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Caso clinico HIV staff medico

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Gisy Karina Manuel Arrieta

on 4 October 2013

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Transcript of Caso clinico HIV staff medico

Published the treatise "Some thoughts concerning education" in 1693 in which he states that education must have a purpose.
Physician, Philosopher, Revolutionary
John Locke
1632 - 1704
Jean-Jacques Rousseau
1712 - 1778
Philosopher, writer, composer
Introduced the concept of teaching by example, questioned the role of power between teacher and student and stated that there must be a degree of friendship between educator and learner.
Immanuel Kant
1724 - 1804
Philosopher, educator, astronomer, scholar
Kant believed that knowledge is gained through experience including those that are sensory in nature. He was the first to conceptualize humanistic education.
Paulo Freire
1921 - 1997
Educator, revolutionary
Modernized the term popular education in his work on critical pedagogy and theories of education.
John Dewey
1859 - 1952
Philosopher, psychologist, educational reformer.
Dewey has often been referred to as the father of Progressive Education. Progressive Education emphases group work, hands-on learning, problem-solving, development of social skills, and commitment to life-long learning.
Born Francois-Marie Arouet, Voltaire believed in education for all men and that it should be based in reason and free of religion.
Philosopher, historian, writer.
Voltaire
1694 - May 1778
Also referred to as the Age of Reason
a time when intellectuals promoted science and intellect in opposition to superstition, intolerance and some abuses by church and state (www.wikipedia.com)
The Enlightenment
1620 - 1789
Myles Horton
1905 - 1990
Educator, social activist.
Horton founded the Highlander Folk School (now called Highlander Research and Education Center). Originally developed as an educational movement in labour and community organizing, it become well known for its involvement in civil and social rights. Horton centred his praxis on the idea that people can make their own decisions. Curriculum focused on problem-solving and communication and developed from where the learner centred themselves.
Karl Marx
1818 - 1883
Philosopher, economist, sociologist, historian, jounalist, revolutionary, and socialist.
Marx is credited as being the father of socialism and communism and for his struggle against class structures. Marx believed that education is always political and knowledge is gained through experience.
Check out more about the Highlander Education and Research Center at
http://highlandercenter.org/
Image retrieved from www.amazon.com
Image retreived from http://highlandercenter.org/media/timeline/
What is the role of the educator?
- Learners and educators treat each other as equals.
- Educators need to be trained in critical dialogue.
- They should not impose an agenda or abdicate responsibility for the actions of the group but rather guide and support them in their actions.
- They must be cognizant of power structures and strive for empowerment and emancipation of all participants regardless of race, religion, sex, or sexual orientation.
- Facilitators guide the participants in determining how everything regarding their learning will be structured including when to take breaks and for how long.
Wiggins (2011) when training educators in popular education praxis sets the following principles.
- "We should constantly seek input to improve our teaching.
- Education should be immediately applicable to our daily reality.
- We all learn more when everyone participates.
- Education should help people identify and solve problems.
- We need opportunities to see and reflect on reality.
- We learn more when we are having fun.
- We learn more when we experience something as reality.
- We all learn more when we are actively involved.
- We learn more when we are comfortable with our fellow-learners."
Dr. Liam Kane is a Senior Lecturer at the University of Glasgow on Life Long Learning and Popular Education
- It is a democratic process where self-directed learning takes place.
- It strives to address the needs of participants and develop critical understanding, self-confidence, and analytical skills and link them with social action.
Power and Pedagogy
Brock University
500 Glenridge Avenue
St. Catharines, ON
L2S 3A1
Image retrieved from www.culturenotebook.wordpress.com
Image retrieved from www.tn4me.org
Image retrieved from www.wikipedia.com
Image retrieved from www.tusconweekly.com
Image retrieved from www.nndb.com
Image retrieved from www.wikipedia.com
Image retrieved from www.uvm.edu
Image retrieved from http://vanderlanpedagogo-vanderlan.blogspot.ca/2011/05/paulo-freire-um-educador.html
"All our knowledge begins with the senses, proceeds then to the understanding, and ends with reason. There is nothing higher than reason."
~Immanuel Kant
"Reading furnishes the mind only with materials of knowledge; it is thinking that makes what we read ours."
~ John Locke
"Is there anyone so wise as to learn by the experience of others?"
~Voltaire
"Knowledge is power."
- Francis Bacon
1561 - 1626
"Teach your scholar to observe the phenomena of nature; you will soon rouse his curiosity, but if you would have it grow, do not be in too great a hurry to satisfy this curiosity. Put the problems before him and let him solve them himself. Let him know nothing because you have told him, but because he has learnt it for himself. Let him not be taught science, let him discover it. If ever you substitute authority for reason he will cease to reason; he will be a mere plaything of other people's thoughts."
~ Jean Jacques Rousseau
Quote from http://www.goodreads.com/author/quotes/7994.Jean_Jacques_Rousseau
"A schoolmaster is a productive labourer when, in addition to belabouring the heads of his scholars, he works like a horse to enrich the school proprietor. That the latter has laid out his capital in a teaching factory, instead of in a sausage factory does not alter the relation."
http://www.marxists.org/archive/marx/works/subject/quotes/index.htm
"Education is not preparation for life; education is life itself."
~ John Dewey
"Education is what happens to the other person, not what comes out of the mouth of the educator."
~ Myles Horton
Quote from http://livingbreathinggrowing.wordpress.com/2012/07/18/the-long-haul-myles-horton/
"To educate is essentially to form."
~ Paulo Freire
http://userwww.service.emory.edu/~rpuscas/
A sidetrack moment about the Highlander Education and Research Centre
STAFF MEDICO
CASO CLINICO HIV/SIDA Y TBC

DATOS PACIENTE

-Mujer
-50 años
-Ama de casa

SERVICIO DE URGENCIAS
-1er ingreso
AP:
-VIH (+) 2003, en tto. Con ARV- 2005
-TBC diseminada (tratada en el 2005-2012 por poca adherencia al tratamiento)
-CMV (2005)
-Candidiasis esofágica (desde 6/13)
-Hospitalizada hace 1 mes por gastroenteritis
-Fumadora
-Alérgica al trimetropim sulfametoxazol

Farmacologicos:
- Lamivudina 150mg 1 c/12 hrs
- Didanosina 250mg 1 c/dia
- Lopinavir/ Ritonavir 200/50mg 2 tab. c/12 hrs
- Amitriptilina 25 mg ½ tab. c/noche

MC:
“dolor de estomago y diarrea”
E.A:
consulta por cuadro clínico de 1 mes de evolución consistente
en epigastralgia, dolor abdominal tipo cólico, deposiciones liquidas fétidas,
sin moco, sin sangre, fiebre subjetiva.
EF:
- PA: 100/60 mmHg
- FC: 72 lpm
- FR: 18 rpm
- T: 37Cº
Abdomen blando, doloroso a la palpación en epigastrio, peristaltismo
aumentado; extremidades atróficas.
IDX:
- EDA prolongada
- VIH (+)/etapa SIDA

17/ago/13
DX:
-VIH/etapa SIDA
-Infección oportunista gastrointestinal
-Síndrome de desgaste
-Leucopenia
-ITU
-Sarcopenia en extremidades
O:
Paciente en malas condiciones generales, caquéctica
PLAN:
se estudiara por infección oportunista gastrointestinal; se ajusta tratamiento antibiótico empírico (ampicilina-sulbactam) para infección urinaria; se remite para evaluación por infectología .


RONDA MEDICA, MEDICINA INTERNA
18/ago/13
DX:
-Internaciones previas por cuadros de diarrea crónica
desde hace 4 meses; cuadro similar al actual
PARACLINICOS (6/13)
-CD4: 5 ; CD3: 508; CD8: 556
-LBA (6/13) NEG PCR para TBC
PLAN:
Está en estudios por infección oportunista.
PARACLINICOS:
urocultivo positivo (bacilo gram negativo)


23/ago/13
DX:
-VIH –SIDA C3
-Sindrome de Wasting
-Diarrea cronica
-Hipokalemia
-Bicitopenia (anemia-leucopenia)
-ITU
-Hiperamilasemia
O:
Paciente poco colaboradora
PLAN:
Se encuentra a la paciente fumando en la habitación, y difícil manejo,
rechaza el tratamiento, no se toma la medicación.

25/ago/13
Se inició manejo con bactrim forte y claritromicina.

26/ago/13
Paciente refiere constantemente deseos de firmar alta voluntaria; se le explican los riesgos de la decisión, incluso la muerte;
Acepta y firma el alta voluntaria

SERVICIO DE URGENCIAS
2do ingreso

10/sep/13
EA:
diarrea crónica y dolor epigástrico, con dolor para deglutir incluso liquidos, fiebre intermitente
EX FISICO:
- PA: 90/60 mmHg
- FC: 65 lpm
- FR: 15 rpm
- T: 36 c°
Mal estado general, caquéctica, mucosa oral seca; abdomen doloroso a la palpación en epigastrio
IDX:
-VIH + etapa SIDA
-Diarrea crónica
-Descartar esofagitis por hongos
-Enfermedad ácido péptica

RONDA MEDICA, MEDICINA INTERNA
11/sep/13
DX:
-HIV + etapa SIDA C3
-Infección oportunista GIT y pulmonar (TBC diseminada)
-Síndrome de desgaste
-ITU
-Mala adherencia al tratamiento
-Sarcopenia generalizada
O:
Malas condiciones generales, deshidratada.
PLAN:
Se le suspende la terapia ARV; se continua hidratación; tratamiento antibiótico empírico
con meropenem.

12/sep/13
DX:
-Ya mencionados
O:
lesiones compatibles con candidiasis orofaringea y esofagica
PLAN:
se resalta tratamiento incompleto para TBC,
el cuadro GIT se puede asociar a una TBC diseminada; se inicia fluconazol.
PARACLINICOS:
Urocultivo positivo (bacilo gram negativo)

13/sep/13
La paciente es remitida a hospital
de III nivel para manejo por
infectología
ENFOQUE DEL
PACIENTE HIV/SIDA
DESARROLLO DE LA ENFERMEDAD
CLASIFICACION DE LA ENFERMEDAD
CLASIFICACION DE LA OMS DEL VIH/SIDA
CONDICIONES DEFINITORIAS DE SIDA
Candidiasis bronquial, traqueal o pulmonar
Candidiasis esofágica
Síndrome de desgaste.
M tuberculosis de cualquier sitio
Infecciones por Mycobacterium spp. Diseminada o extrapulmonar
Enfermedad por citomegalovirus
( hígado, bazo o ganglios linfáticos)
Cáncer ivasivo de cérvix
Coccidiomicosis diseminada o extrapulmonar
Criptococosis extrapulmonar
Criptosporidiosis crónica intestinal ( > 1 mes de duración)
Retinitis por citomegalovirus
Encefalitis por HIV
Herpes simple ( ulcera crónica > 1 mes de duración )
Sarcoma de Kaposi
Neumonia linfoide intersticial
Complejo hiperplasi linfoide pulmonar
Linfoma de burkit
Linfoma inmunoblastico
Linfoma primario de cerebro
M avium diseminado o extrapulmonar
M kansassi disemiado o extrapulmonar
Neumonia por P jiroveci
Neumonía recurrente
Leucoencefalopatia multifocal progresiva
Sepsis recurrente por Salmonella spp
Toxoplasmosis cerebral



P. jiroveci

Riesgo de cd4 menor de 200 celulas/ml (o menos del 14 %), historia de candidiasis mucocutanea. 

El régimen recomendado para profilaxis primaria es TMP/SMX 160/800/ dia, régimen alternativo TMP/SMX 160/180 MG 1 TABLETA 3 VECES POR SEMANA, 

TAMBIEN SE PUEDE UTILIZAR DAPSONA 100 MG/ DIA O 50 MG 2 VECES DIA.

PROFILAXIS PRIMARIA PARA ALGUNOS AGENTES CAUSALES FRECUENTES
TOXOPLASMA GONDII

Paciente con CD4 menor de 100 celulas/mml mas IgG para toxoplasma positivo


El régimen recomendado es TMP/SMX 80/400mg/día y se puede suspender cuando los CD4 suben por encima de 200 celulas/ml en un periodo de seguimiento mayor a 6 meses.

Tratamiento de la TBCMDR
Duración Aproximadamente 24 Meses, El Inyectable mínimo 6 meses y se suspende después de 2 cultivos consecutivos negativos.

TERAPIA ARV
TUBERCULOSIS
-En quienes la lectura de la PPD es de 5mm o mas







-En contactos recientes PPD negativa






Se descarta TB activa
-Iniciar profilaxis para TB latente con isoniazida 300 mg  diarios mas piridoxina 50 mg diarios por 9 meses
-Alternativa la rifampicina 10 mg/kg Máx. 600 mg día por 4 meses
Repetir prueba a las
12 semanas e iniciar profilaxis
si la prueba sigue siendo negativa,
se retira la profilaxis
GRACIAS...
AL-m-cr
Ac-m-cr
Full transcript