01/2011

P R Z Y P A D K I

K L I N I C Z N E

'UQPHG-DFHN5]HV]RWDUVNL

OHWQL FKRU\ ] FXNU]\FÈ W\SX  SU\ZDWQ\ SU]HGVLÚELRUFD EUDQĝ\ EXGRZODQHM]RVWDïVNLHURZDQ\GR3RUDGQL'LDEHWRORJLF]QHM]SRZRGX Z\VRNLFK ZDUWRĂFL JOLNHPLL XWU]\PXMÈF\FK VLÚ ZHGïXJ FKRUHJR RG RNRïRURNXFHOHPPRG\ILNDFMLOHF]HQLDLSU]HSURZDG]HQLDHGXNDFML Wywiad: FXNU]\FÚ W\SX  UR]SR]QDQR  ODW WHPX QD SRGVWDZLH GRXVWQHJR WHVWX WROHUDQFML JOXNR]\ 'R WHM SRU\ FKRU\ SR]RVWDZDï SRG RSLHNÈ OHNDU]D SRGVWDZRZHM RSLHNL ]GURZRWQHM 3RF]ÈWNRZR OHF]RQ\ W\ONR GLHWÈ SR URNX GR OHF]HQLD ZïÈF]RQR PHWIRUPLQÚ DODWSöěQLHMGUXJLOHNGRXVWQ\SRFKRGQÈVXOIRQ\ORPRF]QLND Schemat aktualnie stosowanej terapii:  PHWIRUPLQD ļPJ[G]LHQQLH ZF]DVLHJïöZQ\FKSRVLïNöZ  JOLPHSLU\G ļPJ[G]LHQQLHUDQRSU]HGĂQLDG  FLOD]DSULO ļPJ[G]LHQQLH  ELVRSURORO ļPJ[G]LHQQLH  DWRUYDVWDW\QD ļPJ[G]LHQQLHZLHF]RUHP NZDVDFHW\ORVDOLF\ORZ\ ļPJ[G]LHQQLH  WDPVXOR]\QD ļPJ[G]LHQQLHZLHF]RUHP 3RZLNïDQLDFXNU]\F\VWDELOQDSU]HZOHNïDFKRUREDQLHGRNUZLHQ QDVHUFDUR]SR]QDQDODWDWHPX]WHJRSRZRGXFKRU\SRGRSLHNÈ 3RUDGQL.DUGLRORJLF]QHM &KRURE\ ZVSöïLVWQLHMÈFH QDGFLĂQLHQLH WÚWQLF]H KLSHUOLSLGHPLD PLHV]DQDVWïXV]F]HQLHZÈWURE\ïDJRGQ\SU]HURVWSURVWDW\ 3UREOHP NOLQLF]Q\ Z\VRNLH ZDUWRĂFL JOLNHPLL V]F]HJöOQLH QD F]F]RLJRG]LQ\SRĂQLDGDQLXZ\VRNLSR]LRP+E$FQDGZDJD SRGZ\ĝV]RQH55 :DUWRĂFLJOLNHPLLļSURILOHPJGO  >ZRSDUFLXRGDQH]]HV]\WXVDPRNRQWUROL@

WDE

1DF]F]R

141

129

138

JRG]SRĂQLDGDQLX

211

182

196

JRG]SRRELHG]LH

144

129

140

JRG]SRNRODFML

156

147

161

3URILOHJOLNHPLL 300 270 240 210 180 150 120 90 60 30 0

JRG] SRRELHG]LH

JRG] SRNRODFML

%DGDQLHSU]HGPLRWRZH :]URVW ļFP 0DVDFLDïD ļNJ %0, ļNJP2 55 ļPP+J Badania dodatkowe: 'QRRND ļEH]]PLDQFXNU]\FRZ\FK /LSLGRJUDP ļFKROHVWHUROFDïNRZLW\ ļPJGO   +'/ ļPJGO   /'/ ļPJGO   7* ļPJGO .UHDW\QLQD ļPJGO +E$F ļ &SHSW\G ļQJPO

=DVWRVRZDQH OHF]HQLH &KRUHJR SU]HV]NRORQR Z ]DNUHVLH VWRVR ZDQLD ZïDĂFLZHM GLHW\ FXNU]\FRZHM L SURZDG]HQLD VDPRNRQWUROL =PRG\ILNRZDQROHF]HQLHKLSRJOLNHPL]XMÈFH:REHFGXĝHMKLSHUJOLNH PLLSRUDQQHM]ZLÈ]DQHM]HZ]PRĝRQÈZÈWURERZÈSURGXNFMÈJOXNR]\ ZJRG]LQDFKQRFQ\FKGROHF]HQLDGRïÈF]RQRLQVXOLQÚED]RZÈMHGQR F]HĂQLH RGVWDZLRQR SRFKRGQÈ VXOIRQ\ORPRF]QLND = XZDJL QD QDG ZDJÚFKRUHJRZ\VWÚSXMÈFH]DEXU]HQLDOLSLGRZHLVWïXV]F]HQLHZÈWUR E\ SU]\ EUDNX SU]HFLZZVND]Dñ ]ZLÚNV]RQR GDZNÚ PHWIRUPLQ\ GR [PJ1RZ\VFKHPDWOHF]HQLDFXNU]\F\Z\JOÈGDïQDVWÚSXMÈFR  $YDPLQD ļPJ[G]LHQQLH ZF]DVLHJïöZQ\FKSRVLïNöZ  *HQVXOLQ1 ļMRNRïRJRG]LQ\ 6NRU\JRZDQRUöZQLHĝOHF]HQLHKLSRWHQV\MQHJG\ĝFKRU\QLHVSHï QLDï NU\WHULöZ 37' ļ ]ZLÚNV]RQR GDZNÚ LQKLELWRUD NRQZHUWD]\ FLOD]DSULOXGRPJ[G]LHQQLHUDQR 'RERZHSURILOHļSRPRG\ILNDFMLOHF]HQLDPJGO 

WDE

1DF]F]R

107

102

98

KSRĂQLDGDQLX

141

133

127

KSRRELHG]LH

129

126

116

KSRNRODFML

142

132

121

3URILOHJOLNHPLL 300 270 240 210 180 150 120 90 60 30 0

,SURILO ,,SURILO ,,,SURILO VWDQGDUG\ 37'

QDF]F]R

JRG] SRĂQLDGDQLX

JRG] SRRELHG]LH

JRG] SRNRODFML

+E$FSRPLHVLÈFDFKWHUDSLLļ

,,SURILO

5RG]DMVWRVRZDQHMWHUDSLLKLSRJOLNHPL]XMDFHMļNRU]\ĂFL ľ ]PLDQD OHF]HQLD SROHJDMÈFD QD RGVWDZLHQLX SRFKRGQHM VXOIR Q\ORPRF]QLNDL]ZLÚNV]HQLXGDZNLPHWIRUPLQ\RUD]ZïÈF]HQLH LQVXOLQ\ 13+ SU]HG VQHP Z GDZFH  M SR]ZROLïR QD OHSV]H Z\UöZQDQLHJOLNHPLLQDF]F]RLSRSRVLïNDFK ľ SRPLHVLÈFDFKWDNLHJROHF]HQLDVWZLHUG]RQRZ\UDěQÈUHGXN FMÚ+E$FLļFRQDOHĝ\SRGNUHĂOLÊļQLHREVHUZRZDQRZ]URVWX U\]\NDQLHGRFXNU]Hñ ľ SRïÈF]HQLHLQVXOLQ\ED]RZHM]PHWIRUPLQÈMHVWEH]SLHF]QHSRQLH ZDĝ PHFKDQL]P G]LDïDQLD ELJXDQLGöZ SROHJD QD KDPRZDQLX V\QWH]\JOXNR]\SU]H]ZÈWUREÚLMHVWRGPLHQQ\RGPHFKDQL]PX G]LDïDQLD LQVXOLQ\ ZLHOX OHNDU]\ GRGDMÈF GR OHF]HQLD FXNU]\F\ LQVXOLQÚ13+]DOHFDNRQW\QXRZDQLHSU]\MPRZDQLDZV]\VWNLFK GRXVWQ\FKOHNöZSU]HFLZFXNU]\FRZ\FKQDOHĝ\MHGQDNSDPLÚWDÊ R U\]\NX KLSRJOLNHPLL Z SU]\SDGNX MHGQRF]HVQHJR VWRVRZDQLD LQVXOLQ\LSRFKRGQ\FKVXOIRQ\ORPRF]QLND ľ ]ZLÚNV]HQLHGDZNLLQKLELWRUDNRQZHUWD]\DQJLRWHQV\Q\FLOD]D SULOXGRPJ[G]LHQQLHSR]ZROLïRQDX]\VNDQLH]DOHFDQ\FK GODFKRU\FKQDFXNU]\FÚZDUWRĂFL55SRQLĝHMPP+J

VWDQGDUG\ 37'

JRG] SRĂQLDGDQLX

ļPOPLQP2 ļ,8O ļ,8O ļEH]]PLDQ ļZÈWUREDRSRGZ\ĝV]RQHM HFKRJHQLF]QRĂFLSRZLÚNV]RQD

,SURILO

,,,SURILO

QDF]F]R

H*)5ZJ0'5'  $VS$7   $O$7   %DGDQLHRJöOQHPRF]X 86*MDP\EU]XV]QHM

4. 'UQPHG-DFHN5]HV]RWDUVNL

Przypadek 4.

Podsumowanie: 3RGF]DV ZL]\W\ NRQWUROQHM Z 3RUDGQL 'LDEHWR ORJLF]QHM SR  PLHVLÈFDFK ĂUHGQLH ZDUWRĂFL JOLNHPLL QD F]F]R Z\QRVLï\PJGODJRG]LQ\SRSRVLïNDFKPJGO +E$FPDVDFLDïDNJ55PP+J

5