formare profesional\u0103 pentru munci statice, accesibile handicapului postural sau\/\u015fi de gestualitate.<\/p>\n<\/td>\n

\n

Furnizare de mijloace protetice, de adaptare a utilajelor, reorganizarea muncii la nevoie, cu atribuirea sarcinilor ce nu pot fi \u00eendeplinite altor membri ai colectivului.<\/p>\n

Pentru deficien\u0163ii locomotori posturali:<\/p>\n

\u00cen afara protez\u0103rii adecvate \u015fi adapt\u0103rii locului de munc\u0103 astfel \u00eenc\u00e2t sa nu fie solicitat\u0103 postura pe care nu o poate realiza, se recomand\u0103 facilitarea prin mijloace suplimentare de sprijin (scaune adaptate ergonomic) sau permiterea cu u\u015furin\u0163\u0103 a modific\u0103rilor posturale impuse de munc\u0103, prin balustrade sau m\u00e2nere de sprijin.<\/p>\n

Transferul unor comenzi ale ma\u015finii de la picior la m\u00e2n\u0103 sau automatizarea comenzilor respective.<\/p>\n

Pentru cei care au asociat\u0103 afectarea mobilit\u0103\u0163ii coloanei vertebrale: sisteme mecanice de manevrare a greut\u0103\u0163ilor \u015fi c\u0103rucioare de transport de \u00een\u0103l\u0163imea bancului de lucru astfel \u00eenc\u00e2t transferul greut\u0103\u0163ilor de pe c\u0103rucior pe banc \u015fi invers s\u0103 se fac\u0103 prin alunecare.<\/p>\n

Pentru persoanele cu deficien\u0163\u0103 fizic\u0103 cu afectarea gestualit\u0103\u0163ii:<\/p>\n

Este posibil\u0103, dupa caz, protezare sau ortezare, eventual proteze de munc\u0103 adaptate \u00een raport cu secven\u0163ele muncii (pense, c\u00e2rlige etc.), schimbarea lateralit\u0103\u0163ii \u015fi adapt\u0103ri ale utilajului, ca de pild\u0103 transferul comenzilor de la o m\u00e2n\u0103 la alta sau de la m\u00e2n\u0103 la picior, schimbarea sistemului de p\u00e2rghii ale comenzilor pentru sc\u0103derea efortului fizic.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Idem handicap accentuat<\/p>\n<\/td>\n

\n

– Idem handicap accentuat;<\/p>\n

– Dupa protezare, adaptare la proteze\/orteze:<\/p>\n

– asigurarea de mijloace de deplasare pentru persoanele cu deficien\u0163\u0103 postural\u0103 (baston sau cadru pentru cele cu amputa\u0163ii unilaterale, fotoliu rulant, c\u0103rucioare pentru cele cu amputa\u0163ii bilaterale);<\/p>\n

– asigurarea de mijloace de autoservire sau\/\u015fi de munc\u0103 pentru cei cu pierderea bilateral\u0103 a gestualit\u0103\u0163ii;<\/p>\n

– sprijin total pentru \u00eengrijire \u015fi activit\u0103\u0163ile cotidiene, de autogospod\u0103rire.<\/p>\n

Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Afec\u0163iuni neurologice*<\/p>\n

* Se refer\u0103 la:<\/p>\n

a)Afec\u0163iuni neurologice congenitale sau contractate precoce cu tulbur\u0103ri posturale \u015fi gestuale de intensitate variat\u0103, de exemplu:<\/p>\n

– malforma\u0163ii congenitale (ex: mielomeningocelul, porencefalia, hidrocefalia, microcefalia);<\/p>\n

– sechele neurologice (pareze, paralizii etc.) – dup\u0103 meningoencefalopatii infantile;<\/p>\n

– leziuni traumatice ale SNC;<\/p>\n

– sechele dupa sindrom ischemic medular cu parapareze sau plegii, tertrapareze sau tetraplegii, monopareze sau monoplegii;<\/p>\n

– sechele dup\u0103 traumatisme cerebrale severe;<\/p>\n

– paralizii de plex brahial;<\/p>\n

– leziuni de nervi periferici care produc tulbur\u0103ri de manipula\u0163ie, uni sau bilaterale;<\/p>\n

– tulbur\u0103ri neurologice sechelare cu deficit tip bi-tri-tetraparetic\/plegic cu\/f\u0103r\u0103 tulbur\u0103ri trofice, afect\u00e2nd deplasarea \u015fi gestualitatea normal\u0103 sau tulbur\u0103ri de tip epileptic ori alte tulbur\u0103ri de focar;<\/p>\n

– sechele dup\u0103 poliomielit\u0103 \u015fi afec\u0163iuni medulare infec\u0163ioase;<\/p>\n

– paralizii cerebrale: ex. hemiplegie-hemipareza infantil\u0103, paraplegie-paraparez\u0103 spastic\u0103 infantil\u0103, boala Little;<\/p>\n

– tumori cerebrale benigne care determin\u0103 prin extensie tulbur\u0103ri de focar, tumori maligne.<\/p>\n

b)Accidentele vasculare cerebrale (A VC): hemoragice, trombotice sau embolice, cu diverse localiz\u0103ri, cu deficite locomotorii secundare, disfazie\/afazie sau\/\u015fi tulbur\u0103ri sfincteriene indiferent de v\u00e2rst\u0103 \u015fi statut, la persoanele cu:<\/p>\n

– Sechele A VC care au drept cauze o malforma\u0163ie congenital\u0103 vascular\u0103;<\/p>\n

– Sechele A VC embolice dup\u0103 valvulopatii reumatismale contractate precoce sau congenitale;<\/p>\n

– Sechele A VC din angiocardiopatiile congenitale;<\/p>\n

– Sechele A VC din cardiomiopatiile primitive (idiopatice sau primare);<\/p>\n

– Sechele A VC din HTA reno-vascular\u0103;<\/p>\n

– Deficite motorii din afec\u0163iunile hemoragipare (cuagulopatii, trombocitopenii s.a.), din afec\u0163iuni hematologice (policitemia vera);<\/p>\n

– Deficite motorii ale unor neoplazii – primar sau secundar cerebrale – de sistem nervos, osteoarticular, p\u0103r\u0163i moi.<\/p>\n

c)Parapareze\/paraplegii, tetrapareze\/tetraplegii, monopareze\/monoplegii – indiferent de etiologie (traumatic\u0103, vascular\u0103, infec\u0163ioas\u0103, tumoral\u0103, degenerativ\u0103 etc.), indiferent de v\u00e2rst\u0103 \u015fi statut.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Examen neurologic;<\/p>\n

Eco Doppler;<\/p>\n

CT, RMN cerebral;<\/p>\n

Examen oftalmologic (acuitate vizual\u0103, campimetrie, fund de ochi);<\/p>\n

EKG;<\/p>\n

EEG;<\/p>\n

Glicemie,<\/p>\n

Teste de coagulare;<\/p>\n

Hemoleucogram\u0103 complet\u0103;<\/p>\n

Angiografie carotidian\u0103;<\/p>\n

Echocardiografie.<\/p>\n<\/td>\n

\n

Se stabilesc \u00een func\u0163ie de structura\/structurile afectate.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Deficit motor minim la un membru sau care nu afecteaz\u0103 prehensiunea, manipula\u0163ia.<\/p>\n

Tulbur\u0103ri de coordonare \u015fi echilibru u\u015foare.<\/p>\n

Se poate deplasa, mersul fiind posibil dar cu oscila\u0163ii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Deficit motor al unui membru inferior sau al ambelor membre inferioare dar care nu afecteaz\u0103 desf\u0103\u015furarea activit\u0103\u0163ilor vie\u0163ii cotidiene sau profesionale;<\/p>\n

Se deplaseaz\u0103 cu u\u015foar\u0103 dificultate pe distan\u0163e lungi sau cu dificultate moderat\u0103 pe distan\u0163e scurte, dar f\u0103r\u0103 sprijin, put\u00e2nd desf\u0103\u015fura activit\u0103\u0163i profesionale normale, \u00een func\u0163ie de natura profesiei.<\/p>\n

Deficit motor la un membru superior care afecteaz\u0103 minimum mobilitatea, gestualitatea \u015fi prehensiunea.<\/p>\n

Dificult\u0103\u0163i de coordonare \u015fi de manipula\u0163ie neinfluen\u0163ate de deficitul motor. Se poate deplasa f\u0103r\u0103 sprijin pe distan\u0163e variabile, cu dificultate, cu oscila\u0163ii (vezi criteriile de la afectarea func\u0163iei de coordonare).<\/p>\n

Tulbur\u0103ri u\u015foare de vorbire: dizartrie, balbism, alte tulbur\u0103ri ale vorbirii specifice unor afec\u0163iuni neurologice (vezi criteriile de la afec\u0163iunile respective: boala Parkinson, miastenia gravis s.a.).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie accentuat\u0103. Se poate deplasa sprijinit \u00een baston (sprijin unilateral) sau nesprijinit, dar cu mare dificultate. Nu poate realiza mersul normal, nici chiar pe distan\u0163e scurte.<\/p>\n

Deficit motor total al unui membru superior ce afecteaz\u0103 activitatea profesional\u0103 \u015fi cea cotidian\u0103 sau deficit motor bilateral moderat.<\/p>\n

Tulbur\u0103ri accentuate de coordonare: se deplaseaz\u0103 cu sprijin unilateral sau nesprijinit dar cu mare greutate, cu baz\u0103 de sus\u0163inere l\u0103rgit\u0103, cu tendin\u0163\u0103 la devia\u0163ii \u00een cazul asocierii unor tulbur\u0103ri vestibulare de intensitate medie (vezi criteriile de la afectarea func\u0163iilor de coordonare).<\/p>\n

Tulbur\u0103ri de vorbire de tipul afaziei expresive moderate.<\/p>\n

Permite, \u00een cazul \u00een care nu se asociaz\u0103 deficit de locomo\u0163ie, de manipula\u0163ie, de coordonare, exercitarea activit\u0103\u0163ilor vie\u0163ii cotidiene \u015fi, eventual, efectuarea unor activit\u0103\u0163i specifice profesiunii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Deficit grav de locomo\u0163ie:<\/p>\n

– persoana nu se poate deplasa nici cu sprijin nici f\u0103r\u0103 sprijin, fiind dependent\u0103 de un mijloc de transport adecvat (fotoliu rulant, alte dispozitive) sau este imobilizat la pat;<\/p>\n

– nu \u00ee\u015fi poate \u00eendeplini activit\u0103\u0163ile vie\u0163ii cotidiene, nu-\u015fi poate asigura existen\u0163a prin activitatea pentru care a fost preg\u0103tit\u0103;<\/p>\n

– nu se poate autoservi;<\/p>\n

– necesit\u0103 asistent personal.<\/p>\n

NB. Persoanele cu paraplegii, parapareze forte pot presta activit\u0103\u0163i legate de capacitatea \u015fi de preg\u0103tirea intelectual\u0103, beneficiind de o asisten\u0163\u0103 social\u0103 adecvat\u0103 \u015fi de prezen\u0163a asistentului personal deoarece necesit\u0103\u0163ile sunt mult sporite din punct de vedere material, social, psihologic etc.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Structurile afectate indiferent de data contract\u0103rii, cauz\u0103, localizare, pot determina tulbur\u0103ri:<\/p>\n

– ale staticii, mobilit\u0103\u0163ii – locomo\u0163iei sau\/\u015fi ale manipula\u0163iei (gestualit\u0103\u0163ii) sau\/\u015fi de coordonare \u015fi echilibru sau\/\u015fi de vorbire,cu implica\u0163ii diferite, \u00een func\u0163ie de predominanta lor \u015fi limitarea la via\u0163a social\u0103, comunitara \u015fi familiala.<\/p>\n

\u00a0<\/p>\n

<td”>HANDICAP GRAV<\/td”><\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice munc\u0103 cu program normal, cu evitarea celor care impun activitatea la \u00een\u0103l\u0163ime.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii cu condi\u0163ia monitoriz\u0103rii medicale, evitarea activit\u0103\u0163ii la \u00een\u0103l\u0163ime sau care impune varia\u0163ii posturale mari \u015fi deplas\u0103ri pe distan\u0163e mari.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 – loc de munc\u0103 f\u0103r\u0103 suprasolicitare postural\u0103, activit\u0103\u0163i preponderent statice, f\u0103r\u0103 deplas\u0103ri posturale, f\u0103r\u0103 suprasolicitare fizic\u0103 \u015fi psihic\u0103, \u00een condi\u0163ii de confort organic, f\u0103r\u0103 rela\u0163ii cu publicul dac\u0103 sunt asociate tulbur\u0103ri de vorbire.<\/p>\n<\/td>\n

\n

Sprijin pentru asigurarea locului de munc\u0103 adecvat \u00een vederea desf\u0103\u015fur\u0103rii activit\u0103\u0163ii cu program normal sau redus sau, dac\u0103 nu este posibil, schimbarea locului de munc\u0103;<\/p>\n

Monitorizare medico-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

– Edem \u00een 1\/2 superioar\u0103 a fe\u0163ei;<\/p>\n

– Deficit muscular de grade diferite (de la fatigabilitate p\u00e2n\u0103 la incapacitatea de a ridica bra\u0163ul \u015fi coapsele);<\/p>\n

– Teste enzimatice (transaminaza, creatinfosfokinaza, lactico-dehidrogenaza);<\/p>\n

– Traseu EMG caracteristic pentru afectare fibrelor musculare;<\/p>\n

– Biopsia – necroze focale.<\/p>\n<\/td>\n

\n

\u00cen conformitatea cu criteriile prezentate la Cap. 4: evaluarea gradului de handicap \u00een afectarea func\u0163iei mu\u015fchilor.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Capacitate func\u0163ional\u0103 complet\u0103 cu posibilitatea de a executa normal profesiunea.<\/p>\n<\/td>\n

\n

– Sunt necesare m\u0103suri profilactice:<\/p>\n

evitarea frigului, umezelii, curen\u0163ilor de aer la locul de munc\u0103;<\/p>\n

– Dispensarizare la medicul de familie sau reumatologie, ambulatorii de specialitate pentru controale periodice;<\/p>\n

– Profilaxia infec\u0163iilor acute \u015fi tratarea infec\u0163iilor cronice pentru a preveni progresiunea alter\u0103rilor func\u0163ionale.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Capacitate func\u0163ional\u0103 normal\u0103 cu excep\u0163ia handicapului durerii \u015fi redorii la una sau mai multe articula\u0163ii;<\/p>\n

– Limitarea gestualit\u0103\u0163ii profesionale \u015fi a mersului;<\/p>\n

– Activit\u0103\u0163i cu solicit\u0103ri fizice reduse f\u0103r\u0103 deplas\u0103ri posturale pe distan\u0163e mari, f\u0103r\u0103 ridicarea de greut\u0103\u0163i, urcat-cobor\u00e2t sc\u0103ri;<\/p>\n

– Unele limit\u0103ri \u00een activit\u0103\u0163ile cotidiene, casnice.<\/p>\n<\/td>\n

\n

– Sunt necesare m\u0103suri profilactice: evitarea frigului, umezelii, curen\u0163ilor de aer la locul de munc\u0103;<\/p>\n

– Dispensarizare la medicul de familie sau reumatologie, ambulatorii de specialitate pentru controale periodice;<\/p>\n

– Profilaxia infec\u0163iilor acute \u015fi tratarea infec\u0163iilor cronice pentru a preveni progresiunea alter\u0103rilor func\u0163ionale;<\/p>\n

– M\u0103suri pentru asigurarea unui loc de munc\u0103 f\u0103r\u0103 solicitare fizic\u0103\/trepida\u0163ii, \u00een condi\u0163ii de microclimat corespunz\u0103tor sau<\/p>\n

schimbarea locului de munc\u0103, recalificare profesional\u0103 dup\u0103 caz, \u00een func\u0163ie de v\u00e2rst\u0103, procesele evolutive \u015fi r\u0103spunsul la tratamentul aplicat.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Capacitate func\u0163ional\u0103 limitat\u0103 permi\u0163\u00e2nd numai o parte din activit\u0103\u0163ile casnice \u015fi autoservirea;<\/p>\n

– Imposibilitatea efectu\u0103rii unor activit\u0103\u0163i profesionale \u00een sistem organizat;<\/p>\n

– Eventuale activit\u0103\u0163i de colaborare \u00een func\u0163ie de deficitul de prehensiune;<\/p>\n

– Se va avea \u00een vedere faptul c\u0103:<\/p>\n

– – se ridic\u0103 cu greutate de pe scaun, chiar \u015fi cu sprijin,<\/p>\n

– – nu poate ridica \u015fi transporta greut\u0103\u0163i,<\/p>\n

– – dexteritatea se realizeaz\u0103 cu dificultate.<\/p>\n<\/td>\n

\n

– \u00cen general afectarea accentuat\u0103 a posturii, a deplas\u0103rilor posturale (mobilizarea), alternant\u0103 postural\u0103, gestualitatea – prehensiunea \u015fi manipula\u0163ia – fac imposibil\u0103 participarea la activit\u0103\u0163i profesionale;<\/p>\n

– Necesit\u0103 sprijin pentru facilitarea mobiliz\u0103rii (baston, scaun rulant);<\/p>\n

– Monitorizare periodic\u0103 medical\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Infirmitate important\u0103 – persoana cu handicap imobilizat\u0103 la pat sau \u00een fotoliu;<\/p>\n

– Nu se poate ocupa de propria sa \u00eengrijire sau o face cu foarte mult\u0103 dificultate;<\/p>\n

– Necesit\u0103 \u00eengrijire \u015fi supraveghere permanent\u0103, nu poate sta confortabil pe scaun, nu se poate ridica din pozi\u0163ia \u015fez\u00e2nd \u00een cea ortostatic\u0103;<\/p>\n

– Nu pot p\u0103stra ortostatismul nesprijinit \u015fi f\u0103r\u0103 ajutor;<\/p>\n

– Nu se pot \u00eembr\u0103ca, dezbr\u0103ca, nu-\u015fi pot t\u0103ia alimentele;<\/p>\n

– Capacitatea de autoservire \u015fi auto\u00eengrijire este afectat\u0103 major.<\/p>\n<\/td>\n

\n

– Suplinirea pierderii \u00een totalitate a capacit\u0103\u0163ii de autoservire, auto\u00eengrijire \u015fi autogospod\u0103rire;<\/p>\n

– Dependen\u0163a social\u0103 permanent\u0103;<\/p>\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

II.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA MOBILIT\u0102\u0162II COLOANEI VERTEBRALE*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

1.Spondilita anchilozant\u0103 (SA), forma central\u0103, periferic\u0103 sau mixt\u0103 (central\u0103 \u015fi periferic\u0103) – afec\u0163iune inflamatori cronic\u0103 care afecteaz\u0103 preponderent coloana vertebral\u0103, procesul inflamator debut\u00e2nd frecvent la nivelul articula\u0163iilor sacro-iliace \u015fi progreseaz\u0103 ascendent.<\/p>\n

2.Cifoscolioze \u015fi scolioze deformante – idiopatice, cu grad mare de curbur\u0103, operate sau nu, care \u00eempiedic\u0103 capacitatea respiratorie normal\u0103 \u015fi\/sau cu tulbur\u0103ri neurologice (parapareze, paraplegii)<\/p>\n

1.<\/strong>Spondilit\u0103 anchilozant\u0103 (SA)<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

– Examen radiologic**:<\/p>\n

– radiografie bazin,<\/p>\n

– radiografia altor zone interesate,<\/p>\n

– tomografie – TC, RMN<\/p>\n

– scintigram\u0103 osteo-articular\u0103;<\/p>\n

– Investiga\u0163ii biologice:<\/p>\n

– VSH crescut\u0103,<\/p>\n

– electroforez\u0103 cu hiperalfaglobuline crescute \u015fi u\u015foar\u0103 hipergamaglobulinemie,<\/p>\n

– proteina C reactiv\u0103 pozitiv\u0103,<\/p>\n

– fibrinogen \u00een s\u00e2nge crescut,<\/p>\n

– imunelectroforez\u0103 serica IGA crescut\u0103,<\/p>\n

– factori reumatoizi negativi,<\/p>\n

– antigen HLA B27<\/sub>\u00a0*** prezent;<\/p>\n

– Probe paraclinice:<\/p>\n

– testarea mobilit\u0103\u0163ii coloanei vertebrale \u015fi a articula\u0163iilor mari,<\/p>\n

– spirometrie,<\/p>\n

– examen oftalmologic,<\/p>\n

– examen neurologic.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Sacroileit\u0103 gr. IV sau\/\u015fi pun\u0163i vertebrale \u00eentre dou\u0103 corpuri vertebrale;<\/p>\n

– F\u0103r\u0103 semne inflamatorii clinice;<\/p>\n

– Rectitudinea sau redoarea coloanei DL;<\/p>\n

– Mobilitatea coloanei CDL \u00een limite fiziologice sau o reducere cu 40% din valorile fiziologice ale flexiei, extensiei, \u00eenclin\u0103ri laterale dreapta \u015fi st\u00e2nga;<\/p>\n

– Semne biologice de inflama\u0163ie (\u00een puseele acute): VSH u\u015for crescut, fibrinogen u\u015for crescut, proteina C absent\u0103, antigen HLA B27<\/sub>\u00a0pozitiv,<\/p>\n

– F\u0103r\u0103 afectare ocular\u0103;<\/p>\n

– F\u0103r\u0103 disfunc\u0163ie respiratorie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Forma central\u0103:<\/p>\n

– generalizarea sindesmofitilor cu formare de pun\u0163i la un num\u0103r important de discuri vertebrale;<\/p>\n

– mobilitatea coloanei CDL: reducere cu 50% din valorile fiziologice ale flexiei, extensiei, \u00eenclin\u0103ri laterale, rota\u0163ii;<\/p>\n

– redoare matinal\u0103 coloan\u0103 CDL persistent\u0103;<\/p>\n

– deficien\u0163\u0103 ventilatorie restrictiv\u0103 u\u015foar\u0103;<\/p>\n

– f\u0103r\u0103 deficien\u0163\u0103 vizual\u0103 sau cu deficien\u0163\u0103 u\u015foar\u0103.<\/p>\n

Forma periferic\u0103:<\/p>\n

– articula\u0163ii periferice afectate de proces inflamator cronic, frecvent asimetric, cel mai des la genunchi;<\/p>\n

– tendinite, fascit\u0103 plantar\u0103,<\/p>\n

– mobilitatea articula\u0163iilor periferice redus\u0103 cu 30- 40% din valorile fiziologice;<\/p>\n

– semnele biologice moderat crescute;<\/p>\n

– antigen HLA B27 pozitiv.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Forma central\u0103:<\/p>\n

– cu prinderea coloanei CDL;<\/p>\n

– fixarea coloanei cervicale \u00een flexie \u00een mod ireversibil, \u00een puseele acute; – deficien\u0163\u0103 ventilatorie medie de tip restrictiv;<\/p>\n

– deficien\u0163\u0103 vizual\u0103 medie prin sechele de iridociclit\u0103;<\/p>\n

– afectarea mobilit\u0103\u0163ii coloanei vertebrale cu peste 70% din valorile fiziologice (urc\u0103 \u015fi coboar\u0103 sc\u0103rile dar cu dificultate)<\/p>\n

Forma mixt\u0103:<\/p>\n

– cu prinderea coloanei CDL;<\/p>\n

– cu prinderea centurilor scapulo-humerale \u015fi coxo-femurale, bilateral;<\/p>\n

– deficien\u0163\u0103 ventilatorie medie sau accentuat\u0103 de tip restrictiv;<\/p>\n

– deficien\u0163\u0103 vizual\u0103 medie prin afectare ocular\u0103 sechelar\u0103 iridociclitei;<\/p>\n

– afectarea func\u0163ionalit\u0103\u0163ii articula\u0163iilor periferice p\u00e2n\u0103 la 80% din valorile fiziologice (se deplaseaz\u0103 cu greutate cu baston sau c\u00e2rje \u015fi pe distan\u0163e mici); Forma periferic\u0103:<\/p>\n

– cu prinderea articula\u0163iilor mari: coxo-femurale, genunchi, articula\u0163ia coatelor, pumn \u015fi degete; – afectarea func\u0163iilor articula\u0163iilor periferice cu peste 80-85% din valorile fiziologice.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Forma central\u0103:<\/p>\n

– cu prinderea centurilor toracice \u015fi pelviene,<\/p>\n

– cu prinderea umerilor (anchiloza \u00een adduc\u0163ie),<\/p>\n

– cu prinderea coxo-femural\u0103 bilateral cu tendin\u0163\u0103 la anchiloze,<\/p>\n

– deficien\u0163\u0103 ventilatorie sever\u0103 de tip restrictiv.<\/p>\n

Forma periferic\u0103:<\/p>\n

– cu anchiloza pumnilor, coatelor – \u00een semiflexie, anchiloza tibio-tarsian\u0103 \u00een equin,<\/p>\n

– cu deformarea accentuat\u0103 a antepiciorului.<\/p>\n

Forma mixt\u0103:<\/p>\n

– forma sever\u0103 cu\/f\u0103r\u0103 afectarea grav\u0103 a acuit\u0103\u0163ii vizuale.<\/p>\n

NB.<\/p>\n

Persoanele cu SA stadiul IV se deplaseaz\u0103 cu mare dificultate \u015fi sprijinite. Sunt \u00een imposibilitatea realiz\u0103rii activit\u0103\u0163ilor vie\u0163ii zilnice de autoservire \u015fi \u00eengrijire. Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Principalul criteriu de diagnostic pozitiv poate consta, \u00een func\u0163ie de evolu\u0163ie, \u00een:<\/p>\n

– Sacroileit\u0103 gr. III (moderat\u0103): scleroz\u0103 \u015fi osteocondensare ale articula\u0163iilor;<\/p>\n

– sacroileit\u0103 grad IV: anchiloz\u0103 cu dispari\u0163ia spa\u0163iilor articulare;<\/p>\n

– apari\u0163ia de pun\u0163i intervertebrale (ini\u0163ial D11<\/sub>-D12,<\/sub>\u00a0L1<\/sub>-L2<\/sub>) – sindesmofite (osific\u0103ri interligamentare), ulterior se generalizeaz\u0103 – aspect „trestie de bambus”;<\/p>\n

– afectarea articula\u0163iilor interapofizare cu tendin\u0163\u0103 la pensare \u015fi anchiloze care pot lua aspect de „\u015fin\u0103 de tramvai”<\/p>\n

*** Antigenul HLA B27<\/sub>: are semnifica\u0163ie predispozant\u0103 pentru afec\u0163iune; este prezent la 80 – 90 % dintre persoane.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103.<\/p>\n

Pot desf\u0103\u015fura activit\u0103\u0163i fizice, nu au probleme cu mobilizarea, urcatul \u015fi cobor\u00e2tul de sc\u0103ri \u015fi ridicarea de greut\u0103\u0163i. Pot desf\u0103\u015fura activit\u0103\u0163i casnice (sociale \u015fi ale vie\u0163ii zilnice)<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ie, necesit\u0103:<\/p>\n

– monitorizare medical\u0103,<\/p>\n

– controale periodice,<\/p>\n

– cure balneare \u015fi<\/p>\n

– program de kinetoterapie.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu evitarea suprasolicit\u0103rilor gestuale, posturale – ortostatismul sau mersul prelungit, ridicarea de greut\u0103\u0163i, \u00eentr-un mediu adecvat, f\u0103r\u0103 curen\u0163i de aer, varia\u0163ii termice, trepida\u0163ii.<\/p>\n<\/td>\n

\n

– Asigurarea unui loc de munc\u0103 accesibil pentru prevenirea evolu\u0163iei spre stadii superioare;<\/p>\n

– Sprijin din partea angajatorilor \u015fi al familiei pentru aplicarea m\u0103surilor profilactice:<\/p>\n

– dispensarizare medic de familie sau serviciul de reumatologie,<\/p>\n

– program de kinetoterapie (gimnastic\u0103 medical\u0103),<\/p>\n

– eventual schimbarea locului de munc\u0103 pentru activit\u0103\u0163i f\u0103r\u0103 eforturi fizice, f\u0103r\u0103 ortostatism prelungit, \u00een mediu cu curen\u0163i de aer, umezeal\u0103, pozi\u0163ii vicioase – fixe \u00een timpul muncii.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare postural\u0103, f\u0103r\u0103 deplas\u0103ri prelungite sau care s\u0103 impun\u0103 variante posturale;<\/p>\n

– Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103 \u015fi vizual\u0103.<\/p>\n

\u00cen general au redus\u0103 capacitatea de efectuare a oric\u0103rei activit\u0103\u0163i profesionale organizate, cu program normal,<\/p>\n

– Au limitat\u0103 posibilitatea de a realiza majoritatea activit\u0103\u0163ilor necesare vie\u0163ii zilnice \u015fi pentru cele de autoservire (ex: aplecat, \u00eembr\u0103cat\/dezbr\u0103cat, transport greut\u0103\u0163i);<\/p>\n

– Au limitat\u0103 capacitatea de mobilizare (se deplaseaz\u0103 cu greutate cu baston) precum \u015fi posibilitatea de men\u0163inere \u00eendelungat\u0103 a pozi\u0163iei ortostatice sau \u015fez\u00e2nde \u015fi a variantelor posturale;<\/p>\n

– Capacitatea de efort fizic – redus\u0103.<\/p>\n<\/td>\n

\n

Participare \u00een condi\u0163ii de monitorizare medical\u0103 \u015fi profesional\u0103:<\/p>\n

– Internare \u00een sec\u0163ii de reumatologie \u00een puseele acute, pentru tratament particularizat \u015fi controlat;<\/p>\n

– Dispensarizare medic de familie sau specialist reumatolog pentru control periodic;<\/p>\n

– Program de kinetoterapie la domiciliu sau dispensar, ambulatoriu de specialitate;<\/p>\n

– Schimbarea locului de munc\u0103 sau orientare pentru munci f\u0103r\u0103 efort fizic, ortostatism prelungit, frig, curen\u0163i de aer, umezeal\u0103, pozi\u0163ii vicioase, suprasolicitarea vederii.<\/p>\n

\u00cen timpul muncii:<\/p>\n

– Sprijin din partea angajatorilor pentru asigurarea unui loc de munc\u0103 adaptat;<\/p>\n

– Ajutor din partea familiei pentru realizarea unor activit\u0103\u0163i necesare \u00eengrijirii \u015fi gospod\u0103ririi (vie\u0163ii cotidiene).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Pierderea total\u0103 a capacit\u0103\u0163ii de munc\u0103, de autoservire sau\/\u015fi de orientare spa\u0163ial\u0103;<\/p>\n

– Limitarea major\u0103 a capacit\u0103\u0163ii de mobilizare;<\/p>\n

– Limitarea major\u0103 a posibilit\u0103\u0163ii de realizare a activit\u0103\u0163ilor vie\u0163ii cotidiene, instrumentale \u015fi de auto\u00eengrijire.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal;<\/p>\n

– Necesit\u0103 sprijin pentru ob\u0163inerea unor mijloace de deplasare (baston, fotoliu rulant etc.)<\/p>\n

– Asisten\u0163\u0103 medical\u0103 la domiciliu, particularizat\u0103.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Cifoscolioze idiopatice<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

DETERMINAREA PARAMETRILOR FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Radiografii coloan\u0103 vertebral\u0103, umeri \u015fi \u015fold, \u00een raport de consecin\u0163ele secundare;<\/p>\n

– Tomografie (TC), RMN;<\/p>\n

– Examen ortopedic;<\/p>\n

– Examen neurologic;<\/p>\n

– Testarea mobilit\u0103\u0163ii coloanei vertebrale;<\/p>\n

– Testarea mobilit\u0103\u0163ii articula\u0163iilor mari;<\/p>\n

– Probe ventilatorii.<\/p>\n<\/td>\n

\n

\u00cencadrarea \u00een grad de handicap se realizeaz\u0103 \u00een raport de existen\u0163a \u015fi intensitatea tulbur\u0103rilor de postur\u0103, locomotorii, respiratorii \u015fi motorii – conform criteriilor stabilite \u00een afectarea structurilor respective.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i accesibile \u015fi participare efectiv\u0103 \u00een func\u0163ie de intensitatea deficien\u0163ei func\u0163ionale \u015fi gradul de handicap prezentate \u00een afectarea func\u0163iilor motorii, statice \u015fi locomo\u0163iei.<\/p>\n

Orientarea profesional\u0103 a tinerilor spre locuri de munc\u0103 accesibile, concomitent cu monitorizarea medical\u0103 adecvat\u0103 pentru prevenirea consecin\u0163elor secundare.<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

III.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR MOTORII (A STATICII \u015eI MOBILIT\u0102\u0162II – LOCOMO\u0162IEI SAU\/\u015eI GESTUALIT\u0102\u0162II)<\/p>\n

1.<\/strong>Amputa\u0163ii*<\/p>\n

* Se refer\u0103 la:<\/p>\n

a)Amputa\u0163ii congenitale, contractate precoce (copil\u0103rie-adolescen\u0163\u0103), unilateral sau bilateral de membru inferior sau superior, indiferent de nivel, dezarticula\u0163ie membru pelvin, dezarticula\u0163ie membru toracal, protezabile, neprotezabile sau greu protezabile.<\/p>\n

b)Amputa\u0163ii de membru superior sau inferior, unilateral sau bilateral (protezabile, protezabile ineficient, greu protezabile, neprotezabile), indiferent de v\u00e2rst\u0103 \u015fi statut.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Examen ortopedic;<\/p>\n

Examen radiologic:<\/p>\n

– bont,<\/p>\n

– articula\u0163ia suprajacent\u0103, contralateral, coloan\u0103 vertebral\u0103, \u00een func\u0163ie de localizare, pentru evaluarea consecin\u0163elor handicapului locomotor;<\/p>\n

Testarea bontului;<\/p>\n

Testarea func\u0163ionalit\u0103\u0163ii protezei \u015fi a membrului\/membrelor;<\/p>\n

Indici oscilometrici;<\/p>\n

Test\u0103ri biometrice particularizate structurii afectate;<\/p>\n

Testarea mobilit\u0103\u0163ii articulare;<\/p>\n

Test\u0103ri musculare;<\/p>\n

Testarea mobilit\u0103\u0163ii coloanei vertebrale.<\/p>\n<\/td>\n<\/tr>\n

\n

F\u0103r\u0103 deficien\u0163e<\/p>\n<\/td>\n

\n

Infirmitate locomotorie<\/p>\n<\/td>\n

\n

Amputa\u0163ie total\u0103 sau par\u0163ial\u0103 a degetelor de la unul sau ambele picioare;<\/p>\n

Se va evalua \u00een func\u0163ie de tulbur\u0103rile secundare.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie u\u015foar\u0103:<\/p>\n

Amputa\u0163ie Lisfrank,<\/p>\n

Amputa\u0163ie Chopart,<\/p>\n

Deficien\u0163\u0103 de manipula\u0163ie u\u015foar\u0103:<\/p>\n

Lipsa prin amputa\u0163ie a 1-3 degete (\u00een afara policelui);<\/p>\n

Lipsa ultimilor falange de la toate degetele de la o m\u00e2n\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie medie:<\/p>\n

Amputa\u0163ie gamb\u0103 unilateral\u0103 (la orice nivel);<\/p>\n

Amputa\u0163ie coaps\u0103 – bont protezat, protez\u0103 func\u0163ional\u0103, f\u0103r\u0103 consecin\u0163e secundare.<\/p>\n

Deficien\u0163\u0103 de manipula\u0163ie medie:<\/p>\n

Lipsa degetelor de la o m\u00e2n\u0103;<\/p>\n

Dezarticula\u0163ie radio-carpian\u0103;<\/p>\n

Amputa\u0163ia membrului toracic: antebra\u0163-bra\u0163, de la diferite nivele, \u00een raport de v\u00e2rst\u0103, cauz\u0103 \u015fi cu gestualitatea \u015fi deservirea necesar\u0103.<\/p>\n

NB. Pentru perioade limitate, \u00een vederea adapt\u0103rii la unimanualitate, transfer gestualitate – handicap accentuat.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie accentuat\u0103:<\/p>\n

Amputa\u0163ie coapse – bont greu protezabil sau neprotezabil sau cu protez\u0103 nefunc\u0163ional\u0103;<\/p>\n

Dezarticula\u0163ie coxo-femural\u0103;<\/p>\n

Amputa\u0163ie bilateral\u0103 membru pelvin, de la nivelul gambelor – protezate, proteze func\u0163ionale;<\/p>\n

Deficien\u0163\u0103 de manipula\u0163ie accentuat\u0103:<\/p>\n

Dezarticula\u0163ie scapulo-humeral\u0103;<\/p>\n

Amputa\u0163ia membrului toracic unilateral\u0103 cu reducerea prehensiunii contralateral.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Imposibilitatea realiz\u0103rii ortostatismului – deficien\u0163\u0103 locomotorie grav\u0103:<\/p>\n

Lipsa prin amputa\u0163ie a ambelor coapse, protezate sau neprotezate;<\/p>\n

Lipsa prin dezarticula\u0163ie a unui membru pelvin asociat cu anchiloza membrului pelvin opus;<\/p>\n

Lipsa prin dezarticula\u0163ie sau prin amputa\u0163ie a unui membru pelvin, cu amputa\u0163ie sau dezarticula\u0163ie de membru toracal;<\/p>\n

Amputa\u0163ie bilateral\u0103 a membrelor pelvine de la nivelul gambelor – protezate ineficient sau neprotezate.<\/p>\n

NB. Pentru perioade limitate \u00een vederea protez\u0103rii \u015fi adapt\u0103rii la protez\u0103.<\/p>\n

Imposibilitatea realiz\u0103rii gestualit\u0103\u0163ii \u015fi manipula\u0163iei:<\/p>\n

Amputa\u0163ii ambele membre toracice de la diferite nivele cu\/f\u0103r\u0103 redori str\u00e2nse ale articula\u0163iilor.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Amputa\u0163ii cu dificult\u0103\u0163i de realizare a ortostatismului, mersului ori gestualit\u0103\u0163ii.<\/p>\n

\u00cen evaluarea deficien\u0163ei func\u0163ionale se vor avea \u00een vedere:<\/p>\n

Cauza care a condus la indica\u0163ia de amputa\u0163ie:<\/p>\n

a)distrugerea unui membru prin strivire,<\/p>\n

b)pierderea vasculariza\u0163iei,<\/p>\n

c)gangrene de cauze variate (arteriopatii, diabet zaharat, embolii),<\/p>\n

d)durere sever\u0103 de pcauz\u0103 circulatorie,<\/p>\n

e)tumori maligne,<\/p>\n

f)infec\u0163ie necontrolabil\u0103 terapeutic;<\/p>\n

Starea bontului: scurt; cu cicatrici vicioase; cu calus vicios; cu nevroame hiperalgice, cu leziuni trofice, fistule cronice; cu sechele complexe;<\/p>\n

Nivelul amputa\u0163iei, la membrul sau membrele afectate.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 f\u0103r\u0103 limit\u0103ri, cu excep\u0163ia celor care solicit\u0103 gestualitate fin\u0103, de precizie.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii.<\/p>\n

Necesit\u0103 schimbarea locului de munc\u0103 \u00een cazul unor profesiuni (ex: pianist, violonist s.a.).<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice profesie cu excep\u0163ia celor care solicit\u0103:<\/p>\n

– ortostatism \u015fi deplas\u0103ri posturale prelungite,<\/p>\n

– bimanualitate.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 accesibil.<\/p>\n

Formare \u015fi \u00eendrumare profesional\u0103 \u00een func\u0163ie de v\u00e2rst\u0103 persoanelor care \u015fi-au pierdut bimanualitatea, cu referire la muncile manuale – necalificate.<\/p>\n

Asigurare cu proteze, orteze, proteze estetice diferen\u0163iate \u00een vederea activ\u0103rii \u00een via\u0163a social\u0103 f\u0103r\u0103 restric\u0163ii.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Locuri de munc\u0103 f\u0103r\u0103 solicitare fizic\u0103, f\u0103r\u0103 deplas\u0103ri \u015fi variante posturale sau\/\u015fi gestuale, \u00een func\u0163ie de deterior\u0103rile morfofunc\u0163ionale.<\/p>\n

NB. \u00cen elaborarea programelor de recuperare se vor avea \u00een vedere:<\/p>\n

– localizarea \u015fi nivelul amputa\u0163iei,<\/p>\n

– cauzele care au produs-o,<\/p>\n

– eficien\u0163a protez\u0103rii,<\/p>\n

– v\u00e2rsta,<\/p>\n

– preg\u0103tirea generala \u015fi profesional\u0103 – \u00een func\u0163ie de care se recomand\u0103:<\/p>\n

– schimbarea locului de munc\u0103 sau – formare profesional\u0103 pentru munci statice, accesibile handicapului postural sau\/\u015fi de gestualitate.<\/p>\n<\/td>\n

\n

Furnizare de mijloace protetice, de adaptare a utilajelor, reorganizarea muncii la nevoie, cu atribuirea sarcinilor ce nu pot fi \u00eendeplinite altor membri ai colectivului.<\/p>\n

Pentru deficien\u0163ii locomotori posturali:<\/p>\n

\u00cen afara protez\u0103rii adecvate \u015fi adapt\u0103rii locului de munc\u0103 astfel \u00eenc\u00e2t sa nu fie solicitat\u0103 postura pe care nu o poate realiza, se recomand\u0103 facilitarea prin mijloace suplimentare de sprijin (scaune adaptate ergonomic) sau permiterea cu u\u015furin\u0163\u0103 a modific\u0103rilor posturale impuse de munc\u0103, prin balustrade sau m\u00e2nere de sprijin.<\/p>\n

Transferul unor comenzi ale ma\u015finii de la picior la m\u00e2n\u0103 sau automatizarea comenzilor respective.<\/p>\n

Pentru cei care au asociat\u0103 afectarea mobilit\u0103\u0163ii coloanei vertebrale: sisteme mecanice de manevrare a greut\u0103\u0163ilor \u015fi c\u0103rucioare de transport de \u00een\u0103l\u0163imea bancului de lucru astfel \u00eenc\u00e2t transferul greut\u0103\u0163ilor de pe c\u0103rucior pe banc \u015fi invers s\u0103 se fac\u0103 prin alunecare.<\/p>\n

Pentru persoanele cu deficien\u0163\u0103 fizic\u0103 cu afectarea gestualit\u0103\u0163ii:<\/p>\n

Este posibil\u0103, dupa caz, protezare sau ortezare, eventual proteze de munc\u0103 adaptate \u00een raport cu secven\u0163ele muncii (pense, c\u00e2rlige etc.), schimbarea lateralit\u0103\u0163ii \u015fi adapt\u0103ri ale utilajului, ca de pild\u0103 transferul comenzilor de la o m\u00e2n\u0103 la alta sau de la m\u00e2n\u0103 la picior, schimbarea sistemului de p\u00e2rghii ale comenzilor pentru sc\u0103derea efortului fizic.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Idem handicap accentuat<\/p>\n<\/td>\n

\n

– Idem handicap accentuat;<\/p>\n

– Dupa protezare, adaptare la proteze\/orteze:<\/p>\n

– asigurarea de mijloace de deplasare pentru persoanele cu deficien\u0163\u0103 postural\u0103 (baston sau cadru pentru cele cu amputa\u0163ii unilaterale, fotoliu rulant, c\u0103rucioare pentru cele cu amputa\u0163ii bilaterale);<\/p>\n

– asigurarea de mijloace de autoservire sau\/\u015fi de munc\u0103 pentru cei cu pierderea bilateral\u0103 a gestualit\u0103\u0163ii;<\/p>\n

– sprijin total pentru \u00eengrijire \u015fi activit\u0103\u0163ile cotidiene, de autogospod\u0103rire.<\/p>\n

Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Afec\u0163iuni neurologice*<\/p>\n

* Se refer\u0103 la:<\/p>\n

a)Afec\u0163iuni neurologice congenitale sau contractate precoce cu tulbur\u0103ri posturale \u015fi gestuale de intensitate variat\u0103, de exemplu:<\/p>\n

– malforma\u0163ii congenitale (ex: mielomeningocelul, porencefalia, hidrocefalia, microcefalia);<\/p>\n

– sechele neurologice (pareze, paralizii etc.) – dup\u0103 meningoencefalopatii infantile;<\/p>\n

– leziuni traumatice ale SNC;<\/p>\n

– sechele dupa sindrom ischemic medular cu parapareze sau plegii, tertrapareze sau tetraplegii, monopareze sau monoplegii;<\/p>\n

– sechele dup\u0103 traumatisme cerebrale severe;<\/p>\n

– paralizii de plex brahial;<\/p>\n

– leziuni de nervi periferici care produc tulbur\u0103ri de manipula\u0163ie, uni sau bilaterale;<\/p>\n

– tulbur\u0103ri neurologice sechelare cu deficit tip bi-tri-tetraparetic\/plegic cu\/f\u0103r\u0103 tulbur\u0103ri trofice, afect\u00e2nd deplasarea \u015fi gestualitatea normal\u0103 sau tulbur\u0103ri de tip epileptic ori alte tulbur\u0103ri de focar;<\/p>\n

– sechele dup\u0103 poliomielit\u0103 \u015fi afec\u0163iuni medulare infec\u0163ioase;<\/p>\n

– paralizii cerebrale: ex. hemiplegie-hemipareza infantil\u0103, paraplegie-paraparez\u0103 spastic\u0103 infantil\u0103, boala Little;<\/p>\n

– tumori cerebrale benigne care determin\u0103 prin extensie tulbur\u0103ri de focar, tumori maligne.<\/p>\n

b)Accidentele vasculare cerebrale (A VC): hemoragice, trombotice sau embolice, cu diverse localiz\u0103ri, cu deficite locomotorii secundare, disfazie\/afazie sau\/\u015fi tulbur\u0103ri sfincteriene indiferent de v\u00e2rst\u0103 \u015fi statut, la persoanele cu:<\/p>\n

– Sechele A VC care au drept cauze o malforma\u0163ie congenital\u0103 vascular\u0103;<\/p>\n

– Sechele A VC embolice dup\u0103 valvulopatii reumatismale contractate precoce sau congenitale;<\/p>\n

– Sechele A VC din angiocardiopatiile congenitale;<\/p>\n

– Sechele A VC din cardiomiopatiile primitive (idiopatice sau primare);<\/p>\n

– Sechele A VC din HTA reno-vascular\u0103;<\/p>\n

– Deficite motorii din afec\u0163iunile hemoragipare (cuagulopatii, trombocitopenii s.a.), din afec\u0163iuni hematologice (policitemia vera);<\/p>\n

– Deficite motorii ale unor neoplazii – primar sau secundar cerebrale – de sistem nervos, osteoarticular, p\u0103r\u0163i moi.<\/p>\n

c)Parapareze\/paraplegii, tetrapareze\/tetraplegii, monopareze\/monoplegii – indiferent de etiologie (traumatic\u0103, vascular\u0103, infec\u0163ioas\u0103, tumoral\u0103, degenerativ\u0103 etc.), indiferent de v\u00e2rst\u0103 \u015fi statut.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Examen neurologic;<\/p>\n

Eco Doppler;<\/p>\n

CT, RMN cerebral;<\/p>\n

Examen oftalmologic (acuitate vizual\u0103, campimetrie, fund de ochi);<\/p>\n

EKG;<\/p>\n

EEG;<\/p>\n

Glicemie,<\/p>\n

Teste de coagulare;<\/p>\n

Hemoleucogram\u0103 complet\u0103;<\/p>\n

Angiografie carotidian\u0103;<\/p>\n

Echocardiografie.<\/p>\n<\/td>\n

\n

Se stabilesc \u00een func\u0163ie de structura\/structurile afectate.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Deficit motor minim la un membru sau care nu afecteaz\u0103 prehensiunea, manipula\u0163ia.<\/p>\n

Tulbur\u0103ri de coordonare \u015fi echilibru u\u015foare.<\/p>\n

Se poate deplasa, mersul fiind posibil dar cu oscila\u0163ii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Deficit motor al unui membru inferior sau al ambelor membre inferioare dar care nu afecteaz\u0103 desf\u0103\u015furarea activit\u0103\u0163ilor vie\u0163ii cotidiene sau profesionale;<\/p>\n

Se deplaseaz\u0103 cu u\u015foar\u0103 dificultate pe distan\u0163e lungi sau cu dificultate moderat\u0103 pe distan\u0163e scurte, dar f\u0103r\u0103 sprijin, put\u00e2nd desf\u0103\u015fura activit\u0103\u0163i profesionale normale, \u00een func\u0163ie de natura profesiei.<\/p>\n

Deficit motor la un membru superior care afecteaz\u0103 minimum mobilitatea, gestualitatea \u015fi prehensiunea.<\/p>\n

Dificult\u0103\u0163i de coordonare \u015fi de manipula\u0163ie neinfluen\u0163ate de deficitul motor. Se poate deplasa f\u0103r\u0103 sprijin pe distan\u0163e variabile, cu dificultate, cu oscila\u0163ii (vezi criteriile de la afectarea func\u0163iei de coordonare).<\/p>\n

Tulbur\u0103ri u\u015foare de vorbire: dizartrie, balbism, alte tulbur\u0103ri ale vorbirii specifice unor afec\u0163iuni neurologice (vezi criteriile de la afec\u0163iunile respective: boala Parkinson, miastenia gravis s.a.).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deficien\u0163\u0103 locomotorie accentuat\u0103. Se poate deplasa sprijinit \u00een baston (sprijin unilateral) sau nesprijinit, dar cu mare dificultate. Nu poate realiza mersul normal, nici chiar pe distan\u0163e scurte.<\/p>\n

Deficit motor total al unui membru superior ce afecteaz\u0103 activitatea profesional\u0103 \u015fi cea cotidian\u0103 sau deficit motor bilateral moderat.<\/p>\n

Tulbur\u0103ri accentuate de coordonare: se deplaseaz\u0103 cu sprijin unilateral sau nesprijinit dar cu mare greutate, cu baz\u0103 de sus\u0163inere l\u0103rgit\u0103, cu tendin\u0163\u0103 la devia\u0163ii \u00een cazul asocierii unor tulbur\u0103ri vestibulare de intensitate medie (vezi criteriile de la afectarea func\u0163iilor de coordonare).<\/p>\n

Tulbur\u0103ri de vorbire de tipul afaziei expresive moderate.<\/p>\n

Permite, \u00een cazul \u00een care nu se asociaz\u0103 deficit de locomo\u0163ie, de manipula\u0163ie, de coordonare, exercitarea activit\u0103\u0163ilor vie\u0163ii cotidiene \u015fi, eventual, efectuarea unor activit\u0103\u0163i specifice profesiunii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Deficit grav de locomo\u0163ie:<\/p>\n

– persoana nu se poate deplasa nici cu sprijin nici f\u0103r\u0103 sprijin, fiind dependent\u0103 de un mijloc de transport adecvat (fotoliu rulant, alte dispozitive) sau este imobilizat la pat;<\/p>\n

– nu \u00ee\u015fi poate \u00eendeplini activit\u0103\u0163ile vie\u0163ii cotidiene, nu-\u015fi poate asigura existen\u0163a prin activitatea pentru care a fost preg\u0103tit\u0103;<\/p>\n

– nu se poate autoservi;<\/p>\n

– necesit\u0103 asistent personal.<\/p>\n

NB. Persoanele cu paraplegii, parapareze forte pot presta activit\u0103\u0163i legate de capacitatea \u015fi de preg\u0103tirea intelectual\u0103, beneficiind de o asisten\u0163\u0103 social\u0103 adecvat\u0103 \u015fi de prezen\u0163a asistentului personal deoarece necesit\u0103\u0163ile sunt mult sporite din punct de vedere material, social, psihologic etc.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

NB. Structurile afectate indiferent de data contract\u0103rii, cauz\u0103, localizare, pot determina tulbur\u0103ri:<\/p>\n

– ale staticii, mobilit\u0103\u0163ii – locomo\u0163iei sau\/\u015fi ale manipula\u0163iei (gestualit\u0103\u0163ii) sau\/\u015fi de coordonare \u015fi echilibru sau\/\u015fi de vorbire,cu implica\u0163ii diferite, \u00een func\u0163ie de predominanta lor \u015fi limitarea la via\u0163a social\u0103, comunitara \u015fi familiala.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice munc\u0103 cu program normal, cu evitarea celor care impun activitatea la \u00een\u0103l\u0163ime.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii cu condi\u0163ia monitoriz\u0103rii medicale, evitarea activit\u0103\u0163ii la \u00een\u0103l\u0163ime sau care impune varia\u0163ii posturale mari \u015fi deplas\u0103ri pe distan\u0163e mari.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 – loc de munc\u0103 f\u0103r\u0103 suprasolicitare postural\u0103, activit\u0103\u0163i preponderent statice, f\u0103r\u0103 deplas\u0103ri posturale, f\u0103r\u0103 suprasolicitare fizic\u0103 \u015fi psihic\u0103, \u00een condi\u0163ii de confort organic, f\u0103r\u0103 rela\u0163ii cu publicul dac\u0103 sunt asociate tulbur\u0103ri de vorbire.<\/p>\n<\/td>\n

\n

Sprijin pentru asigurarea locului de munc\u0103 adecvat \u00een vederea desf\u0103\u015fur\u0103rii activit\u0103\u0163ii cu program normal sau redus sau, dac\u0103 nu este posibil, schimbarea locului de munc\u0103;<\/p>\n

Monitorizare medico-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

\u00cen general nu pot presta activit\u0103\u0163i profesionale datorit\u0103 intensit\u0103\u0163ii afect\u0103rii func\u0163iilor motorii sau\/\u015fi de manipula\u0163ie, coordonare, vorbire;<\/p>\n

\u00cen cazul deficitelor motorii de tip paraparetic, tetraparetic, sunt posibile activit\u0103\u0163i adaptate, cu solicit\u0103ri fizice reduse, f\u0103r\u0103 deplas\u0103ri posturale, \u00een condi\u0163ii de confort organic.<\/p>\n<\/td>\n

\n

Asigurare mijloace de deplasare (baston, c\u00e2rje, cadru, fotoliu rulant – \u00een func\u0163ie de intensitatea deficitului motor la membrele superioare sau\/\u015fi inferioare);<\/p>\n

Asigurare dispozitive de mers (orteze) \u00een special pentru persoanele cu sechele dup\u0103 afect\u0103ri de neuroni motori periferici;<\/p>\n

Sprijin familial \u015fi comunitar (\u00een func\u0163ie de caz \u015fi situa\u0163ie) pentru efectuarea unor activit\u0103\u0163i cotidiene \u015fi de \u00eengrijire.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Intensitatea afect\u0103rii func\u0163iei motorii face imposibil\u0103 desf\u0103\u015furarea oric\u0103ror activit\u0103\u0163i profesionale, activit\u0103\u0163i cotidiene, de auto\u00eengrijire, autogospod\u0103rire;<\/p>\n

\u00cen cazul persoanelor cu parapareze forte, paraplegii, f\u0103r\u0103 afectarea func\u0163iilor intelectuale (\u00een situa\u0163ii particulare) este posibil \u015fi indicat acces pentru prestarea profesiunilor cu preg\u0103tire superioar\u0103, activit\u0103\u0163i legate de preg\u0103tirea intelectual\u0103, \u00een ritm liber, beneficiind de asistent personal.<\/p>\n<\/td>\n

\n

Necesit\u0103 asistent personal.<\/p>\n

Monitorizare medical\u0103 la domiciliu pentru recuperare (CFM) \u015fi pentru prevenirea leziunilor de decubit.<\/p>\n

Asigurarea mijloacelor de transport adecvat (c\u0103rucioare – alte dispozitive) sau de mobilizare (fotoliu rulant).<\/p>\n

Pentru cei care sunt \u00eencadra\u0163i \u00een munc\u0103 \u015fi folosesc fotoliul rulant – este necesar\u0103 ajustarea bancului de lucru \u015fi a spa\u0163iului de sub banc, precum \u015fi eliberarea c\u0103ilor de acces pentru a permite persoanei cu handicap s\u0103 ajung\u0103 la locul de munc\u0103.<\/p>\n

Organizarea planului de lucru astfel \u00eenc\u00e2t s\u0103 reg\u0103seasc\u0103 \u00een aria de munc\u0103 materia prim\u0103 \u015fi uneltele necesare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Afec\u0163iuni demielinizante – degenerative*<\/p>\n

* Se refer\u0103 la leuconevraxit\u0103: sinonime – scleroz\u0103 \u00een pl\u0103ci, encefalopatie diseminat\u0103 cronic\u0103, encefalopatie periaxial\u0103 difuz\u0103, boal\u0103 Devic (oftalmoneuromielit\u0103), indiferent deforma clinic\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen neurologic**;<\/p>\n

– Examen oftalmologic; (AV, campimetrie, FO);<\/p>\n

– ENG;<\/p>\n

– PEV auditive \u015fi vizuale;<\/p>\n

– Diplopie provocat\u0103;<\/p>\n

– Imunoglobulin\u0103 G \u00een LCR \u015fi s\u00e2nge;<\/p>\n

– RMN, CT.<\/p>\n<\/td>\n

\n

\u00cen formele oligosimptomatice cu:<\/p>\n

– Sindrom bipiramidal frust;<\/p>\n

– Sindrom vestibular frust;<\/p>\n

– Sindrom cerebelos frust, sus\u0163inute pe<\/p>\n

examen RMN sau CT.<\/p>\n<\/td>\n

\n

\u00cen formele clinice cu perioade de remisiune, cu tulbur\u0103ri u\u015foare \u015fi medii de mers<\/p>\n

– deplasare posibil\u0103 f\u0103r\u0103 sprijin, cu men\u0163inerea:<\/p>\n

– sindromului piramidal,<\/p>\n

– sindromului vestibular,<\/p>\n

– sindromului cerebelos,<\/p>\n

Parametrii func\u0163ionali confirm\u0103 afec\u0163iunea demielinizant\u0103 (modific\u0103ri FO, PEV, diplopie, ENG, RMN, CT, ImG \u00een s\u00e2nge \u015fi LCR)<\/p>\n<\/td>\n

\n

\u00cen formele clinice cu evolu\u0163ie progresiv\u0103 sau cu pusee acute frecvente:<\/p>\n

tulbur\u0103ri accentuate de mers, mers dificil, uneori cu sprijin unilateral;<\/p>\n

tulbur\u0103ri de echilibru;<\/p>\n

tulbur\u0103ri de coordonare;<\/p>\n

tulbur\u0103ri de manipula\u0163ie; sindromul piramidal tip paretic;<\/p>\n

cerebelo-vestibular; tulbur\u0103ri vizuale (diplopie, modific\u0103ri CV);<\/p>\n

tulbur\u0103ri de sensibilitate.<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie continu\u0103 care conduc la pierderea autonomiei locomotorii, f\u0103c\u00e2nd dependent\u0103 persoana de o alt\u0103 persoan\u0103 (par\u0163ial sau total), datorit\u0103:<\/p>\n

a. sindromului piramidal variat:<\/p>\n

– hemiplegie dr\/stg,<\/p>\n

– paraplegie-paraparez\u0103 accentuat\u0103,<\/p>\n

– tetraparez\u0103 – tetraplegie;<\/p>\n

b. sindromului vestibulo-cerebelos cu tulbur\u0103ri de static\u0103 \u015fi echilibru grave.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Examen neurologic complet cu precizarea formei de evolu\u0163ie \u015fi a sindroamelor afectate, respectiv sindromul pur sau combinate.<\/p>\n

NB. Diagnosticul pozitiv se sus\u0163ine pe:<\/p>\n

– simptome \u015fi tulbur\u0103ri tranzitorii ca: oftalmopareze, deficite piramidale sau de sensibilitate, sindroame medulare acute, afectarea altor nervi cranieni, combina\u0163ii de semne subiective \u015fi obiective;<\/p>\n

– diagnosticul s\u0103 cuprind\u0103 forma clinic\u0103 de evolu\u0163ie \u015fi sindroamele respective (combinate sau pure).<\/p>\n

Forme clinice:<\/p>\n

– forme cu rec\u0103deri \u015fi remisiuni,<\/p>\n

– forma primar generalizat\u0103,<\/p>\n

– forma secundar progresiv\u0103.<\/p>\n

Sindroame:<\/p>\n

Sindromul motor:<\/p>\n

– paraparetic (paraplegic) spastic,<\/p>\n

– hemiparetic (hemiplegic) spastic,<\/p>\n

– monoparetic sau tetraparetic (tetraplegic) spastic.<\/p>\n

Sindromul ataxic:<\/p>\n

– ataxie prin tulbur\u0103ri cerebeloase;<\/p>\n

– ataxie prin tulbur\u0103ri vestibulare;<\/p>\n

– ataxie prin tulbur\u0103ri de sensibilitate profund\u0103.<\/p>\n

Semne oculare caracteristice:<\/p>\n

– oftalmopareze;<\/p>\n

– tulbur\u0103ri de acuitate vizual\u0103 \u015fi c\u00e2mp vizual;<\/p>\n

– modific\u0103ri FO: decolorare papilar\u0103 global\u0103 sau numai temporal\u0103 (mai frecvent).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i cu program normal \u00een locuri de munc\u0103 care nu impun deplas\u0103ri posturale prelungite sau o gestualitate rapid\u0103 \u015fi cu precizie.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 accesibil \u00een pozi\u0163ie dominant \u015fez\u00e2nd, f\u0103r\u0103 suprasolicitare fizic\u0103 \u015fi ritm impus.<\/p>\n

Monitorizarea medical\u0103 pentru prevenirea agrav\u0103rii deficitului motor, vestibular \u015fi cerebelos.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i cu program normal sau redus, cu solicit\u0103ri mici sau medii, f\u0103r\u0103 ritm impus, care nu solicit\u0103 mi\u015fc\u0103ri de precizie \u015fi rapide din partea membrelor superioare \u015fi inferioare, \u00eentr-un microclimat de confort organic.<\/p>\n<\/td>\n

\n

Participare cu condi\u0163ia asigur\u0103rii unor locuri de munc\u0103 f\u0103r\u0103 solicit\u0103ri fizice mari, deplas\u0103ri posturale prelungite \u015fi gestualitate rapid\u0103 \u015fi de precizie;<\/p>\n

Monitorizare permanent\u0103 pentru prelungirea duratei remisiunii \u015fi pentru prevenirea apari\u0163iei puseelor acute.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

\u00cen general, intensitatea tulbur\u0103rilor func\u0163ionale limiteaz\u0103 prestarea oric\u0103rei activit\u0103\u0163i profesionale organizate. Pot, eventual, efectua activit\u0103\u0163i de colaborare \u00een ritm liber, cu efect psihoterapeutic; Este conservat\u0103 capacitatea de auto\u00eengrijire.<\/p>\n<\/td>\n

\n

Pentru persoanele cu preg\u0103tire superioar\u0103: sprijin pentru efectuarea unor activit\u0103\u0163i de colaborare \u00een func\u0163ie de posibilit\u0103\u0163ile psiho-fizice \u015fi de suportul familial;<\/p>\n

Sprijin pentru ob\u0163inerea mijloacelor de deplasare (baston, c\u00e2rje, scaun rulant s.a.), par\u0163ial pentru activit\u0103\u0163ile de auto\u00eengrijire \u015fi autogospod\u0103rire \u015fi pentru monitorizarea medico-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Datorit\u0103 intensit\u0103\u0163ii tulbur\u0103rilor de postur\u0103, de mers, gestualitate sau\/\u015fi de vedere, nu pot presta nici o activitate; Capacitatea de autoservire par\u0163ial\/total afectata;<\/p>\n

Capacitatea de mobilizare: de la mers cu sprijin bilateral prin for\u0163e proprii, p\u00e2n\u0103 la imobilizare;<\/p>\n

Limitarea gestualit\u0103\u0163ii p\u00e2n\u0103 la imposibilitatea execut\u0103rii unor mi\u015fc\u0103ri cu membrul respectiv;<\/p>\n

Afectarea vederii p\u00e2n\u0103 la cecitate relativ\u0103 \u015fi absolut\u0103.<\/p>\n<\/td>\n

\n

Necesit\u0103 asistent personal.<\/p>\n

Asigurarea de mijloace de mobilizare (cadru, fotoliu rulant, c\u0103rucior) pentru deplasare \u00een cadrul locuin\u0163ei;<\/p>\n

Dispensarizarea medical\u0103 (la domiciliu sau, c\u00e2nd este necesar, la serviciul de specialitate).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

IV.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR MU\u015eCHILOR*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

1.Neuromiopatii: afectarea unit\u0103\u0163ii motorii (a fibrei musculare striate), a pl\u0103cii neuro-musculare, nervului motor \u015fi nervului motor spinal – cu amiotrofii \u015fi determinare genetic\u0103:<\/p>\n

a)DMP:<\/p>\n

– Forma sever\u0103 (Duchenne,)<\/p>\n

– Forma benign\u0103 (Becker);<\/p>\n

b)Fenotipul Duchenne – forma centurilor;<\/p>\n

c)DMP forma:<\/p>\n

– Facio-scapulo-humeral\u0103,<\/p>\n

– Distal\u0103,<\/p>\n

– Oculo-faringian\u0103.<\/p>\n

2.Miotonii (determinate genetic) – este implicat un deficit de membran\u0103 celular\u0103:<\/p>\n

a)miotonia congenital\u0103 (Thompson),<\/p>\n

b)distrofia miotonic\u0103 (Steinert).<\/p>\n

3.Polimiozita primitiv\u0103 (cu leziuni musculare de tip inflamator)<\/p>\n

4.Miastenia (boala sinapsei neuro-musculare)<\/p>\n

5.Boli degenerative \u015fi heredodegenerative ale SNC (boli genetice cu aspect anatomo-patologic de tip degenerativ):<\/p>\n

a)amiotrofia neuronal\u0103 Charcot – Marie Tooth,<\/p>\n

b)scleroza lateral\u0103 amiotrofic\u0103 (SLA),<\/p>\n

c)eredoataxia spinocerebeloas\u0103 Friedreich,<\/p>\n

d)heredo-ataxia cerebeloas\u0103 Pierre Marie.<\/p>\n

6.Anomalii \u015fi malforma\u0163ii musculare congenitale, dac\u0103 \u00eempiedic\u0103 statica \u015fi locomo\u0163ia (de ex: hipertrofii, redori, refrac\u0163ii musculare mutilante).<\/p>\n

1.<\/strong>Evaluare grad de handicap \u00een distrofia muscular\u0103 progresiv\u0103 (DMP) \u015fi formele ei<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Examen neurologic:<\/p>\n

– deficit motor \u00een func\u0163ie de forma clinico-genetic\u0103, indiferent dac\u0103 debutul este distal sau proximal, afectarea grupelor musculare se generalizeaz\u0103;<\/p>\n

Deficitul motor are ca expresie:<\/p>\n

– amiotrofii progresive-simetrice;<\/p>\n

– retrac\u0163ii tendinoase;<\/p>\n

– ROT vii.<\/p>\n

Paraclinic:<\/p>\n

– cre\u015fterea activit\u0103\u0163ii unor enzime glicolitice (de ex: LDH);<\/p>\n

– biopsia muscular\u0103 este sugestiv\u0103, eviden\u0163iaz\u0103 modific\u0103ri de tip miogen;<\/p>\n

– EMG:<\/p>\n

– absen\u0163a activit\u0103\u0163ii bioelectrice spontane,<\/p>\n

– diminuarea amplitudinii maxime a traseelor;<\/p>\n

– reducerea duratei medii a poten\u0163ialelor.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Deficit motor frust.<\/p>\n

Amiotrofii simetrice distal \u015fi proximal nesemnificative.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Deplasarea cu dificultate prin sc\u0103derea performan\u0163ei de ortostatism \u015fi mers prelungit \u015fi prin tulbur\u0103ri de precizie \u015fi vitez\u0103 a mi\u015fc\u0103rilor.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deplasare cu mare dificultate prin for\u0163a proprie, nesprijinit \u015fi cu sprijin.<\/p>\n

Imposibilitatea efectu\u0103rii aproape a oric\u0103rei gestualit\u0103\u0163i profesionale.<\/p>\n

Dificult\u0103\u0163i de respira\u0163ie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Persoana nedeplasabil\u0103 prin for\u0163a proprie.<\/p>\n

Tulbur\u0103ri de gestualitate bilateral.<\/p>\n

Pierderea capacit\u0103\u0163ii de autoservire.<\/p>\n

Tulbur\u0103ri mari de degluti\u0163ie \u015fi respira\u0163ie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Evaluare grad de handicap \u00een miotonii*<\/p>\n

* Sunt caracterizate printr-o lentoare a relax\u0103rii musculare dup\u0103 contrac\u0163ie voluntar\u0103, fenomenul diminu\u00e2nd progresiv dup\u0103 repetarea contrac\u0163iei voluntare (fenomen de \u00eenc\u0103lzire).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

\u00cen miotonia Thompson<\/p>\n

Examen neurologic:<\/p>\n

– distribu\u0163ia fenomenului mitotonic la flexorii degetelor, mu\u015fchii policelui, a musculaturii orbiculare, pleoape \u015fi pe parcursul evolu\u0163iei – hipertrofii musculare difuze la toate grupele musculare, cu predominan\u0163\u0103 la membrele inferioare (aspect halterofil).<\/p>\n

Examen paraclinic:<\/p>\n

– EMG: cre\u015fterea progresiv\u0103 a amplitudinii poten\u0163ialelor cu o frecvent\u0103 de 40\/50 cicli\/sec (criteriul patognomonic = fenomen de \u00eenc\u0103lzire)<\/p>\n

\u00cen distrofia miotonic\u0103 Steinert<\/p>\n

Examen neurologic:<\/p>\n

– amiotrofii musculare distale la membrele superioare \u015fi inferioare;<\/p>\n

– mu\u015fchii fonatori, cu modificarea vocii;<\/p>\n

– mu\u015fchiului cardiac;<\/p>\n

– atrofie gonadic\u0103.<\/p>\n

Examene paraclinice:<\/p>\n

– microscopia electronic\u0103 eviden\u0163iaz\u0103 afectarea arhitecturii miofibrilelor, care apar \u015fterse;<\/p>\n

– microscopia optic\u0103 eviden\u0163iaz\u0103 alternan\u0163a de fibre musculare atrofiate cu fibre hipertrofiate, dezorganizarea miofibrilelor;<\/p>\n

EMG – desc\u0103rc\u0103ri spontane repetitive, \u00een salve, asociate cu modific\u0103ri ale unit\u0103\u0163ii motorii de tip miopatic;<\/p>\n

Enzimograma seric\u0103 (LDH, FCK, TGO, TGP sunt sc\u0103zute sau normale).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

\u00cen formele u\u015foare cu manifest\u0103ri fruste care nu afecteaz\u0103 capacitatea fizic\u0103 de presta\u0163ie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Sc\u0103derea for\u0163ei musculare distale la membrele superioare;<\/p>\n

Oboseal\u0103 precoce;<\/p>\n

Sc\u0103derea for\u0163ei \u015fi vitezei de executare a mi\u015fc\u0103rilor;<\/p>\n

Sc\u0103derea capacit\u0103\u0163ii fizice de presta\u0163ie la efort, manipularea de greut\u0103\u0163i.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deplasare cu dificultate;<\/p>\n

Tulbur\u0103ri de manipula\u0163ie \u015fi gestualitate bilateral;<\/p>\n

Tulbur\u0103ri de vedere \u015fi de vorbire.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen formele clinice cu evolu\u0163ie \u00eendelungat\u0103 care conduc la deplasarea dificil\u0103 sau la imobilizare datorit\u0103 atrofiilor musculare marcate, cu tulbur\u0103ri respiratorii, tulbur\u0103ri de degluti\u0163ie, fona\u0163ie, alimenta\u0163ie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Evaluare grad de handicap \u00een polimiozit\u0103 primitiv\u0103*<\/p>\n

* Se caracterizeaz\u0103 printr-o simptomatologie dureroas\u0103 cu traseu EMG polimorf \u015fi leziuni musculare de tip inflamator.<\/p>\n

Sunt delimitate trei tipuri de polimiozit\u0103:<\/p>\n

a)Polimiozita primitiv\u0103 incomplet\u0103,<\/p>\n

b)Polimiozita din colagenoze – trebuie luate \u00een considerare criteriile stabilite pentru afec\u0163iunile respective,<\/p>\n

c)Polimiozita paraneoplazic\u0103 – trebuie luate \u00een considerare criteriile stabilite pentru afec\u0163iunile respective.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

EMG = caracterizat\u0103 printr-un traseu const\u00e2nd din activitate bioelectric\u0103 spontan\u0103 reprezentat\u0103 de poten\u0163iale de fibrila\u0163ie, poten\u0163iale polifazice care apar la contrac\u0163ii voluntare, activitate repetitiv\u0103 cu frecven\u0163\u0103 rapid\u0103, evocate de stimularea mecanic\u0103 a mu\u015fchilor.<\/p>\n

AP: aspect histologic greu de diferen\u0163iat de cel al distrofiilor musculare.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Criterii de \u00eencadrare \u00een grad de handicap asem\u0103n\u0103toare cu cele din distrofia muscular\u0103 progresiv\u0103, cu precizarea c\u0103 evolu\u0163ia este ondulant\u0103 cu agrav\u0103ri \u015fi remisiuni spontane \u015fi terapeutice<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Evaluare grad de handicap \u00een miastenie*<\/p>\n

* Este o boal\u0103 a sinapsei neuromusculare care se caracterizeaz\u0103 prin oboseal\u0103 excesiv\u0103 \u015fi defect al musculaturii striate ce apare la efort \u015fi se recupereaz\u0103, par\u0163ial sau total \u00een repaos \u015fi sub ac\u0163iunea unor substan\u0163e anticolinesterazice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Clinic:<\/p>\n

– deficitul motor miastenic se produce prin relaxarea progresiv\u0103 a mu\u015fchiului care face efortul \u015fi prin diminuarea progresiv\u0103 a for\u0163ei, iar repaosul reface for\u0163a muscular\u0103;<\/p>\n

– o caracteristic\u0103 a fenomenului miastenic = deficitul miastenic este mai accentuat \u00een a doua parte a zilei;<\/p>\n

– ROT prezente sau u\u015for diminuate.<\/p>\n

Paraclinic:<\/p>\n

– proba de efort, care caracterizeaz\u0103 sau eviden\u0163iaz\u0103 deficitul motor;<\/p>\n

– testul cu miostin sau tensilon amelioreaz\u0103 deficitul dar de scurt\u0103 durat\u0103;<\/p>\n

– EMG: cu stimularea nervului cubital \u015fi culegerea poten\u0163ialului evocat din eminen\u0163a hipotenar\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

NB. La \u00eencadrarea \u00een grad de handicap trebuie s\u0103 se \u0163in\u0103 seama de intensitatea deficitului miastenic, care se poate manifesta prin:<\/p>\n

1. tulbur\u0103ri oculare (strabism, diplopie, ptoza palpebral\u0103 \u015fi chiar imposibilitatea convergen\u0163ei);<\/p>\n

2. tulbur\u0103ri de fona\u0163ie (disfonie, nazonare, dizartrie), care apar sau se accentueaz\u0103 la efort;<\/p>\n

3. tulbur\u0103ri de degluti\u0163ie, la \u00eenceput pentru solide, apoi lichide \u015fi \u00een cazuri grave pentru saliv\u0103;<\/p>\n

4. tulbur\u0103ri de mastica\u0163ie: apar mai mult sau mai pu\u0163in precoce, pot merge p\u00e2n\u0103 la deficit total \u015fi se pot asocia cu c\u0103derea mandibulei;<\/p>\n

5. atingerea musculaturii faciale, deformarea mimicii (facies-ul miastenic caracteristic);<\/p>\n

6. afectarea musculaturii cefei, trunchiului \u015fi membrelor poate s\u0103 produc\u0103:<\/p>\n

– c\u0103derea capului – necesit\u0103 men\u0163inerea b\u0103rbiei cu m\u00e2na,<\/p>\n

– trecerea din clinostatism la ortostatism, poate fi imposibil\u0103 sau se execut\u0103 cu dificultate (cu efort mare),<\/p>\n

7. interesarea membrelor inferioare se remarc\u0103 ini\u0163ial la urcatul \u015fi cobor\u00e2tul sc\u0103rilor, iar ulterior \u015fi la mersul pe nivel plat,<\/p>\n

8. tulbur\u0103ri respiratorii: exprimate prin dispnee, sunt obiectivate de reducerea capacit\u0103\u0163ii vitale.<\/p>\n

Deficitul miastenic, indiferent de manifestare, se poate ameliora la tratamentul medicamentos corespunz\u0103tor.<\/p>\n

Gradul de handicap se evalueaz\u0103 \u00een func\u0163ie de intensitatea deficien\u0163elor func\u0163ionale, dup\u0103 criteriile prezentate pentru afectarea func\u0163iilor respective, reversibilitatea \u015fi rezisten\u0163a la tratamentul medicamentos specific.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Evaluare grad de handicap \u00een afec\u0163iunile degenerative \u015fi heredo – degenerative ale SNC<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

a) Amiotrofia neuronal\u0103 Charcot – Marie Tooth:<\/p>\n

– atrofii musculare simetrice distale:<\/p>\n

– la membrul inferior aspect de picior de cocos;<\/p>\n

– la membrul superior 1\/3 inferioar\u0103 antebra\u0163 – aspect de atrofii \u00een m\u0103nu\u015f\u0103<\/p>\n

– tulbur\u0103ri de sensibilitate de tip polinevritic;<\/p>\n

– tulbur\u0103ri vegetative – hipersudora\u0163ie;<\/p>\n

– tulbur\u0103ri endocrine (insuficien\u0163\u0103 gonadic\u0103);<\/p>\n

– examen bioptic: atrofii musculare de tip neuronal altern\u00e2nd cu zone hipertrofice.<\/p>\n

b) Scleroz\u0103 lateral\u0103 amiotrofic\u0103 (SLA):<\/p>\n

– amiotrofii distale, simetrice, progresive;<\/p>\n

– semne piramidale (spasticitate osteo-tendinoas\u0103, Babinschi prezent);<\/p>\n

– fenomene bulbare (tulbur\u0103ri de fona\u0163ie, de degluti\u0163ie, atrofii ale limbii, atrofii simetrice ale fe\u0163ei);<\/p>\n

– EMG: aspect = denervare;<\/p>\n

– microscopie electronic\u0103: \u00eentreru\/pperi la nivelul miofibrilelor, \u015ftergerea arhitecturii, depozit de glicogen;<\/p>\n

– microscopia optic\u0103: depozite de lipofuscin\u0103.<\/p>\n

c) Eredoataxia spinocerebeloas\u0103 Freidreich:<\/p>\n

– ataxie cerebeloas\u0103 (mers ebrios, cu baz\u0103 de sus\u0163inere l\u0103rgit\u0103,dizartrie,vorbire lent\u0103, ROT abolite precoce); – amiotrofii distale (aspect picior de cocos sau picior scobit);<\/p>\n

– EMG aspect de denerevare;<\/p>\n

– biopsie: aspect de degenerescent\u0103 axonal\u0103<\/p>\n

d) Eredoataxia cerebeloas\u0103 Pierre Marie: asem\u0103n\u0103tor eredoataxiei Freidreich, cu semne piramidale mai evidente \u015fi tulbur\u0103ri de sensibilitate profund\u0103 mai reduse, ROT vii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Sc\u0103derea u\u015foar\u0103 a performan\u0163elor de ortostatism \u015fi mers prelungit, \u00een precizia \u015fi viteza mi\u015fc\u0103rilor (realizarea gestualit\u0103\u0163ii).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Mobilizare cu greutate;<\/p>\n

Sc\u0103derea performan\u0163elor de ortostatism \u015fi mers prelungit;<\/p>\n

Scade precizia \u015fi viteza mi\u015fc\u0103rilor (afectarea medie a manipula\u0163iei \u015fi gestualit\u0103\u0163ii).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Persoana se deplaseaz\u0103 cu mare dificultate prin for\u0163a proprie, nesprijinit \u015fi cu sprijin;<\/p>\n

Nu poate efectua eficient gesturi profesionale, cele cotidiene sunt p\u0103strate;<\/p>\n

Dificult\u0103\u0163i de respira\u0163ie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie \u00eendelungat\u0103 care duc la:<\/p>\n

deplasarea dificil\u0103 sau la imobilizare datorit\u0103 atrofiilor musculare sau\/\u015fi la<\/p>\n

tulbur\u0103ri marcate de respira\u0163ie,<\/p>\n

tulbur\u0103ri marcate de degluti\u0163ie,<\/p>\n

tulbur\u0103ri marcate de alimenta\u0163ie,<\/p>\n

imposibilitatea realiz\u0103rii activit\u0103\u0163ilor de auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

6.<\/strong>Evaluare grad de handicap \u00een malforma\u0163ii musculare*<\/p>\n

* Se refer\u0103 la persoane cu anomalii \u015fi malforma\u0163ii congenitale sau contractate precoce (copil\u0103rie – adolescen\u0163\u0103), de ex: hipertrofii, redori, refrac\u0163ii musculare mutilante, care \u00eempiedic\u0103 statica \u015fi locomo\u0163ia.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Teste biometrice \u015fi musculare;<\/p>\n

Dinamometrie pentru aprecierea for\u0163ei musculare – \u00een func\u0163ie de localizare \u015fi tipul de sechel\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

\u00cencadrarea \u00een grad de handicap se realizeaz\u0103 \u00een func\u0163ie de limitarea sau pierderea capacit\u0103\u0163ii de realizare a staticii, mobilit\u0103\u0163ii sau\/\u015fi gestualit\u0103\u0163ii. Evaluare \u00een conformitate cu criteriile stabilite pentru persoanele cu miopatii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu evitarea celor care necesit\u0103 gestualitate cu vitez\u0103 \u015fi precizie \u015fi deplas\u0103ri posturale prelungite.<\/p>\n<\/td>\n

\n

Sprijin pentru asigurarea unui loc de munc\u0103 f\u0103r\u0103 efort fizic mare, deplas\u0103ri posturale prelungite sau, eventual, pentru schimbarea locului de munc\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu evitarea celor care necesit\u0103 mi\u015fc\u0103ri cu vitez\u0103 \u015fi precizie \u015fi deplas\u0103ri posturale prelungite. Sunt contraindicate activit\u0103\u0163ile care impun fine\u0163e, repere mici, ritm impus.<\/p>\n<\/td>\n

\n

Sprijin pentru asigurarea unui loc de munc\u0103 f\u0103r\u0103 efort fizic mare, deplas\u0103ri posturale prelungite sau, eventual, pentru schimbarea locului de munc\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i cu efort fizic ne\u00eensemnat, \u00een postur\u0103 predominant \u015fez\u00e2nd, care nu necesit\u0103 fine\u0163e, vitez\u0103, complexitate \u015fi alternan\u0163\u0103 gestual\u0103. De exemplu: munci de birou pentru cei cu preg\u0103tire superioara sau medie.<\/p>\n<\/td>\n

\n

Participare \u00een cazul asigur\u0103rii unui loc de munc\u0103 accesibil, f\u0103r\u0103 efort fizic de intensitate mare \u015fi medie, ortostatism prelungit, deplas\u0103ri posturale, care s\u0103 necesite suprasolicitare gestual\u0103.<\/p>\n

S\u0103 fie scutite de eforturi fizice mari. Pentru aceasta s\u0103 se utilizeze sisteme mecanice de manipulare a greut\u0103\u0163ilor, s\u0103 se monteze sisteme de sus\u0163inere a m\u00e2inii pentru a evita oboseala muscular\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Au pierdut\u0103 capacitatea de autoservire, autogospod\u0103rire \u015fi auto\u00eengrijire.<\/p>\n<\/td>\n

\n

Necesit\u0103 asistent personal.<\/p>\n

Sprijin pentru asigurarea unor mijloace de deplasare (baston, cadru, fotoliu rulant, c\u0103rucior).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

V.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR DE COORDONARE*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

a)Sindroamele extrapiramidale, de cauz\u0103 divers\u0103, postencefalitice, vasculare, medicamentoase, toxice, tumorale;<\/p>\n

b)Boala Parkinson (paralizie agitat\u0103);<\/p>\n

c)Coreea cronica Huntington (sindromul de neostriat-putamino-caudat), care produce sindromul distono-diskinetic, tulbur\u0103ri locomotorii \u015fi gestuale, ce \u00eempiedic\u0103 activitatea normal\u0103.<\/p>\n

Boal\u0103 ereditar\u0103, cu debut de regul\u0103 la 30-35 de ani.<\/p>\n

Tulbur\u0103ri func\u0163ionale asem\u0103n\u0103toare sindromului extrapiramidal, bolii Parkinson, cu deosebirea c\u0103 mi\u015fc\u0103rile involuntare sunt mai ample \u015fi tulbur\u0103rile psihice evolueaz\u0103 spre demen\u0163\u0103 lent progresiv\u0103;<\/p>\n

d)Boala Wilson – degenerescent\u0103 hepato-lenticular\u0103 (sindromul de panstriat cu ataxie, coreeo-atetoza cu afectarea posturii \u015fi gestualit\u0103\u0163ii).<\/p>\n

Afec\u0163iune metabolic\u0103 cu determinare genetic\u0103, caracterizat\u0103 prin acumularea de cupru \u00een SNC, ficat, cornee, rinichi, cu doua entit\u0103\u0163i:<\/p>\n

– Boala Wilson – debut la 7-15 ani, dominat\u0103 de rigiditate extrapiramidal\u0103, facies hipomimic, bradikinezie, puerilism, degradare involutiv\u0103 progresiv\u0103.<\/p>\n

– Boala Westphall – Strumpell – debut la 25-40 de ani, tablou clinic dominat de tremur\u0103tur\u0103 ce declan\u015feaz\u0103 spasme \u00een musculatur\u0103 opozi\u0163ional\u0103, de o violen\u0163\u0103 mare, degradare psihic\u0103, modific\u0103ri biochimice (cupremia poate fi sc\u0103zut\u0103).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI **<\/p>\n<\/td>\n

\n

Examen neurologic: tablou dominat de trei semne cardinale:<\/p>\n

1. tremorul (ritm lent, apare \u00een repaus, uneori \u00een men\u0163inerea unei atitudini – tremur postural).<\/p>\n

Aspect caracteristic la membrele superioare – „num\u0103rarea banilor”, „r\u0103sucirea \u0163ig\u0103rilor”, iar la membrele inferioare – „pedalare”, „b\u0103tut tactul”.<\/p>\n

2. rigiditate – varianta particular\u0103 de hipertonie -, intereseaz\u0103 toate grupele musculare, predomin\u00e2nd la r\u0103d\u0103cina membrelor – eviden\u0163iat\u0103 prin fenomenul de roat\u0103 din\u0163at\u0103;<\/p>\n

3. bradi sau akinezie (apare imobil, cu activitate gestual\u0103 s\u0103rac\u0103). Eviden\u0163iat\u0103 prin proba marionetelor, b\u0103tutul tactului, pensa digital\u0103 cu fiecare deget.<\/p>\n

Aspectul caracteristic: facies fijat, imobil, atitudinea caracteristic\u0103 a capului \u015fi trunchiului (\u00eenclinate), mers cu pa\u015fi mici, tulbur\u0103ri de vorbire.<\/p>\n

Examen obiectiv: ROT vii, tulbur\u0103ri de motilitate ocular\u0103, tulbur\u0103ri vegetative (sialoree, hipercrinie), tulbur\u0103ri psihice.<\/p>\n

Examene paraclinice:<\/p>\n

PEG, CT = atrofie cortical\u0103 cu localizare \u00een general frontal\u0103 \u015fi, uneori, hidrocefalie;<\/p>\n

EEG = modific\u0103ri difuze exprimate prin activarea undei Theta, predomin\u00e2nd fronto-temporal;<\/p>\n

EMG: deceleaz\u0103 caracteristicile fiziologice ale tremur\u0103turii (desc\u0103rc\u0103ri ritmice de 4-7 cicli\/sec); Determin\u0103ri biochimice (dozarea dopaminei \u00een LCR \u015fi urin\u0103 sau\/\u015fi sanguin).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Semne pu\u0163in caracteristice, tulbur\u0103ri vegetative, forme cu tremor cu caracter localizat la membrele superioare (hemisindrom Parkinson), hipertonie discret\u0103. Semnul Noica \u015fi tremur discret, eviden\u0163iat prin EMG.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Simptomatologie subiectiv\u0103 \u015fi modific\u0103ri obiective caracteristice. Sunt de intensitate medie \u015fi tind s\u0103 devin\u0103 permanente, influen\u0163ate par\u0163ial de tratament.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Formele la care predomin\u0103 tremorul sau cele akineto-hipertonice, la care simptomatologia este permanent\u0103, influen\u0163at\u0103 par\u0163ial de terapie, \u00eenso\u0163ite de tulbur\u0103ri de locomo\u0163ie, static\u0103 \u015fi mers, de tulbur\u0103ri de manipula\u0163ie, degluti\u0163ie, fona\u0163ie \u015fi vorbire.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Formele clinice cu evolu\u0163ie \u00eendelungat\u0103 care pot duce la imobilizare. Pot fi \u00eenso\u0163ite de tulbur\u0103ri psihice \u015fi de vorbire (afazie expresiv\u0103).<\/p>\n

Deficien\u0163e de degluti\u0163ie \u015fi respira\u0163ie permanente, rezistente la diverse variante terapeutice.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Diferen\u0163e nesemnificative \u00een func\u0163ie de structura afectat\u0103 care a determinat tulburarea de coordonare.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu limitarea celor care impun precizie, fine\u0163e \u00een mi\u015fc\u0103ri, suprasolicitare fizic\u0103 \u015fi psihic\u0103.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu condi\u0163ia asigur\u0103rii \u00eencadr\u0103rii sau \u00eendrum\u0103rii profesionale spre un loc de munc\u0103 adecvat.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i profesionale care nu impun deplas\u0103ri prelungite, ortostatism \u00eendelungat, mi\u015fc\u0103ri (gesturi) de vitez\u0103 \u015fi precizie.<\/p>\n

– Sunt indicate activit\u0103\u0163ile statice, cu solicit\u0103ri fizice reduse, \u00een condi\u0163ii de confort microambiental.<\/p>\n<\/td>\n

\n

– Este necesar s\u0103 li se asigure un sistem de fixare \u015fi ghidaj care s\u0103 le permit\u0103 executarea sarcinilor de munc\u0103.<\/p>\n

– Evitarea activit\u0103\u0163ilor de fine\u0163e, cu repere mici.<\/p>\n

– Asigurarea unui climat relaxant, neconflictual, \u00een cadrul colectivului de munc\u0103 \u015fi \u00een familie.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Sunt incapabili de prestarea oric\u0103ror activit\u0103\u0163i profesionale.<\/p>\n

– Autoservirea este par\u0163ial afectat\u0103.<\/p>\n

– Se pot deplasa cu mare dificultate prin for\u0163e proprii, nesprijinit sau cu sprijin unilateral.<\/p>\n<\/td>\n

\n

– Necesit\u0103 sprijin pentru ob\u0163inerea de mijloace de deplasare (baston, c\u00e2rje, scaun rulant);<\/p>\n

– Monitorizarea evolu\u0163iei tulbur\u0103rilor func\u0163ionale \u00een condi\u0163ii de tratament corect administrat \u015fi sus\u0163inut.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

<><\/p>\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

\u00cen general nu pot presta activit\u0103\u0163i profesionale datorit\u0103 intensit\u0103\u0163ii afect\u0103rii func\u0163iilor motorii sau\/\u015fi de manipula\u0163ie, coordonare, vorbire;<\/p>\n

\u00cen cazul deficitelor motorii de tip paraparetic, tetraparetic, sunt posibile activit\u0103\u0163i adaptate, cu solicit\u0103ri fizice reduse, f\u0103r\u0103 deplas\u0103ri posturale, \u00een condi\u0163ii de confort organic.<\/p>\n<\/td>\n

\n

Asigurare mijloace de deplasare (baston, c\u00e2rje, cadru, fotoliu rulant – \u00een func\u0163ie de intensitatea deficitului motor la membrele superioare sau\/\u015fi inferioare);<\/p>\n

Asigurare dispozitive de mers (orteze) \u00een special pentru persoanele cu sechele dup\u0103 afect\u0103ri de neuroni motori periferici;<\/p>\n

Sprijin familial \u015fi comunitar (\u00een func\u0163ie de caz \u015fi situa\u0163ie) pentru efectuarea unor activit\u0103\u0163i cotidiene \u015fi de \u00eengrijire.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Intensitatea afect\u0103rii func\u0163iei motorii face imposibil\u0103 desf\u0103\u015furarea oric\u0103ror activit\u0103\u0163i profesionale, activit\u0103\u0163i cotidiene, de auto\u00eengrijire, autogospod\u0103rire;<\/p>\n

\u00cen cazul persoanelor cu parapareze forte, paraplegii, f\u0103r\u0103 afectarea func\u0163iilor intelectuale (\u00een situa\u0163ii particulare) este posibil \u015fi indicat acces pentru prestarea profesiunilor cu preg\u0103tire superioar\u0103, activit\u0103\u0163i legate de preg\u0103tirea intelectual\u0103, \u00een ritm liber, beneficiind de asistent personal.<\/p>\n<\/td>\n

\n

Necesit\u0103 asistent personal.<\/p>\n

Monitorizare medical\u0103 la domiciliu pentru recuperare (CFM) \u015fi pentru prevenirea leziunilor de decubit.<\/p>\n

Asigurarea mijloacelor de transport adecvat (c\u0103rucioare – alte dispozitive) sau de mobilizare (fotoliu rulant).<\/p>\n

Pentru cei care sunt \u00eencadra\u0163i \u00een munc\u0103 \u015fi folosesc fotoliul rulant – este necesar\u0103 ajustarea bancului de lucru \u015fi a spa\u0163iului de sub banc, precum \u015fi eliberarea c\u0103ilor de acces pentru a permite persoanei cu handicap s\u0103 ajung\u0103 la locul de munc\u0103.<\/p>\n

Organizarea planului de lucru astfel \u00eenc\u00e2t s\u0103 reg\u0103seasc\u0103 \u00een aria de munc\u0103 materia prim\u0103 \u015fi uneltele necesare.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Afec\u0163iuni demielinizante – degenerative*<\/p>\n

* Se refer\u0103 la leuconevraxit\u0103: sinonime – scleroz\u0103 \u00een pl\u0103ci, encefalopatie diseminat\u0103 cronic\u0103, encefalopatie periaxial\u0103 difuz\u0103, boal\u0103 Devic (oftalmoneuromielit\u0103), indiferent deforma clinic\u0103.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

– Examen neurologic**;<\/p>\n

– Examen oftalmologic; (AV, campimetrie, FO);<\/p>\n

– ENG;<\/p>\n

– PEV auditive \u015fi vizuale;<\/p>\n

– Diplopie provocat\u0103;<\/p>\n

– Imunoglobulin\u0103 G \u00een LCR \u015fi s\u00e2nge;<\/p>\n

– RMN, CT.<\/p>\n<\/td>\n

\n

\u00cen formele oligosimptomatice cu:<\/p>\n

– Sindrom bipiramidal frust;<\/p>\n

– Sindrom vestibular frust;<\/p>\n

– Sindrom cerebelos frust, sus\u0163inute pe<\/p>\n

examen RMN sau CT.<\/p>\n<\/td>\n

\n

\u00cen formele clinice cu perioade de remisiune, cu tulbur\u0103ri u\u015foare \u015fi medii de mers<\/p>\n

– deplasare posibil\u0103 f\u0103r\u0103 sprijin, cu men\u0163inerea:<\/p>\n

– sindromului piramidal,<\/p>\n

– sindromului vestibular,<\/p>\n

– sindromului cerebelos,<\/p>\n

Parametrii func\u0163ionali confirm\u0103 afec\u0163iunea demielinizant\u0103 (modific\u0103ri FO, PEV, diplopie, ENG, RMN, CT, ImG \u00een s\u00e2nge \u015fi LCR)<\/p>\n<\/td>\n

\n

\u00cen formele clinice cu evolu\u0163ie progresiv\u0103 sau cu pusee acute frecvente:<\/p>\n

tulbur\u0103ri accentuate de mers, mers dificil, uneori cu sprijin unilateral;<\/p>\n

tulbur\u0103ri de echilibru;<\/p>\n

tulbur\u0103ri de coordonare;<\/p>\n

tulbur\u0103ri de manipula\u0163ie; sindromul piramidal tip paretic;<\/p>\n

cerebelo-vestibular; tulbur\u0103ri vizuale (diplopie, modific\u0103ri CV);<\/p>\n

tulbur\u0103ri de sensibilitate.<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie continu\u0103 care conduc la pierderea autonomiei locomotorii, f\u0103c\u00e2nd dependent\u0103 persoana de o alt\u0103 persoan\u0103 (par\u0163ial sau total), datorit\u0103:<\/p>\n

a. sindromului piramidal variat:<\/p>\n

– hemiplegie dr\/stg,<\/p>\n

– paraplegie-paraparez\u0103 accentuat\u0103,<\/p>\n

– tetraparez\u0103 – tetraplegie;<\/p>\n

b. sindromului vestibulo-cerebelos cu tulbur\u0103ri de static\u0103 \u015fi echilibru grave.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Examen neurologic complet cu precizarea formei de evolu\u0163ie \u015fi a sindroamelor afectate, respectiv sindromul pur sau combinate.<\/p>\n

NB. Diagnosticul pozitiv se sus\u0163ine pe:<\/p>\n

– simptome \u015fi tulbur\u0103ri tranzitorii ca: oftalmopareze, deficite piramidale sau de sensibilitate, sindroame medulare acute, afectarea altor nervi cranieni, combina\u0163ii de semne subiective \u015fi obiective;<\/p>\n

– diagnosticul s\u0103 cuprind\u0103 forma clinic\u0103 de evolu\u0163ie \u015fi sindroamele respective (combinate sau pure).<\/p>\n

Forme clinice:<\/p>\n

– forme cu rec\u0103deri \u015fi remisiuni,<\/p>\n

– forma primar generalizat\u0103,<\/p>\n

– forma secundar progresiv\u0103.<\/p>\n

Sindroame:<\/p>\n

Sindromul motor:<\/p>\n

– paraparetic (paraplegic) spastic,<\/p>\n

– hemiparetic (hemiplegic) spastic,<\/p>\n

– monoparetic sau tetraparetic (tetraplegic) spastic.<\/p>\n

Sindromul ataxic:<\/p>\n

– ataxie prin tulbur\u0103ri cerebeloase;<\/p>\n

– ataxie prin tulbur\u0103ri vestibulare;<\/p>\n

– ataxie prin tulbur\u0103ri de sensibilitate profund\u0103.<\/p>\n

Semne oculare caracteristice:<\/p>\n

– oftalmopareze;<\/p>\n

– tulbur\u0103ri de acuitate vizual\u0103 \u015fi c\u00e2mp vizual;<\/p>\n

– modific\u0103ri FO: decolorare papilar\u0103 global\u0103 sau numai temporal\u0103 (mai frecvent).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i cu program normal \u00een locuri de munc\u0103 care nu impun deplas\u0103ri posturale prelungite sau o gestualitate rapid\u0103 \u015fi cu precizie.<\/p>\n<\/td>\n

\n

Asigurarea unui loc de munc\u0103 accesibil \u00een pozi\u0163ie dominant \u015fez\u00e2nd, f\u0103r\u0103 suprasolicitare fizic\u0103 \u015fi ritm impus.<\/p>\n

Monitorizarea medical\u0103 pentru prevenirea agrav\u0103rii deficitului motor, vestibular \u015fi cerebelos.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i cu program normal sau redus, cu solicit\u0103ri mici sau medii, f\u0103r\u0103 ritm impus, care nu solicit\u0103 mi\u015fc\u0103ri de precizie \u015fi rapide din partea membrelor superioare \u015fi inferioare, \u00eentr-un microclimat de confort organic.<\/p>\n<\/td>\n

\n

Participare cu condi\u0163ia asigur\u0103rii unor locuri de munc\u0103 f\u0103r\u0103 solicit\u0103ri fizice mari, deplas\u0103ri posturale prelungite \u015fi gestualitate rapid\u0103 \u015fi de precizie;<\/p>\n

Monitorizare permanent\u0103 pentru prelungirea duratei remisiunii \u015fi pentru prevenirea apari\u0163iei puseelor acute.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

\u00cen general, intensitatea tulbur\u0103rilor func\u0163ionale limiteaz\u0103 prestarea oric\u0103rei activit\u0103\u0163i profesionale organizate. Pot, eventual, efectua activit\u0103\u0163i de colaborare \u00een ritm liber, cu efect psihoterapeutic; Este conservat\u0103 capacitatea de auto\u00eengrijire.<\/p>\n<\/td>\n

\n

Pentru persoanele cu preg\u0103tire superioar\u0103: sprijin pentru efectuarea unor activit\u0103\u0163i de colaborare \u00een func\u0163ie de posibilit\u0103\u0163ile psiho-fizice \u015fi de suportul familial;<\/p>\n

Sprijin pentru ob\u0163inerea mijloacelor de deplasare (baston, c\u00e2rje, scaun rulant s.a.), par\u0163ial pentru activit\u0103\u0163ile de auto\u00eengrijire \u015fi autogospod\u0103rire \u015fi pentru monitorizarea medico-social\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Datorit\u0103 intensit\u0103\u0163ii tulbur\u0103rilor de postur\u0103, de mers, gestualitate sau\/\u015fi de vedere, nu pot presta nici o activitate; Capacitatea de autoservire par\u0163ial\/total afectata;<\/p>\n

Capacitatea de mobilizare: de la mers cu sprijin bilateral prin for\u0163e proprii, p\u00e2n\u0103 la imobilizare;<\/p>\n

Limitarea gestualit\u0103\u0163ii p\u00e2n\u0103 la imposibilitatea execut\u0103rii unor mi\u015fc\u0103ri cu membrul respectiv;<\/p>\n

Afectarea vederii p\u00e2n\u0103 la cecitate relativ\u0103 \u015fi absolut\u0103.<\/p>\n<\/td>\n

\n

Necesit\u0103 asistent personal.<\/p>\n

Asigurarea de mijloace de mobilizare (cadru, fotoliu rulant, c\u0103rucior) pentru deplasare \u00een cadrul locuin\u0163ei;<\/p>\n

Dispensarizarea medical\u0103 (la domiciliu sau, c\u00e2nd este necesar, la serviciul de specialitate).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

IV.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR MU\u015eCHILOR*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

1.Neuromiopatii: afectarea unit\u0103\u0163ii motorii (a fibrei musculare striate), a pl\u0103cii neuro-musculare, nervului motor \u015fi nervului motor spinal – cu amiotrofii \u015fi determinare genetic\u0103:<\/p>\n

a)DMP:<\/p>\n

– Forma sever\u0103 (Duchenne,)<\/p>\n

– Forma benign\u0103 (Becker);<\/p>\n

b)Fenotipul Duchenne – forma centurilor;<\/p>\n

c)DMP forma:<\/p>\n

– Facio-scapulo-humeral\u0103,<\/p>\n

– Distal\u0103,<\/p>\n

– Oculo-faringian\u0103.<\/p>\n

2.Miotonii (determinate genetic) – este implicat un deficit de membran\u0103 celular\u0103:<\/p>\n

a)miotonia congenital\u0103 (Thompson),<\/p>\n

b)distrofia miotonic\u0103 (Steinert).<\/p>\n

3.Polimiozita primitiv\u0103 (cu leziuni musculare de tip inflamator)<\/p>\n

4.Miastenia (boala sinapsei neuro-musculare)<\/p>\n

5.Boli degenerative \u015fi heredodegenerative ale SNC (boli genetice cu aspect anatomo-patologic de tip degenerativ):<\/p>\n

a)amiotrofia neuronal\u0103 Charcot – Marie Tooth,<\/p>\n

b)scleroza lateral\u0103 amiotrofic\u0103 (SLA),<\/p>\n

c)eredoataxia spinocerebeloas\u0103 Friedreich,<\/p>\n

d)heredo-ataxia cerebeloas\u0103 Pierre Marie.<\/p>\n

6.Anomalii \u015fi malforma\u0163ii musculare congenitale, dac\u0103 \u00eempiedic\u0103 statica \u015fi locomo\u0163ia (de ex: hipertrofii, redori, refrac\u0163ii musculare mutilante).<\/p>\n

1.<\/strong>Evaluare grad de handicap \u00een distrofia muscular\u0103 progresiv\u0103 (DMP) \u015fi formele ei<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Examen neurologic:<\/p>\n

– deficit motor \u00een func\u0163ie de forma clinico-genetic\u0103, indiferent dac\u0103 debutul este distal sau proximal, afectarea grupelor musculare se generalizeaz\u0103;<\/p>\n

Deficitul motor are ca expresie:<\/p>\n

– amiotrofii progresive-simetrice;<\/p>\n

– retrac\u0163ii tendinoase;<\/p>\n

– ROT vii.<\/p>\n

Paraclinic:<\/p>\n

– cre\u015fterea activit\u0103\u0163ii unor enzime glicolitice (de ex: LDH);<\/p>\n

– biopsia muscular\u0103 este sugestiv\u0103, eviden\u0163iaz\u0103 modific\u0103ri de tip miogen;<\/p>\n

– EMG:<\/p>\n

– absen\u0163a activit\u0103\u0163ii bioelectrice spontane,<\/p>\n

– diminuarea amplitudinii maxime a traseelor;<\/p>\n

– reducerea duratei medii a poten\u0163ialelor.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Deficit motor frust.<\/p>\n

Amiotrofii simetrice distal \u015fi proximal nesemnificative.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Deplasarea cu dificultate prin sc\u0103derea performan\u0163ei de ortostatism \u015fi mers prelungit \u015fi prin tulbur\u0103ri de precizie \u015fi vitez\u0103 a mi\u015fc\u0103rilor.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deplasare cu mare dificultate prin for\u0163a proprie, nesprijinit \u015fi cu sprijin.<\/p>\n

Imposibilitatea efectu\u0103rii aproape a oric\u0103rei gestualit\u0103\u0163i profesionale.<\/p>\n

Dificult\u0103\u0163i de respira\u0163ie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Persoana nedeplasabil\u0103 prin for\u0163a proprie.<\/p>\n

Tulbur\u0103ri de gestualitate bilateral.<\/p>\n

Pierderea capacit\u0103\u0163ii de autoservire.<\/p>\n

Tulbur\u0103ri mari de degluti\u0163ie \u015fi respira\u0163ie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.<\/strong>Evaluare grad de handicap \u00een miotonii*<\/p>\n

* Sunt caracterizate printr-o lentoare a relax\u0103rii musculare dup\u0103 contrac\u0163ie voluntar\u0103, fenomenul diminu\u00e2nd progresiv dup\u0103 repetarea contrac\u0163iei voluntare (fenomen de \u00eenc\u0103lzire).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

\u00cen miotonia Thompson<\/p>\n

Examen neurologic:<\/p>\n

– distribu\u0163ia fenomenului mitotonic la flexorii degetelor, mu\u015fchii policelui, a musculaturii orbiculare, pleoape \u015fi pe parcursul evolu\u0163iei – hipertrofii musculare difuze la toate grupele musculare, cu predominan\u0163\u0103 la membrele inferioare (aspect halterofil).<\/p>\n

Examen paraclinic:<\/p>\n

– EMG: cre\u015fterea progresiv\u0103 a amplitudinii poten\u0163ialelor cu o frecvent\u0103 de 40\/50 cicli\/sec (criteriul patognomonic = fenomen de \u00eenc\u0103lzire)<\/p>\n

\u00cen distrofia miotonic\u0103 Steinert<\/p>\n

Examen neurologic:<\/p>\n

– amiotrofii musculare distale la membrele superioare \u015fi inferioare;<\/p>\n

– mu\u015fchii fonatori, cu modificarea vocii;<\/p>\n

– mu\u015fchiului cardiac;<\/p>\n

– atrofie gonadic\u0103.<\/p>\n

Examene paraclinice:<\/p>\n

– microscopia electronic\u0103 eviden\u0163iaz\u0103 afectarea arhitecturii miofibrilelor, care apar \u015fterse;<\/p>\n

– microscopia optic\u0103 eviden\u0163iaz\u0103 alternan\u0163a de fibre musculare atrofiate cu fibre hipertrofiate, dezorganizarea miofibrilelor;<\/p>\n

EMG – desc\u0103rc\u0103ri spontane repetitive, \u00een salve, asociate cu modific\u0103ri ale unit\u0103\u0163ii motorii de tip miopatic;<\/p>\n

Enzimograma seric\u0103 (LDH, FCK, TGO, TGP sunt sc\u0103zute sau normale).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

\u00cen formele u\u015foare cu manifest\u0103ri fruste care nu afecteaz\u0103 capacitatea fizic\u0103 de presta\u0163ie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Sc\u0103derea for\u0163ei musculare distale la membrele superioare;<\/p>\n

Oboseal\u0103 precoce;<\/p>\n

Sc\u0103derea for\u0163ei \u015fi vitezei de executare a mi\u015fc\u0103rilor;<\/p>\n

Sc\u0103derea capacit\u0103\u0163ii fizice de presta\u0163ie la efort, manipularea de greut\u0103\u0163i.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Deplasare cu dificultate;<\/p>\n

Tulbur\u0103ri de manipula\u0163ie \u015fi gestualitate bilateral;<\/p>\n

Tulbur\u0103ri de vedere \u015fi de vorbire.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen formele clinice cu evolu\u0163ie \u00eendelungat\u0103 care conduc la deplasarea dificil\u0103 sau la imobilizare datorit\u0103 atrofiilor musculare marcate, cu tulbur\u0103ri respiratorii, tulbur\u0103ri de degluti\u0163ie, fona\u0163ie, alimenta\u0163ie.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3.<\/strong>Evaluare grad de handicap \u00een polimiozit\u0103 primitiv\u0103*<\/p>\n

* Se caracterizeaz\u0103 printr-o simptomatologie dureroas\u0103 cu traseu EMG polimorf \u015fi leziuni musculare de tip inflamator.<\/p>\n

Sunt delimitate trei tipuri de polimiozit\u0103:<\/p>\n

a)Polimiozita primitiv\u0103 incomplet\u0103,<\/p>\n

b)Polimiozita din colagenoze – trebuie luate \u00een considerare criteriile stabilite pentru afec\u0163iunile respective,<\/p>\n

c)Polimiozita paraneoplazic\u0103 – trebuie luate \u00een considerare criteriile stabilite pentru afec\u0163iunile respective.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

EMG = caracterizat\u0103 printr-un traseu const\u00e2nd din activitate bioelectric\u0103 spontan\u0103 reprezentat\u0103 de poten\u0163iale de fibrila\u0163ie, poten\u0163iale polifazice care apar la contrac\u0163ii voluntare, activitate repetitiv\u0103 cu frecven\u0163\u0103 rapid\u0103, evocate de stimularea mecanic\u0103 a mu\u015fchilor.<\/p>\n

AP: aspect histologic greu de diferen\u0163iat de cel al distrofiilor musculare.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Criterii de \u00eencadrare \u00een grad de handicap asem\u0103n\u0103toare cu cele din distrofia muscular\u0103 progresiv\u0103, cu precizarea c\u0103 evolu\u0163ia este ondulant\u0103 cu agrav\u0103ri \u015fi remisiuni spontane \u015fi terapeutice<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4.<\/strong>Evaluare grad de handicap \u00een miastenie*<\/p>\n

* Este o boal\u0103 a sinapsei neuromusculare care se caracterizeaz\u0103 prin oboseal\u0103 excesiv\u0103 \u015fi defect al musculaturii striate ce apare la efort \u015fi se recupereaz\u0103, par\u0163ial sau total \u00een repaos \u015fi sub ac\u0163iunea unor substan\u0163e anticolinesterazice.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Clinic:<\/p>\n

– deficitul motor miastenic se produce prin relaxarea progresiv\u0103 a mu\u015fchiului care face efortul \u015fi prin diminuarea progresiv\u0103 a for\u0163ei, iar repaosul reface for\u0163a muscular\u0103;<\/p>\n

– o caracteristic\u0103 a fenomenului miastenic = deficitul miastenic este mai accentuat \u00een a doua parte a zilei;<\/p>\n

– ROT prezente sau u\u015for diminuate.<\/p>\n

Paraclinic:<\/p>\n

– proba de efort, care caracterizeaz\u0103 sau eviden\u0163iaz\u0103 deficitul motor;<\/p>\n

– testul cu miostin sau tensilon amelioreaz\u0103 deficitul dar de scurt\u0103 durat\u0103;<\/p>\n

– EMG: cu stimularea nervului cubital \u015fi culegerea poten\u0163ialului evocat din eminen\u0163a hipotenar\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

NB. La \u00eencadrarea \u00een grad de handicap trebuie s\u0103 se \u0163in\u0103 seama de intensitatea deficitului miastenic, care se poate manifesta prin:<\/p>\n

1. tulbur\u0103ri oculare (strabism, diplopie, ptoza palpebral\u0103 \u015fi chiar imposibilitatea convergen\u0163ei);<\/p>\n

2. tulbur\u0103ri de fona\u0163ie (disfonie, nazonare, dizartrie), care apar sau se accentueaz\u0103 la efort;<\/p>\n

3. tulbur\u0103ri de degluti\u0163ie, la \u00eenceput pentru solide, apoi lichide \u015fi \u00een cazuri grave pentru saliv\u0103;<\/p>\n

4. tulbur\u0103ri de mastica\u0163ie: apar mai mult sau mai pu\u0163in precoce, pot merge p\u00e2n\u0103 la deficit total \u015fi se pot asocia cu c\u0103derea mandibulei;<\/p>\n

5. atingerea musculaturii faciale, deformarea mimicii (facies-ul miastenic caracteristic);<\/p>\n

6. afectarea musculaturii cefei, trunchiului \u015fi membrelor poate s\u0103 produc\u0103:<\/p>\n

– c\u0103derea capului – necesit\u0103 men\u0163inerea b\u0103rbiei cu m\u00e2na,<\/p>\n

– trecerea din clinostatism la ortostatism, poate fi imposibil\u0103 sau se execut\u0103 cu dificultate (cu efort mare),<\/p>\n

7. interesarea membrelor inferioare se remarc\u0103 ini\u0163ial la urcatul \u015fi cobor\u00e2tul sc\u0103rilor, iar ulterior \u015fi la mersul pe nivel plat,<\/p>\n

8. tulbur\u0103ri respiratorii: exprimate prin dispnee, sunt obiectivate de reducerea capacit\u0103\u0163ii vitale.<\/p>\n

Deficitul miastenic, indiferent de manifestare, se poate ameliora la tratamentul medicamentos corespunz\u0103tor.<\/p>\n

Gradul de handicap se evalueaz\u0103 \u00een func\u0163ie de intensitatea deficien\u0163elor func\u0163ionale, dup\u0103 criteriile prezentate pentru afectarea func\u0163iilor respective, reversibilitatea \u015fi rezisten\u0163a la tratamentul medicamentos specific.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

5.<\/strong>Evaluare grad de handicap \u00een afec\u0163iunile degenerative \u015fi heredo – degenerative ale SNC<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

a) Amiotrofia neuronal\u0103 Charcot – Marie Tooth:<\/p>\n

– atrofii musculare simetrice distale:<\/p>\n

– la membrul inferior aspect de picior de cocos;<\/p>\n

– la membrul superior 1\/3 inferioar\u0103 antebra\u0163 – aspect de atrofii \u00een m\u0103nu\u015f\u0103<\/p>\n

– tulbur\u0103ri de sensibilitate de tip polinevritic;<\/p>\n

– tulbur\u0103ri vegetative – hipersudora\u0163ie;<\/p>\n

– tulbur\u0103ri endocrine (insuficien\u0163\u0103 gonadic\u0103);<\/p>\n

– examen bioptic: atrofii musculare de tip neuronal altern\u00e2nd cu zone hipertrofice.<\/p>\n

b) Scleroz\u0103 lateral\u0103 amiotrofic\u0103 (SLA):<\/p>\n

– amiotrofii distale, simetrice, progresive;<\/p>\n

– semne piramidale (spasticitate osteo-tendinoas\u0103, Babinschi prezent);<\/p>\n

– fenomene bulbare (tulbur\u0103ri de fona\u0163ie, de degluti\u0163ie, atrofii ale limbii, atrofii simetrice ale fe\u0163ei);<\/p>\n

– EMG: aspect = denervare;<\/p>\n

– microscopie electronic\u0103: \u00eentreru\/pperi la nivelul miofibrilelor, \u015ftergerea arhitecturii, depozit de glicogen;<\/p>\n

– microscopia optic\u0103: depozite de lipofuscin\u0103.<\/p>\n

c) Eredoataxia spinocerebeloas\u0103 Freidreich:<\/p>\n

– ataxie cerebeloas\u0103 (mers ebrios, cu baz\u0103 de sus\u0163inere l\u0103rgit\u0103,dizartrie,vorbire lent\u0103, ROT abolite precoce); – amiotrofii distale (aspect picior de cocos sau picior scobit);<\/p>\n

– EMG aspect de denerevare;<\/p>\n

– biopsie: aspect de degenerescent\u0103 axonal\u0103<\/p>\n

d) Eredoataxia cerebeloas\u0103 Pierre Marie: asem\u0103n\u0103tor eredoataxiei Freidreich, cu semne piramidale mai evidente \u015fi tulbur\u0103ri de sensibilitate profund\u0103 mai reduse, ROT vii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Sc\u0103derea u\u015foar\u0103 a performan\u0163elor de ortostatism \u015fi mers prelungit, \u00een precizia \u015fi viteza mi\u015fc\u0103rilor (realizarea gestualit\u0103\u0163ii).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Mobilizare cu greutate;<\/p>\n

Sc\u0103derea performan\u0163elor de ortostatism \u015fi mers prelungit;<\/p>\n

Scade precizia \u015fi viteza mi\u015fc\u0103rilor (afectarea medie a manipula\u0163iei \u015fi gestualit\u0103\u0163ii).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Persoana se deplaseaz\u0103 cu mare dificultate prin for\u0163a proprie, nesprijinit \u015fi cu sprijin;<\/p>\n

Nu poate efectua eficient gesturi profesionale, cele cotidiene sunt p\u0103strate;<\/p>\n

Dificult\u0103\u0163i de respira\u0163ie.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u00cen formele cu evolu\u0163ie \u00eendelungat\u0103 care duc la:<\/p>\n

deplasarea dificil\u0103 sau la imobilizare datorit\u0103 atrofiilor musculare sau\/\u015fi la<\/p>\n

tulbur\u0103ri marcate de respira\u0163ie,<\/p>\n

tulbur\u0103ri marcate de degluti\u0163ie,<\/p>\n

tulbur\u0103ri marcate de alimenta\u0163ie,<\/p>\n

imposibilitatea realiz\u0103rii activit\u0103\u0163ilor de auto\u00eengrijire \u015fi autogospod\u0103rire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

6.<\/strong>Evaluare grad de handicap \u00een malforma\u0163ii musculare*<\/p>\n

* Se refer\u0103 la persoane cu anomalii \u015fi malforma\u0163ii congenitale sau contractate precoce (copil\u0103rie – adolescen\u0163\u0103), de ex: hipertrofii, redori, refrac\u0163ii musculare mutilante, care \u00eempiedic\u0103 statica \u015fi locomo\u0163ia.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

Teste biometrice \u015fi musculare;<\/p>\n

Dinamometrie pentru aprecierea for\u0163ei musculare – \u00een func\u0163ie de localizare \u015fi tipul de sechel\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

\u00cencadrarea \u00een grad de handicap se realizeaz\u0103 \u00een func\u0163ie de limitarea sau pierderea capacit\u0103\u0163ii de realizare a staticii, mobilit\u0103\u0163ii sau\/\u015fi gestualit\u0103\u0163ii. Evaluare \u00een conformitate cu criteriile stabilite pentru persoanele cu miopatii.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu evitarea celor care necesit\u0103 gestualitate cu vitez\u0103 \u015fi precizie \u015fi deplas\u0103ri posturale prelungite.<\/p>\n<\/td>\n

\n

Sprijin pentru asigurarea unui loc de munc\u0103 f\u0103r\u0103 efort fizic mare, deplas\u0103ri posturale prelungite sau, eventual, pentru schimbarea locului de munc\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu evitarea celor care necesit\u0103 mi\u015fc\u0103ri cu vitez\u0103 \u015fi precizie \u015fi deplas\u0103ri posturale prelungite. Sunt contraindicate activit\u0103\u0163ile care impun fine\u0163e, repere mici, ritm impus.<\/p>\n<\/td>\n

\n

Sprijin pentru asigurarea unui loc de munc\u0103 f\u0103r\u0103 efort fizic mare, deplas\u0103ri posturale prelungite sau, eventual, pentru schimbarea locului de munc\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i cu efort fizic ne\u00eensemnat, \u00een postur\u0103 predominant \u015fez\u00e2nd, care nu necesit\u0103 fine\u0163e, vitez\u0103, complexitate \u015fi alternan\u0163\u0103 gestual\u0103. De exemplu: munci de birou pentru cei cu preg\u0103tire superioara sau medie.<\/p>\n<\/td>\n

\n

Participare \u00een cazul asigur\u0103rii unui loc de munc\u0103 accesibil, f\u0103r\u0103 efort fizic de intensitate mare \u015fi medie, ortostatism prelungit, deplas\u0103ri posturale, care s\u0103 necesite suprasolicitare gestual\u0103.<\/p>\n

S\u0103 fie scutite de eforturi fizice mari. Pentru aceasta s\u0103 se utilizeze sisteme mecanice de manipulare a greut\u0103\u0163ilor, s\u0103 se monteze sisteme de sus\u0163inere a m\u00e2inii pentru a evita oboseala muscular\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Au pierdut\u0103 capacitatea de autoservire, autogospod\u0103rire \u015fi auto\u00eengrijire.<\/p>\n<\/td>\n

\n

Necesit\u0103 asistent personal.<\/p>\n

Sprijin pentru asigurarea unor mijloace de deplasare (baston, cadru, fotoliu rulant, c\u0103rucior).<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

V.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR DE COORDONARE*<\/u><\/p>\n

* Se refer\u0103 la:<\/p>\n

a)Sindroamele extrapiramidale, de cauz\u0103 divers\u0103, postencefalitice, vasculare, medicamentoase, toxice, tumorale;<\/p>\n

b)Boala Parkinson (paralizie agitat\u0103);<\/p>\n

c)Coreea cronica Huntington (sindromul de neostriat-putamino-caudat), care produce sindromul distono-diskinetic, tulbur\u0103ri locomotorii \u015fi gestuale, ce \u00eempiedic\u0103 activitatea normal\u0103.<\/p>\n

Boal\u0103 ereditar\u0103, cu debut de regul\u0103 la 30-35 de ani.<\/p>\n

Tulbur\u0103ri func\u0163ionale asem\u0103n\u0103toare sindromului extrapiramidal, bolii Parkinson, cu deosebirea c\u0103 mi\u015fc\u0103rile involuntare sunt mai ample \u015fi tulbur\u0103rile psihice evolueaz\u0103 spre demen\u0163\u0103 lent progresiv\u0103;<\/p>\n

d)Boala Wilson – degenerescent\u0103 hepato-lenticular\u0103 (sindromul de panstriat cu ataxie, coreeo-atetoza cu afectarea posturii \u015fi gestualit\u0103\u0163ii).<\/p>\n

Afec\u0163iune metabolic\u0103 cu determinare genetic\u0103, caracterizat\u0103 prin acumularea de cupru \u00een SNC, ficat, cornee, rinichi, cu doua entit\u0103\u0163i:<\/p>\n

– Boala Wilson – debut la 7-15 ani, dominat\u0103 de rigiditate extrapiramidal\u0103, facies hipomimic, bradikinezie, puerilism, degradare involutiv\u0103 progresiv\u0103.<\/p>\n

– Boala Westphall – Strumpell – debut la 25-40 de ani, tablou clinic dominat de tremur\u0103tur\u0103 ce declan\u015feaz\u0103 spasme \u00een musculatur\u0103 opozi\u0163ional\u0103, de o violen\u0163\u0103 mare, degradare psihic\u0103, modific\u0103ri biochimice (cupremia poate fi sc\u0103zut\u0103).<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI **<\/p>\n<\/td>\n

\n

Examen neurologic: tablou dominat de trei semne cardinale:<\/p>\n

1. tremorul (ritm lent, apare \u00een repaus, uneori \u00een men\u0163inerea unei atitudini – tremur postural).<\/p>\n

Aspect caracteristic la membrele superioare – „num\u0103rarea banilor”, „r\u0103sucirea \u0163ig\u0103rilor”, iar la membrele inferioare – „pedalare”, „b\u0103tut tactul”.<\/p>\n

2. rigiditate – varianta particular\u0103 de hipertonie -, intereseaz\u0103 toate grupele musculare, predomin\u00e2nd la r\u0103d\u0103cina membrelor – eviden\u0163iat\u0103 prin fenomenul de roat\u0103 din\u0163at\u0103;<\/p>\n

3. bradi sau akinezie (apare imobil, cu activitate gestual\u0103 s\u0103rac\u0103). Eviden\u0163iat\u0103 prin proba marionetelor, b\u0103tutul tactului, pensa digital\u0103 cu fiecare deget.<\/p>\n

Aspectul caracteristic: facies fijat, imobil, atitudinea caracteristic\u0103 a capului \u015fi trunchiului (\u00eenclinate), mers cu pa\u015fi mici, tulbur\u0103ri de vorbire.<\/p>\n

Examen obiectiv: ROT vii, tulbur\u0103ri de motilitate ocular\u0103, tulbur\u0103ri vegetative (sialoree, hipercrinie), tulbur\u0103ri psihice.<\/p>\n

Examene paraclinice:<\/p>\n

PEG, CT = atrofie cortical\u0103 cu localizare \u00een general frontal\u0103 \u015fi, uneori, hidrocefalie;<\/p>\n

EEG = modific\u0103ri difuze exprimate prin activarea undei Theta, predomin\u00e2nd fronto-temporal;<\/p>\n

EMG: deceleaz\u0103 caracteristicile fiziologice ale tremur\u0103turii (desc\u0103rc\u0103ri ritmice de 4-7 cicli\/sec); Determin\u0103ri biochimice (dozarea dopaminei \u00een LCR \u015fi urin\u0103 sau\/\u015fi sanguin).<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Semne pu\u0163in caracteristice, tulbur\u0103ri vegetative, forme cu tremor cu caracter localizat la membrele superioare (hemisindrom Parkinson), hipertonie discret\u0103. Semnul Noica \u015fi tremur discret, eviden\u0163iat prin EMG.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Simptomatologie subiectiv\u0103 \u015fi modific\u0103ri obiective caracteristice. Sunt de intensitate medie \u015fi tind s\u0103 devin\u0103 permanente, influen\u0163ate par\u0163ial de tratament.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Formele la care predomin\u0103 tremorul sau cele akineto-hipertonice, la care simptomatologia este permanent\u0103, influen\u0163at\u0103 par\u0163ial de terapie, \u00eenso\u0163ite de tulbur\u0103ri de locomo\u0163ie, static\u0103 \u015fi mers, de tulbur\u0103ri de manipula\u0163ie, degluti\u0163ie, fona\u0163ie \u015fi vorbire.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

Formele clinice cu evolu\u0163ie \u00eendelungat\u0103 care pot duce la imobilizare. Pot fi \u00eenso\u0163ite de tulbur\u0103ri psihice \u015fi de vorbire (afazie expresiv\u0103).<\/p>\n

Deficien\u0163e de degluti\u0163ie \u015fi respira\u0163ie permanente, rezistente la diverse variante terapeutice.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

** Diferen\u0163e nesemnificative \u00een func\u0163ie de structura afectat\u0103 care a determinat tulburarea de coordonare.<\/p>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate profesional\u0103 cu limitarea celor care impun precizie, fine\u0163e \u00een mi\u015fc\u0103ri, suprasolicitare fizic\u0103 \u015fi psihic\u0103.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii, cu condi\u0163ia asigur\u0103rii \u00eencadr\u0103rii sau \u00eendrum\u0103rii profesionale spre un loc de munc\u0103 adecvat.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i profesionale care nu impun deplas\u0103ri prelungite, ortostatism \u00eendelungat, mi\u015fc\u0103ri (gesturi) de vitez\u0103 \u015fi precizie.<\/p>\n

– Sunt indicate activit\u0103\u0163ile statice, cu solicit\u0103ri fizice reduse, \u00een condi\u0163ii de confort microambiental.<\/p>\n<\/td>\n

\n

– Este necesar s\u0103 li se asigure un sistem de fixare \u015fi ghidaj care s\u0103 le permit\u0103 executarea sarcinilor de munc\u0103.<\/p>\n

– Evitarea activit\u0103\u0163ilor de fine\u0163e, cu repere mici.<\/p>\n

– Asigurarea unui climat relaxant, neconflictual, \u00een cadrul colectivului de munc\u0103 \u015fi \u00een familie.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Sunt incapabili de prestarea oric\u0103ror activit\u0103\u0163i profesionale.<\/p>\n

– Autoservirea este par\u0163ial afectat\u0103.<\/p>\n

– Se pot deplasa cu mare dificultate prin for\u0163e proprii, nesprijinit sau cu sprijin unilateral.<\/p>\n<\/td>\n

\n

– Necesit\u0103 sprijin pentru ob\u0163inerea de mijloace de deplasare (baston, c\u00e2rje, scaun rulant);<\/p>\n

– Monitorizarea evolu\u0163iei tulbur\u0103rilor func\u0163ionale \u00een condi\u0163ii de tratament corect administrat \u015fi sus\u0163inut.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Pierderea capacit\u0103\u0163ii de autoservire \u015fi auto\u00eengrijire.<\/p>\n

– Nedeplasabili prin for\u0163e proprii – este mobilizat numai cu ajutorul altei persoane.<\/p>\n

– Tulbur\u0103rile de limbaj fac imposibil\u0103 stabilirea rela\u0163iilor cu mediul \u00eenconjur\u0103tor.<\/p>\n

– Tulbur\u0103rile de degluti\u0163ie \u015fi respira\u0163ie permanente, impun asistarea din partea altei persoane.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

VI.<\/strong>EVALUARE GRAD DE HANDICAP \u00ceN DISFUNC\u0162IILE ACTIVIT\u0102\u0162II CORTICALE*<\/u><\/p>\n

* Se refer\u0103 la epilepsie (malconvulsivant) cu debut precoce (copil\u0103rie-adolescen\u0163\u0103), indiferent de etiologie.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

– Anamneza;<\/p>\n

– EEG**;<\/p>\n

– CT cerebral (RMN);<\/p>\n

– Angiografie carotidian\u0103.<\/p>\n<\/td>\n

\n

Eviden\u0163iaz\u0103:<\/p>\n

– Disfunc\u0163ia activit\u0103\u0163ii corticale;<\/p>\n

– Procese expansive cerebrale;<\/p>\n

– Malforma\u0163ii vasculare cerebrale<\/p>\n<\/td>\n<\/tr>\n

\n

** Uneori EEG cu activare (numai \u00een centre specializate).<\/p>\n

\u00cen 10-20% din cazuri aspect EEG normal \u00een special \u00een faza intercritic\u0103.<\/p>\n

NB. 1. Numai prin corelarea datelor anamnestice, clinice \u015fi paraclinice se poate confirma sau infirma diagnosticul de epilepsie.<\/p>\n

2. Documentele medicale trebuie s\u0103 obiectiveze: existen\u0163a crizelor, aspectul lor, frecven\u0163a lor, confirmarea clinic\u0103 sau\/\u015fi EEG, evolu\u0163ia bolii \u00een sensul num\u0103rului de crize \u00eentr-un interval de timp dat (sub tratament), existen\u0163a tulbur\u0103rilor psihice asociate.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

Persoane cu crize par\u0163iale mai rar de una pe s\u0103pt\u0103m\u00e2n\u0103 sau o criza generalizat\u0103 mai rar de o dat\u0103 pe lun\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

Crize generalizate, convulsive sau nu, sub tratament adecvat, 1 – 2\/lun\u0103 generalizate, sau 1-2 crize par\u0163iale\/s\u0103pt\u0103m\u00e2n\u0103, sau\/\u015fi prezen\u0163a unor tulbur\u0103ri psihice.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

Crize generalizate cel pu\u0163in 2-3\/lun\u0103 sau<\/p>\n

Crize par\u0163iale 2-3\/s\u0103pt\u0103m\u00e2n\u0103 cu stare postcritic\u0103 prelungit\u0103, cu tratament anticonvulsivant sau\/\u015fi prezen\u0163a de tulbur\u0103ri psihice specifice.<\/p>\n<\/td>\n<\/tr>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

\u0162ine mai pu\u0163in de frecven\u0163a crizelor, aspectul lor, starea postcritic\u0103 \u015fi mai mult de frecven\u0163a episoadelor subintrante, dar \u00een special de prezen\u0163a unor tulbur\u0103ri psihice grave: psihoza epileptic\u0103, care pune \u00een pericol via\u0163a persoanei \u00een cauz\u0103 sau a anturajului s\u0103u.<\/p>\n

Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

ACTIVIT\u0102\u0162I – LIMIT\u0102RI<\/p>\n<\/td>\n

\n

PARTICIPARE – NECESIT\u0102\u0162I<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

– Orice activitate profesional\u0103 cu limitarea celor care se execut\u0103 la \u00een\u0103l\u0163ime, l\u00e2ng\u0103 ap\u0103, foc, mecanisme \u00een mi\u015fcare, curen\u0163i de \u00eenalta tensiune.<\/p>\n

– Contraindica\u0163ie pentru meseriile de conduc\u0103tor auto sau care \u0163in de siguran\u0163a circula\u0163iei.<\/p>\n<\/td>\n

\n

– \u00cen cazul activit\u0103\u0163ilor contraindicate se recomand\u0103 schimbarea locului de munc\u0103 \u015fi reconversia profesional\u0103.<\/p>\n

– Respectarea strict\u0103 a recomand\u0103rilor medicale \u015fi tratamentului medicamentos.<\/p>\n

– Monitorizare la serviciul de specialitate care \u00eel are \u00een eviden\u0163\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

– Evitarea activit\u0103\u0163ilor cu efort fizic mare, munc\u0103 \u00een ture, de noapte.<\/p>\n

– Este interzis s\u0103 lucreze<\/p>\n

– la \u00een\u0103l\u0163ime,<\/p>\n

– conduc\u0103tor auto,<\/p>\n

– \u00een siguran\u0163a circula\u0163iei,<\/p>\n

– \u00een contact cu surse de foc,<\/p>\n

– \u00een preajma utilajelor \u00een mi\u015fcare.<\/p>\n<\/td>\n

\n

– Asigurarea unui loc de munc\u0103 corespunz\u0103tor\/schimbarea locului de munc\u0103 sau orientarea tinerilor spre profesii accesibile.<\/p>\n

– Monitorizare pentru respectarea tratamentului medicamentos, a regimului de via\u0163\u0103, evitarea st\u0103rilor conflictuale, munca \u00een ture, munca de noapte, consumul de cafea, alcool, al\u0163i excitan\u0163i.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

– Pot presta munci statice cu solicitare fizic\u0103 \u015fi psihic\u0103 limitat\u0103 \u00een condi\u0163ii de confort organic.<\/p>\n<\/td>\n

\n

– Monitorizare medical\u0103 \u015fi socio-profesional\u0103 prin grija familiei \u015fi a colectivului de munc\u0103.<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n

\n

– Limitarea major\u0103 a capacit\u0103\u0163ii de auto\u00eengrijire \u015fi autogospod\u0103rire datorit\u0103 crizelor subintrante sau tulbur\u0103rilor psihice grave.<\/p>\n<\/td>\n

\n

– Necesit\u0103 asistent personal.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n

CAPITOLUL<\/strong>\u00a08:<\/strong>\u00a0FUNC\u0162IILE<\/strong>\u00a0PIELII<\/strong><\/p>\n

EVALUAREA GRADULUI DE HANDICAP \u00ceN AFECTAREA FUNC\u0162IILOR PIELII<\/u><\/p>\n

Afectarea func\u0163iei de protec\u0163ie \u015fi reparatorie a pielii*<\/p>\n

* Se refer\u0103 la:<\/p>\n

1.Dermatoze:<\/p>\n

a)\u00cen psoriazis (dermatoz\u0103 cu evolu\u0163ie cronic\u0103 \u015fi tendin\u0163\u0103 la recidive):<\/p>\n

– psoriazis pustulos<\/p>\n

– generalizat<\/p>\n

– palmo – plantar<\/p>\n

– psoriazis eritrodermic<\/p>\n

– psorizis artropatic<\/p>\n

b)Pemfigus – afec\u0163iune cutanat\u0103 autoimun\u0103, caracterizat\u0103 prin bule intradermice \u015fi eroziuni extinse;<\/p>\n

c)Ihtioza ereditar\u0103 caracterizat\u0103 prin acumularea excesiv\u0103 de scuame pe suprafa\u0163a pielii. Poate fi asociat\u0103 cu manifest\u0103ri de tip polinevritic, tulbur\u0103ri mentale. Poate fi \u00eent\u00e2lnit\u0103 \u015fi \u00een unele boli sistemice.<\/p>\n

d)Epidermoliza buloas\u0103 (simpl\u0103 sau distrofic\u0103):<\/p>\n

– \u00een formele esofagiene cu stenoze cicatriceale<\/p>\n

– \u00een formele retiniene cu dezlipire de retin\u0103<\/p>\n

2.Dermatomiozite:<\/p>\n

– \u00een formele cu scleroz\u0103 muscular\u0103 cronic\u0103 \u015fi difuz\u0103,<\/p>\n

– \u00een formele care determin\u0103 deforma\u0163ii ireductibile ale membrelor.<\/p>\n

3.Neurofibromatoza Recklinghausen:<\/p>\n

– Afec\u0163iune congenital\u0103 caracterizat\u0103 prin tumorete cutanate \u015fi noduli subcutana\u0163i localiza\u0163i pe traiectul nervilor periferici;<\/p>\n

– Se pot asocia cu afect\u0103ri cerebrale \u015fi viscerale.<\/p>\n

4.Tumori maligne ale pielii, de ex. melanomul.<\/p>\n

\u00a0<\/p>\n\n\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n\n\n\n
\n

AFEC\u0162IUNE<\/p>\n<\/td>\n

\n

PARAMETRI FUNC\u0162IONALI<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 U\u015eOAR\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 MEDIE<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 ACCENTUAT\u0102<\/p>\n<\/td>\n

\n

DEFICIEN\u0162\u0102 GRAV\u0102<\/p>\n<\/td>\n<\/tr>\n

\n

HANDICAP U\u015eOR<\/p>\n<\/td>\n

\n

HANDICAP MEDIU<\/p>\n<\/td>\n

\n

HANDICAP ACCENTUAT<\/p>\n<\/td>\n

\n

HANDICAP GRAV<\/p>\n<\/td>\n<\/tr>\n

\n

Dermatoze<\/p>\n<\/td>\n

\n

Psoriazis<\/p>\n<\/td>\n

\n

Se vor selecta \u00een func\u0163ie de manifest\u0103rile structurale:<\/p>\n

– Examen fizic am\u0103nun\u0163it;<\/p>\n

– Examen dermatologic;<\/p>\n

– Examen bioptic (\u00een cazul \u00een care sugereaz\u0103 malignitate);<\/p>\n

– Punc\u0163ie-biopsie;<\/p>\n

– Examen microscopic asupra produselor ob\u0163inute dup\u0103 r\u0103zuire;<\/p>\n

– Culturi-antibiogram\u0103;<\/p>\n

– Vizualizarea pielii \u00een camera \u00eentunecat\u0103 cu lamp\u0103 Wood;<\/p>\n

– Teste de imunofluorescen\u0163\u0103 (imunelectroforez\u0103);<\/p>\n

– Glicemie;<\/p>\n

Examen radiologic (\u00een cazul complica\u0163iilor articulare secundare).<\/p>\n<\/td>\n

\n

Psoriazis localizat, sensibil la tratament.<\/p>\n<\/td>\n

\n

Psoriazis cronic cu acutiz\u0103ri frecvente.<\/p>\n<\/td>\n

\n

Psoriazis generalizat sau artropatic neinfluen\u0163at de tratament.<\/p>\n<\/td>\n

\n

Formele maligne de psoriazis pustulos cu pusee subintrante, ca \u015fi \u00een cel artropatic, cu tulbur\u0103ri grave de gestualitate, locomo\u0163ie.<\/p>\n<\/td>\n<\/tr>\n

\n

Pemfigus<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

\u00cen formele cronice cu evolu\u0163ie prelungit\u0103.<\/p>\n<\/td>\n

\n

\u00cen formele cronice generalizate cu r\u0103spuns inconstant \u015fi invizibil la tratament, cu reac\u0163ii adverse \u015fi complica\u0163ii<\/p>\n<\/td>\n<\/tr>\n

\n

Ihtioza ereditar\u0103<\/p>\n<\/td>\n

\n

\u00cen formele cu hiperkeratoz\u0103 la plante sau\/\u015fi palme care limiteaz\u0103 ortostatismul sau\/\u015fi gestualitatea.<\/p>\n<\/td>\n

\n

\u00cen formele cu hiperkeratoz\u0103 generalizat\u0103, epidermolitice (eritrodermia ihtioziform\u0103 congenital\u0103 buloas\u0103) cu evolu\u0163ie \u00eendelungat\u0103, care necesit\u0103 tratament \u00eendelungat >= 1 an.<\/p>\n<\/td>\n<\/tr>\n

\n

Epidermoliza buloas\u0103<\/p>\n<\/td>\n

\n

– \u00cen formele esofagiene cu stricturi esofagiene;<\/p>\n

– \u00cen formele retiniene cu dezlipire de retin\u0103;<\/p>\n

Evaluare grad de handicap \u00een func\u0163ie de intensitatea tulbur\u0103rilor de nutri\u0163ie (deficit ponderal) \u015fi de afectarea func\u0163iilor acuit\u0103\u0163ii vizuale – vezi criterii de evaluare grad de handicap \u00een afectarea func\u0163iei vizuale.<\/p>\n<\/td>\n<\/tr>\n

\n

Dermatomiozit\u0103<\/p>\n<\/td>\n

\n

\u00cen formele incipiente<\/p>\n<\/td>\n

\n

\u00cen formele cu modific\u0103ri cutanate cu alter\u0103ri func\u0163ionale medii<\/p>\n<\/td>\n

\n

\u00cen formele cu alter\u0103ri avansate ale func\u0163iei motorii cu sclerodermie sistemic\u0103<\/p>\n<\/td>\n

\n

\u00cen formele cu tulbur\u0103ri mari de gestualitate, tulbur\u0103ri ventilatorii restrictive severe, tulbur\u0103ri digestive, de degluti\u0163ie<\/p>\n<\/td>\n<\/tr>\n

\n

Neurofibromatoz\u0103 Recklinghausen<\/p>\n<\/td>\n

\n

\u00cen formele cu afectare:<\/p>\n

– de nervi periferici,<\/p>\n

– cerebral\u0103,<\/p>\n

– visceral\u0103;<\/p>\n<\/td>\n

\n

Evaluare grad de handicap \u00een raport de intensitatea tulbur\u0103rilor func\u0163ionale neurologice, psihice, locomotorii, digestive \u015fi generate de afectarea func\u0163iei respective<\/p>\n<\/td>\n<\/tr>\n

\n

Tumori maligne ale pielii<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

\u00cen formele cu metastazare direct\u0103 la piele<\/p>\n<\/td>\n

\n

\u00cen formele cu metastazare la organe interne, inoperabile, cu pierderea capacit\u0103\u0163ii de autoservire \u015fi cu necesitatea de \u00eengrijire permanent\u0103<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/p>\n\n\n\n\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

DERMATOZE<\/p>\n<\/td>\n

\n

DERMATOMIOZIT\u0102<\/p>\n<\/td>\n

\n

NEUROFIBROMATOZ\u0102 RECKLINGHAUSEN<\/p>\n<\/td>\n

\n

TUMORI MALIGNE ALE PIELII<\/p>\n<\/td>\n<\/tr>\n

\n

Activit\u0103\u0163i – limit\u0103ri<\/p>\n<\/td>\n

\n

Participare – necesit\u0103\u0163i<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i – limit\u0103ri<\/p>\n<\/td>\n

\n

Participare – necesit\u0103\u0163i<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i – limit\u0103ri\/Participare – necesit\u0103\u0163i<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i – limit\u0103ri\/ Participare – necesit\u0103\u0163i<\/p>\n<\/td>\n<\/tr>\n

\n

U\u015eOR<\/p>\n<\/td>\n

\n

Orice activitate f\u0103r\u0103 limit\u0103ri.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii.<\/p>\n<\/td>\n

\n

Orice activitate f\u0103r\u0103 limit\u0103ri.<\/p>\n<\/td>\n

\n

Participare f\u0103r\u0103 restric\u0163ii.<\/p>\n<\/td>\n

\n

Prezentate la persoanele cu afect\u0103ri ale unor func\u0163ii neurologice, psihice, locomotorii \u015fi de Nutri\u0163ie<\/p>\n<\/td>\n

\n

\u00cen raport de structur\u0103, func\u0163iile afectate \u015fi intensitatea deficien\u0163ei sau deficien\u0163elor pe care le genereaz\u0103, pierderea capacit\u0103\u0163ii de autoservire \u015fi de auto\u00eengrijire<\/p>\n<\/td>\n<\/tr>\n

\n

MEDIU<\/p>\n<\/td>\n

\n

Orice activitate cu evitarea expunerii la soare, varia\u0163ii termice.<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii cu condi\u0163ia de a se asigura o \u00eembr\u0103c\u0103minte adecvat\u0103. Preocup are pentru auto\u00eengrijire \u015fi igien\u0103 personal\u0103.<\/p>\n<\/td>\n

\n

Orice activitate \u00een condi\u0163ii de confort organic.<\/p>\n<\/td>\n

\n

F\u0103r\u0103 restric\u0163ii cu asigurarea igienei personale.<\/p>\n<\/td>\n<\/tr>\n

\n

ACCENTUAT<\/p>\n<\/td>\n

\n

– Activit\u0103\u0163i \u00een condi\u0163ii de confort organic, evitarea mediului prea cald, umed, uscat, cu substan\u0163e iritante pentru piele.<\/p>\n

– Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103 sau psihic\u0103.<\/p>\n<\/td>\n

\n

Asigurarea unui mediu socio-familial \u015fi de igien\u0103 personal\u0103 care s\u0103 nu agraveze afectarea func\u0163iilor de protec\u0163ie \u015fi reparatorie ale pielii.<\/p>\n<\/td>\n

\n

Activit\u0103\u0163i f\u0103r\u0103 suprasolicitare fizic\u0103, gestual\u0103 +\/- postural\u0103 \u00een condi\u0163ii ambientale adecvate.<\/p>\n<\/td>\n

\n

M\u0103suri compensatorii sau adapt\u0103ri ale locului de munc\u0103 pentru reducerea efortului fizic, gestual, +\/- postural.<\/p>\n<\/td>\n<\/tr>\n

\n

GRAV<\/p>\n<\/td>\n

\n

– Limitarea major\u0103 a gestualit\u0103\u0163ii sau\/\u015fi autonomiei<\/p>\n

– Limitarea capacit\u0103\u0163ii de auto\u00eengrijire pentru majoritatea activit\u0103\u0163ilor curente \u00een func\u0163ie de forma clinic\u0103, tulbur\u0103ri func\u0163ionale predominante.<\/p>\n<\/td>\n

\n

– Sprijin pentru suplinirea capacit\u0103\u0163ii de auto\u00eengrijire pentru activit\u0103\u0163ile vie\u0163ii cotidiene.<\/p>\n

– Sprijin pentru limitarea autonomiei locomotorii prin dispozitive de mers, cadru, c\u00e2rje<\/p>\n<\/td>\n

\n

Dependent total sau aproape total pentru activit\u0103\u0163ile de baz\u0103 ale vie\u0163ii.<\/p>\n<\/td>\n

\n

Asisten\u0163\u0103 din partea altei persoane pentru \u00eengrijire \u015fi suplinirea pierderii capacit\u0103\u0163ii de autoservire.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Publicat \u00een Monitorul Oficial cu num\u0103rul 885 bis din data de 27 decembrie 2007<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"excerpt":{"rendered":"

\u00cen temeiul art. 84 alin. (5) din Legea nr.\u00a0448\/2006\u00a0privind protec\u0163ia \u015fi promovarea drepturilor persoanelor cu handicap, cu modific\u0103rile \u015fi complet\u0103rile ulterioare, av\u00e2nd \u00een vedere prevederile: – art. 14 din Hot\u0103r\u00e2rea Guvernului nr.\u00a0381\/2007\u00a0privind organizarea \u015fi func\u0163ionarea Ministerului Muncii, Familiei \u015fi Egalit\u0103\u0163ii de \u015eanse; – art. 7 alin. (4) din Hot\u0103r\u00e2rea Guvernului nr.\u00a0862\/2006\u00a0privind organizarea \u015fi func\u0163ionarea Ministerului […]<\/p>\n","protected":false},"author":1,"featured_media":106,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"cybocfi_hide_featured_image":"yes"},"categories":[2],"tags":[27,25,26,24,23],"yoast_head":"\nCriteriilor medico-psihosociale de \u00eencadrarea \u00een grad de handicap - info.dizabil.eu<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Criteriilor medico-psihosociale de \u00eencadrarea \u00een grad de handicap - info.dizabil.eu\" \/>\n<meta property=\"og:description\" content=\"\u00cen temeiul art. 84 alin. (5) din Legea nr.\u00a0448\/2006\u00a0privind protec\u0163ia \u015fi promovarea drepturilor persoanelor cu handicap, cu modific\u0103rile \u015fi complet\u0103rile ulterioare, av\u00e2nd \u00een vedere prevederile: – art. 14 din Hot\u0103r\u00e2rea Guvernului nr.\u00a0381\/2007\u00a0privind organizarea \u015fi func\u0163ionarea Ministerului Muncii, Familiei \u015fi Egalit\u0103\u0163ii de \u015eanse; – art. 7 alin. (4) din Hot\u0103r\u00e2rea Guvernului nr.\u00a0862\/2006\u00a0privind organizarea \u015fi func\u0163ionarea Ministerului […]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/\" \/>\n<meta property=\"og:site_name\" content=\"info.dizabil.eu\" \/>\n<meta property=\"article:published_time\" content=\"2019-12-23T08:34:04+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2019-12-23T08:40:58+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.dizabil.eu\/info\/wp-content\/uploads\/2019\/12\/grad-handicap.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"225\" \/>\n\t<meta property=\"og:image:height\" content=\"225\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Scris de\" \/>\n\t<meta name=\"twitter:data1\" content=\"dizabil.eu\" \/>\n\t<meta name=\"twitter:label2\" content=\"Timp estimat pentru citire\" \/>\n\t<meta name=\"twitter:data2\" content=\"258 de minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebSite\",\"@id\":\"https:\/\/www.dizabil.eu\/info\/#website\",\"url\":\"https:\/\/www.dizabil.eu\/info\/\",\"name\":\"info.dizabil.eu\",\"description\":\"site destinat persoanelor cu dizabilitati\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/www.dizabil.eu\/info\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"ro-RO\"},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/#webpage\",\"url\":\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/\",\"name\":\"Criteriilor medico-psihosociale de \u00eencadrarea \u00een grad de handicap - info.dizabil.eu\",\"isPartOf\":{\"@id\":\"https:\/\/www.dizabil.eu\/info\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/#primaryimage\"},\"datePublished\":\"2019-12-23T08:34:04+00:00\",\"dateModified\":\"2019-12-23T08:40:58+00:00\",\"author\":{\"@id\":\"https:\/\/www.dizabil.eu\/info\/#\/schema\/person\/45a43d786483fdbbf17f59603cdbbf53\"},\"breadcrumb\":{\"@id\":\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/#breadcrumb\"},\"inLanguage\":\"ro-RO\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Prima pagin\u0103\",\"item\":\"https:\/\/www.dizabil.eu\/info\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Criteriilor medico-psihosociale de \u00eencadrarea \u00een grad de handicap\"}]},{\"@type\":\"Person\",\"@id\":\"https:\/\/www.dizabil.eu\/info\/#\/schema\/person\/45a43d786483fdbbf17f59603cdbbf53\",\"name\":\"dizabil.eu\",\"image\":{\"@type\":\"ImageObject\",\"@id\":\"https:\/\/www.dizabil.eu\/info\/#personlogo\",\"inLanguage\":\"ro-RO\",\"url\":\"https:\/\/secure.gravatar.com\/avatar\/51be15a827648a4a30b866920625e032?s=96&d=mm&r=g\",\"contentUrl\":\"https:\/\/secure.gravatar.com\/avatar\/51be15a827648a4a30b866920625e032?s=96&d=mm&r=g\",\"caption\":\"dizabil.eu\"},\"url\":\"https:\/\/www.dizabil.eu\/info\/author\/vasy\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Criteriilor medico-psihosociale de \u00eencadrarea \u00een grad de handicap - info.dizabil.eu","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/www.dizabil.eu\/info\/content-criterii-pe-baza-carora-se-stabileste-incadrarea-in-grad-de-handicap\/","og_locale":"ro_RO","og_type":"article","og_title":"Criteriilor medico-psihosociale de \u00eencadrarea \u00een grad de handicap - info.dizabil.eu","og_description":"\u00cen temeiul art. 84 alin. 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