{"id":116,"date":"2011-06-08T19:17:23","date_gmt":"2011-06-08T18:17:23","guid":{"rendered":"http:\/\/mimiryudo.free.fr\/blog\/?p=116"},"modified":"2013-01-28T18:08:00","modified_gmt":"2013-01-28T17:08:00","slug":"cas-n1-corrige-un-jardinier-na-plus-la-peche","status":"publish","type":"post","link":"https:\/\/www.mimiryudo.com\/blog\/2011\/06\/cas-n1-corrige-un-jardinier-na-plus-la-peche\/","title":{"rendered":"Cas n\u00b01 corrig\u00e9 – Un jardinier n’a plus la p\u00eache"},"content":{"rendered":"

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<\/p>\n\n\tT\u00e9l\u00e9chargez le cas clinique n\u00b01 en PDF, sous licence Creative Commons BY-NC-ND\t(11492 t\u00e9l\u00e9chargements\t)\n<\/a>\n\n

Commentaire : A priori le traitement du t\u00e9tanos n’est pas au programme, mais il s’agit surtout de mesures g\u00e9n\u00e9rales… La p\u00e9nicilline G ne serait peut-\u00eatre pas cot\u00e9e, certes. Pensez \u00e0 mettre les traitements \u00ab\u00a0en cas d’allergie\u00a0\u00bb. Enfin, la mode depuis 2011 semble \u00eatre \u00e0 \u00ab\u00a0donnez 5 r\u00e9ponses\u00a0\u00bb, \u00ab\u00a0faites 3 propositions\u00a0\u00bb…
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Items\u00a0: <\/em><\/p>\n

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-45 – Addiction et conduites dopantes<\/em><\/p>\n

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-103 – Pr\u00e9vention du t\u00e9tanos<\/em><\/p>\n

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-207 – Infection aigu\u00eb des parties molles<\/em><\/p>\n


\n1\/ Quel est votre diagnostic ?<\/strong><\/p>\n\n\n\n\n\n\n\n
Phlegmon de la gaine synoviale digito-palmaire \/ digito-carpienne du V<\/td>\n5<\/td>\n<\/tr>\n
Stade II \/ t\u00e9nosynovite purulente collect\u00e9e (per-op\u00e9ratoire)<\/td>\nNC<\/td>\n<\/tr>\n
Compliquant un panaris du V<\/td>\n3<\/td>\n<\/tr>\n
Droit<\/td>\n2<\/td>\n<\/tr>\n
Associ\u00e9 \u00e0 un t\u00e9tanos (trismus isol\u00e9) \/ Infection \u00e0 Clostridium tetani<\/td>\n10<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2\/ Quel est votre bilan initial ? (5 r\u00e9ponses)<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n
En urgence, sans en attendre les r\u00e9sultats<\/td>\nNC<\/td>\n<\/tr>\n
Bilan inflammatoire : NFS, CRP<\/td>\n3+3<\/td>\n<\/tr>\n
Bilan infectieux : H\u00e9mocultures a\u00e9ro-ana\u00e9robies<\/td>\n6<\/td>\n<\/tr>\n
Bilan du terrain (diab\u00e8te et phlegmon) \/ diff\u00e9rentiel (trismus) : Glyc\u00e9mie veineuse<\/td>\n4<\/td>\n<\/tr>\n
\n

ZERO A LA QUESTION si oubli de la glyc\u00e9mie<\/em><\/strong><\/p>\n<\/td>\n

<\/td>\n<\/tr>\n
Bilan des complications : radiographie de la main droite (ost\u00e9o-arthrite)<\/td>\n4<\/td>\n<\/tr>\n
Bilan pr\u00e9-op\u00e9ratoire : TP, TCA, IUC, ECG<\/td>\nNC<\/td>\n<\/tr>\n
Le diagnostic est clinique. Pas de quick-test ici.<\/td>\nNC<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

3\/ Quels sont les principes de votre prise en charge initiale ?<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Hospitalisation en USI \/ r\u00e9animation \/ transfert m\u00e9dicalis\u00e9<\/td>\n5<\/td>\n<\/tr>\n
En urgence<\/td>\n5<\/td>\n<\/tr>\n
\n

ZERO A LA QUESTION si pas de notion de r\u00e9animation OU d’urgence<\/em><\/strong><\/p>\n<\/td>\n

<\/td>\n<\/tr>\n
\n

Mise en condition : monitoring cardiorespiratoire, au calme<\/p>\n<\/td>\n

NC<\/td>\n<\/tr>\n
A je\u00fbn \/ arr\u00eat de l’alimentation per os \/ sonde naso-gastrique sous s\u00e9dation apr\u00e8s chirurgie (alimentation hypercalorique hyperprotidique)<\/td>\n2<\/td>\n<\/tr>\n
Si n\u00e9cessaire : intubation oro-trach\u00e9ale sous curare \/ trach\u00e9otomie<\/td>\nNC<\/td>\n<\/tr>\n
D\u00e9truire les bacilles t\u00e9taniques de la plaie : P\u00e9nicilline G (4-12 MUI\/24h 7 jours)<\/td>\n5<\/td>\n<\/tr>\n
Si allergie aux p\u00e9nicillines : cycline<\/td>\n2<\/td>\n<\/tr>\n
Neutraliser la toxine circulante : \u03b3<\/span>-globulines\/ s\u00e9rum anti-t\u00e9tanique 5000 UI IM<\/td>\n5<\/td>\n<\/tr>\n
Vaccination anti-t\u00e9tanique sur un autre site (maladie non immunisante)<\/td>\n2<\/td>\n<\/tr>\n
Mise \u00e0 jour des vaccinations<\/td>\nNC<\/td>\n<\/tr>\n
\n

Myorelaxant \/ s\u00e9datif \/ benzodiaz\u00e9pine \/ diaz\u00e9pam IV avec relais PO<\/p>\n<\/td>\n

5<\/td>\n<\/tr>\n
\n

Pas de points si prescription de\u00a0 midazolam \/ baclof\u00e8ne intrath\u00e9cal (d\u00e9riv\u00e9 de GABA) \/ curare car il ne s’agit pas d’une forme g\u00e9n\u00e9ralis\u00e9e mais d’un trismus isol\u00e9 <\/em><\/p>\n<\/td>\n

<\/td>\n<\/tr>\n
\n

Nursing : isolement sensoriel, kin\u00e9sith\u00e9rapie motrice, pr\u00e9vention d’escarres<\/p>\n<\/td>\n

2<\/td>\n<\/tr>\n
\n

Anticoagulation \u00e0 dose isocoagulante \/ pr\u00e9ventive<\/p>\n<\/td>\n

2<\/td>\n<\/tr>\n
\n

Traitement du phlegmon :<\/p>\n<\/td>\n

<\/td>\n<\/tr>\n
\n

– chirurgie sous anesth\u00e9sie loco-r\u00e9gionale avec garrot pneumatique<\/p>\n

ALR mieux que AG dans ce contexte pour \u00e9viter d’intuber \u00ab\u00a0contre\u00a0\u00bb le trismus…<\/em><\/p>\n<\/td>\n

5<\/td>\n<\/tr>\n
\n

– excision de la porte d’entr\u00e9e, ouverture de gaine, pr\u00e9l\u00e8vements bact\u00e9riologiques, lavage<\/p>\n<\/td>\n

NC<\/td>\n<\/tr>\n
\n

– si stade II confirm\u00e9 : synovectomie compl\u00e8te avec respect des poulies, pas de fermeture, cicatrisation dirig\u00e9e (tulle gras)<\/p>\n<\/td>\n

2<\/td>\n<\/tr>\n
\n

– amoxicilline-acide clavulanique \/ AUGMENTIN (5 jours)<\/p>\n<\/td>\n

2<\/td>\n<\/tr>\n
\n

– immobilisation courte, kin\u00e9sith\u00e9rapie pr\u00e9coce<\/p>\n<\/td>\n

NC<\/td>\n<\/tr>\n
\n

Surveillance de l\u2019efficacit\u00e9 et de la tol\u00e9rance du traitement<\/p>\n<\/td>\n

2<\/td>\n<\/tr>\n
\n

D\u00e9claration obligatoire \u00e0 l’Agence R\u00e9gionale de Sant\u00e9 (ARS, ex-DDASS)<\/p>\n<\/td>\n

2<\/td>\n<\/tr>\n
\n

D\u00e9claration en accident de travail<\/p>\n<\/td>\n

2<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

4\/ Quel est votre diagnostic ?
\n<\/strong><\/p>\n\n\n\n
\n

Addiction psychique aux hallucinog\u00e8nes (il n’existe pas d’addiction physique)<\/p>\n<\/td>\n

10<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/p>\n\n

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\n\t\t\t\"Loading\n <\/div>\n <\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Commentaire : A priori le traitement du t\u00e9tanos n’est pas au programme, mais il s’agit surtout de mesures g\u00e9n\u00e9rales… La p\u00e9nicilline G ne serait peut-\u00eatre pas cot\u00e9e, certes. Pensez \u00e0 mettre les traitements \u00ab\u00a0en cas d’allergie\u00a0\u00bb. Enfin, la mode depuis … Continuer la lecture →<\/span><\/a><\/p>\n\n

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