Cng Bnh Hc C S cho Dc

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Cng Bnh Hc C S cho Dc

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Bi 1:VIM I TRNG MN
I. i cng : 1. Kn : Cc bnh i trng mn tnh gm cc bnh c tn thng vim mn tnh i trng v k c tn thng . Bnh do nhiu nguyn nhn gy nn nhng c 1 s biu hin lm sng ging nhau . L bnh ph bin trong nhn dn v trong qun i . 2. Phn loi : - Nhm c tn thng vim : + Vim i trng do VR,VK, KST, nm . + Vim i trng do bnh t min dch + Vim lot trc i trng chy mu Corhn. - Nhm k c tn thng vim : IBs , lon khun rut II. Triu trng chung : 1. Lm sng : * Triu trng c nng: - au bng: + V tr: xut pht au thng l vng h chu hai bn hoc vng h sn phi v tri (vng i trng gan gc, gc lch). au lan dc theo khung i trng. + Tnh cht, cng au: thng au qun tng cn, c khi au m . Khi au thng mt i ngoi , i ngoi c th gim au. + Cn au d ti pht + au nhiu v m. - Ri lon tiu ho : + Chng bng, si bng, trung tin nhiu . + Ch yu l a lng nhiu ln mt ngy, phn c nhy, mu. + To bn, sau bi phn c nhy, mu. + To lng xen k nhau (vim i trng khu vc). + Mt rn, a gi, sau i ngoi au trong hu mn. *Triu chng ton thn: Ngi bnh mt mi, n ng km, chn n, y bng, gim tr nh, hay cu gt, c th c st. Nu b bnh nng th c th gy st hc hc. * Triu chng thc th: - n h chu c th c ting c ch, chng hi, n dc khung i trng au. - C th s thy thng xch ma nh mt ng chc, t di ng. *XN : - Phn : c hng cu , TB m , albumin ha tan (+), soi amip. - Cy phn : tm vi khun - Mu : Hng cu, huyt sc t, bch cu, mu lng t thay i. - Soi trc trng v sinh thit . - Chp khung i trng c chun b :
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- X quang : loi tr u , di phnh i trng

III. Mt s bnh i trng : 1.Vim lot trc i trng chy mu : - i cng : + gp chu u ,Bm ,chu A + Bnh nguyn : nhim trng, t min , thn kinh + GPBL : vim ht , lot , gi polyp , dng ng - Lm sng : + a lng, phn c mu + au bng , c th ging l + st , st cn ,suy kit ,thiu mu + km theo au khp ,vim mng mt ,vim then ,gan ,mt - Cn lm sng : ni soi, sinh thit : vim ht ,lot ,gi polyp - Bin chng : Thiu mu Phnh i trng ,nhim c Thng Ung th ho Nhim trng ,suy kit . - iu tr : + Ch n: n cc cht d tiu giu nng lng. Gim cc cht kch thch. Khng n cc cht i thui, cc cht c nhiu x. +Thuc : iu tr theo nguyn nhn m la chn thuc cho ph hp. CC : thuc to bn ,gin c . Mesalazine(5 ASA ):ch nh trong tt c cc th Corticoid : ch nh trong va v nng.VT do bnh t min th dng. + Liu dng: 30 - 40mg/50kg/24 gi. + V d: Prednisolon (vin 5mg): Ch cho ung thuc vo lc no, khng dng khi c lot d dy - t trng, i tho ng, cao huyt p. CMD : trong nng hoc khng corticoid( Cyclosporin hnay hay c sdng ). Vitamin : B1,B6, C Thiu mu : truyn mu, b sung st KSinh: VT do nhim khun Klion (Flagyl) 0,25: liu 2-4mg/kg/24 gi Enterosepton 0,25: vi liu 2mg/kg/24 gi. Chlorocid 0,25: vi liu 20mg/kg/24 gi Ganidan 0,5: vi liu 6 - 8 vin/50kg/24 gi Biseptol 0,25: vi liu 2mg/kg/24 gi. m
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+ iu tr triu chng : * Chng a lng: - Sousnitratbismuth: 2 - 4g/24 gi chia 2 - 3 ln ung. - Tanalbin: 2 - 5g/24 gi cho n khi ht a lng. - Opiroic 0,5: liu 1 - 2 vin/24 gi/ 50kg, ht a lng th ngng ung thuc. * Chng to bn: - Parafin 10ml/24 gi chia 2 ln ung trong 3 - 5 ngy. - Magiesunfat 5 - 10g/24 gi, trong 3 - 4 ngy - Tht tho phn khi cn thit. * Gim au chng co tht: - Atropin 1/2mg: ngy 1 - 2 ng tim di da trong 5 - 7 ngy. - Papaverin 0,04 : dng 4 vin/24 gi hoc 0,02 x 1 - 2 ng tim di da. - Seduxen 5mg x 1 - 2 vin/24 gi ung vo ti. - Gacdenal 0,1 x 1vin/24 gi ung vo ti. + Ngoi khoa : Khi : Chy mu nng ,thng ,phnh ,nhim c , ung th . 2. Hi chng rut kch thch ( IBS) ( Vim i trng mn hu l ) - i cng : + KN : Thompson WG : IBS l ri lon chc nng mn tnh ca rut tI I tI li nhiu ln m k c tn thng v giI phu ,t choc hc ,sinh ho . + L bnh ph bin ,chim > 20% DS ,n >nam, tr tui ,VN : lquan n nhim khun v k sinh trng li hu qu RLCNng . + Bnh sinh : S tng nhn cm ni tng Stress Cc ri lon vn nh bt thng ca rut Ch n + loi thc n . - Triu trng : + Tiu chun Rome II (1999) : au bng or kh chu bng xy ra trong 12 thng lin tc or t nht trong 12 tun . C t nht 2 trong 3 c im sau : au bng km theo : 1. Bt i sau i tin 2. Kt hp thay i dng phn. 3. Kt hp thay i s ln i ngoi Nhng triu trng gip chun on : i ngoi >3ln /ngy or <3ln/ tun Phn k bnh thng . i tin k bnh thng . - Cn lm sng : + CTM , sinh ho : bnh thng. + Xquang ,ni soi ,sinh thit ,k c tn thng . + Xt nghim phn k thy VK, nm gy bnh . - iu tr : + Ch n ,luyn tp : King cht kch thch gy d ng . Hn ch ng ,bt ,cht c gas.
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Tng rau xanh ,hoa qu ,cc cht x Tp thi quen I ngoi ,vn ng , xoa bng ,th gin . Ngh ngi an dng trong t nng . + Thuc : - Chng au,chng co tht - Chng y hi - Chng to bn - Hng thn - Cm i lng - Vitamin

Bi 2:Vim tu cp v mn tnh
1.Vim tu cp : *i cng: - L cc tn thng ph n ,xung huyt ,hoi t nhu m tu,hu qu ca s thot ra ca cc enzym tuy ngay trong tu . - Vim tu cp c th phc hi hon ton nh rng n c th ti pht nhiu ln ,nguc li vi vim tu mn : l nhng tn thng k phc hi ,trong VTM c nhg t cp triu trng lm sng v iu tr c xem nh ca VTC. - NNhn : ch tc ng tu , ng mt + Do ung ruu : 80% + Nghin ru cp tnh rt d gy VTC . + NA, VN nnhn chnh do si ng mt ,ng tu ,giun sn + T nnhn chnh do ung ru - Tn thng gii phu bnh : t f n cp tnh , xung huyt ,xut huyt ,hoi t ; 80% th f n . - Cn nguyn ,bnh sinh : + Thuyt tu t tiu ho c chp nhn rng ri hn c : cc nnhn lm men tripsinogen c hot ho ngay tu ,tripsin gy tiu hu t chc ng thi hot ho cc enzym cn li tu t tiu hy. + Thuyt tro ngc *Triu trng v chun on : - Hi chng au : + C nng: au bng thnh cn d di na bng trn or thng v or quanh rn thng sau ba n thnh son or c ru . au lin tc k dt ,nu ngi gp ngi ra trc 2 tay b gi p chn vo bng th they gim au . - Hi chng ri lon tiu ho : Nn ,chng bng ,b trung tin l nhg triu trng thng gp . + Thc th : Tam gic t tu au . Du hiu Mallet - Guy (+) Du hiu Mayo Robson (+) - Hi chng nhim trng ,nhim c : mt mi , bn chn ,lo s, st nh n st cao 38-39 C. Th nhanh nng ,da mt or xanh tm ,da lnh nhp m hi, thm ch shock. - Tng amylase huyt thanh trn 3ln trong 24 ting u (90% trng hp) so vi mc bt l ch da vng chc cho chn on VTC ( nu loi tr c bnh ca tuyn nc bt ,thng tng rng , hoi t rut ,vim ti mt, suy thn ) - Tng bch cu - C th tng ng huyt .
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- Tng AST thong qua - Tng LDH l yu t tin lng xu . - Tng BUN sau khi truyn dch . - C th tng Bilirubin huyt thanh - C th gim calci huyt - Gim albumin huyt thanh l yu t tin lng nng. - Cc chn on hnh nh : + Siu m : nhu m ty tng (n ln ), nhu m th cc b ,ton din . Khi c hoi t cc nang nh nang nc ,xung quanh ty thng c dch. + Chc chn nht v hnh nh chn on vim ty : chp CT Scan . + Ngoi ra c X quang , in tm , soi ng mt ty ngc dng , Sinh thit ty qua da 2. Thuc iu tr : * VTC : - B nc in gii bng dch truyn ng trng v aminoacid . - Khng sinh : Cephalosporin th h 3 nn kt hp nhm Imidazol hoc Quinolon nu nguyn nhn c si (ng mt ,ty ), giun - Gim au : meperidin 75-100 mgtieem bp tht cch qung 3-4 h, nu k gim c th dng Novocain 0,25%x 10-20ml tim tmach chem., or truyn Lidocain bng ng ven, dng paracetamol i vi au nh v va . - Gim tit : 1. Anticholin ( nh atropine ) 2. C th th H2 (Cimetidin 0,8-1,2g/24h ,ranitidin, famotidin ,nizatidin, rosatidin (ang nghin cu) 3. C bm proton ( omeprazol, lanzoprazol, pantoprazol, rabeprazol , esomeprazol .) C th dng c 3 nhm thuc gim tit ,trn LS thng k.hp 1+2 v 1+3 Nu l vim ty hoi t s dng ngay t u 1 trong 2 hormon Ortteotid(8aa- C a tuyn ngoi tit tieu ha ) v Somatostatin( 14aa- C a tuyn ngoi tit tiu ha c sinh ra hang v ,t trng , i th ) - iu tr loi b nguyn nhn nh si mt . * VTM : - t cp iu tr ging nh VTC . - Nhm : gam au ,b sung men ty , iu tr cc bin chng khc . - Ch n : B bia ru ,thuc l Gim m ,tng m - Thuc c th: + Gim au; Efferalgan codein / NSAIDs / i khi phI dng morphin . Lidocain Nu do si ty dng thm gin c trn . + Khi ng ty teo v x ha biu hin lm sng khi bnhn tiu chy nhiu ln trong ngy gy st cn nhanh ,phn c nhiu thc n cha tiu th b sung men ty : 30.000 n v Lipase+ 10.000 n v Amylase + 3000 v protease/ ngy
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Nu thiu insulin b sung insulin - iu tr ni khoa can thip . - iu tr ngoi khoa khi phng php ni khoa v ni khoa can thip km hiu qu.

Bi 3: Bnh x gan (Cirrhosis)

I. i cng. 1. Khi nim:X gan l bnh mn tnh gy thng tn nng lan to cc thu gan. c im thng tn l m x pht trin mnh, ng thi cu trc cc tiu thu v mch mu ca gan b o ln mt cch khng hi phc c (irreversible) 2. Nguyn nhn: - Vim gan do virut: virut B, virut C (khng A, khng B) - Nghin ru: ung nhiu v ko di nhiu nm. - X gan do tc mt,do mch mu,do ri lon chuyn ha di truyn,.. - Do sd thuc v ho cht cha bnh gy tn thng gan: oxyphenisatin (cha to bn) clopromazin (cha bnh tm thn), INH, Rifampycin (cha lao), hoc sd cc ho cht c hi gan nh aflatoxin, dioxin - S thiu dinh dng, gy tnh trng gan nhim m, sau dn n x gan. - K sinh trng: sn mng (schistosomia mansoni) sn l nh (clonorchis sinensis). - X gan cn nguyn n: c mt t l khng t, x gan khng bit nguyn nhn. 3. Phn loi: a. Theo hnh thi hc: c 3 loi x gan:X gan cc ti to,x gan cc ti to to,x gan mt ng ta cn phn chia thnh cc loi: x gan ph i, x gan teo, x gan c lch to. b. Phn loi theo nguyn nhn: VD:x gan sau vim gan virut B hoc C,x gan do ru,x gan mt: tin pht - th pht,x gan do ho cht v thuc II. Cc biu hin lm sng 1. Th x gan tim tng C x gan nhng khng c triu chng lm sng. Pht hin ny ch l s tnh c phu thut bng v mt nguyn nhn khc, quan st gan thy c hnh nh x. 2. Th x gan cn b tt: 2.1. Lm sng: + Ri lon tiu ho: n khng tiu, y bng, chng hi. + Tc nh vng h sn phi. + Chy mu cam khng r nguyn nhn. + Nc tiu thng vng xm. + Suy gim tnh dc. Nam gii: lit dng, n gii v kinh, v sinh. - Thc th: + C th gan hi to v chc, lch to qu b sn. + C mao mch lng v ngc, mn lng bn tay. + Lng nch, b phn sinh dc tha tht.
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+ Mng tay kh trng. + nam gii: tinh hon teo nho, v to. 2.2. Xt nghim: - Xt nghim ho sinh v gan c mt s ri lon: + in di protein: albumin gim, gama globulin tng. (A/G < 1) + Maclagan tng trn 10 n v. + Nghim php BSP (+). - Siu m: c s thay i kch thc gan v vang m ca nhu m gan th, khng thun nht. - Soi bng v sinh thit: cho thy hnh nh gan x. 3. Th x gan mt b: 3.1. Lm sng: - Ton thn: gy st nhiu, chn tay khng khiu, huyt p thp. - C nng: + Ri lon tiu ho thng xuyn, chn n, n khng tiu, a phn lng, sng phn. + Mt mi thng xuyn, t ng, gim tr nh. + Chy mu cam, chy mu chn rng. - Thc th: + Da mt xm (do sc t melanin lng ng). + Nhiu m xut huyt da bn chn, bn tay, vai v ngc. + Ph hai chn. + Gan teo (hoc to), mt chc, b sc trn mt c u cc. + C c trng, tun hon bng h bng. + Lch thng to hn bnh thng, chc. 3.2 Xt nghim: - Cc xt nghim ho sinh v gan: + in di protein: albumin gim, gamma globulin tng cao. + T l prothrombin gim vi test kohler m tnh. + Nghim php BSP (+) r rt. + Bilirubin mu, men transaminaza tng trong cc t tin trin. - Xt nghim mu: hng cu, bch cu. tiu cu thng gim. Chp v soi thc qun: c th thy gin tnh mch thc qun. - Siu m: trn mt gan c nhiu nt m m, c hnh nh gin tnh mch ca, gin tnh mch lch. - Soi bng: khi lng gan c th to, c th teo. nht mu. trn mt gan c nhng hn nh u, hoc hn to nh khng u, dy chng trn xung huyt, lch to, c dch bng. Cc bin chng ca x gan: + Chy mu tiu ho do v gin tnh mch thc qun + C trng: do tng p lc tnh mch ca v suy gan lm cho cc t vim cng nng v kh cha. + Ri lon no - gan dn n hn m gan. + Hi chng gan - thn: do trong x gan s tun hon nui dng thn gim st, dn n suy thn cng vi suy gan.
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+ Cc nguy c nhim khun: vim phc mc t pht do nhim khun, nhim khun huyt, lao phi. + Lch to v cng tnh lch dn n h bch cu, tiu cu, HC + Ri lon v ng mu + Nhng bnh hay i cng vi x gan: lot d dy- hnh t trng, thot v thnh bng ( bnh nhn b c trng to), si mt. + Ung th gan trn nn x (coi x gan l mt trng thi tin ung th). IV. iu tr v d phng 1. iu tr a. Ch n ung, ngh ngi - Trong t tin trin, c trng xut hin: bnh nhn cn c ngh ngi tuyt i, nht l nm vin. - Ch n: cht, hp khu v bnh nhn, calo, nhiu m,nhiu sinh t, hn ch m, ch n nht khi c ph n. Khi c du hiu tin hn m gan phi hn ch lng m trong khu phn thc n. b. Ch thuc men: + Thuc lm ci thin chuyn ho t bo gan v cc hocmon glucococticoit: - Thuc lm ci thin chuyn ho t bo gan:Vitamin C, Vitamin B12, Cyanidanol - Thuc Glucocorticoid (ch dng trong t tin trin ca x gan do vim gan virut, x gan mt): VD: Prednizolon - Testosteron (tng cng chuyn ho m, khi dng phi theo di kim tra): - Flavonoit Sylimarin (bit dc Carcyl, Legalon) - Y hc dn tc: cc bi thuc: nhn trn, Actiso, tam tht, mt gu... c tc dng iu tr tt i vi bnh gan, cn c nghin cu, nh gi y hn. . + Tim truyn dch: - truyn mu ti cng nhm tu mc mt mu. - i vi bnh nhn x gan b gim nhiu protein mu, c bit albumin th nn dng plasma m c v dung dch albumin 20% hoc truyn cc loi m tng hp: alvezin, moriamin + iu tr c trng: - Dng thuc li tiu chng thi kali: VD:sd Aldacton nu c trng gim t th c th chuyn sang dng nhm thuc li tiu mnh hn nhng mt kali nh: Furocemid (Lasix - i vi trng hp c trng dai dng vi thuc nh trn khng c kt qu th phi chc ht nc c trng nhiu ln (thm ch rt ht nc c trng), kt hp truyn Albumin, Dextran tnh mch. + iu tr x gan khi c v gin tnh mch thc qun gy xut huyt tiu ho: - Truyn nh git tnh mch Glanduitrin 20 - 40 n v ho trong Glucoza 50% 300ml. - Ni soi cm mu bng tim thuc gy x ho ch chy mu (polidocanol). 2. D Phng: - Phng vim gan virut B v C:cc bin php v sinh, tim phng virut B,v trng v kh khun tht tt trong tim chc, chm cu, loi b ngun mu c virut B... - Chng thi quen nghin rn.
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- Ch n ung cht. - Phng nhim sn l gan nh: khng n c sng. - iu tr tt cc bnh ng mt. - Thn trng khi dng cc thuc c th gy hi cho gan. - D phng phng iu tr tt cc bnh vim gan cp, mn tnh.

Bi 4: Vim gan mn tnh Ii cg 1. Khi nim:VGMT l bnh gan c tn thg vim v hoi t t bo gan , s x ha khng ng k 6 thng. 2. Mt s ng.nhn Do virus: HBV, HCV, HDV, HGV, HEV, -nguyn nhn nhim c: do ru gy tn thg gan nng n, thuc l,ha cht, sd thuc khng ng cch, ng liu,loi thuc(thuc an thn Aminazin ) - Cc bnh l t min v nguyn nhn tim tng II- Triu chng LS 1. LS -Mt mi: thg l triu chng gi bnhan i khm. - St nh, au tc vng gan, ri lon tiu ha, nc tiu vng. -Gan to, mt chc: 100% - Da, nim mc vng, -> nu c Mt mi, au tc vng gan, gan to, chc l c th khng nh c. 2. Cn LS: sd cc XN sinh ha nh: GOT(AST), GPT(ALT), GGT, Albumin, Prothrombin,Bilirubin min dch nh: HBV,HCV, HDV.. III-Phn loi:c nhiu cch phn loi, hay sd hn l; 1. theo nguyn nhn chia ra thnh: -VGM do virus:HBV,HCV,HDV,.. -VGM do nhim c: ru, thuc l, ha cht. -VGM t min. -VGM khng r ng nhn. 2. Cn c vo tn thng m hc v tin trin ca bnh, ngi ta chia vim gan mn ra cc loi sau ( t nh n nng ) : Vim gan mn tn ti, vim gan mn tiu thy v vim gan mn hot ng. IV.iu tr vim gan mn i vi vim gan mn do thuc v cht c : khng cho bnh nhn ung ru, ht thuc l hoc gim dn dn,lu trong tip xc vi cc loi ha cht c hi. ch cn ngng thuc hoc cch ly vi cht c, ngh ngi l bnh c th t khi
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i vi vim gan mn tn ti v vim gan mn tiu thy nu c ngh ngi v ch dinh dng hp l th a s cng thng tin trin n khi hon ton ( tr nguyn nhn do virut ). Do vy ni n thuc iu tr vim gan mn th ch yu l i vi vim gan mn th tn cng Nhng nhm thuc chnh c s dng trong iu tr VGM l : - Thuc tc ng ti tnh trng min dch + Thuc c ch min dch : corticoid + Thuc iu bin min dch : levamisol + Thuc kch thch min dch : Thymogen, Thymodulin ( Thymocom ). - Thuc khng virut : Lamivudin, Ribavirin. - Interferon alpha ( IFN ) - Thuc c ngun gc thc vt ( tho dc ) -i vi vim gan do virut +trg hp VGM do virut B: tri khi + ALT, AST 2N (gp 2 ln bnh thg), + khng nguyn nhn HBeAg(+)/(-), + HBV-DNA > 3.102cps/ml (y l tiu chun chnh) + H ch s hot ng m hc: HAI> 4 im. Cc thuc : - cc dn cht ca Guanin: Lamivudin, Adefovir: hiu qu n 4050% nu sd lin tc, trong k nghim ngt. - Interferon ( IFN ) + Ch nh iu tr cho bnh nhn vim gan mn tn cng c men Transaminase tng, HBV DNA thp v thi gian mc bnh ngn ( < 1,5 nm ) Nhng trng hp ny thng cho kt qu iu tr kh quan hn. + Liu v thi gian iu tr : thp nht l 3 triu UI/ ngy n 10 triu UI/ ngy tim bp tht hoc tim di da hng ngy hoc 3 ln/ tun ( cch ngy ). Thi gian iu tr t nht l 4 thng. + Tc dng ph : st, hi chng gi cm , c ch tu xng ( nh ), rng tc, mc ban, nga, a chy, c th vim tuyn gip t min ( him )...Tc dng ph mt nhanh sau khi ngng thuc. Thuc phi bo qun thng xuyn nhit 2 8*C v gi thnh hin nay l rt t. - Lamivudin Lamivudin l cht ng ng ca nucleoside, c hot tnh khng virut do c ch men sao m ngc, nn c ch tng hp HBV DNA. Lamivudin c s dng iu tr vim gan mn do HBV v iu tr ngi nhim HIV/ AIDS . Thuc hp thu nhanh, dung np tt, v rt t tc dng ph. Thuc lm lm gim nhanh nng HBV DNA, lm mt HBeAg, men Transaminase tr v bnh
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thng. Nhng trng hp c s t bin gen Polymerase ca HBV ( gi l t bin YMDD ), tip tc iu tr bng Lamivudin thy vn c tc dng. Liu dng : vin 100 mg, ung 1 vin/ngy, ung hng ngy, ko di t nht 1 nm. c nghin cu cho thy iu tr di hn ( hai, ba nm ) tc dng tt hn. C bnh nhn iu tr 4 nm thuc vn dung np tt. - Thuc ngun gc thc vt : Hin nay c nhiu loi thuc c ngun gc thc vt ang c ng dng iu tr vim gan cp v mn do HBV... Tuy nhin, chng minh cc thuc ny c tc dng iu tr vim gan mn do HBV cn c nghin cu mt cch nghim tc, vi s lng bnh nhn ln hn, Mt s thuc c cc tc gi Trung Quc v Vit nam s dng l : + Phyllantus ( Phyllantin...), c chit xut t cy Dip h chu ng hay l cy ch rng ca ( tn khoa hc : Phyllantus amarus schum ). + Haima : c chit xut t cy c gai leo ( Solanum hainanese ). - iu tr kt hp thuc : + Corticoid trong 6 tun (Prednisolon : 60 mg/ngy x 2 tun, sau gim xung 40 mg/ ngy x 2 tun tip v 20 mg/ ngy x 2 tun cui ), tip theo dng IFN ( liu lng v cch dng nh trn ) : Hiu qu ca IFN tang ln. + IFN + lamivudin ( liu lng v cch dng mi thuc nh trn ) + IFN ( nh trn ) + thuc kch thch min dch ( Thymocom, Thymomodulin... ) 80 mg x 1 2 vin/ ngy x 6 12 thng. + Trg hp VGM do HDV : IFN liu cao : 9 triu UI/ ngy x 3 ln/ tun. Hiu qu km hn v d ti pht khi ngng thuc. +Trg hp VGM do HCV: IFN c hiu qu tt hn, liu 2 5 triu UI/ ngy x 3 ln/ tun x 6 thng. IFN + Thuc khng virut ( Ribavirin, vin 200 mg x 5 - 6 vin/ ngy x 1 nm ). i vi vim gan mn t min : - corticoid liu php : Prednisolon 20 mg/ ngy, tng ln cho ti liu tc dng, sau gim n liu duy tr, ko di 6 - 12 thng. Khi ngng thuc li ti pht v khng ngn c x gan. - Corticoid + Azathioprine ( 50 mg/ ngy ).

Bi 2: Bnh vim lot dd-t trng

Bnh sinh:hin cha r,trong nhng nm gn y,ng ta tm ra VK Helico Bacter- Pylori (HP) trong dd v ta trng.l nguyn nhn chnh gy ra bnh lot dd- t trng, tuy nhin dn n bnh cn nhiu nguyn nhn: yu t TK, thin tai, cc thuc Non-steroid. - Cc yu t tn cng: Pepsin, HCl, HP, NSAIDS, ru, thuc l. - Cc yu t bo v: Mucin, lp nhy, NaHCO3. ->Lot l s vt tri ca yu t tn cng so vi yu t bo v.
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I- Triu chng 1.LS * C nng: -au khu tr vng thng v,au m nhng cng c cn tri ln, au theo gi nht nh trong ngy. - Ri lon tiu ha: + hi, chua. +y bng, chm tiu, n ung km, bun nn hoc nn. + To lng tht thg -Suy nhc TK: hay cu gt, nhc u mt ng, suy gim tr nh. * Thc th : + khm bng trong cn au:im thng v au(lot dd), im mn vhnh ta trng au(lot hnh ta trng) + khm bng ngoi cn au: Khng pht hin c du hiu thc th 2.Cn LS: - Xt nghim u tin c gi tr nht l ni soi: cho bit v tr v tnh cht vt lot, - Chp X-quang:cho bit hnh nh gin tip v lot. - XN dch v: tng toan, tng tit, tng pepsin. II-Bin chng Cc bin chng Lot dd Lot t trng Chy mu 20%, nng kh 10% 20-30%, ti pht 40% Thng 5-10% 15-20% Ung th ha 10% Hp mn v 80% Vim dnh cc tng ln cn khng Nhiu III-D phng v iu tri 1-D phng: Lm vic, sinh hot diu , trnh mi kch thch qu mc. n ung y hp l, ko ung ru nhiu, tri cc bnh vim nhim c lien quan: ming, mi, hng.thg xuyn ktra sc khe pht hin sm bnh lot. 2-iu tr: * Nguyn tc tri: Ton din, c h thng, ng phc , thi gian,Mang tnh c th, tri ngoi khoa khi c bin chng or tht bi tri ni * Mc ch: Lm gim au hn, lin so nhanh, d phng ti pht. * tri ni khoa: - Nhm gim tit: + Nhm hy m cholin: Atropin v cc ch phm. Thuc c td gim tit tt, ct au nhanh, nhng nhc im l lm tim p nhanh, kh ming,ng t gin. Nhm C chn lc m1 cholin: ch yu tri chc nng tit, chc nng vn ng ca d dy (t nhc im hn). VD: Gashozepin, Pypenzepin, Buscolipsin. + Nhm C th th H2:th th H2 duy tr chc nng tit ca dd, b l tit dch v khi i, thuc: Cimetidin, Ranitidin, famotidin, Nizatidin Td ph: C dn truyn trong c tim lm ri lon dn truyn tht,lm gimar tnh dc (b l thuc Cimetidin), + Nhm C bm proton:Bm proton vn chuyn K+ ra ngoaif, H+ vo trong qua men ATPase, Cc thuc: Omeprazol, Lanzoprazol, Pantoprazol, Rabeprazol, Esomeprazol. Nhm thuc ny gim tit ti 80% dch tit ca dd, td ph gn nh rt t. -Nhm antacid(trung ha dch v) + thg sd Maalox (Mg(OH)2, Al(OH)3)
12

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+ Thuc Nabica (NaHCO3)nhiu td ph, d gy kim ha dch dd-> hin nay it sd, ch sd tri trong nhng cn cp, hoc cho ngi cn thay i cn bng kim toan: Gut, -Nhm thuc khng sinh: + Nhm cyclin(tetracyclin, Doxycyclin), nhm -lactam(Amoxycilin), nhm Macrolid(Clarithromycin,hin cha b khng thuc), sd nhm metronidazol(timidazol) thg sd kt hp vi nhm C bm proton, v nhm bng se nim mc. -Nhm bng se nim mc: Bismuth(B) dois dng v c v di dng nh tg c td rt tt,bit dc l Trymo(ca n ), Denol(ca Anh ). C ch: nhng gc S-H ca B trong cu ni S-S gn vi Albumin ha tan trong t chc lot, ngn acid tn cng. Thn trng khi sd vi ng suy gan, thn, c tin s ng kinh. + ngoi ra cn sd sucrafat,gastropulgite, smecta(t st hay cao lanh) Sucrafat: l ng a phn t, khi ung vo s kt hp vi dch mt,gel bm vo y lot, ngn s tip xc. -Nhm tn ti to nim mc: +Nhm tng Prostaglandin E(1,2) gip tng ti mu, tng tit nhy, v gim tit dch.Cc thuc nh Mysoprostol(Cytotec, Gastec) td tt, chng li s tn cng ca cc thuc nhm NSAIDS Chng ch nh(CCD): PN c thai, i lng, au bng. +Nhm gin tip tng Prostaglandin: Dimixen, selbex. -Nhm nng cao sc khng:Cc vitamin B1,B6,PP,C -Cc thuc an thn:Andaxin,seduxen, Thuc ng y:mt ong, l khi, n s 12

A2
Bi 1: SUY TIM
1. nh ngha - Suy tim l tnh trng tim ko kh nng cung cp mu, nhn mu theo yu cu c th c khi ngh ngi v khi gng sc. 2. C ch bnh sinh Cung lng tim (CO) = th tch nht bp x tn s tim/pht Cung lng tim ph thuc nhiu yu t: sc co bp c tim, tn s tim, tin gnh, hu gnh - Sc co bp c tim: ph thuc + TB c tim + Mch vnh + th cm th
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+ h catecholamine + nng Ca2+ - Tn s tim: ph thuc + h TKGC + h catecholamine + cc bnh l ca nt xoang v ng dn truyn - Tin gnh: ph thuc + p lc MP + th tch mu v tim + H RAA + Nng hormone ADH - Hu gnh (co v gin mch ngoi vi): ph thuc + th cm th + h RAA + th cm th AT1 ca angiotensin + nng Na+, Ca2+ + yu t ni mc mch mu 3. iu tr a. Nguyn tc - iu tr theo nguyn nhn - Loi tr cc yu t lm nng bnh - iu tr bng thuc phi hp vi cc bin php ko dng thuc - iu tr thay th: ghp tim b. Cc bin php ko dng thuc - Hn ch vn ng, ngh ngi th gin, trnh stress - Hn ch cnn nng nu bo ph - Hn ch lng mui n vo (<2g/ngy) - Hn ch nc ung vo (<1,5l.ngy) - Thm phn v lc thn khi ko c p ng vi thuc li tiu - Ngng thuc gy gim sc co bp c tim: thuc C GC, chn dng Ca, thuc iu tr lon nhp tim - Th oxy ngt qung - Ngng ht thuc l, ung ru c. Thuc iu tr suy tim SD thuc theo giai on bnh nhm ngn chn tin trin ca bnh, gim s ln nhp vin, ko di thi gian sng. - Thuc li tiu:
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+ li tiu nhm thiazide: hypothiazid 25,50mg x1-4v/ngy, gy h k mu=> cn b sung K bng Kaliclorid 600mg x 1-2v/ngy + li tiu quai: lasix 20mg x1-4 ng, tim bp hoc TM, cng gy gim K mu. + Thuc li tiu ko gim K mu Spironolacton, aldacton 50,100mg x1-4v/ngy\ Triamterpen 100mg x 2 ln/ngy Amilorid 5-20mg/ngy =>chng ch nh vi cc BN tng K mu - Thuc cng tim nhm Digitalis + tng sc co bp c tim qua s C men Na-K ATPase mng TB, lm tng nng ca Ca ni bo, gy sc co bp c tim + ch nh: suy tim cp v mn c tn s tim nhanh, cung ng nh, rung nh, cung nh. +chng C: Nhp tim chm 50CK/pht Block tim, RL dn truyn ang dng cc thuc c Ca Nhy cm vi thuc digitalis hoc ang c nhim c digitalis + PP s dng: Suy tim nng cp tnh c ch nh dng ouabain hoc digoxin tim TM cng vi cc thuc khc t suy tim bng pht: chia 2 giai on: gd u a nhp tim v bnh thng (50-100CK/p), sau chuyn sang gds au h liu thuc digitalis duy tr nhp tim bnh thng trong 7-15 ngy. Suy tim mn 3 v 4, phi ung thuc cng tim lin tc, ko di, nhng phi d phng nhim c thuc. o Trong khi dng thuc phi theo di hng ngy tnh trng nhim c thuc: nhp tim chm, lon nhp o nn, bun nn, i lng o mt nhn b ri lon cc mu vng, , xanh o suy tim ko gim m nng them o lon thn o nu nh lng c nng digoxin mu > 2,5 ng/ml Nu c nhim c phi c bin php cp cu iu tr, nu ko suy tim c th nng ln v t vong. Thuc dng ph bin hin nay: digoxin ng1/2mg tim bp, TM hoc pha dch truyn, vin 1/4mg ung - Thuc cng tim c td hng phn th cm th , 1, 2 (nhm amin GC)
15

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+ tn loi thuc Adrenalin v nordrenalin Isuprel Dopamine (2,5-10g/kg/p) Dobutamin Methoxamine + ch nh Suy tim cp tnh ( hen tim, ph phi cp) Sc tim, p tim Cp cu ngng tun hon Suy tim c HA thp Suy tim c block tim Suy tim 4, suy tim kh hi phc + chng ch nh Suy tim c tng HA Suy tim c nhp tim nhanh Suy tim c RL nhp tim - Thuc cng tim C c hiu men phosphodiesterase => tng AMP vng trong TB c tim, tng nng Ca2+ ni bo, tng sc co bp c tim. Amrinone, Milrinone - Thuc gip tng chuyn ha ti ty lp th c tim, loi tr cc gc t do: decaquinon. - Thuc gin mch: 3 loi + thuc gin M Gin c trn trc tip: hydralazin 25mg/ngy C knh Ca2+ : nipedifin, normodipin + thuc gin TM: nhm nitrat v dn cht Nitroglycerin Lenitral Imdur + thuc gin c M v TM: thuc C men chuyn dng enzyme convertin: enalaprin, coversyl, captopril.. C ca thuc gin mch: suy tim 1 n 4 CC: HA thp Hp kht l van 2 l, hp kht l van MC Hp M thn 2 bn Hp eo MC bm sinh Gim nng phn s tng mu
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Tng K mu Ko dung np thuc hoc khi dng thuc c nhiu tc dng ko mong mun: ho, ph 2 chi di, d ng.

Bi 2:TNG HUYT P NG MCH H THNG

( Hypertension) I- i cng 1. Khi nim - THA l tng p lc M h thng. Khi o HA theo PP Korottkof, nu HA tm thu 140mmHg v/hoc HA tm trng 90mmHg => THA - Khi o HA lin tc trong 24h, nu TBHA trong 24h 135/83mmHg => THA HATB = (HA tm thu + 2 x HA tm trng)/2 HATB 110mmHg => THA - HA tng 220mmHg => cn THA kch pht - BN c iu tr phi hp 3 loi thuc chng THA liu TB trong 1 tun m HA vn 140/90 => THA khng tr - BN tip xc vi BS v nhn vin y t m HA tm thu tng hn 2030mmHg v/hoc HA tm trng tng cao hn 5-10 mmHg => THA o chong trng. 2. T l THA - VN: 10,62% DS, t l tng dn theo la tui, nam > n, thi k tin mn kinh nh nhau. - M: 8%, Thi Lan: 6,8%... 3. Phn loi THA - THA tin pht ko r nguyn nhn => bnh THA, chim 90-95% - THA th pht (c nguyn nhn) chim 5-10% 4. Phn THA Bng phn THA theo WHO(2003) ngi >18t

HA v THA Bnh thng ti u Bnh thng Bnh thng cao THA

HA tm thu (mmHg) <120 <130 130-139

17

HA tm trng (mmHg) <80 <85 85-89

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1 2 THA n c tm thu HA ranh gii gia bnh thng v bnh l

140-159 v/ hoc 90-99 160-179 v hoc 100-109 >140 v <90 140-149 v <90

5. Phn chia giai on THA - Gd1: THA nhng cha c bin chng tn thng cc CQ ch - Gd2: THA v c t nht 1 du hiu tn thng CQ ch + ph i tht tri ( bng in tm, X quang hoc siu m) + hp M vng mc (ton th hay khu tr) + Protein niu v/ hoc tng nh creatinin mu t 12-20mg + mng va x MC, M i hoc M cnh - Gd3: bnh gy nhiu bin chng, THA km theo cc tn thng CQ ch nng: + tim: au tht ngc, nhi mu c tim, suy tim + no: cn thiu mu no thong qua, tai bin mch mu no + mt: xut tit hoc xut huyt, c hoc ko c ph gai th + thn: creatinnin mu > 20g/l + M: phnh M, tc M chi di II- Nguyn nhn, yu t nguy c 1. THA tin pht Cc yu t nguy c - Yu t gia nh - Cng thng tm l ko di - n mn 6-10 g mui/ ngy - Bo ph BMI > 23 - Ht thuc l 10 iu/ngy/ 3 nm lin tc - Ung ru 60ml ru mnh /ngy/ 3 nm lin tc - N tin mn kinh hoc > 60t, nam >55t - Ri lon m mu - i tho ng typ 2 - Va x M - t hot ng th lc - Tin s gia nh c ngi rut tht mc bnh tim mch sm n <65t, nam < 55t 2. THA th pht: Nguyn nhn: - Cc bnh v thn:
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+ vim cu thn cp, mn + si thn + vim thn, b thn + vim cu thn cp v mn + thn a nang + suy thn mn + hp M thn + u sn sinh rennin Cc bnh ni tit: + u ty thng thn + hi chng Cushing + cng aldosterol tin pht (Conn) + cng nng tuyn gip Bnh rim mch: + h van MC + hp eo MC + bnh Takayasu: vim, hp MC + va x MC Do dng thuc: + thuc trnh thai + thuc nhm corticoid + cam tho + thuc cng giao cm: epherdrin, adrenalin.. Cc nguyn nhn khc; + nhim c thai nghn + bnh thn kinh: u no tng p lc ni s, vim a dy TK, a u ty xng

III-

Bnh sinh

HA = cung lng tim x sc cn M ngoi vi Cung lng tim = phn s nht bp x tn s tim/ pht HA ph thuc cung lng tim v sc cn ngoi vi: khi tng CLT v/ hoc tng SCNV => THA M h thng CLT v SCNV ph thuc nhiu yu t - Tng hot ngTKGC => tng nng adrenalin v noradrenalin => tng nhp tim, tng co tht M => THA - Hot ha h Renin Angiotensin aldosterol (RAA) => co mch, gi mui, nc => THA

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- RL chc nng TB ni mc M : tng sn sinh cc yu t co mch, gim cc yu t gin mch => tng SCNV => THA - Qu trnh va x M => gim n hi thnh mch, tng sinh lp trong mc M, ph i thnh mch => tng SCNV => THA - Nng ion Na, Ca trong mu => tng co mch v kch thch h RAA. IVLm sng v cn lm sng 1. Lm sng - Tim: THA gy bin chng sm h tim mch + ph i tht tri: ph i ng tm hay lch tri => tng khi lng c tht tri v ch s khi lng c tht tri. + suy chc nng tm trng tht tri => suy chc nng tm thu tht tri => gd sau: suy tim tri huyt (EF% < 40%) + RL nhp tim: ngoi tm thu tht, nhanh tht, rung tht gy t t + au ngc, nhi mu c tim + ph, gin, hp MC, M chu, M chi di - No: + au u, hoa mt chng mt, RL gic ng + cn thiu mu no cc b thong qua + t qu no: t qu xut huyt hoc t qu thiu mu no - Thn: + tiu m nhiu + protein niu + suy thn - Nhng biu hin khc; + ph phi cp + xut huyt mi + au thng v, lot, thng DD hnh t trng 2. Mt s th THA th pht thng gp: - Hp eo MC + V tr: ngay di ch phn chia ra M di n tri, nghe thy ting thi tm thu di n tri v nch tri + HA chi trn cao hn chi di, HA tm thu tng cao, HA tm trng h thp + tun hon bn theo M lin sn + siu m hoc chp MC cn quang xc nh v tr v mc hp ch nh phu thut. - U ty thng thn:
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+ u TB a crome, hay gp ty thng thn v hch giao cm. Nhng TB ny tng tit adrenalin v noradrenalin => co mch, THA vi c im tng cn km theo tng ng mu v tng BC E, tng cc sn phm chuyn ha ca catecholamine trong nc tiu. + xc nh khi u bng siu m, chp CT scanner hoc MRI tuyn thng thn ch nh phu thut. - Hp M thn: + THA do hp M thn lun nng, khng thuc iu tr + biu hin LS: nghe vng cnh rn c ting thi m thu. CLS giai on v sau l suy thn mn. + siu m Doppler M thn hp thy tng tc dng mu, tng ch s tr khng (RI) > 0,7; chp M thn cn quang chn lc xc nh c v tr hp v mc hp ca M thn ch nh phu thut. - Bnh v hi chng Cushing: + bnh tuyn yn tng tit ACTH kch thch lp v tuyn thng thn thnh u tng tit Cortison => bnh Cushing + nu v tuyn thng thn c u t pht => hi chng Cushing + THA thng km theo biu hin LS: mt to trn, bng to, mc ru, vt rn bng, i.., tng glc mu. + nu ch tng chc nng v thng thn th xt nghim nh lng nng cortisone mu v niu thy tng cao. + nu c u th siu m, chp CT scanner, MRI thng thn, s no s gip chn on v ch nh phu thut -Cn THA kch pht: + khi HA tm thu 220mmHg v/ hoc HA tm trng 120mmHg => THA kch pht + c th gp BN v cn hoc THA th pht + c nhiu th bnh, tin lng ph thuc vo nhng bin chng do cn THA kch pht gy ra (VD: nhi mu c tim cp, t qu no) + l cp cu ni khoa thng gp, khi iu tr phi h dn HA cho n khi t mc ch iu tr. V.iu tr THA 1.Nguyn tc -Loi tr cc yu t nguy c -iu tr nguyn nhn gy THA -THA v cn phi iu tr ko di sut i,dng thuc chng THA theo bc thang iu tr ca WHO duy tr mc HA 120-135/80, kt hp vi cc PP khc -Kt hp iu tr bin chng do THA gy ra
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-Tuyn truyn, qun l, theo di nh k iu chnh phc iu tr thch hp cho tng BN 2.Ch ko dng thuc: -Gim cn duy tr BMI < 23 -Hn ch mui < 6g/ ngy -Hn ch ung ru mnh, b thuc l -Ch n ph hp, gim cholesterol -Tp luyn u n ph hp 3.Cc nhm thuc a.Nhm li tiu -Li tiu thi mui nhm thiazide: + hypothiazide 25-50 mg/ ngy, thuc gy gim K mu nn phi nh k b sung K + fludex 2,5mg x 1v/ ngy + natrilix 1,5mg x 1v/ ngy 2 thuc c tc dng ko di, t ri lon in gii, td ch yu gy gin mch -Li tiu quai: + thuc ung furosemide 40mg x 1-2v/ ngy + thuc tim lasix 20mg x 1-2 ng/ ngy, tim bp hoc TM => cc thuc td nhanh mnh => ch dng khi c THA nng v cp cu, sau chuyn thuc khc trnh td ph. -Li tiu ko gy mt K + aldacton + spironolacton + triamteren + diamox =>td li tiu km hn, ko cn phi b sung K, c gi tr i vi 1 s THA do hi chng Conn hoc THA km theo bnh tm ph mn. b.Nhm td trn h giao cm -Nhm td trn h GCT: kch thch th cm th 2 T hoc I1 Imidazoli => trng lc GC ngoi vi => gim HA -methyldopa 250mg/ngy -Lit hch GC: h HA tt, dng nhiu ln/ ngy. Nay dng trong trng hp THA kh iu tr hoc ngi ln tui. Arphonade 250 500mg/ ngy -Thuc tc ng ln th th GC v 1 GC + thuc chn GC: *Cc thuc: propanolol 40mg x 1-2v/ngy, atenolol 20-120mg/ngy.
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*Td ph: gim nhp tim, lot DD t trng,lit dng trm cm *Chng C: tim chm < 60CK/pht, block nh tht II, III, hen ph qun, lot DD t trng ang tin trin, suy tim nng. Ko dng thuc t ngt dn n THA kch pht. + thuc chn GC: *h HA tt nhng c th h HA qu mc ln u *td ph: au u, chng mt, tt HA t th ng. + thuc va c Td chn Gc v GC *gim HA trong cc trng hp THA c suy tim tri, bnh mch vnh *carvedilol 1mg/ngy c.Nhm thuc chn dng Ca2+ + chn dng Ca vo Tb c trn thnh mao mch => gin mch h HA + td ph: ty phn nhm, thng l: au u, ph u chi, mn nga, h HA t th + CC: nhp chm, block tim + nifedipin. Verapamin, madiplot, amlordipin d.nhm thuc C men chuyn dng angiotensin: - C men chuyn t angiotensin I sang algiotensin II + td ph: dng ko di b ho khan, bun nn, d ng, tng K mu + CC: hp M thn 2 bn, hp eo MC, hp nng van 2 l, tng K mu, Pn c thai + captopril, enalapril, coversyl, zestril -Thuc i khng th th AT1 losartan, irbesartan e.Thuc tng tng hp prostacyclin PGI2 Cicletamin 50-100g/ngy F,Thuc gin mch trc tip + dng cho PN c thai THA iu tr thuc khc ko c hiu qu + Td ph: au u, bun nn, tim nhanh, h HA t th ng, c th gy hi chng ging Lupus ban iu tr duy tr ko di bnh THA thng la chn 1 trong s cc nhm thuc, nu cha t mc tiu th phi hp 2 hoc 3 nhm vi nhau, ko phi hp cc thuc trong cng 1 nhm vi nhau. 4 nhm thuc hin nay u tin THA l: thuc li tiu thiazide, chn GC, chn knh Ca,C men chuyn. 4.iu tr THA bng cc thuc YHCT a.Kh cng dng sinh b.Cc thuc li tiu ng y: ru ng, r c tranh, hoa he.

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Bi 3: H VAN NG MCH CH
1. nh ngha: -H van ng mch ch l tnh trng van ng mch ch ng ko kn gy tnh trng mu tro ngc t ng mch ch v bung tht tri trong thi k tm trng. -Bao gi h van ng mch ch cng l tn thng thc th. 2. Nguyn nhn: -Do thp tim l nguyn nhn ph bin nht chim 75% tng s bnh nhn h van ng mch ch.Thp tim lam van vim , dy , co rt lm van ng mch ch h thng km tn thng van 2 l -Bnh tim bm sinh : van ng mch ch c 2 hay 1 l van thay v l 3 l van . -Vim mng trong tim nhim khun ( Thng nhanh chng gy suy tim ) -Bnh to keo : luput ban , giang mai , phnh bc tch ng mch ch => h van cp tnh ( au ngc ), do hi chng Marfan 3. C ch bnh sinh: -Trong h van ng mch ch do van ko dc ng kn nn c s tro ngc dng mu t ng mch ch v tht tri th tm truong lm cho V tht tri tng ln , bung tt tri gin ra => suy tim tri. -Do V tht tri ci tm trng tng nn k tm thu tht tri phi co bp mnh tng lng mu ln hn bnh thng vo ng mch ch gy tng huyt p tm thu => gim p lc tm trng => mu long. -Mch nhanh ( ny cng , xp nhanh ) do V tm thu tng , tm trng gim. -u bnh nhn gt g theo nhp p ca tim - H van ng mch ch mu vo tm trng => au mch vnh -H van ng mch ch thiu mu no => ngt 4. Lm sng v cn lm sng: 4.1- Triu chng c nng -kh t khi gng sc -au tht ngc do thiu mu mch vnh \ -Ngt do thiu mu no
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4.2-Tru chng thc th Khm c triu chng ti tim v ngoi vi *Ti tim : -H van ng mch ch ting tim th 2 m - Nghe ting thi tm trng (m ,du v tr vnh ng mch hng lan dc b tri c xuongs mm tim )=>phn bietj vi h van ng ch phi . * Ngoi vi : -o huyt p : HA tm thu cao , tm trng thp => HA dong -Mch baets ny nhanh, xp nhanh => mch corrigan -Bnh nhn ngi u gt g theo nhp p ca tim => dy hiu Muset. -Nghe (bt mch ng mch i) ting thi tm thu , tm trng (gi l ting thi kp) 4.3- Triu chng cn lm sng *in tim : -Tht tri dy , gin tht tri (in tim ) => trc in tim chuyn tri , ch s Sokolow-Lyon >35 mm -Tht tri to , gin (X-quang) => bong tim to ch yu cung di tri to. *Thng tim : Cn c m ca thuc cn quang xung tht tri nh gi mc bnh nn nh . *Siu m : thy cc dng h ( dng mu tro ngc t ng mch ch v nh tht tri ) cn c din tch dng nh gi mc h. 5. iu tr: * iu tr ni khoa -Phn ln thng thp tim nn phi d phng thp thng dng penicillin tim chm 1 thng /ln , erythromycin tim 1 tun /ln . -iu tr vim ni tm mc nhim khun : iu tr sm khi bnh nhn vim hng , xy xc ngoi da bng khng sinh . -Bnh nhn suy tim : dng thuc cng tim , li tiu , gin mch :
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+Dioxin (rung nh ) => tng V dng mu ( thuc cng tim ) +Nitrat ( thuc gin mch , gim tin ghnh do gim lng mu v tim) +Chn knh calci , c ch vn chuyn ( thuc gi hu gnh ) +Thuc li tiu dung trng hp bnh nhn suy tin tr hay dung clasix nhng ch theo di in gii b cho bnh nhn *iu tr ngoi khoa -M sa van , khu hp cc mp van , nht l trong trng hp do gin ,thng . -Thay van bng van nhn to hay van sinhh hc .Ch cjo bnh nhn dung thuc chng ng Santro, theo di ch so INR lun khong 1,5-3, nu trn 3 tng ng mu .

Bi 4: VA X NG MCH
1. Yu t nguy c: -Tui >=55 , ng mch gim kh nng n hi, cng ng mch do qu trnh lo ha , y l mt trong nhng yu t VXDM. -Gii tnh: Nam gii t l mc cao hn n nhng n tui tin mn kinh th t l mc bng nhau . -Yu t di truyn v gia nh : ang nghin cu nhng thc t i vi bnh nhn VXDM c nhiu gia nh c nhiu th h b VXDM .-Tng HA >= 140/90 mmHg lu ngy ko di =>VXDM pht sinh -Ch s BMI : BMI >=30 -Tng lipid mu : tng cholesteron >=5,5 mmo/l , tng triglyceride >=2,3 mmol/l -Tng glucose mu lc i ( 6,1-6,9 mmol/l ) , ri lon dung np glucose mu , i tho ng tuyp nht l tuyp II ( glucose lc i >=7mmol/l hoc sau khi lm nghim php dung np glucose mu >=11mmol/l) -t hot ng th dc : lm c quan , tr c , vn phng 6-8 h / ngy-Cng thng thn kinh , tm l -n mn : bnh thng 2-6g mui , nht < 2g mui ,mn > 6g mui / ngy =>ion Na+ => tng gi nc => tng huyt p .
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Thc t nhiu ngi n mn ko tng huyt p do tng nhy th cm th cm nhn mui -Tng nng acid uric mu .

2. C ch bnh sinh: V nguyn nhn gy bnh cha r nguyn nhn nn c ch gy bn ch l nhng gi thuyt -Tn thng thnh ng mch : vim , chn , thng , tng HA => tng tc dng chy -i thc bo n nhn : thng l trn mng t bo c cc tiu phn gn lipid khi t bo b tn thng i thc bo xm nhp vo n lp o gia ca ng mch , t bo b hoi t li nhiu nhng tiu phn lipid i din l cholesteron . -Gi thuyt n dng : tai ni tn thng ca ng mch sn sinh ra cht chng li chnh mnh . -Gim hot tnh ca enzyme lipase -Ri lon chc nng t bo lp ni mc ng mch +Tng tit cc yu t gy co mch +Gim tit cc yu t gy gin mch . -Ga thuyt v ty lp th : ty lp th tit men gy tn thng thnh ng mch trn c s pht trin VXDM -Gi thuyt v lipid : nh: +Nhn ca mng VXDM l cholesteron + Ngi c nng cholesteron > 6mmol/l -Ngoi ra cn mt s gi thuyt na nhng tnh thuyt phc ko cao . Kt lun : M tn thng => TB xuyn mch vo lp o gia ca thnh M mang tiu phn lipid (cholesteron ) tch t , tp trung .Sau tn thng MTB => TB cht li di lipid > Ti y cc lien cu , hng cu , bch cu , qu trnh ng mu , s lng ng ion Ca2+ to mng bao bc mng va x =>tit enzymphas hy mng
27

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=> mng va x v nt =>kch hot qu trnh ng mu to thnh nhng cc mu dng . 3. M bnh hc: C 8 mc -Mc 1 : TB c bt -Mc 2 : Di m v TB c bt -Mc 3 : di m nm ngoi TB s lng t -Mc 4 : di m nm ngoi TB s lng nhiu -Mc 5 : tn thng si , to mng lp v bc nhn l lipid -Mc 6 : Mng va x c huyt khi hoc xut huyt -Mc 7 : Vi ha do lng ng calci -M 8 : Lipid ca mng va x c thay bng cht to keo. 4. Biu hin lm sng: *VXDM no -gp M no gia -Giai on u ch l ri lon chc nng hng phn v c ch thiu mu no -Giai on sau c nhng cn thiu mu thong qua -Nng : tc mach no gy t qu thiu mu => lit , hn m, t vong. -Chn don : siu m xuyn s , chp M no , chp no ct lp *VXDM mt : -Ri lon th lc , m do tn thuongr vng mc -Chn on : soi ay mt * VXDM cnh -Hay gp MC chung , MC trong , hp nh <70%ng knh ko gy triu chn lm sng , hp > 70% mi c : thiu mu no=hoa mt chng mt , nhc u -Chn on : siu m , chp MC *VXDM mc treo
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-VXDM trn , di , thng v => thiu mu , lot , thng , ri lon chc nng vng nui dng tng ng . *VXDM thn -Gy hp M thn => tng HA km suy thn -Chn on : siu m , chp M thn cn quang *VXDM vnh -Hay gp M vnh tri =>hp MV => thiu mu MV=> cn au tht ngc , hnh thnh cc mu ng => gy tc mch => nhi mu c tim . -Chn on : da lm sng , din tim , x hnh tim, chp MV l chn on quyt nh . * VXDM ch -Va x giai on gn hoc xa => phnh/phnh bc tch => v M ch = >t t -Chn don : chp X-quang , siu m mch *VXDM chi di -Gp VXDM i chung , M di nng hay su , M chy , M mc , M kheo _Biu hin : c au cch hi , v sau hoi t u chi , c khi phi ct ct -Chn don : siu m Doppler, chp M cnh quang 5. iu tr: Cha r nguyn nhn nn ko iu tr kh c , iu tr gp phn lm chm qu trnh bnh , gim bin chng hn ch tn thng do cc bin chng -Loi tr cc yu t tc ng xu : ht thuc , ung ru , tng lipid mu , iu tr tng huyt p , tc dng liu php , n king , iu tr i tho ng -Dng cc thuc h m mu : dng ph bin 2 nhm +Nhm fibrates : lopid 300mg x1v/ngy , lipanthyl 100,200,300 mg/ngy +Nhm statin : zocor, lipitor 10mg x 1-2v /ngy . -Dng thuc gin mch +ng ch l nhm chn dng calci nh amlordipin 5-10mg x 1v /ngy .=> tc dng n nh mng va x , trnh nt v mng va .
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+i vi bnh nhn i tho ng nn dung thuc gin mch c ch men chuyn dng angiotensin c tc dng bo v thnh mch ,chng qu trnh ti cu tr thnh ng mch nh coversyl 4mgx 1v/ngy. -Thuc c ch kt tiu cu +ai din : pirin i vi d phong cp I , ung ko di nu ko c chng ch nh . +D phng cp II : bnh nhn c triu chng do tc mch => pirin 325mg /ngy . + Ngoi ra cn nhiu nhm khc c th dung dn c hoc kt hp Aspirin nh: dipyridamol 400mg/ngay , ticlopidine 250 mg x 2 ln /ngy , clopidogrel 75mg/ngy -Ch nhng thuc d phng VXDM c ch kt dinh tiu cu u pi ung hang ngy v ko di . -Ngoi ra : iu tr = phng php ng y , y hc dn tc , vt l tr liu, diu tr ngoi khoa bng bin php can thip nh t gi , ly b VXDM , ct ct chi hoai t do thiu mu, phu thut .. -Cc bin php kt hp cc Phng php trn .

Bi 5: CHN ON IU TR MT S RI LON NHP TIM

1. Nhp chm xoang: - bnh thng: 60-99ck/ 1ph, bnh l: <60ck/1ph (<50ck/1ph) - ng/nhn: cng ph giao cm, nhi mu c tim, hi chng yu nt xoang, do thuc nh: chn th cm th giao cm, digitalis, quinidin. - triu chng:au ngc , chong vng, ngt, lm nu ko di dn n suy tim - iu tr: +hy ph giao cm: Atropin- vin/ng (1/2,1/4mg) gy kh ming ,gin ng t Ld:1-2mg/ngy. Tim th 1mg atropin/ tnh mch : ktra p ng thuc +thuc giao cm: adrenalin, noradrenalin, isuprel. Hng phn giao cm: ephedrine 0,01mg 2-3v/ ngy +nhp chm xoang do tng cm xoang ng mch cnh gy ngt th iu tr = phu thut ct tiu th xoang ng mch cnh. + nhp chm xoang do hi chng yu nt xoang hoc ko iu tr c = thuc th phi kch thch tim nh t my to nhp tim.
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2. Nhp xoang nhanh. - bnh l; >100ck/1ph ng ln >120ck/1ph- tr em. -ng/nhn: cng thn kinh giao cm, cng chc nng tuyn gip, st , nhim khun, bnh van tim, bnh tim bm sinh.. -tr/chng: hi hp, nh trng ngc, kh th, t tay chn, au tc vng trc tim. -/tr: +/tr ng/nhn gy nhp xoang nhanh +tin hnh nghim php cng ph giao cm +thuc: seduxen 5-10g/ngy ty theo tn s nhp Nhm thuc chn th cm th giao cm nh;propanolol (40-80g/ngy) Ch td ph ca nhm ny: hen PQ, lot DD-HTT, HA thp 3.Rung nh -l tnh trng tng b si co bp ko ng thi do nhng xung ng kch thch bnh l khc nhau v hng, tgian ,bin .. -ng/nhn:nhim khun cp tnh, nhi mu c tim cp, hp l van 2 l, ng c ru , basedow.. -tr/ chng: hi hp , nh trng ngc , kh th. Xhin cc sng f nh (frilation-rung) Khong cch RR ko u nhau. Bin sng R ko u nhau. -/tr: +/tr bnh gy ra cn rung nh cp tnh: v/phi, NMCT cp, sc.. +dung thuc: digitalis, verapamil, disopyramid, propafenon +o nhp = pp sc in khi v nhp xoang th dung 1 trong s thuc trn duy tr nhp xoang, ch ngng thuc khi ti pht rung nh. +/tr thuc chng ng mu d phng tc mch: thuc khng vit K( warfarin, sintrom ). 4.Rung tht: - l tnh trng tng vng c tht rung ln, cc b si c tht co bp khc nhau, ko ng b do nhng lc v tr trong trong tht pht xung ng lon x gy ra. Hu qu l tim mt chc nng bm mu. Tim ngng p , mt mch , mt thc , t vong. -ng/nhn:hu ht gp nhng ngi c bnh tim nng , suy tim nng do NMCT, bnh c tim tin pht, bnh van 2 l, bnh van MC.. -tr/chng: mt thc t ngt Mt mch ln , cp cu ngng tim , phi ,no HA=0 -cp cu /tr: + th/hin cc bc c/cu ngng tun hon: ly b d vt trong ming, khai thong dng th, h hi thi ngt (bp Mask) +t ni kh qun. +p tim: 80-100l/1ph. +/tr: adrenalin 1mg-2-3 ng/l, tim nhc li sau 15-30ph Tim TM di n Tim vo kh qun ( liu gp i).
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5. Blc tim: -l nhng ri lon to thnh xung ng hay dn truyn xung ng t nt xoang n mng li Purkinje. -ng/nh:cng ph g/cm, thiu mu c tim cc b , bnh van tim, thp tim, vim c tim. -gm : ngng xoang Blc nh tht Blc trong tht. 5.1 ngng xoang: l khi nt xoang ngng pht nhp trong khong tgian ngn -LS: ph thuc vo tng tgian ngng xoang di hay ngn : hi hp nh trng ngc , lim , ngt, t t. -/tr: + /tr ng/nhan gy ra ngng xoang + atropine mg-2mg /ngy, duy tr nhp xoang 60-80ck01ph. + ephedrine 0,012-6v/ngy +isuprel 1-2mg (1-2v/ngy) ngm di li +t my to nhp 5.2.blc nh- tht: chia 3 - 1: PQ>=20 s - 2 - 3: nhp nh , nhp tht thng b/hin = phc b QRST c tn s chm 30-40ck/ph. - 2-3 l nhng ri lon nhp tim nng , thng gy ngt ,lm hay t vong do v tm thu. - tr/chng v /tr ging nhp chm xoang. 5.3.blc trong tht - ng/nh: + bnh tim bm sinh, bnh tim-phi mn tnh , tc MP cp, bnh van MC , tng HA...... + bnh NMCT cp tnh, vim c tim, sau phu thut tim. - LS: + blc nhnh phi b His c th gp ngi b/thng + blc nhnh tri b His ch gp nhng ngi b bnh tim. +nhng ngi b blc trong tht m c bnh tim thng b chong vng. +nhn b/nhn c nhiu blc tim kt hp th c tin lng nng. -/tr :ging nh /tr bloc nh tht.

Bi 6: IU TR RI LON NHP TIM

1.phn loi ri lon nhp tim:
Da vo c ch bnh sinh ca ri lon nhp tim chia 3 nhm: - ri lon qu trnh to xung ng(ri lon nt xoang): nhp xoang nhanh hay chm, ngoi tm thu, cung ng v rung. - Ri lon qu trnh dn truyn xung ng:blc xoang nh, blc nh- tht, blc trong tht.. - Ri lon hn hp(kt hp gia ri lon to thnh xung ng v dn truyn xung ng): phn ly nh tht, hi chng qu kch thch dn truyn sm. *ri lon nt xoang: HC nt xoang bnh l HC qu mn xoang cnh. *ri lon nhp trn tht: ngoi tm thu nh Cung nh Rung nh Nhp nhanh nh, nhp nhanh b ni kch pht 32

107- Dc 11 HC kch thch sm *ri lon nhp tht: ngoi tm thu tht Nhp nhanh tht Cung tht,rung tht Xon nh,nhp t tht. *blc tim: blc nh tht 1,2,3. Blc nhnh phi, nhnh tri& blc phn nhnh.

2.phng php iu tr ri lon nhp tim.

2.1.iu tr = thuc : bng phn loi thuc ca Vaughan-Williams *Nhm1:nhm chn dng Na+(thuc lm gim vn tc cc i ca giai on kh cc do c ch dng Na+ va) +thuc lm gim Vmax tt c cc tn s tim:quinidin, procainamid, +thuc lm gim Vmax tn s tim nhanh:lidocain (IM hoc IV), phenytoin, mexiletin +thuc lm gim Vmax tn s tim bthng: propafenon *nhm 2: thuc chng giao cm- c ch th th giao cm , gim hot tnh nt xoang, gim vn tc dn truyn nh- tht: +propanolol:chn (1&2) +metoprolol: chn 1 +atenolol. *nhm 3: cc thuc ko di tgian in th hot ng t bo( chn knh K+ ra ngoi t bo):Amiodarone(cordarone,sedacorone) vin;0,2g- ng:0,15g *nhm4: thuc chn dng Ca+( gim dn truyn & tng thi k tr) +nifedipine +diltiazem... *1 s thuc ko xp vo bng ny nhng c tc dng iu tr lon nhp :digitalis,isupren, atropin, adrenalin, noradrenalin.... 2.2.iu tr =in : sc in , my to nhp tim... 2.3.diu tr = pp ngoi khoa :ct b phn phnh tim, ct cc ng dn truyn tt...

Bi 7: H VAN HAI L
1.k/nim: l t/trng van 2 l ng ko kn trong th tm thu lm cho 1 lng mu pht
ngc tr li t tht tri v nh tri trong th tm thu. 2. ng/nh: +thp tim: ng/nh hang u +RL cu trc van: sa van,NMCT , thiu mu c tim cc b +bnh c tim th gin +thoi ha van +bnh tim bm sinh: van 2 l hnh d +chn thng :rch l van , thng l van, t dy chng.

3.SL bnh: - h van 2 l ph thuc vo k/thc l h v chnh p gia nh tri v tht tri. Mu di ngc v nh tri trong th tm thu gy mu. Trong th tm trng mu t nh tri v tht tri nhiu lm tng V tht tri cui tm trng, tht tri gin ra dn lm suy tim tri h van nng hn. - mu nh tri lm tng p lc MP, TMP, MMP nhng ko nng = hp van 2 l.
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4.LS 4.1. tr/ch c nng: mt mi hi hp trng ngc, kh th khi gng sc Ho v m Kh th v m, c th c hen tim, ph phi cp. 4.2. tr/ch thc th: mm tim p mnh ,lch sang tri. TM c ni cng , p ny Nghe tim: T1 m, T2 anh tch i Ting thi tm thu chim ton b th tm thu 5. Cn LS: - in tim - X_quang tim-phi - Siu m tim: quyt nh gip /gi t/trng van, vng van, dy chng 6. Bin chng: vim mng trong tim do nhim khun Ph phi cp, bi nhim phi Rung nh &cc RL nhp khc. Tc mch Suy tim tri trc ri suy tim ton b. 7. Chn on phn bit :/bit l da vo s/m tim Doppler - hp l van MC - h van 3 l - thng lin tht 8. iu tr : 8.1. /tr ni khoa: -thuc gim hu gnh lm gim gnh nng cho tim tri v gim lng mu pht ngc : sd thuc C men chuyn v gin mch nu HA cho php Coversyl 4mg -1/2-1v/ng hoc zestril 5mg -1v /ng hoc hydralazin 25mg 1v/ngy - thuc C th th 1 liu thp: betaloc 50mg-1/2-1v/ngy - khi c suy tim r , gim chc nng tm thu tht tri sd them li tiu v digitalis. 8.2./tr ngoi khoa: ch nh phu thut da vo mc h van, tr/chng c nng , mc suy tim tri. -phu thut sa van & dy chng: khu hp vng van, khu l thng, khu vi bt dy chng. - phu thut thay van( van c hc hay sinh hc) : sau thay van dung thuc chng ng ko di (sintrom 1mg/ngy)

Bi 8: HP VAN HAI L
1. k/nim: -van 2 l nm gia nh tri v tht tri gip mu i theo 1 hng t nh tri xung tht tri - van 2 l gm: l van trc v sau . di van l t chc tr c v dy chng. -BT: Svan m th tm trng= 4-6cm2. khi Svan <4cm2 l hp.
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2. ng/nhn: - phn ln l do hu qu ca thp tim, 1 s ko c tin s thp r rng ( thp th n). - bm sinh: van 2 l hnh d, thoi ha van 3. SL bnh: -BT: chnh p qua van 2 l l 4-5 mmHg to /kin cho mu t nh tri xung tht tri. - khi hp : mu nh tri lm tng p lc nh tri , MP gy kh th /bit khi gng sc. - p lc MP tng tim phi tng cng co bp mu v phi dn s suy tim phi. - mu nh tri lm nh tri gin gy thoi ha c nh , rung nh, to c s hnh thnh cc mu ng , tc mch. 4. LS: Tr/chng c nng: - ngi gy mt mi , kh th v m v khi gng sc. - ho nhiu v m, ho ra mu .(do tr t/hon mu) - au ngc hi hp nh trng ngc( do thiu mu vnh, rung nh) - khn ting, nut kh, nghn( nh tri gin chn vo thc qun v tkinh) - t qu no, tc mch chigy cn au d di cp tnh( tr/chng do tc mch) tr/chng thc th - T1 anh mm - T2 anh, tch i lien sn 3 cnh c tri - Clc m van 2 l:l tr/chng q/trng khi c hp kht l van 2 l. Nu c h van 2 l kt hp th tr/chng ny ko r na. - Rng tm trng mm, nghe r khi nghing tri: tr/chng hay gp tuy nhin trong: hp hnh phu l van 2 l, vi ha hon ton l van v vng van th ko nghe thy. - Ting thi tin tm thu - C th nghe ting thi tm thu mi c hay ting thi tm trng lien sn 2,3. - Tr/chng lon nhp tim, tc mch 5. cn LS: in tm Xquang Siu m tim: siu m TM , siu m 2D, siu m Doppler + siu m 2D: o Svan bit mc hp Hp nh: 2,5-4 cm2 Hp va: 2,5-1,5cm2 Hp kht: <1,5 cm2 Hp rt kht: <1cm2 + siu m Doppler: o chnh p qua van bit mc hp Mc chnh p ti a qua van 5-10mmHg
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Mc hp l van 2 l Hp nh

107- Dc 11

Hp TB Hp nng

10-15mmHg >15mmHg

6. Chn on phn bit: phi da vo siu m tim p/bit vi: - u nhy nh tri - h van MC nng - hp l van 3 l - bnh c tim ph i 7. Bin chng : 4 nhm bin chng: - bin chng cp tnh lquan n ri lon huyt ng - bin chng lquan n ri lon nhp tim - bin chng lquan n tc mch - bin chng lquan n nhim khun 8.iu tr 8.1. nguyn tc: /tr ng/nhn gy hp /tr thp tim & d phng thp tim ti pht /tr ti ch hp( thay van , nong van) /tr suy tim, cc bin chng ch sh lao ng ph hp vi tng bnhan. 8.2. iu tr ni khoa:hn ch lao ng gng sc, n nht - sd thuc cng tim: digitalis ch sd khi c rung nh - suy tim phi , HA thp sd nhm amyl cng tim( heptamyl, dopamin) - dung thuc chn g/cm /tr nhp tim nhanh trong hp l van 2 l( betaloc, concor) - thuc li tiu & nitrat sd khi suy tim phi, tng p lc MP Thuc li tiu: lasix, hypothiazid. (bsung K+ trnh ha kali mu) - /tr tc mch: d phng = heparin, fraxiparin, sintrom, aspirin. - /tr ri lon nhp = thuc , sc in 8.3. iu tr ngoi khoa: - nong bng qua da - nong van 2 l kn =tay - phu thut sa cha to hnh van - phu thut thay van D nong van hay thay van th vn cn k/hp vi /tr ni khoa d phng thp tim ti pht, chng ng mu, RL nhp ko di c/sng cho b/nhn.

A3
Bi 1: MT S BNH H HP.
1.Vim ph qun cp: vim nim mc ph qun, thc y qu trnh cht t nhin ca nim mc ph qun. Sau vim khng li di chng.
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2. Vim ph qun mn: vim ph hy cc lp c, sn, nim mc dn dn b teo t bc l nt thn kinh.Khi c cc kch thch nh gy ho, co tht c trn ph qun, gin ph qun. Ho khc mi nm 3 thng tr ln,2 nm lin tip tr ln. 3. Hen ph qun: S co tht c trn ph qun do s tng kch thch ca ng th(mun cha hen phi iu tr vim ph qun mn).Thuc iu tr: corticoid(khng nn lm dng,khng dng vi ngi mi mc,tr em). 4. Gin ph qun: Gin khng hi phc cc ph qun c sn. Gin ph qun gy ph hy mch mu ho ra mu.Tuyn nhy b kch thch bnh nhn thng hay ho khc (ho kh: ho ra mu hoc ho t: khc nh m ) . 5. Ung th ph qun: bnh do nhiu c ch : virus, ho cht, vim mn tnh lu ngy - Thuc l: +gy c ch cc dung mao, ri lon hot ng dung mao. +c ch i thc bo, khng th trong ng h hp. gy vim nhim, ph hy ph qun gy nn bnh kh ph thng, vim ph qun mn. +Cc cht trong thuc l gy t bin cc t bo ph qun Ung th phi nguyn pht. 6.COPD: bnh phi tc nghn mn tnh: vim ph qun v kh ph thng khi c ri lon tc nghn khng hi phc. 7. Vim phi: c 2 loi: - Vim phi cng ng: tt c cc bnh vim phi mc ngoi bnh vin(nguyn nhn do t cu,ph cu,lin cu,virus) - Vim phi bnh vin: bnh nhn nm bnh vin(> 72h) b mc vim phi. 8. Apxe phi: s hoi t phi. Nguyn nhn: vi khun,amip. 9. Trn dch mng phi: do lao, ung th lm tng tit dch l thnh giam hp thu dich l tng gy chn p phi, bnh nhn khng th c. 10. Trn kh mng phi: do thng phi( do kh ph thng) kh trn ra ngoi, chn p phi gy tc th. 11. lao phi: do vi trng lao gy tn thng mn tnh phi, c bin chng(ho ra mu, suy kit). Bnh ny ly qua ng h hp.

Bi 2: LAO.
1.Tnh hnh lao Vit Nam: - T l mc lao hin nay cao(Vit Nam ng th 13 trong 22 nc c s bnh nhn lao cao trn ton cu). - Chng trnh chng lao ch t hiu qu 85%. - Sau i dch HIV, lao pht trin nhiu. - Tnh trng lao khng thuc ngy cng tng. - Chn aons lao l vn rt kh. - iu tr lao c hai phc : iu tr lao mi v iu tr lao ti pht. 2. Lm sng: - Ho khc m trn 2 tun. - St v chiu. - Ho ra mu ti c ui khi huyt(s lng gim nhng mu mu tng dn). - Tn thng nhiu 2 phi nn gy kh th. - Ran n ri rc nht l na trn hai phi. 3. Cc phng php chn on lao:
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- Chn on bng lm sng: hi, khm, hi bnh s(cc triu chng ton thn gi cho hi chng nhim c, triu chng c nng, triu chng thc th) ca bnh nhn, nhng nguy c mc lao(tiu ng, dng corticoid ko di, phu thut ct d dy). - Chn on bng X Quang : mang tnh nh hng, c du hiu tn thng sau: + Tn thng nt: ht k, nt nh, nt ln. + Tn thng thm nhim. + Tn thng hang. + Tn thng x: trong tn thng lao thng c x ha. + Vi ha: trong lao c, lao mm tnh, di chng lao n nh. - Chn on bng vi sinh: tm thy vi trng lao trong m(BK). + Vi trng lao gm 3 loi: lao b, lao chim, lao ngi. + Vi khun lao khng cn v khng acid(AFB: acid fast bacilli). Cy trong mi trng thng thng sau 2 thng mi mc, cy trong mi trng ng v C14 sau 14 ngy mc. + Phng php thc hin: soi trc tip, phng php thun nht, nui cy, phng php tim truyn ng vt(dng trong phng th nghim), cy BK h thng, k thut PCR(c th gy dng tnh gi: nhy: 100%, c hiu: 50%). - Thm d min dch: + Test tuberculin: phn ng mantose, phn ng chm, tim vo tay sau 48 72h c kt qu. + ELISA(enzyme linked immuno sorbent assay ): dng khng nguyn BK pht hin khng th khng lao trong huyt thanh hoc dch no ty ca bnh nhn lao, phng php ny c nhy v c hiu tng i cao. - Xt nghim m bnh: c gi tr quyt nh chn on . + Sinh thit(phi, mng phi, mng bng, thanh qun, ph qun): bnh phm chn on m bnh nang lao(thnh phn: hoi t b u gia, xung quanh c cc t bo bn lin v cc t bo khng l Langhans, ngoi cng l cc lympho bo ) quyt nh chn on lao. + Chc ht dch ni tn thng( hch, ty, mng ht dch khp) xt nghim t bo hc xc nh s c mt cc thnh phn ca nang lao ring r gi chn on v chn on phn bit. - Ni soi: ph qun, mng phi, thanh qun Qua ni soi thy thuc c th thy r tn thng trong cc c quan ny. - iu tr th: bin php cui cng khi cc bin php trn khng c hiu qu. + Nguyn l: iu tr theo hng khi nhanh. Dng khng sinh sau 5 7 ngy chp X Quang tn thng ht: iu tr vim phi. tn thng khng ht: iu tr th. + iu tr th lao: mnh, thi gian(t nht l 1 thng) chp X Quang tn thng gn nh ng im. 4. iu tr lao: 4.1 Mc ch v nguyn tc: 4.1.1 Mc ch: - Tiu dit ht khun lao trong tn thng khi bnh v trnh ti pht, hn ch cc bin chng v hn ch t vong. - Dp tt cc ngun ly vi khun lao cho cng ng, lm gim t l nhim lao hng nm v gim s bnh nhn lao mi mc lao hng nm tin ti thanh ton bnh lao. 4.1.2 Nguyn tc iu tr:
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- iu tr phi hp t nht t 3 n 4 thuc. - Dng thuc thi gian trnh ti pht. - iu tr theo 2 giai on: giai on tn cng(2 3 thng), giai on cng c (4 6 thng i vi lao mi v 6 9 thng i vi lao c). - Mi loi thuc phi dng ng liu. - Dng thuc ng gi, u n(ngy 1 ln trc ba n tra 2 h). - iu tr c kim sot. - Ch : trong qu trnh iu tr phi thng xuyn kim tra chc nng gan, thn. 4.2 Cc thuc iu tr lao: 4.2.1 Phn loi: - Theo tc dng: + loi ch yu: rifampicin, isoniazid + loi hiu qu tt: streptomycin, ethambutol + loi th yu: PAS, kanamycin - Theo hot tnh chng lao: + Loi trit khun; rifampicin, pyrazinamid + Loi dit khun: isoniazid, steptomycin + Loi ngng khun: ethambutol 4.2.2 Cc thuc hay s dng: * Isoniazid (H): - bit dc : rimifon, rimicidthuc dit khun mnh ngoi bo v ni bo. - hm lng: vin 0.05; 0.1 ;0.15g. - liu lng: +hng ngy: 5mg/kg/24h +ngt qung: 12 15 mg/kg/24h. - tc dng ph : vim gan(nht l khi phi hp vi rifampicin), vim thn kinh ngoi vi(cn phi hp vi vitamin B6), ri lon tm thn, lon dng * Rifampicin (R): - bit dc:rimactan, rifadindit khun, trit khun ni v ngoi bo. - hm lng: vin 0.15; 0.3g Loi phi hp vi isoniazid(RH) : 0.25g. - liu lng: liu dng hng ngy v liu dng ngt qung: 10mg/kg/24h. - tc dng ph: + m hi , phn , nc tiu + nng: vim gan, mt, c th gy sc, hn m gan + nh : c hi chng da, hi chng gi cm * Pyrazinamid (Z): - l thuc dit khun v trit khun mi trng toan v ni bo. - hn lng: vin 0.5g. - liu lng: + liu hng ngy: 15 25 mg/kg/24h. + liu ngt qung: 50mg/kg/24h. - tc dng ph: + nng: vim gan, si thn, au khp + nh: ni ban, ri lon tiu ha * Ethambutol (E) : - bit dc: myambutol, dexambutoll thuc km hm s pht trin ca vi khun.
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- hm lng: 0.2; 0.25; 0.4g. - liu lng: + liu hng ngy: 15 20mg/kg/24h. + liu ngt qung: 30 40mg/kg/24h. - tc dng ph: + nng: vim dy thn kinh th gic, gim th lc, hp th trng, c vi thn + nh: ni ban, ri lon tiu ha * Streptomycin (S): - bit dc: thuc dit khun loi sinh sn nhanh ngoi bo. - hm lng: thuc tim l 1g. - liu lng: 15mg/kg/24h. Ngi trn 45 tui nng di 50kg: 0.75g/24h. Ngi gi: 0.5g/24h. - tc dng ph: gy vim day thn kinh s VIII gy ic, ri lon tin nh, d ng, sc phn v, t mi * Ethionamid (ETH): - km v dit BK nng cao. - hm lng: vin 250mg. - liu dng: 10 15mg/kg/24h. - tc dng ph: vim gan, ri lon tiu ha(50%), y bng, chn n, au khp * PAS( acid para amino salicylic). - km hm s pht trin ca BK. - hm lng: vin 0.5g. - liu dng: 150mg/kg/24h - tc dng ph: ri lon tiu ha, vim d dy, vim gan * Cc thuc khc: - Thioacetazon (TB): tc dng ph: ri, lon tiu ha, ban , vim gan, gim tiu cu - Cyclocerin: tc dng ph: c tnh v tai bin: ri lon tiu ha v vim d dy, vim gan - Nhm aminoglucozid: tc dng ph: rt c vi thn kinh s VIII v ng thn. 4.3 Phc iu tr lao phi: 4.3.1 Ha tr liu ngn hn: 2SRHZ/6HE (4RH). - Ch nh: lao mi, lao cp tnh nng, lao nhiu c quan 4.3.2 iu tr li ha tr liu ngn hn: 2SRHEZ/1RHZE/5R3H3E3 Mt tun dng 3 ngy(2-4-6 hoc 3-5-7) - Ch nh: tht bi sau ha tr liu ngn hn, lao ti pht, lao b tr 4.4 Corticoid trong iu tr lao: - Tc dng: chng vim, gim vng vim khng c hiu thuc chng lao pht huy tc dng, hn ch bin chng v di chng. - Ch p dng trong lao cp tnh v mt s th lao c bit: lao k, lao phi b u - Liu lng: 30 40mg/ngy, sau gim dn liu. - Nguyn tc: dng sm, phi hp vi thuc c tr, theo di st phng ti bin v bin chng ca thuc. 5. iu tr phu thut:
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- Ch nh trong mt s trng hp: u lao> 1cm, lao x hang khng thuc 6. D phng lao phi: - Loi b ngun ly: cch ly bnh nhn v iu tr sm, tch cc. - Tim chng BCG cho tr s sinh. - D phng bng thuc INH cho: + Tr em di 3 tui c phn ng Mantoux(+), c tip xc vi ngun ly. + Ngi c phn ng Mantoux(+), c tip xc thng xuyn vi bnh nhn lao.

A4
Bi 1: I CNG V BNH THN KINH
I- c im gii phu-chc nng h thn kinh (TK) 1. Chc nng: -TK l mt h c quan c tnh bit ha rt cao, VD:in hnh l cc t bo nron Tk (cht xm):khng bao gi phn chia, khi tr sinh ra, s lng nron c bao nhiu th khi ln ln cng c tng v n ch cht i. -c chc nng thit lp v iu ha MQH gia c th vi MT, iu ha cc hot ng sng ngay trong c th, phi hp cc hot ng bn trong v bn ngoi sao cho thng nht, bo m cho c th thch nghi v tn ti trong MT, thong qua cm gic, phn x, vn ng, dinh dng. 2.Gii phu - Bn cu i no: chia ra cc thy khc nhau, l trung khu cao cp nht ca h TK iu khin chc nng ca cc c quan bn di. - Thn no gm: no gia, cung no,cu no, hnh no, l ni cha cc trung khu thc vt, dinh dng, cha ng dn truyn i t v no xung n ty sng. - Ty sng: l ni cha cc t bo vn ng,thc vt, cm gic chi phi cho thn mnh v t chi, cng l ni cha cc ng dn truyn i t v no xung n tn cng.
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- H Tk ngoi vi: gm cc dy TK, l ni thc hin cc chc nng ca h tk, c ch o t trn xung(t h TKTW). - Mng no ty: l ni bo v no, gia mng vi no c lp dch no ty ng vai tr l t chc m, nui dng cho no. - Hng ro mu no: l vng tip gip gia mch mu v t bo no. II- c im mt s bnh v h tk 1. Cc bnh v ri lon chc nng: - Bnh l tm thn (A6) - Hn m nhim c (cc bon, ch, kim loi nng, coban) 2.Cc bnh tn thng thc th 2.1. Bnh l mch mu no: Hay gp nht trong tai bin mch mu no(t qu no),xut huyt, nhi mu no (gy tc mch-> t bo mu no thiu oxy-> tn thng no cc mc ). - bnh ny hay gp nhng ngi cao tui,c tin s huyt p cao, bnh bo ph, hay ht thuc, nghin ru. - Nu dng cp, nng bnh nhn c th hn m v t vong. Nh c th gy ra cc thiu st tk nh lit, mt ngn ng - ngi tr thng hay gp nht l d dng mch mu no hay au u, thnh thong ngt hoc co git. 2.2.Cc bnh vim, nhim trng(NT) TK - Vim no: do vi khun nh lao, m no cu, lin cu. Do virut nh vim no Nht Bn B NT ty sng nh bnh bi lit. Vim ty c th do vi khun hoc do vut -Chn thnng h TK nh chn thng s no, ty sng, c th dn n tnh trng lit, tn ph, t vong. iu tr tn km m hi phc cng km. 2.3.Cc khi u(u no, u ty): i vi cc khi u pht trin, ta phi tin hnh phu thut v kt hp iu tr ni khoa. 2.4. Thoi ha, di truyn h TK: u tin sd cc thuc chng lo ha, thng c cha gc t do nh cc vitamin E,C 2.5 au u: c th do co tht mch mu no, (cn na) 2.6. Cc bnh ca h ngoi vi cng lm t lit chn tay, hn ch kh nng lao ng. iu tr; phi sd vitamin liu cao.

Bi 2: CC THUC THNG DNG TRONG CHUYN NGNH THN KINH

1- Cc thuc tri bnh TKTW 1.1. Cc thuc tng tun hon mu no: phn theo c ch td * Lm gin mch no, nht l cc mao mch (nu tc ng vo nhng mch ln d gy h huyt p nn t sd) - Ch nh: sd cc trg hp thiu nng tun hon no, thiu mu no cc b, nhi mu no. Hay dng nh Vinpocetin, Buflomedil
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- Thn trng: xut huyt no giai on mi. * Tng lng bo ha oxy mu ng mch:thng sd trong cc bnh v thiu mu no, bnh k v c tai- tin nh, bnh l v mt,ng mch vng mc, ri lon ng quan. VD: Duxil *Gim chuyn ha Glucose v oxy (Gim nhu cu sd oxy ca no): sd khi vim no, chn thng s no, tai bin mch mu no. VD: thuc Lucidrin. * Tng bin dng ca hng cu( Gip chui c vo cc mch mu nh trao i oxy) VD: thuc Buflomedil, Piracetam. *Gim nht ca mu, gim kt tp tiu cu ( tng cung lng tun hon, mu long ra -> gim nht):D iu tr thiu mu no VD: Ginkobiloba. Chng ch nh: khng sd cho xut huyt no. 1.2. Cc thuc dinh dng v bo v t bo TK Thuc Cerebrolysin:chit sut t no ca ln, c bn cht l cc chui peptid, sd cho cc trg hp sa st tr tu, mt tr nh, chn thng, tai bin mch mu no, azeimer(hay qun) Thuc nhm Citicolin - c ch thoi ha bin mng (lipid mng) t bo TK,gip bo v t bo Tk khi b tn thng, thiu oxy v b cc cht trung gian tn cng, tng cng tr nh. Thuc c sd rng ri nhng k nn lm dng. Thuc c td an thn: - Trn tnh; nh sd benzo diazepin (gy nghin), Seduxen(gip trn tnh, bnh thn, gim lo u) Mnh sd clomazin (Amilazin): sd cho ngi kch ng,vt v, gay ng mnh. - Thuc ng: Gardenal,Rotunda(C TKTW v gy ng) sd chon ng b ri lon gic ng. - Hng thn(A6): chng hoang tng, chng o gic. Thuc hng thn: hng phn h tkTW - Cm sd v gy nghin nng nh heroin, cocain. - Thuc chng trm cm(1/4 d/s TG tng c giai on b trm cm) Thuc chng ph no: u no, chn thg s no, vim no, hay sd l manitol(Thuc li tiu thm thu), - Thuc li ti gim tun hon mu - Corticoid:c td chng ph no, u, chn thg, vim no. - Thuc ung:Glycerin, Glycerol Thuc tri bnh Parkinson (bnh run): - td ln h Polypeptid, c acetylcholine no VD: Artan, Tryhexi phenyl - Thuc b sung h dopamine: Levodopa
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- Td ln receptor dopamine: Trirastal Thuc chng co git: - An thn - Chng co git: kch thch h GABA C Na+ vng t bo TK dn n hng phn mng -> tri ng kinh, co git do thiu oxy, nhim c Thuc: Carbamazepin, valproat Natri 2-Cc thuc tri bly Tk ngoi vi 2.1.Thuc gim au, chng vim, h nhit: gim au lng, au dy Tk ngoi bin, au u. - au c th do:+ th th (d y, cu vo, khp, nht, mt, rng)hay au do vim -> sd thuc c ch bnh sinh. + Tn thng TK (t 1 dy tk, thot v a m), tn thg g dn truyn Tk -> sd thuc gim au Tk +hn hp(vim v tn thg dn truyn Tk)-> sd c 2 loi thuc. + au do tm l -> thuc an thn 2.2. Thuc corticoid: sd khi vim no, vim dy tk ngoi vi, cc thot v a m, chng ph no trong mt s trng hp, - Lu : y l mt nhm thuc c rt nhiu td ph(gy vim lot , t trng, THA, tng g mu, tng chuyn ha lipid, C min dch, bng pht lao, gim lin so, chm ln tr em, c th gy lon thn) nn cn thn trng trong sd. 2.3 Thuc gin c vn: tri au lng cp, au c, vo c, co c cng(nguyn nhn do chn thg, bnh l Tk ngoi vi). C ch: C cung pxa ty sng lm gin c. Khng sd cho bnh nhn b nhc c,hn ch cho ngi gi,tr em Thuc: Mydocalm, Myonal 2.4 Thuc tng dn truyn TK: sd cho nhng trg hp tn thg dy, r TK, vim(tn thg, chn thg sau phu thut ni dy tk) cod td kch thch Acetylchlin ngoi vi Thuc galantamin, (C men cholinesterase-> phn hy acetylcholin) ->td ph: gy bun nn,au bng, hoa mt , chng mt- sd sau n. 2.5 Cc vitamin nhm B: tham gia vo qu trnh ti to v chuyn ha cc mng myerin , t bo (B6, B12), cc vitamin hg TK, c th sd dng n c hoc phi hp 2.6 Thuc tri nhc c: c nhm C min dch (corticoid, CMD khc), nhm thuc kch thch Acetylcholin ngoi vi.

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A5
I.Bi 4: NHIM HIV AIDS.
1.nh ngha: Hi chng suy gim min dch mc phi l mt h chng bnh l gy ra do tc ng ca virus gy suy gim min dch trn ngi (HIV) lm cho c th mt sc khng vi cc vi sinh vt gy bnh v nhng vi sinh vt bnh thng khng gy bnh tr thnh gy bnh to ra cc nhim trng c hi v ung th. VSV gy bnh gy bnh . HIV SK VSV cng sinh gy bnh. VD: trong c th c th c vi khun lao mc lao. HIV 2. Dch t: 2.1 Mm bnh: - Virus c ARN. Virus b bt hot nhanh bi cc tc nhn l ha, khng b tiu dit bi tia cc tm. 2.2 Ngun bnh:
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- Duy nht l con ngi: ngi nhim HIV, bnh nhn AIDS. 2.3 ng ly: - Quan h tnh dc: cng gii hoc khc gii(t l ly nhim 0.1 %). - ng mu: + Nhn mu v cc sn phm ca mu b nhim(t l mc bnh theo ng ny gim do s dng cc test sng lc). + Dng chung bm kim tim(chch ma ty). + Tai nn ngh nghip: mu v dch tit b bnh bn vo da v nim mc b tn thung.(xc sut 0.25%). - Truyn t m sang con: + Trong qu trnh mang thai s dng thuc AVR cho ngi m. + Trong qu trnh : dng thuc cho ngi m trc sinh, cho b sau sinh hoc m ly thai. + Cho con b. 2.4 C th cm th: - Mi ngi u c th nhim bnh. 3. C ch min dch: - HIV c i tnh ch yu vi t bo lympho TCD4 (T bo trung tm ch huy iu hnh h thng min dch ca c th) khi t bo ny b suy gim v s lng v chc nng gy nn suy gim min dch t bo v min dch dch th, do bnh nhn b nhim trng c hi v ung th xut hin. - HIV tn cng lm suy gim v s lng v cht lng ca t bo TCD4. 4. Lm sng: phn loi ca WHO, HIV chia lm 4 giai on ngi ln: - Giai on 1: Nhim HIV khng triu chng: bnh nhn hon ton khe mnh nhng c hch nh ti nch, bn. - Giai on 2: C biu hin mc nh. - Giai on 3: Giai on cn AIDS. - Giai on 4: Bnh nhn c cc biu hin lm sng ca bnh AIDS. 5. Mt s nhim trng c hi hay gp trong AIDS: - Phi: +vim phi do Pneumocystis neoformans. + Lao phi. - Thn kinh: +p xe no do Toxoplasma. + Vim mng no do Cryptococus neoformans. + Vim tn thng vng mc do CMV MAC. - Tiu chy do Cryptos poridia, MAC. - bnh da, nim mc. - Ung th: sarcome kapos. Sarcome hch. 6. Chn on: - Chn on 1 ngi HIV khi mu huyt thanh c xt nghim dng tnh vi 3 ln xt nghim vi cc ch phm khng nguyn khc nhau(XN tm khng th). - Chn on AIDS khi bnh nhn c 1 trong 2 hoc 2 tiu chun sau: + Biu hin lm sng giai on cui(Tiu chy ko di trn 1 thng, st ko di trn 1 thng). + T bo TCD4 nh hn 200/1mm mu(Lympho ton b < 1200). 7. iu tr:
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7.1 Hng iu tr: - Dng thuc khng virus ARV(anti retrovirus ) - D phng iu tr cc nhim trng c hi. - Nng cao sc khng cho c th ngi bnh: nui dng tt, dng thuc kch thch min dch. 7.2 Cc thuc khng virus: 7.2.1 Cc nhm thuc: - Cc cht c ch men phin m ngc c cu trc tng t nucleosid (NRTIs): Zidovudine(AZT), stavudine(d4T), lamivudine(3TC), abacavir(ABC), Didanosine(ddI), Tenoflovir(TDF) - Cc cht c ch men phin m ngc c cu trc khng ging nucleosid (NNRTIs) :nevirapine(NVP), delavirdine(DLV), efavirenz(EFV) - Cc cht c ch protease (PIs): ritonavir(RTV),lopinavir(LPV), saquinavir(SQV) - Thuc c ch ha mng: T 20 - Cc thuc b tr: thuc iu ha min dch, thuc phng nga v iu tr bnh c hi. 7.2.2 Mc tiu iu tr: - c ch HIV. - Tng cng p ng min dch: TCD4. - Gim tn s mc nhim trng c hi. - Ci thin sc khe, tng thi gian sng cho bnh nhn. - Gim ly nhim v phng cho nhng ngi b tai nan ngh nghip. 7.2.3 Nguyn tc iu tr: - L 1 phn trong tng th cc bin php chm sc v h tr y t, tm l, x hi cho ngi bnh - Bt k phc no phi c t nht 3 loi thuc. - Tun th iu tr l yu t quan trng nh hng n thnh cng iu tr. - Cc thuc ny ch c tc dng c ch qu trnh nhn ln ca virus m khng cha khi hon ton bnh c do phi dng thuc sut i v trnh ly nhim cho ngi khc. - Khi iu tr ART m tnh trng min dch cha phc hi vn phi tin hnh cc bin php phng nhim trng c hi. + Batrim F: c dng iu tr nhim trng c hi cho bnh nhn HIV phng : Pneumocystis carnii, Tesoplasma no. 7.2.4 Ch nh dng ARV: - Bnh nhn giai on 4. - Bnh nhn giai on 3 c :+ TCD4 < 200. + Lympho <1200. - Bnh nhn giai on 3 c TCD4 <350. 7.2.5 Phc iu tr : * First line: cho nhng ngi cha bao gi iu tr : d4T d4T AZT AZT 3TC 3TC 3TC 3TC
47

NVP EFV NVP EFV

107- Dc 11

- u tin s 1: d4T. Thuc ny chng ch nh trong trng hp:bnh l thn kinh ngoi vi, vim ty (thay th bng: AZT). - AZT : chng ch nh: thiu mu, vim c, bnh l c tim - NVP : chng ch nh: d ng, vim gan, ang s dng khng sinh chng lao (thay th bng EFV). - EFV : chng ch nh: d ng, tin s tm thn hoc b tm thn trong khi dng thuc. - 3TC : t tc dng ph,c th gy thiu mu nh - Cch s dng: 1 ngy 2 vin, cch nhau 12h. +NVP: 2 tun u dng 1 vin, tun 3 tng ln 3 vin(do rt d gy d ng nn tng liu t t ). +EFV : Dng 1 vin/ngy,hp thu mnh cng m khng n nhiu m. * Second line: tht bi iu tr vi phc 1, bnh nhn b chng ch nh vi cc thuc hng 1. ABC TDF 3TC ddI LPV/r IDV NFV

- Khi s dng TDF cm khng phi hp vi ddI thay th bng 3TC. 7.2.6 Hi chng phc hi p ng mim dch : - Sau khi c iu tr bng ARV, chc nng min dch c phc hi gy p ng vim vi cc nhim trng c hi hoc bnh t min. - Thng xut hin trong vng t 2 12 tun gp nhiu hn nhng ngi b suy gim min dch nng khi bt u iu tr ARV. Hi chng phc hi min dch thng lin quan n cn nguyn lao, vim mng no do cryptococus, cc bnh nhim nm khc X tr: + Hi chng vim sau phuc hi MD : s dng thm cc thuc corticoid chng vim. + Khng thuc: i thuc khc. 7.2.7 Hiu qu iu tr: lng virus gim, TCD4 bnh nhn sng lu hn. 7.2.8 Tc dng ph: c nhiu tc dng ph. - Mc nh: bun nn, nn, tiu chy,au bng, mt mi - Mc nng: c tnh vi c, bnh thn kinh ngoi vi, trm cm, c mng, vim ty 8. D phng: da vo ng ly nhim c cc bin php d phng sau: 1. Phng nhim HIV/AIDS ly qua ng tnh dc: - Sng lnh mnh, chung thu mt v mt chng v c hai ngi u cha b nhim HIV. Khng quan h tnh dc ba bi - Trong trng hp quan h tnh dc vi mt i tng cha r c b nhim HIV khng, cn phi thc hin tnh dc an ton bo v cho bn thn bng cch s dng bao cao su mi (condom, o ma, bao k hoch) ng cch. - Dng thuc dit tinh trng v HIV: ph bin l Nonoxynol-9 (Menfagol) c lm di dng kem bi, vin t, hoc tm vo mng xp, bao cao su.
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2. Phng nhim HIV/AIDS ly qua ng mu: - Khng tim chch ma ty. - Ch truyn mu v cc ch phm mu khi tht cn thit, v ch nhn mu v cc ch phm mu xt nghim HIV. - Hn ch tim chch. Ch s dng bm kim tim v trng. Khng dng chung bm kim tim. S dng dng c tit trng khi phu thut, xm, x l, chm cu... - Trnh tip xc trc tip vi cc dch c th ca ngi nhim HIV - Dng ring dng c nhn: dao co, bn chi rng, bm mng tay,... 3. Phng nhim HIV/AIDS ly truyn t m sang con: - Ph n nhim HIV khng nn mang thai, v t l ly truyn HIV sang con l 30%. Nu c thai th ung thuc d phng theo hng dn ca bc s.

Bi 5: VIM GAN VIRUS.

1. nh ngha: - Bnh vim gan do virus l bnh truyn nhim do cc virus hng tnh gan (virus vim gan A,B,C,D,E,G) gy ra. Bnh gy tn thng v hoi t t bo gan, biu hin lm sng: s tng enzym ALT (Alanin transaminase). Trong vim gan virus(VGVR) A,E l nhng VGVR gy bnh c th t gii hn v khi bnh. VGVR B,C,D,G l VGVR c th gy bnh l vim gan mn tnh, s gan, ung th t bo gan 2. Vi nt v dch t hc: - VGMT : vim gan mn tnh. - VGCT : vim gan cp tnh. - NMMBKTC : ngi mang mm bnh khng triu chng Virus ng ly ng tiu ha ng mu ng sinh dc ng t m sang con Acid nhn Tnh cht gy A ++ ARN VGAT B ++ + + ADN VGAT C ++ + + ARN VGAT
49

D ++ + + ARN VGAT

E ++ ARN VGAT

G + ? ? ARN VGAT

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bnh

VGCT NMMB KTC

Marker

VGCT NMMB KTC Mntnh X gan Ung th antiHbsAg HAV(IgM, HbeAg AntiIgG) Hbe ARNHAV AntiHBc (IgG/M) HBVDNA

VGCT NMMB KTC Mntnh X gan Ung th AntiHCV HCVRNV

VGCT NMMB KTC Mntnh X gan Ung th HbsAg AntiHDV HDVDNA

VGCT VGCT NMMB NMMB KTC KTC Mntnh X gan Ung th AntiHGV HEV AntiHEVHGV DNA

3.Bnh vim gan virus cp: 3.1 Thi k khi pht: - Kiu ging cm: ho, ht hi, x mi - Kiu ri lon tiu ha: i ngoi phn lng, bun nn - Kiu vim khp: au mi ton b cc khp - Kiu suy nhc thn kinh: au u,mt mi,mt ng - Kiu kt hp: nhiu triu chng hn hp ca cc kiu khi pht trn. - 3 5 % trng hp vim gan virus th vng da m khng c thi k khi pht 3.2 Thi k ton pht: - Nc tiu c xu hng vng tng ln. Bnh nhn ht st v xut hin vng da. Vng da xu hng ngy 1 tng cao, ch yu l do tng billirubin ton phn, trc tip tng nhiu hn gin tip. - Bnh nhn mt mi nhiu , trong thi k khi pht bnh nhn rt mt, sang giai on ton pht tnh trng mt mi gim(nu mt mi tngvim gan nng). - n ng km, ri lon tiu ha(to bn, i lng), au bng vng h sn phi, suy gim hot ng tnh dc - Gan to, mm. - Xt nghim: + Bch cu : bnh thng. + Mu : billirubin (trc tip l ch yu ). +Enzym: Transaminase: ALT trn 10 ln gii hn bnh thng l mt trong nhng XN quan trng nh gi mc ca bnh. - C th xut hin tnh trng ri lon ng mu. - Nc tiu: c billirubin v urobillinogen. VGCT: thng thng bnh ko di 1 2 thng sau n nh ri khi. Nu bnh ko di > 3 thng Th ko di. Vim gan D,C,G c th chuyn thnh mn tnh khi tin trin ca bnh trn 6 thng. 3.3 Bin chng, di chng: - VGVR l th nng ca bnh, t l<5%. - Mt s chuyn sang VGMT, x gan, ung th gan.
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- Di chng khng pht. 3.4 iu tr: - Ngh ngi ti ch : quan trng nht. - Ch n : nh, d tiu, trnh thc n c nhiu du, m, mn nhiu ng, hoa qu. - Khng iu tr bng thuc khng virus c hiu, iu tr theo c ch bnh sinh. + Dng thuc h tr, bo v t bo gan: C ch: bn vng mng t bo, khng gy v t bo hng lot, tham gia vo thnh phn c cht tng hp mng t bo Thuc c th: -BDD(bifenyl dimethyl dicarbocinat), bit dc: fortex, RB25 -Sylimarin: sn xut t cy k, N c tc dng nh mt cht chng oxy ho, chng li s tn thng do cc gc t do.(liu : 75 mg). -Thuc b sung tng hp phospholipid mng: liboton(chit t u tng: vin 200mg, 4v/ ngy) -Thi c cho gan: Ornithine L Aspartat. 4.Vim gan virus mn(VGM): 4.1 nh ngha: - Tnh trng tn thng hoi t t bo gan ko di lin tc ti thiu 6 thng tr ln - Nguyn nhn: do cc virus vim gan B,C,D,G. Ch yu l B,C. 4.2 Lm sng: - C th l hu qu trc tip ca VGVR cp tnh. - Phn ln bnh nhn VGM c tin trin lm sng rt m nht. Triu chng lm sng ngho nn: mt mi thong qua, n ng km, gy st cn, ch 1 s t cc trng hp tn thng gan bng pht c bnh cnh lm sng nh VGVR cp tnh. - Gan to, chc. ALT tng mc nh( 2 5 ln so vi bnh thng) 4.3 Vim gan B mn: 4.3.1 Tiu chun: - VGB cp tnh tin trin lm sng lin tc trn 6 thng. - Bnh nhn c HBsAg (+) ko di trn 6 thng. - HBsAg (+) v anti- HBsAg (+). - ALT thng xuyn hoc tng t. - XN m bnh hc: tn thng vim v hoi t mc trung bnh tr ln. 4.3.2 Tiu chun iu tr: - XN HBe( khng nguyn E ca virus VG B) phn nh tnh trng sao chp ca virus. - HBV DNA : cc virus c sao chp vo mu, t nh gi nng virus trong mu. - ULN : uppen limit normal. HBe (+) HBe (-) 5 HBV DNA > 10 > 104 ALT > 2 ULN > 2 ULN 4.3.3 iu tr:s dng thuc khng virus. - INF (2a v 2b) : phn t polypeptid do cc t bo gan nhim HBV, cc t bo s non khi c kch thch ca virus tit ra.
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+ C ch tc dng: ly gii chui ARN thng tin lm ngn cn vic sao chp ca virus + Ch nh: cho tt c cc bnh nhn VGB mn tnh tr tr em di 12 tui. + Liu: 5 triu n v cho 1 ln tim di da, 3 ln/ tun, lin tc 6 thng. - Thuc khng virus ng ung: + C ch tc dng: cnh tranh vi cc nucleotid tham gia vo qu trnh tng hp nn cc phn t ARN virus. + Thuc c th: Lamivudine 100mg Cytosin. Adefovir divipoxil Adenin. Entercavir Guanin. Telbivudin Thymin. + iu tr ti thiu 1 nm hoc hn, 1v/ngy. 4.4 Vim gan C mn: - Lm sng: nh VGB mn. - XN anti-HCV (+), HCV-RNA (+) khng nh nhim virus vim gan C. - iu tr kt hp : INF : 3 MUI Ribavirin : 800 1200 1500mg. Kh nng dit tr virus 40% bnh nhn.Thi gian iu tr 1 nm. - Peg interferon kt hp ribavirin.T l p ng virus hc ko di trn 50%.Thi gian iu tr 2 nm.

A7
Cu 1 : Nu cn c phn chia giai on v cc giai on trong bnh hch c tnh ? -U lympho c tnh l cc bnh c tnh pht sinh t t chc lien vng lympho (cn gi l lympho li ) c mt rng khp c th nn u lympho c tnh c th pht sinh t chc ngoi hch v h thng bch huyt nh : phi , no , tinh hon , xng , tiu ha . -phn loi :2 +Bnh Hodgkin . +Lymphom non-Hodgkin ( u lympho c tnh khng Hodgkin ). Hai nhm bnh ny tuy cng ngun gc pht sinh nhng pht trin , bit ha theo 2 qu trnh khc nhau. -Ngi ta phn chia giai on ch yu i vi bnh Hodgkin nhng cng c th p dng cho c lymphom non-hodgkin . +GD 1 :tn thng mt nhm hch mt pha ca c honh . +GD 2 : tn thng t 2 nhm hch tr ln ko k nhau , mt pha ca c honh . +GD 3 : tn thng cc nhm hch 2 pha c honh . +GD 4 : tn thng cc nhm hch ngoi vi v tn thng ph tng . -Ngoi ra da vo triu chng ton thn ( st , gy st cn , m hi trm ) chia thnh giai on A v B . +GD A ; ko c triu chng ton thn , ch c hch to .Ta co : IA, IIA , IIIA , IVA. +GD B : c hch to v c t nht mt triu chng ton thn . Ta c : IB , IIB , IIIB , IVB.
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- ngha : phn chia giai on ca hch gip xc nh phng thc iu tr hp l v tin lng tt . Cu 2 : Nu triu chng ( lm sng v cn lm sang ) ca bnh suy t . N : suy ty l ty xng gim hoc ko cn ch nng sinh mu do bt thng ca t bo gc to mu ty xng . +Dn n gim 3 dng : BC ht , TC mu ngoi vi , HC. +Dn n 3 hi chn trn lm sng: -Gim HC =>hi chng thiu mu . -Gim BC ht =>hi chng nhim khun. -Gim TC mu ngoi vi =.> hi chng xut huyt -Triu chng : +Triu chng lm sng : chia 2 gd *GD khi pht : Din bin t t , mt mi , nhc u , chng mt , st nh , thnh thong c nt xut huyt di da , vim hng *GD ton pht : xut hin 3 hi chng -Hi chng thiu mu : +lm sng : da vo triu chng c nng v thc th ( da xanh , nim mc nht , ting tim nhanh , c ting thi tm thu , long tc d rng ) +XN : Hng cu , huyt sc t gim . -Hi chng nhim khun : +lm sng : bnh nhn c st , vim hng , nhim khun ngoi da , vim phi , vim ng tit niu +XN : bch cu gim , gim notron c t l tng i v s lng tuyt i. -Hi chng xut huyt : +lm sng : xut huyt di da v nim mc dng mng hay nt . +XN : tiu cu gim > -Khng c cc triu chng sau : +gan ,lch ko au . +hch ngoi vi ko au . +ko au xng . +Cn lm sng : -Cng thc mu ngoi vi : + hng cu gim + huyt sc t gim +bch cu ht gim + tiu cu gim -Xt nghim ty : +s lng t bo gim ( bnh thng t 30 100 mg/l) +Gim dng hng cu non trong ty +Gim c v t l tng i v s lng tuyt i ca bch cu a nhn trung tnh . +Gim mu tiu cu trong ty xng +Tng t l tng i dng bch cu n nhn c bit l lympho. -Xt nghim sinh thit ty xng :
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y l tiu chun chn on quyt nh : ty hoang vu , tha tht cc hc to mu , cc hc gim s lng cc t bo to mu . -Nui cy t bo ty: nh gi kh nng tng sinh , bit ha ca cc t bo gc tao mu bnh nhn suy ty. Phng php ny dung ch yu trong nghin cu. -Xt nghim hng cu li :nh gi chc nng sinh hng cu ca ty xng. Cu 3 :Nu triu chng ( lm sng va xt nghim ) ca bnh bch cu ty cp ? _Theo phn loi ca nhm tc gi Anh M -Php bnh bch cu cp chia 2 loi : bch cu ty cp c 8 th dnh s t M1 n M8 va bch cu lympho cp c 3 th l L1, L2, L3. _Triu chng : +Lm sng : -Hi chng nhim trng : st cao , mi kh , li bn, hi th rt hi , le amidal , li .C th vim phi , vim rut , nhim khun huyt. Nhim khun thng l nguyn nhn trc tip dn n t vong bnh nhn bch cu cp. -Hi chng thiu mu : da xanh xao , nim mc nht nht , chng mt , mt mi Thiu mu thng tin trin nhanh , nng . - Hi chng xut huyt : xut huyt di da , nim mc , ng tiu ha , no Xut huyt nng cng l nguyn nhn trc tip dn n t vong . -Gan to ,lch to : to va , ko au nhiu , mt chc , mt nhn.Th M5 thng gan , lch rt to . -Hch to : v tr hch to bt c ni no , thng vng c , nch , bn .Mt hch chc , di ng d dng , ko au . -Dau xng khp : au xng dt , xng di , cj bit xng c g rt au . -U cc ngoi da : thng gp th M5. Ngi ta thng goi cc triu chng gan , lch ,hch to , au xng khp , u cc ngoi da l hi chng u. +Xt nghim : -Cng thc mu ngoi vi : +HC , HST , TC u gim . +S lng BC bnh thng , gim hoc tng cao . +Trong mu xut hin cc blast vi t l cao ,vng mt giai on trung gian gia t bo trng thnh vi blast .Hin tng ny gi l khong trng BC. -Ty : +Ty giu t bo , blast > 30% t bo ty c th n 80-90% +C khong trng t bo r rang. +BC ht , mu TC , HC non gim mnh . -Xt nghim khc : +Tn thng gan , thn +Ri lon ng mu +Xt nghim tm vi khun , v tr nhim khun +Chc sng tht lng tm blast trong dch no ty . Cu 4 :Nu triu chng ( lm sng v xt nghim ) ca bnh thiu mu nhc sc do thiu st ?
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_Thiu mu dinh dng l loi thiu mu do thiu mt hoc nhiu yu t dinh dng cn thit cho qu trnh to mu nh st , ng , km , magie , cc vitamin b12 , acid folic , acid amin _Theo bnh nguyn v bnh sinh chia thanh 4 loi thiu mu : +Thiu mu do chy mu +Thiu mu do thiu yu t to mu +Thiu mu do suy nhc c quan to mu +Thiu mu do tng hy hng cu. _Thiu mu nhc sc do thiu st : do mt cn bng gia cung v cu st , hp thu st km , cc bnh gy chy mu , nhim giun c triu chng sau : +Lm sng : Ngoi triu chng ca thiu mu ni chung cn c cc triu chng khc : -da va nim mc xan nht . -vim ming : nt , l lot mi .. -vim li ; nhn l , mt gai , c vt n rng -ri lon tiu ha : chn n , bun nn , chua , gim toan, gim tit dch d dy .. -ri lon kinh nguyt kem gim toan , gim tit dich d dy cng lam thiu st . -i khi kh nut . -mng tay , chn gn song , cong , bt , lm long thuyn , dy ln , d gy .., +Xt nghim : -HST gim nhiu hn s luongj hng cu . -HC nht mu , hnh vnh khn , kch thc to nh ko u . -St huyt thanh gim < 500 mcgam/lit . -Protoporphirin t do HC tng >700 mcgam /lit . -ty : nguyn hng cu km trng thnh , nguyn sinh cht nht ,nguyn hng cu st <10%. _Ch : phn bit thiu mu nhc sc do thiu st vi cc bnh nh : nhim c ch , vim nhim mn tnh ,bnh HST E , HST H th st huyt thanh thng tng .

A8
Bi 1: THUC BI NGOI DA
I-Ngun thuc bi ngoi da rt a dng v phong ph .Ch yu t 3 ngun chnh : -Ha hc : +V c : kim loi , mui kim loi , kim ,dn xut ca n nh cc oxit , acid. +Hu c : cc cht bo , cht thm , acetone , acid. -Tho mc -Tng hp v bn tng hp II-C ch tc dng -Lm hn ch hay tng cng , cn tr s bc hi nc qua da -nh hng n tun hon ca da c th gy gin hoc co mch ngoi da.in hnh nht l hp cht rayon. -Ty theo cc tc dng thuc m ngm vo da nhiu hay t ,ngm nng hay su .
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VD : thuc m ngm rt su -Thuc c tc dng l hc , ha hc VD : thuc lm thay i PH ca da , nh hng n qu trnh OXH t bo da III- S hp thu ca thuc qua da -S hp thu thuc qua da phi qua phm m trn da , c i lc rt cao vi nc nn cc cht ha tan m thm qua nhiu .VD : mui thy ngn , mui ch . -Lp sng l cn tr chnh cho s hos thu ca thuc . -Nang lng : thuc c th thm qua nang lng ca tuyn b nn khi dng nn xoa v mit 1 lc thuc thm tt hn -Cc vng da c tn thng th ngm thuc mnh hn, cc vng da s so th ngc li . -Cc c tnh ca cc cht ha hc nh chloroform , iod hp thu rt mnh .Cc cht ha tan trong m th ngm chm , cc cht mui hoa tan trong nc c th thm su n tn tun hon . IV- Cc dng thuc bi -Cu to chung ca cc thuc bi gm 2 thnh phn : +Hot cht : cc cht c tc dng chnh iu tr bnh .VD : iod tr nm , acid salicylic tc dng bt sng . +T dc : ko c tc dng iu tr , c tc dng vn chuyn hot cht rt tt .Thuc ngm nng , su , nhanh , chm ph thuc t dc .VD : lanolin , velin -Gm cc dng :Dung dch , bt ,m , kem ,h , du v mt s dng khc . +Dung dch : l hot cht pha trong t dc ,thng t dc l dung mi lng thnh 1 cht lng ng u , ko vn , ko ta .VD : cn , nc , ether, chloroformNh dung dch MIlian gm : -Xanh methylen : 1g -Knh gentian : 1g -Rimalon : 1g -Cn 70 : 10g -Nc ct va : 100g *Cch s dng 1 : p gc tm dung dch v nh dung dich lien tc lm mi trng m t =>gim vim n , chng xung huyt chng chy nc , st khun , chng nga , sch mn *Cch s dng 2 : p gc lnh (tm dung dch lnh ) hay p gc nng (tm dung dch nng ) hoc bi tc dng st khun , ngm tm +Thuc bt : -TD : mt da , kh da , gim xung huyt ,gim vim , nga. -T dc thng dung l bt tho mc ( bt m , bt go , v cy canhkina ),bt khong cht ( bt tan Mgsilicat , bt cao lanh , bmut) -CD : rc ln b mt tn thng ang vim nhim hay ang chy mu hay rc ln cc vt lot lu ngy . +Thuc m : -L dng thuc tc dng ngoi da quan trng nht v ph bin nht -T dc l cht bo ( velin , lanolin ) nhng t l bt < 30% -TD :tng kh nng hp thu thuc cua da , ngm su hn cc dng thuc khc , lm mm da nhng ko gy bt tc , hn ch bc m hi da v gy sung huyt => ko dung thuc m cho cc trng hp vim cp , tn thng da ang chy nc . VD : thuc m benzosali
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-acid benzoic : 6g -acid salicylic : 3g -velin : 100g + Thuc h - Thnh phn gm bt hot cht v m ging nh thuc m nhng t l bt hot cht nhieeuf hn khong 30-50 % - TD : ngm nng hn thuc m => thng dng tn thng da giai on bn cp . VD : h groc , h sarocin +Thuc dng kem -l dng thuc m nhng c thm glycerin v nc -VD : kem Daliboud IV- Mt s bit dc bi ngoi da: 1-St khun -Dung dch rivanmol -Dung dch aric -Dung dch thuc mu : xanh methylen , tm methylen -Kem v cc dng m khng sinh : m clorocip , m tetracelin . 2-Thuc gh -Dep -M gincin -Kem Eurax 3-Thuc tr nm hc lo -ASB, BSI -Benzosalin -Nirozan 4-Thuc tr eczema -Giai on cp : dung cc dung dch trn sau dung cc thuc mu -Hoc dng thuc m corticoid : Eumokhoacte, tempokhoacte,diprozon, diprosalic 5-Thuc bi trng c -Hn dch lu hunh -Kem erylick , eryfluix , daacin T , pannocin 2,5 /5 /10 , oxy 5/10, kem retica 6-Thuc tr vy nn -M salicylic -M daionex , daigopet 7- Thuc bi tr ht cm , mn cc -Duoflin, colomak 8-Thuc bi chng vius -M acylclovir -M zobirac 9-Thuc bi rng tc -Thuc minocydin. 10- Thuc chng sm da , rm nng -Leocodinin B , kem Renova. VI_Vi iu ch khi s dng: Ngoi tc dng ti ch cn tc dng ton thn => lu ngm , din tch
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Bi ph hp giai on bnh , tnh cht bnh l , tui bnh nhn , ngh nghip

Bi 2 :SINH L DA V CC TN THNG C BN
I. Sinh l da: -Da l mt hang ro bo v cc c quan su nh thn kinh , mch mu , c xng , ph tng khi cc tc hi ca cc yu t c hc , l hc , ha hc , vi khun c hi . -Da gm 3 lp ; thng b , trung b , h b . -Cc chc nng cua da : +Chc nng bo v +Chc nng iu ha nhit +Chc nng bi tit +Chc nng d tr chuyn ha +Chc nng to keratin v melanin +Cc nng cm gic +Min dch +Chc nng ngoi hnh II. Cc tn thng c bn 1-nh ngha L tn thng n gin nht ,phn nh nhng bin i bnh l c bn nht ca da .Thng chia thnh 2 loi : tn thng c bn nguyn pht va tn thng co bn th pht . 2-Cc loi tn thng c bn : *Dt : l tn thng c bn ngang mt da , ch nhn thy ko s thy.Ch 2 loi l dt vim v ko vim . -Dt vim : do gin mc ph n t bo gy nn ,thng mu hng , d ti , d tm , sau khi khi ln ko li di tch .Gp tron d ng thuc , ban dng si -Dt ko vim : ko do qu trnh vim , thay i mu sc da , mit da n vo ko thay i ,VD : bch bin , bch tng ( mt t bo sc t ) , xm da ( tng sc t) . *Sn : tn thng cao hn b mt da , tn thng chc , va , nhn v s thy . C 2 loi : sn vim v sn ko vim . -Sn vim : do qu trnh vim gy nn thng xy ra t bo . VD : nht -Sn ko vim : ko do qu trnh vim gy nn m ch do lng ng cc sn phm chuyn ha ln trn da hay lp thng b hoc do tng sinh thng b . VD : mn cc do khun H.P.V *Sn m ay ( sn ph , sn tt ) : Xut hin nhanh , mt nhanh ko li du vt do gin mch t bo gy nn gp mt s bnh : ban , ban m day. *Tn thng lng : l tn thng cao hn mt da nhng cha thanh dch , i khi m hoc mu , hnh trn hoc bn cu,nng hoc su , d v hay kh v , ph thuc dch trong tn thng chia thnh : mn nc , bng nc , phng nc .,mn m
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-Mn nc : l tn thng lng kch thc 1-2mm.Mn nc gp trong bnh eczema nh bng u ghim , nng , t v , san st nhau kn b mt tn thng .Mn nc bnh thy u , gii leo tp trung cm. -Bng nc : tn thng lng kch thc vi mm n 1-2 cm nh trong bnh zona , bnh Duhring-Brocp -Phng nc : kch thc >2cm .Gp trong d ng thuc , bnh pemphigus -Mn m : tn thng lng , g cao ,bn trong cha m nh trong bnh thy u , vy nn mn m = *C : va ni g trn mt da va chm di da .Tin trin qua 4 giai on : vim => v => m => so.Gp : c giang mai , phong th T . *Cc ( nt ) : tn thng hnh thnh e lp h b , trung b sau ni ln b mt da . Gp ban nt do lao , phong * U ( c v lnh tnh ) : ch yu h b t ni ln da . *Gm : tn thng cc su di da qua 4 giai on : vim => mm => chy thnh dch ging socoola => so > Gp giang mai 3 , nm su *Tn thng d rng : vy da , vy tit ( thng do cc mu nc tit ra ) * Tn thng mt da thng do hiu qu iu tr hoc do tc nhn gy bnh . *Tn thng th pht ( lichen ha ) : tn thng cm , dy , thm nhim hoc cc sn a gic . Gp : eczema , vim b thn kinh

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A10
Bi 1: NHIM KHUN H HP CP TNH.
1./ngha: l cc tn thng bnh l xy ra ti ng h hp, thng do vi khun hay virus gy ra 2.phn loi:theo v tr gii phu: ly np thanh qun = ranh gii ng h/hp trn v di - ng h hp trn: thng nh , ch yu do virus (80%) +vim hng , vim amidan, vim va +vim tai gia , vim xoang - ng h hp di:thng nng c th suy h hp,die. + vim thanh qun +vim kh ph qun +vim ph qun phi( TE<3t) +vim ph qun(TE ln) + hen- t do VK + vim tiu ph qun 3. ng/nhn- /kin thun li 3.1 virus: VR cm, cm , si Adeno virus, corona virus, lino virus Hp bo h hp gay suy h hp 3.2 vi khun: + cu khun phi( Str. Pneumoniae) gy vim phi , vng tn thng /c phi
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+ lin cu tan huyt nhm A gy vim hng. B/chng: thp tim +Hemophyllus influenzae gy vim phi TE> 1t +t cu ( b l t cu vng) gy vim phi rt nng v kh /tr (trn m, trn kh, trn dch mng phi, khng thuc cao) * tr s sinh: - gr(-): E.coli, klebsialla, l/cu B gy vim phi rt nng - nm candida : vim phi - KST, u trng , giun. 4. phc /tr theo phn loi ca WHO 4.1. t 2 thng- 5t Du hiu Chn on - nhim khun hh cp Mc nh ( ko c ko c vim phi; vim phi) -vim long: ht hi, s mi, ho , chy nc mi Th nhanh C vim phi Rt lm lng ngc ( co Vim phi nng rt c h hp) vng III di sn Vim phi rt nng Nu tr c 1 trong nhng d/hiu ng/him ( NKHH cp) sau: - ko ung c hay ko b c -ng li b kh nh thc -nghe ting th rt khi nm yn -c co git -nu TE b SDD, bh rt nng

X tr - Theo di v /tr ti nh -kh/khch sd thuc nam - thuc h st nu st Theo di va /tr ti nh rt st nu xh tr/chng n y t /tr ti b/vin. Trc khi chuyn phi cho sd 1 liu KS -/tr st( nu c) - /tr co git (nu c) - /tr th kh kh - cho liu KS u tin -gi i bv cp cu

4.2 TE< 2 thng tui Du hiu Vim long ng hh trn Th nhanh, rt lm lng ngc mnh (>60l/ph)

Chn on Nh( NKHH cp ko c vim phi) Vim phi nng

X tr -c/sc , theo di ti nh - gi m cho tr - cho b nhiu ln -lau sch mi - gi m cho tr - cho liu KS /tin - c/cu bv

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Nu c km theo 1 trong cc d/hiu nguy him

Vim phi rt nng

- gi m cho tr -cho liu KS u tin -c/cu bv, theo di st trn ng vn chuyn.

D hiu rt sm: TSS: b b hay b t TE: ng li b kh nh thc 5. Khng sinh 5.1. KS tuyn 1: + amoxyclin :50-100mg/kg/24h +Co- trimoxazol: 30mg/kg/24h +bn c tin s d ng vi - lactam th chuyn sang nhm KS macrolid: roxythromycin 4-8mg/kg/24h. 5.2.KS tuyn 2:nn p/hp KS : -lactam + aminoglycosid + ampicillin + sulbactam: chng s to thnh men -lactamase. + amoxicillin + a. clavulanic + cephalosporin 6. phng bnh: - n/cao SK ca TE :b sa m - /bo vs c nhn , mi trng. -tim chng.

Bi 2: TIU CHY CP.

1./ ngha:
- tiu chy l t/trng tng bi tit phn v khi lng & tng t l nc ca phn trong 24h.( >10g phn/kg/24h hoc >3l/ngy v lng hn b/thng) - tiu chy cp l 1 t t/chy tha mn kin ko di ko qu 14 ngy. - t t/chy l 1 t bt u = ngy u tin xut hin t/chy n ngy sau >2 ngy tr a phn b/thng. 2.c ch tiu chy: 2.1. RL nc in gii: TE b/thng s hp thu nc &in gii trong long rut c thc hin =2 con ng ch ng th ng . - s hp thu th ng c t/hin qua ni tip gip gia cc TB rut. - s hp thu ch ng c t/hin qua TB rut & ph thuc vo ngun nng lng ATP.men ATPaza c mp bn ca TB rut s tch ATP gii phng nng lng cn thit cho vic hp thu ch ng. Mui &ng c hp thu cng lc nh cc p/t v/chuyn nm trn b nhung mao ca TB rut . - tngb xm nhp vo ng t/ha gy ra a chy do 1 s c ch: + Virus: s nhn ln ca VR trong lin bo nhung mao rut lm ph hy cu trc lien bo & cn nhung mao. Vic mt cc TB hp thu b/thng & thay th cc TB bi tit cha tr/thnh gy bi tit nc /gii rut.nhung mao tn thng c th km mt men disacharidaza lm gim hp thu cc ng i nht l lactose. S phc hi xy ra lhi cc nhung mao ti sinh & lin bo nhung mao tr/thnh
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+ VK bm dnh n/mc:(ETEC, E.coli bm dnh , cholerae 01) phi bm dnh ln n/mc trnh b o thi ra ngoi. S bm dnh gy ra nhng bin i lien bo rut c th lm gim kh nng hp thu hoc tng tit dch. + cc c t gy tit dch :ETEC, cholerae 01 v 1 s VK khc sinh ra cc c t lm gim hp thu Na+ nhung mao & tng bi tit clo hm tuyn dn n s o ngc lung hp thu mui nc, lm xut tit t nc & in gii trong lng rut .s hi phc xy ra khi TB biu m rut b nhim dc t c thay = nhng TB lnh sau 2-4 ngy. + tc nhn x/nhp n/mc : Shigella, C. Jejuni, ETEC , Samonella gy a chy c mu do chng xm nhp & ph hy cc lien bo n/mc rut ch yu xy ra phn cui hi trng & i trng. Cc c t ny s kch thch men adenylcyclase t/dng ln ATP sinh ra AMP vng . h/tng ny s gy ra s o ngc lung hp thu mui nc gy t/trng a chy. 2.2. cc loi mt nc: - mt nc ng trng: lng mui mt = lng nc mt . - mt nc u trng: lng mui mt < lng nc mt . - mt nc nhc trng: lng mui mt > lng nc mt . 3.ng/nhn + k t/li : 3.1.ng/nhn - do dinh dng : ch n ko ng, ko hp l Ko dung np c 1 s loi T. - do nhim khun: + ti rut :cn nguyn xm nhp l cc VSV ni chung (ETEC, EIEC , EPEC , EAEC.....) + ngoi rut : nhim khun cc c quan khc nh: vim tai gia , vim mi hng , nhim khun ng tit niu ..... 3.2.k t/li : - TE th trng SDD , ko c b m , mc bnh mn tnh.... - Thi tit : bnh a chy tng ln trong ma h - Mi trng: k KT-XH thp, thc con ngi km , MT v sinh bn... -do nui dng chm sc: dc nui = sa m hon ton v chm sc tt s t b t/chy . 4.LS 4.1. Mt nc- in gii mc A tr/ch Nhn: Tt, tnh to Ton trng Bnh thng Mt C Nc mt t Ming li Ko kht ,ung Kht bnh thng S: Vo da Np vo da mt

B *Vt v k/ thch Trng Ko Kh Kht * ung ho hc Np vo da mt

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C *Li b hn m Rt trng Ko Rt kh Ung km hoc ko th ung c Np vo da mt

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Chn on

nhanh Ko c du hiu mt nc

chm C mt nc nu c 2 du hiu tr ln trong t nht l 1 du hiu *

rt chm Mt nc nng nu c 2 du hiu tr ln trong t nht l 1 u hiu *

4.2.tr/chng tiu ha: -RLTH chung: nn , chng bng , au bng m hay qun , bing n... ( nu au qun , mt rn , i t l l) - RL t/phn & tnh cht phn : phn lng, phn ko lng nhiu nhng st, nh nc, phn c th t nhy (mu) + mi phn: tanh ( virus) Chua nng (do RL thm thu)... + mu sc: xanh, trng Xm ( do nhim khun) - Tr/chng ton thn: st, do ni c t ca VK s ko st RL in gii gy co git Tim p nhanh Tt HA 5. Cn LS - cng thc mu : BC a nhn trung tnh tng ( do VK) C mu - RL in gii : gim kali /mu, mt nc nhc trng Gim clo / mu Gim natri/ mu: < 130mM/l- nhc trng 130-150 mM/l ng trng > 150 mM/ l u trng - VSV: xt nghim cn nguyn VSV trong phn +test khng nguyn +nui cy phn , phn lp VK + soi phn +in gii 6. iu tr : phi iu tr sm v kp thi 6.1. iu tr mt nc v in gii: Cn c vo tn thng chia 3 phc : phc A: mt nc nh hay ko mt nc =< 5% trng lng c th + cho ung nhiu nc cn c vo s ln i ngoi xc nh lng dch b vo ( b 50-100 ml ORS /l TE< 12 thng tui B 100-200 ml ORS /l TE t 12 thng tui n 10t ) +ch dd: i vi TE <6 thng tui cho b b/thng, nu cho ung sa phi pha long, hn ch ng lactose +thng xuyn theo di pht hin s mt nc sm
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 phc B : iu tr thiu ht ( b li lng dch mt qua phn nn phi b c tgian). Khi mt nc 6-9% trng lng c th phi b trong 4h, b 75 ml/ kg (ORS). + nu nh chuyn sang phc A + nu nng chuyn sang phc C phc C: khi c th mt nc >=10% trng lng c th. B trong khong tgian ph thuc vo tui. b 100 ml/ kg ( ringer lactate, NaCl 0,9%). Khi TE bt u tnh cho n v ung ORS. 6.2 iu tr nguyn nhn: - nu do VR ko sd KS - /tr nhim khun: sd nhm quinolon: Acid nalidixic : 30-50 mg/kg Cyclofloxacin :20-30 mg/kg - /tr KST: metronidazol. - B sung km : 15-30 mg/24h/ TE rt ngn tgian tiu chy, t ti pht. 6.3. /tr tr/chng: - sd thuc gim titdch : smecta - a vo cc VK c li : probiotics 7. phng bnh: - nui con= sa m -ci thin tp qun cho tr n sam - sd ngun nc sch v VS n ung -ra tay trc khi n v sau khi i ngoi - sd h x ng qui cch VS -x l phn TE ng qui cch - tim phng si.

107- Dc 11

B2
Bi 1:VIM MNG TRONG TIM NHIM KHUN BN CP
1.i cng:
- l tnh trng vim mng trong tim c lot si, thng xy ra trn 1 mng trong tim c tn thng bm sinh hoc mc phi t trc. - cn gi l bnh Osler. 2.ng/nhn: 2.1. tc nhn gy bnh : vi khun hoc nm 2.1.1. vi khun: tc nhn chnh trong hu ht cc th/hp - lin cu khun:chim 50% TH bnh. Lin cu khun nhm D l loi rt hay gp c ngun gc t nhim khun t/ha & tit niu sinh dc, t nhy cm vi penicillin thong thng.

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- t cu khun: chim 30% TH bnh thng c ngun gc t nhim khun ngoi da, sau no ph thai, qua cc th thut: ni soi , t ni kh qun.thng c tn thng van 3 l, tnh trng khng KS mnh , hay c hy hoi t chc tim - do cu khun : hay c DD,rut ,niu o v i khi l ming.Khng penicillin tng i ,xut hin sau khi b nhim trng:hay chn thng ng tit niu sinh dc - Do gram m chim khong 10%,khng ks mnh -cc cu khun khc : mi loi vi khun u c th gy bnh ny 2.1.2 Nm -Cc chng loi nm hay gp :Nm men:Candida albicans, Aspergillus thng gy bnh trn c a suy gim min dch hoc dang c dung ks ko di 2.2 ng vo ca tc nhn gy bnh : T y c th suy on c tc nhn gy bnh -nhim khun rng ming: hay gp nht -Nhim khun ngoi da,nhim khun do no ph thai...thng do t cu gy ra -Nhim khun ng tiu ha tit niu-sinh dc thng do lin cu khun nhm D, chim 1 t l quan trng -Gn y t l vim mng trong tim nhim khun c ng vo l tim chch ma ty tng mnh. Bt buc phi lm xt nghim HIV nhng i tng ny 2.3 Vai tr ca bnh tim c sn - t khi gp trn qu tim lnh thng sy ra khi c tn thng tim t trc - 50-80% bnh nhn c tin thp tim gy bnh van tim : h van 2 l , h van ng mch ch... - 10% bnh nhn c bnh tim bm sinh -bnh cn gp bnh nhn thay van nhn to hoc b bnh c tim ph i 3.Lm sng :c cy mu dng tnh(+) trn 1 bnh nhn c bnh tim c 3.1 Hon cnh pht sinh bnh: - Bnh khi pht m thm t t ko di khng r nguyn nhn, c khi st cao rt run hoc st nh kin o nn cn phi thao di nhit c th 3h/ln - C khi bnh c pht hin v suy tim hay tc mch ( no,chi,ph tng...) 1 bnh nhn dang c st 3.2 Khm lm sng -Giai on ton pht ,triu chng r dn: +st : hng nh ko di , rt thay i(nh , va hoc nng) +st km tnh trng sa st: suy nhc , au c khp. Pho cy mu khi ang st , rt run th t l (+) mi cao - Biu hin tim : + Pht hin c bnh tim c sn t trc: h van 2 l, h van mc... +Cc nt si hay bong da gy lot lam thng van tim , t dy chng ct c, thng vch tim gy ting thi thc th mi - Biu hin ngoi tim: + Lch to : 50% trng hp ,rt c gi tr gi cho chn on bnh nhn b bnh tim c st ko di + da v nim mc : Chn m gi l nhng mn mu tm , gia mu trng
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+ Xut huyt di da v nim mc thng xut hin tng t, mi t vi ngy + C th xut huyt lng bn tay , gan bn chn gi l du hiu janeway - Tai bin mch mu : c th phnh v tc ng mch hay c nhi mu : m gan, m lch... 4. Cn lm sng -Xt nghim mu :cy nu l phng php chnh cho php khng nh chn on v c gi tri hng dn iu tr qua ks - Cc xt nghim mu khc : Tc mu lng lun tng cao S lng hng cu gim Bch cu tng nht l bch cu a nhn trung tnh Anpha 2 va globulin tng C s xut hin cc phc hp min dch lu hnh -Siu m tim: Rt c gi tr chn on + siu m qua thnh ngc +siu m qua thc qun -Cc xt nghim khc : Protein (+), 70-80% cc trng hp c i mu vi th (v i mu khng thng xuyn nn phi lm xt nghim nhiu ln) 5.Chn on 5.1 Chn on xc nh a , tiu chun chnh : Cy mu (+), c bng chng ca tn thng ni tm mc trn siu m tim b , tiu chun ph ; C bnh tim t trc hoc tim chch ma ty , st biu hin v mch mu (tc mch no, nhi mu phi ...),hin tng min dch c 1 trong cc biu hin nh: vim cu thn, ht osler, du hiu Roth, yu t dng thp (+),siu m tim 5.2 Chn on chc chn -t/chun vi khun, m bnh hc +VK:tm thy t vic nui cy hay xt ngim nt si tim. +tn thng gp bnh: c nt si hay p xe trong tim. - t/chun LS: 2 tc chnh 1 tc chnh+ 3 tc ph 5 tc ph 5.3. chn on nghi ng: c du hiu VMTTNK nhng cha ch/on x/nh cng ko loi tr. 5.4. loi tr hn: tm c chn on chc chn g/thch c tr/chng tr KS 4 ngy ht tr/chng Ko tm thy bng chng tn thng ca VMTT 5.5. chn on phn bit : - bn c st: loi b cc ng/nhn gy st do virus. Ch loi tr ting thi tm thu c nng do thiu mu& st. -bn c bnh tim, st: + thp tim h/ng: c b/hin vim tim, viem khp , ban vng, ht thp di da. +VMTT Libman- Sachs: c bnh cnh LS ca lupus ban +sau m tim : do vim mng ngoi tim, vim xng c 6. cc th bnh : - th cy mu m tnh
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-th thn - th bn c bnh tim bm sinh l cn ng ng mch - th sau phu thut tim. 7. tin lng 7.1. tin lng gn: - /tr tch cc+ VK nhy cm KS th bnh gim hn. - /tr tch cc m bnh vn nng hn do: KS cha liu hay ko c tdung, c nhng tn thng khu tr ni tng, c th c d/bin nng nh tai bin tc mch no , mch vnh 7.2 tin lng xa - /tr tt :khi ko li di chng. - ti pht: sau ngng /tr 3-4 tun x/hin li - ti nhim: cng loi hay khc loi tc nhn gy bnh , thng xy ra mun hn. 8. bin chng - b/chng tim:hay gp v nng nht , d die. + suy tim do tn thng van tim +tn thng van 3 l +tc mch vnh gy NMCT -b/chng m/mu: tc mch cc ni, phnh dng mch -b/chng thn kinh:tc M no , chy mu no, p xe no. -b/chng thn: vim cu thn tng on , khu tr; nhi mu thn ,p xe thn.... -b/chng khp: vim khp phn ng, m khp. 9. iu tr : 9.1. ng/tc: + sd KS sm sau khi cy mu 3 ln, KS c td dit khun,liu cao, ko di 4-6 tun( nhm aminoside ko nn sd qu 2 tun) phi hp KS, chia u liu trong ngy. +theo di c/nng thn khi sd KS c cho thn . +theo di kt qu /tr = LS & cy mu + p/hin sm v /tr cc b/chng. 9.2. /tr ni khoa: - KS: dng sm sau cy mu nhiu ln Penicillin+ streptomycin( gentamycin) 10-20 triu v/ ngy 10-20mg/kg/ngy Truyn TM tim bp sng chiu - khi c kt qu cy mu v KS th /chnh theo KS . -cy mu (-) : penicillin 10-20 triu n v /ngy hoc ampicillin + gentamycin truyn TM. - ngi c van nhn to : vancomycin 30mg/kg/ngi phi hp gentamycin 3mg/kg/ngy truyn TM. -tg dng thuc: 4-6 tun. - /tr ni khoa khc: trit dng vo, /tr b/chng: suy tim, lon nhp , suy thn....
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9.3. /tr ngoi khoa: sa cha tn thng hoc thay van, loi b nhng nhim khun... 9.4. d phng VMTTNK bn cp: - theo di cht , sd KS d phng. - /tr nhim khun d nh mi ni trong c th. - phu thut sm cho bn tim bm sinh nht l TH cn ng M - gd tt cho bn hiu nguy c mc bnh.

Bi 2: VIM RUT THA CP

1. i cng VRTC l bnh cp cu ngoi khoa thng gp nht trong cp cu bng. Bnh gp mi la tui, gii, nhiu nht tui 20-30. Bnh cnh LS a dng phong ph, binns chng ko lng trc. Cn chn on v m sm.

2. Nguyn nhn v c ch bnh sinh - Theo thuyt NK: VRTC do: + c tr trong lng rut tha v manh trng + ng => vim nim mc => vim rut tha - Thuyt phn x thn kinh: c kch thch bnh l vng c th (thng quanh manh trng) => gy co mao mch, thiu mu t chc thnh rut tha, nu ko di => hoi t TB nim mc => VK c sn trong lng rut xm nhp => VRTC - Thuyt d ng: VRTC c vai tr ca d ng nhng cha c xc minh r 3. Triu chng a. Lm sng - C nng: + au bng vng h chu phi, khi pht u tin c th ti h chu phi hoc cc vng khc, thng thng v hoc quanh rn. au m lin tc, tng dn, ko thnh cn, au tng khi vn ng, i li + bun nn, nn + b trung i tin, 1 s trng hp RL tiu ha - Thc th: + khm h chu phi: au khu tr ti 1 im nu giai on sm, thng gia ng ni gai chu trc trn v rn (im Mac-Burney) + cm ng phc mc: s nn nh ln thnh bng => bnh nhn au d di. Lm u hiu Schotkin Blumberg (+) + khm thy phn ng c thnh bng h chu phi: khm n ln thnh bng h chu phi => trng lc c thnh bng ti tng khng sc n ca bn tay => n nh d, n su kh => P tn ti khch quan ngoi mun ca ngi bnh. + triu chng khc:
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 1 s im au khng in hnh ca rut tha do v tr rut tha thay i: im Lanz (im ni 1/3 gia vi 1/3 ngoi bn phi ca ng lin gai chu trc trn) im Clado ( im gp nhau ca b ngoi c thng to bn phi vi ng lim gai chu trc trn) im sau trn mo chu phi im sau manh trng Mt s du hiu: Rowsing Sitkovski Obrasov Thm trc trng c th thy au - Ton thn: + st nh hoc va < 380C, khi st > 38 390C thng do bin chng v + trng thi nhim khun: mi kh, li bn, hi th hi

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b. Cn lm sng - XN mu: SLBC tng cao, CTBC tng ch yu BC a nhn trung tnh, c th xut hin BC non mu ngoi vi. - Siu m bng: rut tha kch thc ln > 6mm, ng knh ct ngang c hnh nh ca cc vng trn ng tm , c dch t do h chu phi. - Ni soi bng 4. Bin chng - Vim phc mc ton th: do rut tha v trong khoang phc mc =>nng => cn m cp cu ngay - p xe rut tha: rut tha v,c lp vi khoang phc mc => cp cu bng dn lu gii thot dch m ra ngoi, c th phu thut hoc ko. - m qunh rut tha: vim nhng cha v m, cc tng n bao li to m vim dnh => ko m ct rut tha cp cu m iu tr bng khng sinh , sau 3-6 thng mi ct. 5. Cc th lm sng - in hnh + VRTC th xung huyt + VRTC th vim ty + VRTC th hoi t + VRTC th hoi th - Ko in hnh
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+ v tr: sau manh trng, gia cc quai rut, VRTC trong chu hng b, di gan, h chu tri.. + c a: VRTC ngi gi, tr nh, PN c thai, bnh nhn suy gim min dch, bnh nhn bo ph 6. Chn on a. Chn on xc nh: - hi chng nhim khun: st nh hoc va, mi kh, li bn, hi th hi, s lng BC tng, tng BC a nhn trung tnh. - au h chu phi: - khm h chu phi au, im Mac Burney au - c cm ng phc mc h chu phi ( du hiu Schotkin Blumberg (+)) - phn ng thnh bng h chu phi - siu m - ni soi ( vi nhng trng hp kh iu tr) b. Chn on phn bit: phn bit vi cc bnh l khc c au h chu phi: - bnh l bng: H chu phi: manh trng, i trng ln, hi trng, ti tha Merkel Xa h chu phi: d dy, t trng, ti mt,phn ph - sau phc mc: Thai ngoi t cung Si thn, si niu qun phi - lng ngc: vim phi, vim ph qun (tr em) 7. iu tr a. Hng iu tr: VRTC l 1 cp cu ngoi khoa, cn c iu tr bng phu thu cp cu, tr trng hp m qung rut tha b. Phng php: ct rut tha: phu thut bng m hoc phu thut ni soi

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