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EAC-DOR

Carla, 22 anos, sofreu acidente automobilstico na volta da faculdade. Foi


atendida no PS do HBDF, consciente e com extenso ferimento corto-contuso em
membro inferior. Sentia muita dor e foi atendida com o uso de anestsico local para
cuidados imediatos com a leso. Durante a limpeza da ferida, foi observado que a
leso comprometia camadas profundas, como msculos. Neste momento foi
indicada interveno sob analgesia induzida por antagonista NMDA, no centrocirrgico. Carla teve alta com a prescrio de AINE. Retornou trs dias depois se
queixando de dor nas reas adjacentes leso corto-contusa.
Questes:
1. Classifique e caracterize a dor de Carla, sob o aspecto de temporalidade e da
fisiopatologia e explique a existncia ou no de funo biolgica.
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2. Descreva detalhadamente o trajeto do impulso doloroso com delineamento
das fases desde a injria tecidual at a tomada de conhecimento da mesma
por Carla.
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3. Explique porque Carla retornou com dor nas reas adjacentes leso cortocontusa.
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4. Explique a utilizao do anestsico local, dos antiinflamatrios e dos
antagonistas do NMDA para a analgesia, com base no mecanismo de ao
destes frmacos.
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Problema 2
O Sr Manoel, de 56 anos, foi atendido na sala de emergncia de um
hospital geral com queixa de desconforto no peito, de forte intensidade,
surgido h mais ou
menos 90 minutos. Conversando com o mdico,
descreveu o desconforte como uma sensao de presso e aperto, localizado
no centro do trax, com irradiao para o ombro esquerdo e associado
sudorese, nuseas, vmitos e palpitaes. Nunca havia sentido algo
semelhante. Na histria mdica pregressa relatou que hipertenso e usa
regularmente a medicao prescrita por seu cardiologista. Informou tambm
que fuma h mais de 40 anos, 25 cigarros por dia, e que est com mais de 30
Kg acima do peso ideal, o que atribui a uma alimentao inadequada e
sedentarismo. Na histria familiar contou que o pai, hipertenso e diabtico e
ainda vivo, teve um infarto do miocrdio aos 55 anos, porm no sentiu dor.
A histria clnica do Sr Manoel teve grande importncia para a conduo da
investigao diagnstica, que concluiu por um IAM.
Questes:
1. Classifique e caracterize a dor precordial do Sr Manoel.
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2. Explique o mecanismo fisiopatolgico da dor precordial aguda do Sr
Manoel correlacionando com os sintomas nuseas, vmitos e sudorese
tambm apresentados por ele.
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3. Explique o mecanismo fisiopatolgico da dor no ombro esquerdo do Sr
Manoel.
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4. Explique o porqu que o pai do Sr Manoel apresentou IAM sem sentir dor.
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Problema 3
Adalgisa, uma senhora de 79 anos foi atendida pela equipe de
proctologia do HRS, em 2005, com quadro de emagrecimento, alternncia
de trnsito intestinal, com evacuaes em fita e dores em regio lombar,
acompanhadas de nuseas e anorexia. Ainda em investigao
diagnstica, foi usado um analgsico opiide fraco, por via oral, de 6/6h,
para controle da dor sem melhora desta. O diagnstico de cncer coloretal foi fechado e a evoluo do quadro doloroso foi marcada pela
utilizao de instrumentos de avaliao da dor e Adalgisa evolua
referindo 9 na escala numrica, apesar da teraputica instituda. O
mdico assistente realizou colostomia e para o controle da dor fez sua
prescrio com base nas diretrizes bsicas da OMS para controle da dor
crnica prescrevendo um opiide forte associado a um antidepressivo.
Questes:
1. Como se caracterizam os intrumentos de avaliao da dor que
poderiam ser utilizados para avaliar a dor da Sra Adalgisa?
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2. Qual o mecanismo de ao dos analgsicos opiides prescritos para a
Sra Adalgisa? Cite trs de seus efeitos indesejveis.
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3. Quais as diretrizes bsicas para o alvio da dor em pacientes com dor
crnica utilizada pelo mdico assistente da Sra Adalgisa?
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Problema 4
Mrio, de 38 anos de idade, portador de HIV. H 3 meses iniciou com
dor em queimao e pontadas (de intensidade 6) nos ps associados
hiperemia e edema em tarso direito. No Centro de Sade n 08, recebeu
assistncia mdica, alm das medicaes do coquetel e anti-retrovirais e
evoluindo para melhora parcial do quadro. Em sua ltima consulta h 1 ms,
j sem edema e hiperemia em tarso direito informou dor forte (de
intensidade 9) em queimao e pontandas que chegaram a assust-lo em
planta do p direito, no respondendo s tentativas de tratamento com
antiinflamatrios. Refere marcha dificultosa por queda do p direito (p
equino) o que o vem deixando triste e desmotivado, at para comer. Ao

exame fsico, o mdico constatou alodnea e hiperestesia na regio


acometida. Alm de recomendar a adequao do esquema dos antivirais,
prescreveu complexo B e tratamento analgsico com adjuvantes
(anticonculsivante e antidepressivo tricclico).
Questes:
1. Classifique e caracterize a dor inicial de Mrio em queimao e pontadas
no p direito.
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2. Descreva o mecanismo fisiopatolgico da dor inicial de Mrio pelo HIV (dor
em queimao e pontadas, edema e hiperemia em tarso direito).
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3. Descreva o mecanismo fisiopatolgico da dor subsequente para qual
Mrio evoluiu.
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4. Definir os fenmenos de alodnea, hiperestesia e hiperalgesia e explicar o
mecanismo fisiopatolgico da alodnia e hiperalgesia na dor neuroptica.
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5. Explicar
o
mecanismo
de
ao
dos
principais
adjuvantes
(anticonvulsivantes e antidepressivos tricclicos) e sua indicao no
tratamento da dor de Mrio.
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Problema 5

Mrcia, 32 anos, promotora pblica no DF, sofre de cefaleia desde 14


anos. Tem uma sobrecarga de trabalho muito grande, costuma trabalhar
em casa at s 2h analisando processos. Apesar de ter sido orientada
quanto a manter uma dieta sem vinhos, queijos e chocolates, grande
apreciadora destes e no conseguindo seguir a orientao dada. A dor
de localizao temporal, ora direita, ora a esquerda, associada
nuseas, foto e fonofobia. Se no tratada, a dor chega a durar 12h. Suas
crises lgicas no so aliviadas com AINEs e nem com os derivados do
ergot; apenas com uso de triptanos. Uma alterao de campo visual
temporal direito e irritabilidade antecedem a dor. A paciente tem faltado
repetidas vezes o trabalho devido intensidade da dor. A frequncia de
episdios dolorosos chega a trs/semana. Seus exames neurolgico e
oftalmolgico so normais.
Questes:
1. A cefaleia de Mrcia primria ou secundria? Justifique.
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2. Citar as fases clnicas da enxaqueca e descrever o mecanismo da aura
e da dor.
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3. Qual(is) tratamento(s) adicionais (farmacolgico e no farmacolgico)
pode(m) ser institudo(s) no caso da questo?
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