Case lm sng T 3 Nhm 1

Bnh nhn n, 53 tui, nhp vin vi l do sng au v hn ch vn ng khp gi. Trc y c vi t au tng t, dng thuc ng y nhng nay li ti pht. Thm khm thy bnh nhn + Mt mi, gy st, st nh 37,6oC + B au cc khp c tay, bn, ngn tay, u gi, c chn, bn, ngn chn c 2 bn. + Cng khp bui sng: 2h. + Da kh teo, chn phi b ph nh + Hay ra m hi tay, lng bn tay vng. + Mt kh, nhn m. + Teo c gian ngn. + Cc ngn tay, chn khng c bin dng. Tin s gia nh khng c g c bit.

Cu hi 1: C th chn on s b bnh nhn b mc bnh g? Da theo cc triu chng no ?

a) Thoi ho khp b) Vim khp dng thp c) Thp khp cp d) Lupus ban h thng

 Tr li: b v d
Gii thch: - Bnh khng b thoi ho khp. V trong thoi ho khp thng bnh nhn au 1 hoc vi khp nhng khng i xng, khng c triu chng vim, au khi ngh ngi v au khi hot ng. Thng c hin tng ph r khp.

- Bnh khng b thp khp cp. V trong thp khp cp thng bnh nhn au cc khp ln, au khng i xng v c tnh cht di chuyn, cc khp vim b sng, nng, , au. Ngoi ra bnh thp khp cp hay gp bnh nhn tr tui.

 Cc triu chng gip nh hng chn on l VKDT hoc Lupus ban h thng
- BN c triu chng au cc khp nh v nh, au i xng, cc khp sng au, t nng . - C cng khp bui sng. - Ri lon dinh dng (ph). - Da kh teo. - Teo c gian ngn. - Ri lon thn kinh thc vt (ra m hi tay) Tuy Lupus ban c cc mt vi im khc VKDT nh: + Thng gp ph n tr. + Khng c bin dng khp. + Km theo xut hin ban cnh bm hoc hnh a, st ko di, rng tc..., + Thng tn thng thn. Nhng cha th chn on phn bit c ngay.

Cu hi 2: Theo bn vic khai thc k bnh s ca bnh nhn c cn thit trong vic chn on khng ? Ti sao ?

Tr li: Vic khai thc k bnh s ca bnh nhn rt cn thit trong vic chn on bnh, v:

- Cn chn on phn bit gia bnh vim khp dng thp v bnh lupus ban h thng - VKDT thng din bin t t, tng dn hoc din bin thnh tng t. - Khai thc k thi gian v v tr au cc khp gip ta c thm du hiu chn on bnh nhn c b VKDT hay khng

Cu hi 3: Vic cho bnh nhn lm thm cc xt nghim sau c cn thit khng ? Ti sao?

a) Siu m khp b) Sinh thit mng hot dch. c) X Quang d) Sinh ha mu v cng thc mu e) Tm yu t dng thp RF
Nu cn XN sinh ha mu v cng thc mu th c th l cn lm ch tiu chnh g ?

Tr li: C, D, E

Gii thch
2 xt nghim quan trng nht cn phi lm l: + Tm yu t dng thp RF: l du hiu chn on xc nh. + X-quang: l du hiu chn on xc nh v chn on giai on bnh.

* Ngoi ra nn lm thm xt nghim 1 s yu t sinh ha mu v cng thc mu: l xt nghim cn thit tm triu chng cn lm sng, nh gi tnh trng ca bnh nhn, xc nh cc nguy c tim tng.
C th: + T bo mu ngoi vi, mu lng. + Albumin, CRP, men gan. * Khng cn lm: + Siu m khp: khng phn bit c tn thng c hiu ca vim mng hot dch n mn trong VKDT nn t c gi tr chn on, ch c tc dng kim tra phn mm ca khp, c bit l cc khp ln. + Sinh thit mng hot dch: Ch cn lm khi cc triu chng khc khng r rng.

Khai thc bnh s thy: Cch y 4 thng bnh nhn au khp c chn 2 bn km theo cc khp bn ngn chn, khp c tay Cch y 2 thng bnh nhn b au cc khp bn chn, c chn, khp gi 2 bn, khp bn tay, c tay.

Kt qu xt nghim ca bnh nhn nh sau:

a) Xt nghim cng thc mu

Tn xt nghim WBC ( S lng bch cu) NE

Bnh thng 4-10 G/l 50-57 %

Kt qu 9.2 G/l 80.1 %

LY
MO EO BA HGB ( Huyt sc t) MCV (Th tch TB HC) RBC ( S lng hng cu)

20-45 %
0-8 % 0-8 % 0-1 % 125-145 g/l 83-92 fl 3.9-5.4 T/l

10.7 %
7.5 % 1.6 % 0.1 % 120g/l 94.4fl 3.9 T/l

PLT ( S lng tiu cu)

Ch s mu lng 1h 2h

150-450 G/l
10mm 20mm

508G/l
92mm 102mm

Kt qu xt nghim (tip theo)

b) Xt nghim sinh ho Tn xt nghim Albumin CRP ASAT ALAT in gii : Natri Kali Clo 139 3.5 93 133 147 3.4 4.5 94 111 Bnh thng 34-48 g/l < 0.5 mg/dl 31 32 Kt qu 31.0 g/l 14.4 mg/dl < 31 < 31

c) Kt qu chiu chp: Cha thy tn thng xng khp c tay, bn tay 2 bn d) Xt nghim yu t dng thp ( RF): [+]

Cu hi 4: Ta a ra chn on xc nh l bnh nhn mc bnh g ? Da theo cc triu chng v tiu chun chn on no ?

Tr li: Chn on xc nh bnh nhn b mc bnh VKDT

Da theo TCC ARA 1987: Chn on xc nh khi c trn 4 du hiu 1. Cng khp bui sng > 1h. 2. Sng au ti thiu 3/14 v tr khp, ko di trn 6 tun. 3. Sng au ti thiu 1/3 v tr khp (bn tay), ko di trn 6 tun. 4. Sng au i xng. 5. Ht di da. 6. Yu t dng thp dng tnh. 7. Hnh nh X quang in hnh.

Bnh nhn c 5 du hiu sau: - Sng au i xng 2 bn. - Cng khp bui sng: 2h. - au > 1/3 cc khp bn bay trn 6 tun - au > 3/14 v tr khp trn 6 tun. - Yu t dng thp dng tnh tiu chun chn on l VKDT

Cu hi 5 Theo bn trong nhng kt qu xt nghim trn, ngoi xt nghim tm RF v chp X-quang, cn c kt qu no c gi tr trong chn on v iu tr bnh RA ? Ti sao ?

Tr li
- nh gi mc vim + CRP (+) + Albumin gim + Tc mu lng tng. - Xt nghim mu: + BC a nhn trung tnh tng: c tnh trng vim. + Mu lng: theo di p ng thuc. + AST, ALT nh gi chc nng gan v c hng iu tr thuc cho ph hp vi BN.

Cu hi 6: Vy bnh nhn ang giai on no ? Phng hng iu tr ra sao ?

Tr li Giai on 1. Do : + Cc khp vn ng gn nh bnh thng + Hnh nh X- quang khp bnh thng.

Phng hng iu tr: - Ngn chn s hu hoi xng: Vitamin D3, - Thuc bo v, trnh tc dng ph ca thuc: Bo v gan: Eganin - Thuc chng vim gim au: Methylprednisolon - Thuc vim, khp thp khp: Medexa - Tng cng vn ng, trnh dnh khp. - Trnh lnh v m, lm vic nh.

Ht
Chn thnh cm n c v cc bn