Santrauka Profesinis standartas (aprašas) yra administracinės teisės dokumentas, kuris apima rekomendacijas (nurodymus), reglamentuojančius gydytojų veiksmus, diagnozuojant ir gydant atskirus susirgimus bei jų grupes.Teisinė šių rekomendacijų prigimtis yra prieštaringa. Iš vienos pusės, jos yra teisės normos. Rekomendacijos nevykdymas gali užtraukti gydytojo administracinę, civilinę ar baudžiamąją atsakomybę. Iš kitos -šiose rekomendacijose paliepimas gydytojui išreiškiamas sąvokomis, kurios susiformavo medicinos praktikoje istoriškai ir nebūdingos teisės normoms apskritai ("indikuotina" ar "kontraindikuotina", "rekomenduojama" ar "nerekomenduojama", "gali būti naudinga", "turėtų būti atsižvelgta", "galėtų būti atsižvelgta" ir pan.) mokslinio pagrįstumo laipsnį (rekomendacijos klases). Parodoma, kad ir kiekvienos klasės viduje mokslinio pagrįstumo laipsnis tampa pagrindiniu kriterijumi, patikslinant ribą tarp rekomendacijos privalomumo ir gydytojo nuožiūros. Reikšminiai žodžiai: medicinos standartai, diagnostikos ir gydymo rekomendacijos, teisinis sveikatos apsaugos kokybės reguliavimas, reikalavimai medicinos standartams, sveikatos apsaugos priežiūros paslaugų kokybė. ĮvadasMedicinos standartai (aprašai) -tai teisės dokumentai, kurie kreipia (reglamentuoja) gydytojo veiklą, jam sprendžiant atskiras (tai yra su tam tikru susirgimu ar kita sveikatos problema susietas) diagnostikos, klinikines, prevencijos ir pan. problemas 1 . Standartą sudaro normos (rekomendacijos), kurios reglamentuoja gydytojų veiksmus, diagnozuojant, gydant, įspėjant atskirus susirgimus bei jų grupes 2 . Medicinos rekomendacijos, kaip ir visos teisės normos, įteisinamos įstatymo numatyta tvarka. Lietuvoje medicinos standartai įteisinami Sveikatos apsaugos ministro įsakymais ir skelbiami "Valstybės žiniose". Specialus sveikatos apsaugos ministro įsakymas papildomai nustato, kokių kitų (specialių ministro įsakymu nepatvirtintų) medicinos standartų turi laikytis gydytojas savo veikloje. Įsakyme nurodoma, kad "tais atvejais, kai nėra teisės aktų nustatyta tvarka patvirtintų metodikų ar tvarkos aprašų, rekomenduojama vadovautis Pasaulio sveikatos organizacijos dokumentais arba tarptautinių gydytojų profesinių draugijų 1 Justickis, V. ; Saladis, T. Medicinos standartai administracinės teisės sistemoje. Socialinių mokslų studijos. 2012, 4: 1063. 2 Reikia pažymėti, kad terminas "gydytojo profesinis standartas" dar nėra galutinai nusistovėjęs. Žr. Justickis, V.; Saladis, T., supra note 1, p. 1063-1083.
Aim: to present a patient’s clinical case; to demonstrate how important is to suspect rertrobulbar pseudotumor timely, why it is necessary to remove even the smallest metal foreign bodies from the jaw area; to show the importance of an integrated simultaneous clinical delivery on the spot during the investigation of a complex illness. Case report: presenting the clinical case – patient MA (66 years of age) right eye vision started to deteriorate 6 years ago, a small defect of a pupil (abnormal pupil shape) was found; after the remove a cataract operation, the vision improved (during the week after the operation the patient has not used prescribed corticosteroid drops in the eye, this incompliance with prescription caused the uveitis anterior, which went away in 2 months after relevant treatment started). One year after surgery a pain appeared in the area of the right cheek, teeth and beneath the right eye, manifested hearing weakness dextra side. Several dentists treated this patient. Also rhinologist, mouth, face, jaw surgeons and oncologists were involved. Diagnosis: alveolitis, sinusitis, osteomielitis sinus maxilaris dextra, a foreign body in a right maxillary sinus projection. Patient was examined for TBC, sarcoidosis, fungal illness, syphilis, all with negate results. Gradually right eye became blind. After the vision of the left eye began to deteriorate, further cataract surgery was undertaken. The further sudden deterioration in the general condition of the patient was treated in the neurological and supportive therapy departments for several months. Diagnosis: cerebellar degeneration and chronic polyneuropathy ataxia, unspecified dementia, extraocular palsies, metabolic hepatitis, chronic pancreatitis, bladder disturbance. During that time a protrusion of the right eye gradually enlarged and became more exposed. The left eye became blind several months later. KT and MRT: right eye’s retrobulbar tumor spread through eyehole slots intracranial and to left orbit; a small metal foreign body was found subcutaneously in the right cheek. A biopsy was taken from the para- and retrobulbar tissues: fibromatosis was diagnosed. Half a year later a sphenoorbital meningioma was suspected and the surgery aimed to partially remove a tumor from the right orbit was performed. During this stay under the neurosurgeons care it becomes clear that episodes of psychomotor agitation were also present. The eyelids of the right eye were sutured to protect the cornea against perforation. Histologic diagnosis: retrobulbar pseudotumor of both eyes. Metal foreign body remained untouched. The ophthalmologist removed the foreign metal body, which was situated in the cheek subcutaneously, close to N. infraorbitalis with capsule in a local polyclinic soon afterwards. The composition of the foreign metal object was investigated: it was found that 95% of it was iron with small amounts of rare metals usually found in steel alloy, calcium. Histology detected hemosiderosis in connective tissue of capsule. Patient was examined by a rheumatologist on the basis of the suspicion of Wegener granuliomatosis. Data to confirm Wegener’s granulomatosis was not enough; internal organs without lesions, it was diagnosed cholelithiasis and fibrotic lesions in the lungs. It was confirmed systemic transgression of connective tissue with retrobulbar pseudotumor diagnosis. Corticosteroid treatment was given for 1 month. Patient was examined 8, 15 and 27 month after foreign body removal later: the skin of the face was free of scars, eyelids of the right eye has been sutured; the left eye had no inflammation, refracto- and keratometry findings were the same, like 4 years before; levels of immunoglobulins G and E in blood decreased - normal; the systemic transgression of connective tissue remained. Patient walks with a wide-based gait, he becames totally dependent on care (he is blind and desorientated at place and time, his personality has changed; Mini Mental State Examination 13/30). This story showed, how it is important to have a complete understanding of the patients health from various medical specialists at the same physical place and at the same time. The case shows surprising differences of results of radiologic examination of the same case.
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