1/14/2014

1
TUN 1
Ca 1: LOT DDTT
ng B, 57 tui, nhp vin v i ngoi phn en. Cch
y 2 ngy, ng b au d dy nng. Trong vi thng
gn y ng thnh thong c triu chng kh tiu.
ng ht thuc l nhiu nm, suy tim mn tnh
nh v ang dng enalapril 5mg x 2 ln/ngy v
furosemid 40mg/ngy c 2 nm. Gn y, ng
vim khp v dng naproxen 500mg x 2 ln/ngy.
Hm qua, BN lm XN v c kt qu nh sau:
Hgb 10.3 g/dL (12-18 g/dL)
Plt 162.10
9
/L (150 450.10
9
/L
INR 1.1 (0.8 1.2)
HR 87 nhp/pht
BP 115/77 mmHg
BN c truyn 1,5 lt dung dch sinh l
BN va c ni soi ng tiu ha sng nay v c
chn on lot t trng xut huyt. Ngy mai BN s
c k toa cc thuc ng ang dng nu BN n ung
bnh thng.
Tr li cu hi
1. Cc triu chng gi ni soi ng tiu ha?
Lit k cc nguy c ca ng B i vi bnh lot
t trng? Ch tr liu ca BN n thi im
ny thch hp cha?
- Triu chng gi : kh tiu, phn en, au d dy nng
- Nguy c: cao tui, ht thuc, dng NSAIDs
ch tr liu cha thch hp
Tr li cu hi
2. BN nn dng thuc no kim sot lot t trng
xut huyt?
Dng PPI ng ung, do BN vn n ung c
3. Chin thut k tip trong iu tr bnh lot t trng
xut huyt ca BN l g?
- Ngng dng NSAIDs
- PPI lansoprazol 20mg x 3 ln/ngy 4-6 tun
- Nu c xut huyt: PPI 6-8 tun
1/14/2014
2
Tr li cu hi
4. Thuc no nn c k toa khi BN xut
vin?
- Tim mch: thuc c
- Vim khp: paracetamol 500mg + codein 30mg dng ko
di n khi ht p ng, quay li cc thuc NSAIDs v
nga lot
- Nga lot: dng misoprostol, antacid, PPI liu duy tr
thp
Tr li cu hi
5. BN cn c t vn g?
- n nhiu ba, khng qu no hay qu i
- Trnh: cay, chua, nng, kch thch
- B thuc l, ru bia: v l yu t nguy c
- Gi tinh thn lc quan
6. BN theo di iu tr nh th no?
Nu sau 4-6 tun, triu chng khng gim, th xt nghim tm
H.pylori, trc khi lm XN phi ngng PPI t nht 2 tun
TUN 1
Ca 2: LOT DDTT
Trn Th H, n, 80 tui, BN i ngoi phn en v nn cht
nn mu c ph. Mt tun nay mt mi, yu kh chu vng
thng v v bun nn. BN i ngoi phn en ngy hm
trc v nn ra cht nn m c ph hm nhp vin.
BN c tin s bnh xng khp
Tin s gia nh: khng c g c bit
Li sng: khng c g c bit
Tin s dng thuc: BN dng cc thuc sau theo n ca
bs khm iu tr cc bnh ang mc:
- Indomethacin 25mg: 1v x 3 ln/ngy
- Voltaren 50mg: 1v x 2 ln/ngy
- Cytotec 200g: 1v x 2 ln/ngy
Tin s d ng: khng c g c bit
Sinh hiu:
- 51kg, cao 1m56
- Mch: 101 ln/pht
- Nhit : 36,5
o
C
- Huyt p: 125/70 mmHg
- Nhp th: 24 ln/pht
BN da xanh xao, nim mc nht, trng thi lo u, cng thng
1/14/2014
3
Xt nghim:
- Hemoglobin: 85g/l (125-145)
- Hematocrit: 0,3 (0,35-0,47)
- Protein-C: 4,5 mg/l (<5)
- MCV: 75fL (83-92)
- MCH: 25 PG (27-32)
- INR: 1,01
- Na: 141 mmol/l (133-147)
- K: 4,0 mmoll/l (3,4-4,5)
- Creatinin: 70 mol/l (40-80)
- Tiu cu: 264 x 10
9
/l (150-450 x 10
9
)
- Ure: 20,3 mmol/l (1,7-8,3)
Kt qu chn on hnh nh: kt qu ni soi ngay ti
thi im vo vin cho thy BN b lot mn v, c r mu
(Forrest Ib)
Thuc s dng trn BN:
- Cm mu qua ni soi bng adrenalin 1/10000
- BN c k n Esomeprazol 80mg IV, sau truyn
tip liu 8mg/h trong 72h, tip tc ung liu 40mg/ln x 2
ln/ngy x 5 ngy. Mu XN H.pylori (+).
Tr li cu hi
1. Nhng vn cn xem xt ngay
Cm mu, truyn mu
2. Yu t nguy c gy xut huyt BN ny
NSAIDs: indomethacin v diclofenac
3. Hiu qu ca misoprostol
Phng nga lot
4. Khuyn co v thuc m BN ang dng
Ngng dng NSAIDs iu tr xut huyt
5. Nhim H.pylori c lm tng nguy c tn thng nim
mc tiu ha do NSAIDs khng?
C
Tr li cu hi
6. Khuyn co dng thuc g dit H.pylori cho BN? Liu
lng, thi gian, cch dng, TDP, khc phc?
- Phc 3 thuc 14 ngy: PPI + clarithromycin 500mg +
(metronidazol 500mg/hay amoxicillin 1g) 2 ln/ngy
c th thay amox v metro bng tetracyclin 500mg
- Phc 4 thuc 14 ngy: PPI 2 ln/ngy + metronidazol
500mg 3 ln/ngy + (bismuth subsalycilat 525mg + tetracyclin
500 mg) 4 ln/ngy
hay: Khng H2 2 ln/ngy + (bismuth subsalycilat 525mg +
metronidazol 250mg + tetracyclin 500 mg) 4 ln/ngy
- Phc gi u 10 ngy: 5 ngy u PPI + amoxicillin, 5
ngy sau PPI + clarithromycin + metronidazol
1/14/2014
4
TUN 2:
CA HEN SUYN
Lp 12CDSL04
B quyt i i:
Cm in thoi ng gia tri ma sm chp.
Gi in thoi ln ht ln:
Siu nhn Gao, bin hnh!!

Vng, v nu may mn bn s bin thnh Gao en!!!

Subjective: Thng tin ch quan
Thng tin bnh nhn: L, nam, 18 tui
L do vo vin: kh th sau khi i b 200m
Din bin bnh: gn y i tp th dc vo sng sm v
tnh trng kh th ngy cng trm trng
Bnh s: khng r
Tin s gia nh: khng r
Li sng: khng r
Tin s dng thuc: khng r
Tin s d ng: khng r
Objective: Thng tin khch quan
Tui Ch s PEF Gi tr o
18 420 80%
Assesment: nh gi tnh trng BN
- Tnh trng kh th ngy cng trm trng
- o lu lng nh th ra t 80% so vi d kin
- c chn on hen suyn, yu t nguy c c th do
thi tit hay/v vn ng th lc
1/14/2014
5
Assesment: nh gi tnh trng BN
Bnh nhn ang dng thuc:
- Ventolin CR 4mg (salbutamol phng thch chm c kim
sot) 2 vin x 2 ln/ngy
- Becotide MDI (beclomethasone) 2 nht x 2 ln/ngy
Assesment: nh gi tnh trng BN
Bnh nhn c tnh trng kh th, cc bc iu tr hen
suyn theo GINA, u tin bnh nhn phi dng thuc ct
cn 2-agonist tc ng nhanh, v cc thuc corticoid
(MDI) liu thp kim sot cn hen.
y bnh nhn c k toa salbutamol tc ng chm
l khng hp l, v khng c tc dng ct cn m ch kim
sot cn.
Assesment: nh gi tnh trng BN
Thuc ang dng TDP CC
Salbutamol - Tim nhanh, hi hp, run u chi - Mn cm, PNCT
Beclomethasone
-Qu liu ko di: nh hng
chc nng thng thn
- Ti ch: nhim nm candida
- Mn cm
Plan: K hoch iu tr
Xt nghim cn lm thm:
- X-quang phi loi tr cc bnh khc c triu chng hen nh: vim
phi, lao phi, K phi
- Xt nghim cng thc mu xem tr s bch cu acid, nu cao hn
bnh thng th bnh nhn ang tnh trng d ng.
Mc tiu iu tr: kim sot hon ton bnh
Thuc ngh: dng thuc ct cn 2-agonist tc ng nhanh
salbutamol MDI thay th cho Ventolin CR, v thuc beclomethasone
MDI kim sot cn.
1/14/2014
6
Plan: K hoch iu tr
Nu sau khi dng thuc m triu chng khng gim th
phi quay li bc s xem xt v ti khm nng bc.
Dinh dng: n ung y , trnh nhng thc n
tng gy d ng cho bnh nhn.
Vn ng hp l, va sc, trnh thi tit lnh bui sng
sm.
Tr li cu hi
1. Hen suyn l g? Triu chng ca hen suyn?
- Hen l tnh trng vim mn tnh ng th, tng p ng
vi cc kch thch co tht ph qun, khi m lm tc
nghn ng th.
- Triu chng: kh th (th th ra), ho, tc ngc, tng tit
dch h hp. Xy ra vo ban m v sng sm.
Tr li cu hi
2. Cc yu t nguy c hen suyn? Bnh nhn L c yu
t nguy c no?
Nguyn nhn M t
Di truyn D ng, mn cm, bo ph. Di 14
tui: b trai > 2 ln b gi
D ng nguyn Phn hoa, lng th, nm mc
Thuc, ha cht Aspirin, NSAIDs, SO
3
-
nhim Khi thuc l, mi trng
Ngh nghip Nha, thuc ty, Pt, Cr
Nhim trng h hp Virus
Vn ng th lc p xe, bng, chy b
Tm l Ci ln, khc, lo s
Tr li cu hi
Bnh nhn L c yu t nguy c:
- Thi tit: sng sm
- Vn ng th lc: i b th dc
1/14/2014
7
Tr li cu hi
3. ngha lu lng nh (PEF) v m t cch o? Mt
s phng php o chc nng h hp khc?
- ngha PEF: L theo di bin thin ca lu lng nh
th ra theo thi gian nhm xc nh:
Cc du hiu bo trc s xu i ca bnh hen
nng ca bnh hen.
p ng vi thuc trong cn hen.
Chn k hoch hnh ng ph hp
Tr li cu hi
M t cch o PEF:
Bc 1: Di chuyn nt ch ti s 0 hoc s thp nht trn thc
ca lu lng nh k.
Bc 2: ng thng ngi hoc ngi thng lng, ht vo tht
su.
Bc 3: Ngm l thi ca lu lng nh k vo ming; th ra
tht mnh v tht nhanh mt ln (thi ht kh nng), trong 1
hay 2 giy..
Bc 4: Kim tra ch s o c trn lu lng nh k v ghi
li.
o 3 ln, chn ch s cao nht
Tr li cu hi
Mt s phng php o chc nng h hp khc:
- o th tch h hp bng ph dung k
- FEV1: th tch th ra gng sc trong 1 giy
Tr li cu hi
4. Ventolin v Becotide c cha hat cht g? C ch
tc ng v TDP?
Thuc C ch TDP
Ventolin (salbutamol)
Kch thch -
adrenergique c tc
ng chn lc ln th
th trn c ph qun
Tim nhanh, hi hp, run
u chi
Becotide
(beclomethasone)
Khng vim
Nhim nm candida
vng hng
1/14/2014
8
Tr li cu hi
5. M t cch dng MDI (meter dose inhaler):
- M np bnh xt, gi thng ng, lc k
- Ngm ming bnh xt gia hai hm rng, khp mi v th
ra chm
- Nga nh u, n bnh xt ng thi ht chm v tht
su, cng nhiu cng tt.
- Nn th trong khong 10 giy cho thuc hp thu.
Tr li cu hi
6. Nhn xt toa thuc ca bnh nhn L:
y bnh nhn c k toa salbutamol tc ng chm
l khng hp l, v khng c tc dng ct cn m ch kim
sot cn.
Tr li cu hi
7 . Bnh nhn cn t vn kh nng dng Singulair cho
trng hp ca mnh?
SINGULAIR (montelukast) c ch nh cho ngi bnh
ln tui v tr em trn 6 thng tui d phng v iu tr
hen ph qun mn tnh, bao gm d phng c cc triu
chng hen ban ngy v ban m.
Tr li cu hi
8. L c th dng Singulair khng? Dng phi hp hay dng
n l? Theo di trong iu tr bnh hen ca L ra sao?
- Bnh nhn L c th dng Singulair. Theo bc iu tr ca
GINA th dng phi hp vi thuc ct cn, lc ny bnh nhn
khng dng corticoid MDI thm na.
- Theo di iu tr: n ung y , trnh nhng thc n
tng gy d ng cho bnh nhn. Vn ng hp l, va sc,
trnh thi tit lnh bui sng sm.
1/14/2014
9
TUN 2:
CA VIM XOANG
Lp 12CDSL04
Lng mn:
Anh n bn Em trong mt bui chiu, tri ang ma tm
t!!! Nh nhng ly o ma ra, tht du dng anh th th:
......

..

Mua khng em, ch c 5 ngn thi

Subjective: Thng tin ch quan
Thng tin bnh nhn: bnh nhn nam, 34 tui
L do n khm: nght mi nng, au u v nhn m
Din bin bnh: cc triu chng trn c trong 3 ngy
gn y
Bnh s: hen suyn lc nh, va mi b cm lnh
Tin s gia nh: khng r
Li sng: khng r
Tin s dng thuc: 2 vin paracetamol khi b cm lnh
Tin s d ng: thuc penicillin
Objective: Thng tin khch quan
Triu chng chnh Bnh nhn
au nhc vng u (khu vc xoang) C
Chy mi C
Nght mi C
Nga mi
Khng ngi c cc mi C
Assesment: nh gi tnh trng BN
Bnh nhn tng b cm cm mi y, iu tr bng 2 vin
paracetamol, do iu tr khng ng mc nn cc xoang
tr nn vim tc, ph n v ngn tr dch nhy thot ra
mi, dn n nhim trng xoang (dch m mu vng
xanh). iu ny l yu t thun li ca vim xoang.
1/14/2014
10
Plan: K hoch iu tr
Xt nghim cn lm thm: ni soi mi xoang kim tra
tnh trng vim, nu c iu kin th chc ht dch lm
khng sinh
Mc tiu iu tr: gii quyt nhim trng, lm cc triu
chng bnh nh hn v lnh bnh nhanh hn, trnh cc
bin chng
Plan: K hoch iu tr
ngh dng thuc:
- Thuc co mch dng ung: pseudoephedrin 60mg 1 vin x 3
ln/ngy
- Khng sinh chng nhim trng: clarithromycin 500mg 1 vin x
2 ln/ngy: 7 ngy; hay nhm cyclin
- Gim au: paracetamol 500mg 1 vin x 3 ln/ngy
- Khng histamin H1
- Nc mui sinh l: ra mi
Plan: K hoch iu tr
Ch khi dng thuc:
Thuc TDP Ch
Pseudoephedrin
Kh ming, bun ng, h
HA, tim nhanh
Do dng chung vi
khng H1 nn cng
hng tc dng ph l
bun ng mnh
Clarithromycin Ri lon tiu ha
Paracetamol Liu cao: suy gan
Khng H1 Bun ng
Plan: K hoch iu tr
Dn d:
- Khi b cm cm, phi i khm c iu tr ng v dt
im, trnh lm khi pht yu t thun li gy vim xoang.
- Vic quan trng vn l trnh vim mi. Khng nn nhng
ni khng kh b nhim (bi, khi, thuc l...). Trnh thc n b
d ng. n ung y c sc khng. V sinh thn th,
nng ra tay, ra mt, khng tm ni nc bn.
1/14/2014
11
Tr li cu hi
1. Cn hi bnh nhn nhng cu hi g gip cho vic
chn on bnh?
- C au rng khng? (nu c au rng, th c th do vim
xoang hm)
- Chy nc mi trong hay c? (vim d ng: nc mi
trong, vim nhim khun: nc mi xanh vng)
- C nght mi khng?
- C nga mi khng? (nu c, c th do vim d ng)
- C ngi c mi khng? (nu khng ngi c, l tnh
trng vim nng)
- C st v nn i khng?
Tr li cu hi
2. ng A c m mu vng hi xanh trong 3 ngy gn
y cng nhng cn au vng mt quanh mt v mi.
ng b mt kh nng nhn bit mi v v, k t khi b
cm lnh tun trc. Khng st. Nhng bnh m ng
A c th mc phi v chn on bnh cui cng ca
bn?
- Nhng triu chng ca ng A c lin quan n bnh
vim xoang cp do nhim khun (vim xoang trn v
xoang sng trc do gy au khu vc mt v mi;
nc mi mu xanh vng, v b mt khu gic tm thi)
Tr li cu hi
3. Nh c s hin din ca mt s triu chng nht
nh, bn tin rng ng A b vim xoang cp tnh. Hy
k cc yu t nguy c dn n vim xoang?
- ng dch trong xoang khng thot ra c, dn n
nhim khun (vim mi, cm cm)
- D ng, nhim mi trng
- Gim khng
Tr li cu hi
4. La chn iu tr ban u cho ng A?
- Ra mi: NaCl 0,9%
- Co mch dng xt ti ch: xylomethazolin, oxymethazolin
dng trong 3-5 ngy
- Khng sinh nhm macrolid: u tin l nhm B-lactam, nhng
do bnh nhn c tin s d ng penicillin nn khng chn. Cng
c th chn nhm cyclin
- Khng histamin H1
- Gim au: paracetamol
1/14/2014
12
Tr li cu hi
5. Theo bn, ng A c cn s dng beclomethasone
dng xt mi hay khng?
ng A khng cn dng beclamethasone dng xt, v c th
gy trm trng thm tnh trng nhim khun trong xoang
Tr li cu hi
6. Mt tun sau, ng A quay li v cho bit cc triu
chng gim nh nhng n ngy hm qua th ng y
bt u st, chng mt, khng nghe r v au tai. Bn
ngh ng y iu g?
- i n bc s ti khm, v c th c du hiu nhim trng:
st, au
Tr li cu hi
7. Mt bc s thc tp gi n cho bn v nh t vn
khng sinh no cn c k cho ng A?
- Macrolid hay cyclin
Tr li cu hi
8. ng A quay li vi n thuc Doxycyclin 100mg 2
vin/ngy x 7 ngy. Bn cn t vn cho ng A nhng g?
- Phi ung vi ti thiu mt cc nc y, v t th ng,
trnh lot thc qun, v gim kch ng ng tiu ha.
- Khng ung thuc cng lc vi sa (gy gim hp thu), cc
cht chua, antacid
- Trnh nh nng ti a.
- Tun th iu tr.
1/14/2014
13
Tham kho
Phn bit hen suyn v COPD
Ging nhau: u l bnh mn tnh - c tnh trng vim
ng th - tc nghn ng th - tng tit nhy - co tht
cung phi - u lin quan n yu t mi trng. Nn
biu hin lm sng cng c nhng im ging nhau nh
ho, khc m, nng ngc, kh kh, kh th...
Tham kho
Khc nhau:
Tui
Nguyn
nhn
Tin trin bnh
Chc nng
h hp
Hi phc
Hen
Xut hin t
khi nh
a dng
Gia cc cn,
BN khng c
triu chng g
dng nh:
khng nh
hng
C th r rt
COPD
Xut hin khi
trn 40 tui
t, ch yu
tin s l BN
ht thuc
t cp ca c
tn s v
trm trng ngy
cng tng
Ngy cng
nng hn
Rt km hay
khng c
TUN 2:
CA ECZEMA
Subjective: Thng tin ch quan
Thng tin bnh nhn: A, nam, 27 tui
L do vo vin: bnh eczema
Din bin bnh: sau khi bi kem Betnovate, vng da bi
thuc b v chc l
Bnh s: hen suyn t nm 15 tui, thnh thong b
eczema vo ma ng v khi b stress
Tin s gia nh: khng r
Li sng: khng r
Tin s dng thuc: salbutamol xt v beclometason xt
Tin s d ng: khng r
1/14/2014
14
Objective: Thng tin khch quan Assesment: nh gi tnh trng BN
Sau khi bi Betnovate (betamethason), bnh nhn c triu
chng nhim trng ti ch bi kem.
Bnh nhn ang dng thuc hen suyn:
- Salbutamol dng xt (ct cn hen)
- Beclometason dng xt (kim sot cn hen)
Bnh nhn ang dng thuc eczema:
- Betamethason dng bi ti ch
Assesment: nh gi tnh trng BN
Bnh nhn c 2 yu t nguy c c th khi pht bnh
eczema: do c tin s hen suyn (yu t c a) v b
cng thng (yu t ri lon thn kinh)
Assesment: nh gi tnh trng BN
y bnh nhn c k toa cho iu tr hen suyn l
hp l.
iu tr bnh eczema, bnh nhn bi lin tc
betamethason l khng hp l, bi v s lan rng tim n
ca nhim trng c th xy ra do tc dng che du nhim
trng ca corticoid.
1/14/2014
15
Assesment: nh gi tnh trng BN
Thuc ang dng TDP CC
Salbutamol - Tim nhanh, hi hp, run u chi - Mn cm, PNCT
Beclomethasone
-Qu liu ko di: nh hng chc
nng thng thn
- Ti ch: nhim nm candida
- Mn cm
Betamethasone
- Teo da, mng da, gin mch mu
ti ch
- Vim da do virus,
vi khun, vi nm
Plan: K hoch iu tr
Xt nghim cn lm thm:
- Sinh thit da ti ch vim ( loi tr nhim khun da do
virus, vi nm)
Mc tiu iu tr: kim sot triu chng bnh eczema (da
phng rp, thay i mu, ng vy, nga)
Plan: K hoch iu tr
Thuc ngh cho bnh eczema bnh nhn:
- Khi bnh nhn cha b nhim trng: c th dng corticoid
bi ti ch trong thi gian ngn (< 5 ngy).
- Khi bnh nhn c triu chng bi nhim (chc l, ):
khng sinh ng ung
Plan: K hoch iu tr
Trnh dng corticoid + khng sinh dng bi ti ch di
ngy. Sau mt thi gian nu triu chng khng gim, th
phi chuyn sang khng sinh ng ton thn v ngng
dng corticoid ti ch.
1/14/2014
16
Plan: K hoch iu tr
Nu sau khi dng thuc m triu chng khng gim th
phi quay li bc s xem xt v ti khm.
Trnh: gi nga, thc n d ng, tm nhiu, x phng, gi
da m, cng thngv kim sot tt bnh hen suyn.
Tr li cu hi
1. Bnh eczema l nh th no? Cc nguyn nhn
chnh gy eczema? iu tr nh th no?
Eczema l tnh trng vim da mn tnh tin trin thnh
tng t hay ti pht
Nguyn nhn: bnh t min, khng ly
- ngoi: x phng, thi tit, ha cht, d ng lng th,
phn hoa, bi
- trong: hormon, stress, di truyn
Triu chng: nga, ni trn da
Tr li cu hi
iu tr nh th no?
Khng th tr dt im, do l bnh t min nn ch iu tr
theo triu chng
- Khng histamin H1
- Khng vim corticoid
- Gi m da: vaselin, glycerin
- Nu nhim trng: dng khng sinh
Tr li cu hi
2. Beclometason v betamethason thuc nhm thuc
no? Nu cc tc ng ca nhm thuc ny
NhmCorticoid Tc ng
Beclometason & Betamethason
-Sinh l: trn chuyn ha (tng tng
hp glucid, phn b li lipid, tng
thoi ha protein) v trn m (tim
mch, TKTW, tiu ha, to mu)
- iu tr: khng vim, khng d ng,
c ch min dch, iu tr thay th
1/14/2014
17
Tr li cu hi
3. Gii thch thut ng hot tnh glucocorticoid v
hot tnh mineralcorticoid. Nu TDP ton thn v ti
ch ca glucocorticoid?
- Hot tnh glucococorticoid: do lp cu ca thng thn
tit ra, c chc nng ti hp thu natri v bi tit hydro v
kali ng thn, trn chuyn ha (tng tng hp glucid,
phn b li lipid, tng thoi ha protein).
- Hot tnh mineralcorticoid: iu ha nc v in gii
n nh HA v nhp tim.
Tr li cu hi
Nu TDP ton thn v ti ch ca glucocorticoid?
Ton thn Ti ch
-Tng huyt p
- Long xng
- Tng ng huyt
- Nhc c, yu c
- Hi chng Cushing
- Lot d dy t trng
- c thy tinh th, lot gic mc
- Thay i tnh tnh
- Tng nhim khun
- Suy thng thn cp (ngng thuc
t ngt khi dng liu cao ko di)
-Mn trng c, teo da, bi nhim, chm
lin so
- Dng xt: khn hng, nhim candida
- Dng nh mt: c thy tinh th
Tr li cu hi
4. Thuc bi ngoi da Betnovate s dng nh th
no? C s dng trong thi gian di c khng?
Betnovate (betamethason): bi ti ch vng da b vim 2-3
ln mi ngy, nu triu chng gim th gim liu (1
ln/ngy hay 2 ngy bi 1 ln), bi trong thi gian ngn
(khong 5 ngy).
Nu dng ko di, gy trm trng thm tnh trng nhim
khun, v gy tc dng ph ti ch.
Ra tay sau khi bi thuc.
Tr li cu hi
5. Nn ch nh khng sinh no cho bnh nhn? Ch phm
dng ngoi cha corticoid v khng sinh c hiu qu
khng?
y bnh nhn ch nhim khun khu tr, bnh nhn c th
dng corticoid v khng sinh bi ti ch (vd nh Betnovate-N:
betamethason v neomycin).
Nu bnh nhn eczema c tnh trng bi nhim, c th dng
khng sinh ng ton thn (do S.aureus c ni c t, gy
phn ng khng nguyn khng th d di gy tnh trng
vim da nng hn)
1/14/2014
18
TUN 2:
CA ADDISON
Subjective: Thng tin ch quan
Thng tin bnh nhn: bnh nhn n, 43 tui
L do vo vin: mt mi, sm mu da
Din bin bnh: t 3 thng nay, bnh nhn cm thy mt
mi ko di, thng b bun nn, chn n v st gn 3kg,
chng mt khi thay i t th, da sm mu dn d khng
ra nng, thay i khu v, thm n thc n mn nh da
mui.
Bnh s: khng r
Tin s gia nh: khng r
Subjective: Thng tin ch quan
Li sng: bnh nhn l gim c tip th ca mt cng ty
qung co, c 2 con nh. Do tnh cht cng vic, bnh
nhn thnh thong c ung ru vi i tc, khng ht
thuc.
Tin s dng thuc: khng c
Tin s d ng: penicillin (ni ban)
Objective: Thng tin khch quan
Khm bnh:
- Cn nng: 60kg
- Chiu cao: 1m67
- Huyt p: 110/70
- Nhp th: 22 ln/pht
- Nhit : 37
o
C
Khm lm sng:
- Bnh nhn tnh, v mt mi, tip xc tt
- Tim u, phi trong, bng mm, gan lch khng s chm
- Da kh, sm, khng rn, tng sc t lng bn tay, so cng
tay phi sm mu
1/14/2014
19
Objective: Thng tin khch quan
Tr s cn lm sng Bnh nhn Bnh thng
Na 127 mEq/L 135-150
K 5 mEq/L 3,5-5
Cl 98 mEq/L 98-110
BUN 15 mg/dL 7-21
Creatinin 1,1 mg/dL 0,7-1,5
Glucose 103 mg/dL 80-110
Cortisol 1,4 mcg/dL 8-25
ACTH 2096 pg/mL 0-130
Assesment: nh gi tnh trng BN
Theo cc triu chng lm sng v cn lm sng, bnh nhn c chn
on l bnh Addison
Lm sng:
- Sm da, thay i sc t da
- Mt mi
- St cn
- H huyt p t th
- Ri lon tiu ha
Cn lm sng:
- nh lng cortisol mu v ACTH khc hn bnh thng
Plan: K hoch iu tr
Mc tiu iu tr: gim triu chng bnh, a ch s cortisol
mu v ACTH v li bnh thng
ngh dng thuc:
- Cortisol hay Prednisolon 20mg 30mg: dng mt ln 20mg
vo bui sng sau khi n no, v 10mg vo bui chiu, cho ph
hp nhp sinh l c th
- Mineralcorticoid (fludrocortison) 0,05 0,2mg/ngy: duy tr
cn bng Na v K trong c th, do TDP ca cortisol
Plan: K hoch iu tr
Theo di dng thuc: do dng corticoid di ngy trn ph
n, nn theo di s mt xng
Khng ngng thuc t ngt
Thay i np sng, khng ung ru, khng khing vc
nng, tp th dc u n (30-60 pht/ngy).
B sung calci trong thi gian dng thuc 1000 mg/ngy, vit
D 400 n v/ngy.
1/14/2014
20
Tr li cu hi
1. Bnh Addison (suy thng thn mn tnh) l g?
Suy thng thn mn (bnh Addison) l tnh trng tuyn
thng thn gim tit ton b cc hormon (ch yu l cc
hormon ca v thng thn, glucocorticoid, aldosterol,
androgen)
Tr li cu hi
Nguyn nhn:
+ Lao thng thn
+ Ri lon t min (qu trnh t min dch c th ph hy nhiu
t chc nh tuyn ty, tuyn gip...).
+ Di cn ung th, nhim nm, giang mai...
+ Do thuc chng ng dn n xut huyt thng thn.
+ Tc ng mch thng thn (do thai nghn, chn thng).
+ Ri lon ng mu.
+ Phu thut ct c hai tuyn thng thn.
+ Suy gim min dch mc phi (AIDS)...
Tr li cu hi
C ch bnh sinh?
+ Gim aldosteron (hormon chuyn ho khong) s dn n gim kh
nng gi ion Na+ ti ng thn, gim o thi K+. Na+ trong mu a n
gim th tch mu lu thng, gim huyt p v cung lng tim.
+ Gim tit cortisol (hormon chuyn ho ng) s dn n gim d tr
glucogen ti gan, gim tng sinh ng d gy h ng huyt, gim
huy ng v s dng m (bnh nhn thng gy st cn), gim huyt p,
gim bch cu N, tng bch cu i toan v bch cu lympho (L).
+ Gim tit androgen (hormon sinh dc): dn n teo tinh hon hoc
bung trng, v kinh, lnh cm n gii hoc bt lc sinh l nam gii.
+ Tng MSH (melanocyte stimulating hormon do tuyn yn tit ra) ti
trong lp nh ca da v nim mc gy xm da.
Tr li cu hi
Triu chng lm sng:
- Sm da v nim mc
- Mt mi
- H huyt p v h huyt p t th
- St cn v mt nc
- Ri lon tiu ha
- C cc biu hin h ng huyt
- Triu chng tm thn kinh: gim tr nh, l m, nhc u
- Thay i khu v
1/14/2014
21
Tr li cu hi
Triu chng cn lm sng:
+ Thiu mu ng sc, mu c, hematocrit tng do mt nc.
+ Bch cu gim, bch cu a nhn trung tnh gim, tng bch cu lympho v bch cu i
toan.
+ Gim Na+, tng K+ mu, tng canxi mu.
+ Tng ur, creatinin nguyn nhn c th do mu ti thn gim dn n suy thn chc nng.
+ ng mu thp.
+ in tm : in th thp.
+ X quang tim-phi: trn phim chp thng tim nh nh hnh git nc.
+ X quang bng: c th thy nt vi ho thng thn (c th gp trong lao).
+ Cortisol huyt tng gim.
+ Aldosterol mu v nc tiu gim, androgen gim.
+17- cetosteroid nc tiu/24h gim.
+ 17- hydroxycortico-steroid nc tiu/24h gim.
Tr li cu hi
Triu chng cn lm sng:
+ Xt nghim c hiu chn on: nghim php kch thch bng ACTH:
- Ngy th nht: ly nc tiu 24h nh lng 17-cetosteroid v 17-hydrocortico- steroid.
- Ngy th hai: ly mu m bch cu E (bch cu i toan). Sau truyn ACTH 25 n v
pha vi 500- 1000 ml thanh huyt mn 0,9% vi tc 3 n v / gi / truyn lin tc / 8-
10 h. Sau khi truyn ht dch m li s bch cu i toan.
- Ly nc tiu 24 h nh lng 17-cetosteroid v 17-hydroxycortico-steroid.
- Kt qu:
. Ngi bnh thng: bch cu i toan gim 70-90%, 17-cetosteroid tng trn 50%,
17-hydroxycortico-steroid tng trn 200%.
.Trong bnh Addison: bch cu i toan v steroid nc tiu khng thay i.
Tr li cu hi
2. So snh Addison vi suy thng thn cp tnh? Nu cc biu
hin ca hai dng?
nh ngha Biu hin lm sng
Addison
L tnh trng tuyn thng thn gim tit ton b cc
hormon (ch yu l cc hormon ca v thng thn,
glucocorticoid, aldosterol, androgen)
- Sm da v nim mc
- Mt mi
- H huyt p v h huyt p t th
- St cn v mt nc
- Ri lon tiu ha
- C cc biu hin h ng huyt
- Triu chng tm thn kinh: gim tr nh, l m,
nhc u
Suy thng
thn cp
Bnh c tnh cht din bin cp tnh do v thng
thn gim sn xut hormon mt cch t ngt (ch
yu l cortisol) gy nn cc bin lon v lm sng, c
th gy try mch v t vong, phi cp cu ni khoa
Ngi mt l, suy sp nhanh chng.- Nhc u,
bun nn, nn, au bng d di, i lng, st cao,
da kh nhn nheo do mt nc.- thc l ln,
m sng ni lm nhm, vt v, c th co git v
dn n hn m.- Mch nhanh nh, kh bt, ting
tim m, huyt p h, c th sc v try mch.-
Kh th do suy tim cp, da tm ti, nim mc nht
nht, xut huyt di da.- Chy mu chn rng,
xut huyt kt mc mt, xut huyt tiu ho.
cp cu ni khoa
Tr li cu hi
3. bnh nhn H ny c cc triu chng no gi bnh
Addison?
Lm sng:
- Sm da, thay i sc t da
- Mt mi
- St cn
- H huyt p t th
- Ri lon tiu ha
Cn lm sng:
- nh lng cortisol mu v ACTH khc hn bnh thng
- H Na, tng K
1/14/2014
22
Tr li cu hi
4. Gii thch cch hot ng ca trc HPA (h i
tuyn yn tuyn thng thn), t cho bit bnh
nhn b suy thng thn nguyn pht hay th pht
- Trc HPA hot ng theo c ch iu ha ngc, cortisol
trong c th tit ra t, kch thch h i tit hormon CRH
(Corticotropin Releasing hormon), tc dng lm kch thch
thy trc tuyn yn tng hp v bi tit ACTH. ACTH
kch thch tuyn thng thn tit glucocorticoid.
Bnh nhn b suy thng thn nguyn pht.
Tr li cu hi
5. Mc tiu iu tr ca bnh nhn ny l g?
- n nh nng cortisol
- a cc ch s XN v mc n nh
- V lu di, phi kim sot c tnh trng bnh
Tr li cu hi
6. Trnh by phc iu tr Addison cho bnh nhn
ny, nu c th cch dng, liu dng?
- Cortisol hay Prednisolon 20mg 30mg: dng mt ln
20mg vo bui sng sau khi n no, v 10mg vo bui
chiu, cho ph hp nhp sinh l c th
- Mineralcorticoid (fludrocortison) 0,05 0,2mg/ngy:
duy tr cn bng Na v K trong c th, do TDP ca cortisol
Tr li cu hi
7. Gii thch ti sao dng hot cht trong phc iu
tr trn? C nn dng Dexamethason thay th cho hot cht
khng? V sao?
- Dng prednisolon (cortisol) liu cao, khi a vo c th, s b
sung lng Glucocorticoid thiu ht do v thng thn bi tit
t, v ng thi s c ch tuyn yn gim tit CRH theo c ch
iu ha ngc ging nh hormon sinh k c th
- Khng dng Dexamethason thay th, v Dexa (hay Betha) lag
dng tng hp, hot tnh nghing v GC hn, t c MC khng
c tc dng iu ha in gii, thi gian khi pht di
1/14/2014
23
Tr li cu hi
8. Trong qu trnh iu tr di hn, bnh nhn xut hin cn suy
thng thn cp tnh, gii thch ti sao bnh nhn b tnh trng
ny? Cp cu nh th no?
- Cn suy thng thn cp xy ra khi bnh nhn ngng thuc t ngt
(trong lc ang dng liu cao ko di), hay b stress nng.
- Cp cu: truyn IV NaCl 0,9%, b sung MC (dexosycorticosteron)
10mg IM, GC (cortisol) IV nhanh 100mg/8h. Nu BN n nh, gim liu
cortisol 25mg/6-8h (IM/PO), tip tc iu tr nh suy thn mn.
TUN 2:
CA I THO NG TYPE 1
Subjective: Thng tin ch quan
Thng tin bnh nhn: A, n, 18 tui, nng 50kg, cao 1,63m
L do vo vin: mt nc nng v chuyn ha ceton nh
Din bin bnh: t 4 tun tr li y, c triu chng kht
nc nhiu, tiu m nhiu (6 ln/m), mt mi, st
5,5kg
Bnh s: 6 thng va qua, b vim h hp trn ti pht, 3
ln vim m o do candida
Subjective: Thng tin ch quan
Tin s gia nh: khng c bnh i tho ng
Li sng: khng r
Tin s dng thuc: khng r, hin khng dng thuc no
Tin s d ng: khng r
1/14/2014
24
Objective: Thng tin khch quan
Tr s Bnh nhn Bnh thng nh gi
ng huyt
lc i
280 mg/DL 126 mg/DL Cao
HbA1c 14% 7% Cao
- C vt ceton huyt nh
Assesment: nh gi tnh trng BN
BN c cc nguy c v triu chng rm r in hnh ca T
type 1:
- St cn
- Ung nhiu
- Tiu nhiu
- Mt mi
Assesment: nh gi tnh trng BN
Cc yu t tham kho:
- Bnh s: khng di truyn T T type 1
- < 45 tui
- Nhim toan ceton nh
- BN ny (l ph n tr), c nhng t nhim trng, nhim nm
vng sinh dc
Do mc glucose mu khi i ca BN tng rt cao km theo HbA1c
tng trn 9% (14%) nn xt ch nh dng ngay insulin dng tim.
Assesment: nh gi tnh trng BN
Thuc Tc dng TDP CC
Insulin
H ng huyt, n nh
nng ng huyt
D ng ban , nga
ch tim, pht trin m
m
Him gp:
Ni m ay, phn ng
phn v, ph mch.
H kali huyt.
Teo m m ch tim
thuc di da
Mn cm
Dng n thun
insulin tc dng
trung gian v tc
dng ko di trong
trng hp toan
mu hoc hn m
i tho ng
1/14/2014
25
Assesment: nh gi tnh trng BN
Mc tiu iu tr cho BN nh th no?
- Nhanh chng a tr s glucose mu khi i v mc bnh
thng
- a mc HbA1c v mc bnh thng %): lm gim triu
chng v kim sot bin chng
Do mc glucose mu khi i ca BN tng rt cao km theo
HbA1c tng trn 9% (14%) nn xt ch nh dng ngay insulin
dng tim.
Plan: K hoch iu tr
Nu sau khi dng thuc m triu chng tng ng huyt
khng gim th phi quay li bc s xem xt v ti khm
Dinh dng: n ung chn lc theo hng dn ca nhn
vin y t
Vn ng nh nhng mt mn th thao.
Tr li cu hi
1. Bng chng no cho thy BN mc i tho ng type
1?
Lm sng: t ngt
- Ung nhiu
- Tiu nhiu
- St cn, mt mi
- < 45 tui
Cn lm sng:
- ng huyt lc i v HbA1c tng cao
- C tng ceton nh
Bnh s: khng di truyn T T type 1
Tr li cu hi
2. Mc tiu iu tr cho BN nh th no?
- Nhanh chng a tr s glucose mu khi i v mc bnh
thng
- a mc HbA1c v mc bnh thng (<7%): lm gim
triu chng v kim sot bin chng
1/14/2014
26
Tr li cu hi
3. Liu trnh tim insulin cho BN nh th no?
Da vo ch n v li sng ca BN th da theo 3 phc , t d liu
thch hp
Tr li cu hi
4. Hng dn cch tim insulin cho BN?
- Ra tay sch v st trng ch tim, st trng l thuc bng
cn 70%.
- Xoa nh l lm m (trnh kch ng) v trn u insulin
- Ko ng tim ra mt on ly kh bng lng insulin cn
ly v bm lng kh vo l thuc rt ra lng insulin cn dng.
- ui ht kh ra khi ng tim trc khi tim.
- Ko da ln v tim qua da mt gc 45
0
- Sau tim nn gi kim li khong 10 giy insulin c
hp thu ht, khng xoa bp ch st ch tim trnh tnh
trng insulin hp thu nhanh gy h ng huyt qu mc.
- Cn xoay vng v thay i vng tim trnh bin
chng lon dng m (lu : v tr tim gn rn: thuc hp
thu nhanh coi chng h ng huyt t ngt)
Tr li cu hi
5. Theo di iu tr nh th no?
- Theo di ng mu thng xuyn bng my o
- Khi tm c liu tim thch hp th 3-6 thng phi ti
khm xem liu c cn thch hp khng, nu c bin
chng phi iu tr bin chng
- Theo di HbA1c mi 3 thng
1/14/2014
27
TUN 2:
CA I THO NG TYPE 2
Subjective: Thng tin ch quan
Thng tin bnh nhn: bnh nhn n, 30 tui, 60kg, cao
1,60m
L do n khm: mt mi, ngi nng n
Din bin bnh: cc triu chng trn c trong vi tun
gn y
Bnh s: tin i tho ng khng iu tr, au khp gi,
tiu chy
Subjective: Thng tin ch quan
Tin s gia nh: m BN b tiu ng v tng huyt p,
cha Bn b mch vnh v va b t qu
Li sng: ung ru (1-2 ln/tun), rt t vn ng
Tin s dng thuc: metylprednisolon, bactrim
Tin s d ng: bactrim
Objective: Thng tin khch quan
Sinh hiu:
- Mch 90 ln/pht
- Huyt p: 130/85 mmHg
- Thn nhit: 37
o
C
- Nhp th: 15 nhp/pht
1/14/2014
28
Objective: Thng tin khch quan
Tr s Bnh nhn Bnh thng nh gi
Na 137 mEq/L 135 - 150 Bnh thng
K 4,0 mEq/L 3,5 5,2 Bnh thng
Cl 98 mEq/L 95 - 105 Bnh thng
BUN 15 mg/dL 8 - 20 Bnh thng
Creatinin 1,1 mg/dL 0,8 1,2 Bnh thng
HbA1c 8,2% 3,5 5,5 Cao
Glucose huyt i 156 mg/dL 85 - 110 Cao
Glucose huyt ngu
nhin
215 mg/dL < 200 Cao
ALT 34 UI/L < 35 Bnh thng
Assesment: nh gi tnh trng BN
BN c tin s tin i tho ng, c cc yu t nguy c,
cc triu chng lm sng v cn lm sng, chn on BN
mc i tho ng type 2.
Plan: K hoch iu tr
Mc tiu iu tr:
- a lng glucose mu v mc n nh v mc tiu
- a tr s HbA1c v 5-7% trong vng 3 thng
- Ngn nga v kim sot bin chng
- Gim cn
Plan: K hoch iu tr
ngh dng thuc:
- BN c tin s d ng sulfamid nn khng dng nhm
sulfonylure (gy tng men gan v tng cn), nhm glitinid (tng
cn). Nhm Thiazolidinedion v c ch -glucosidase gy c
gan nn cng khng chn.
- BN nn dng nhm Biguanid (metformin): liu khi u
500mg/ngy, ung sau ba n. Liu ti a 2500mg/ngy chia 3
ln.
1/14/2014
29
Plan: K hoch iu tr
Ch khi dng thuc:
Thuc TDP CC
Metformin
- Bun nn, tiu chy
- D ng, ban
- Nhim acid lactic mu
- Mn cm
- Tiu ng type 1 v thai k
- BN c nguy c nhim acid lactic:
suy gan, suy thn, suy tim, suy h
hp
- Nghin ru: gy tng tc thuc
try tim
Plan: K hoch iu tr
BN cn xt nghim ng mu thng xuyn, theo di ch s
HbA1c mi 3 thng.
n nhiu:
- Tri cy.
- Rau.
- Cc loi ng cc.
- Nhng thc phm c nhiu cht dinh dng v t cht bo v
calo. Cng cn n sn phm ng vt v ngt t hn.
Vn ng: iu v va sc, mc tiu gim cn nng xung.
Tr li cu hi
1. Nguy c bnh T type 2 BN ny l g? BMI ca
BN c phi l yu t nguy c khng?
- Tin s b tin i tho ng
- t vn ng v ung ru
- Di truyn: m BN b tiu ng v THA, cha b mch
vnh
- Tin s dng glucocorticoid (metylprednisolon) trong
vim khp
- Ngoi ra xt BMI ca BN = 23,5. Vi n gii th trn 23 l
hi tha cn, nn BMI cng l yu t nguy c
Tr li cu hi
2. Bin chng c th xy ra khi b T type 2 nhng
khng iu tr l g?
Cp tnh Mn tnh
- Hn m nhim toan ceton cp cu
- H glucose mu
- Hn m tng glucose mu khng
nhim toan ceton
- Hn m nhim toan lactic
- Cc bnh nhim trng cp
- Bnh l mch mu v vi mch: x
va mch vnh, x va mch no,
bnh vng mc, bnh l cu thn
- Bnh l thn kinh: thn kinh gic quan
vn ng, thn kinh t ng
- Bnh phi hp thn kinh mch
mu: lot chn, lit c
1/14/2014
30
Tr li cu hi
3. kt lun BN b T type 2, da vo triu chng
lm sng v nhng XN no? Trnh by cch test tiu
ng bng nghim php dung np glucose. ngha
HbA1c?
Lm sng: mt mi, tng cn
Cn lm sng: Glucose huyt i, glucose huyt ngu
nhin, glucose sau n (nghim php dung np glucose)
HbA1c
Tr li cu hi
Trnh by cch test tiu ng bng nghim php dung
np glucose. ngha HbA1c?
- Xt nghim dung np Glucose phi c thc hin vo bui
sng sau khi nhn i qua m ca t nht 8 gi.
- Rt mu o ng huyt. Sau bnh nhn c cho ung
75g Glucose. o li ng huyt sau khi ung 2 gi.
- <140mg/dL l dung np glucose bnh thng.
- 140mg/dL v <200mg/dL l ri lon dung np glucose.
- 200mg/dL: chn on tm thi l i tho ng (cn lp li
ln hai chn on xc nh).
Tr li cu hi
ngha HbA1c? (hemoglobin + glucose)
nh gi mc glucose trung bnh trong mu 2-3 thng
qua.
Dng tr s ny xem c kim sot c bnh khng:
- 5-7%: bnh thng
- >10%: ng huyt cha c kim sot tt
Tr li cu hi
4. Mc tiu iu tr BN ny l g?
- a lng glucose mu v mc n nh hay mc ti
- a tr s HbA1c v 5-7% trong vng 3 thng, nu thp
qu h ng huyt mnh
- Ngn nga v kim sot bin chng
- Gim cn
1/14/2014
31
Tr li cu hi
5. Nn khi u nhm thuc iu tr no cho BN (men
gan hi cao, th trng hi mp)?
- BN c tin s d ng sulfamid nn khng dng nhm
sulfonylure (gy tng men gan v tng cn), nhm glitinid
(tng cn). Nhm Thiazolidinedion v c ch -
glucosidase gy c gan nn cng khng chn.
- BN nn dng nhm Biguanid (metformin): liu khi u
500mg/ngy, ung sau ba n. Liu ti a 2500mg/ngy
chia 3 ln.
Tr li cu hi
6. BN cn lu g v ch n v luyn tp?
n nhiu:
- Tri cy.
- Rau.
- Cc loi ng cc.
- Nhng thc phm c nhiu cht dinh dng v t cht bo v
calo. Cng cn n sn phm ng vt v ngt t hn.
Vn ng: iu v va sc, mc tiu gim cn nng xung.
Thuc:
- Khng dng metylprednisolon, nu vim khp th dng
NSAIDs v bo v d dy.
Tham kho
T type 1 T type 2 T thai k
-Ph thuc insulin
-Tn thng tuyn ty
-t ngt: n nhiu (TB
khng s dng c
ng, thiu nng lng
i), ung nhiu & tiu
nhiu (do ng c tnh
thm thu cao ko v
niu), st cn (do TB ly
ng v nng lng t
cc v tr khc ca c th)
-Khng di truyn
-Tr tui (<30)
-Gy
-Ceton (+)
-iu tr bng insulin,
khng dng thuc
-Khng ph thuc insulin
- khng insulin
-Khi pht chm
-C di truyn
-Ln tui (>40)
-Bo ph
-Ceton (-)
-Dng thuc, nu thuc
khng p ng mi dng
insulin
2-5% PNCT mc T
thai k, trong 40% c
nguy c T type 2 sau
ny
Tham kho
Cc loi insulin:
- Nhanh v ngn: insulin lispro: m bo nng insulin
sinh l
- Trung gian: NPN insulin, lent insulin
- Di v chm: ultralent insulin, glargin
Xc nh T bt k: >200mg/Dl
Xc nh T lc i: >126mg/Dl
Biu hin ceton niu (+): bun nn, au bng, kht, hi
th c mi ceton
1/14/2014
32
Tham kho
Nguy c chung T:
- T thai k
- THA: 20% c nguy c
- Chng tc
Xt BMI trong T:
- <16,5: khng c nguy c
- 18,5 23: nguy c thp
- >23,5: nguy c cao
TUN 5:
CA HUYT P 1
Subjective: Thng tin ch quan
ng Trn Vn A. 53 tui, c chn on tng huyt p
cch y 1 thng. Hm nay ng i khm li, vi kt qu
nh sau:
- Huyt p ti phng khm: 176/108 mmHg
- Ph i tht tri (xc nh qua im tm ECG)
- Bnh s: khng r
- Bn thn: ht thuc l, cao 1m6 nng 75 kg, hay ung
bia vi bn
Subjective: Thng tin khch quan
Phn loi theo JNC7 Huyt p tm thu
(mmHg)
Huyt p tm trng
(mmHg)
Bnh thng <120 v <80
Tin THA 120 -139 hoc 80 89
THA giai on 1 140 -159 hoc 90 99
THA giai on 2 160 hoc 100
THA tm thu n c 140 v 100
Kt lun: 176/108 mm Hg. ng A tng huyt p giai on 2
1/14/2014
33
Objective: Thng tin ch quan
Ty theo cch o m ngng cao huyt p khc nhau:
Phng khm, bnh vin: 140/90 mmHg
Bnh nhn t o huyt p: 135/85 mmHg
o huyt p lin tc 24 gi: 125/80 mmHg
i vi bnh nhn A:
Huyt p o ti nh ca ng l 155/97 mmHg. Nhng khi o
phng khm l 176/108 mmHg. Tc l ng A b tng
huyt p do hin tng o chong trng.
Assesment: nh gi tnh trng BN
ng A mc bnh ph i tht tri tng nguy c bnh tim
mch.
Ht thuc l, hay ung ru bia.
Cng vi huyt p hin ti ca ng th nguy c tim mch
tng gp i.
V vy ng cn phi thay i li sng v tun th theo
iu tr ca mnh.
Plan: K hoch iu tr
ng A b tng huyt p giai on 2: Phi hp 2 thuc ACEI
v CCB
Nu vn khng t mc tiu chng ta c th tng liu,
thm thuc ph hp vi tnh trng bnh nhn.
Thng xuyn ti khm.
Kimtra acid uric, cholesterol, ng huyt
Tr li cu hi
1. C th s dng bin php no gip chn on
tng HA, hng dn bnh nhn ra sao?
Chn on xc nh THA: da vo tr s huyt p o
c sau khi o huyt p ng quy trnh
Hng dn bnh nhn:
- Ngh ngi yn tnh t nht 5 - 10 pht trc khi o huyt p
- Khng dng cht kch thch (c ph, ht thuc, ru bia)
trc 2 gi
1/14/2014
34
Tr li cu hi
- T th o chun: BN ngi gh ta, cnh tay dui thng
trn bn ngang mc vi tim. Ngoi ra, c th o cc t
th nm, ng. i vi ngi cao tui hoc c bnh i
tho ng, nn o thm huyt p t th ng nhm xc
nh c h huyt p t th hay khng.
- Nn o huyt p t nht hai ln, mi ln cch nhau t nht
1-2 pht.
- o hai ln: sng v chiu
- o 7 ngy, thng ly gi tr trung bnh ca 6 ngy cui
Tr li cu hi
2. Huyt p o ti nh l 155/97mgHg? Hy gii thch cho
bnh nhn c s chnh lch gia HA phng khm v
HA ti nh
Loi tr cc yu t ti phng khm: BN vn ng trc khi
o, hay thao tc o sai ca y t th HA chnh lch ca BN
c th do b hi chng o chong trng
Tr li cu hi
3. nh gi bnh nhn?
Cn nng: 75kg
Chiu cao: 1m60
Mc bnh ph i tht tri tn thng c quan ch
Ht thuc l,thng ung ru bia.
Tng huyt p giai on 2.
=> Nguy c tim mch ca ng tng gp i. V vy ng A
phi tch cc thay i li sng v tun th theo di iu tr
ca bc s.
BMI = 29,3 (bo ph)
Tr Li Cu Hi
4. ngh thuc tr liu khi u, cn cn dn BN iu
g?
THA 2, phi hp 2 nhm: ACEI v CCB: do THA c ph i tht tri
ACEI: Enalapril 5mg/ln/ngy
CCB: Amlodipin 5mg/ln/ngy
c ch men chuyn (ACEI)
Captopril
Elanapril
Perinopril
- Tng HA c km thm
nhiu bnh: tiu ng
- L thuc u tay tr suy
timsung huyt
- Dng sau NMCT
phng bin chng suy tim
- H HA liu u
- Ho khan (tc dng ny s
c dung np sau vi
thng s dng)
- Ph mch do d ng
- Tng ion K+ huyt
- Suy thn cp
- Mn cm
- PNCT
- Hp ng mch thn 2
bn
- Tin s ph mch d ng
- Tng K+ huyt
- V niu
Chn knh Ca2+ (CCB)
Thuc nhmDHP
(dihydropyridin):
Nifedipin
Amlodipin
Felodipin
- Tr tng HA
- D phng TN
- Hi chng Raynaud
(thiu mu u chi)
- H HA mnh
- Nhc u, chng mt,
bun nn, bng mt,
ph mt c chn, tim
nhanh
- HA thp
- Sc tim suy tim
- Thn trng cho PNCT
1/14/2014
35
Tr Li Cu Hi
5. Mc tiu iu tr ca bnh nhn ny l g?
a v HA mc tiu: <140/90mmHg, nu nh hng chc
nng tht tri th nn a v <130/90mmHg, y BN ch
b ph i tht tri nn <140/90mmHg l chp nhn c.
Tr Li Cu Hi
6. ln ti khm li, HA ca bnh nhn o c l
155/92mmHg? Hy xc nh cc yu t dn n cha kim
sot c HA? Hng x tr?
- BN khng tun th iu tr khuyn BN tun th
- BN cha thay i li sng dn d BN thay i
- Thuc ang dng cha p ng:
a. c th tng liu Enalapril ln 7,5mg, liu Amlodipin gi
nguyn
b. hay l cng thm li tiu thiazid ( y TDP trn BN bo
ph nn gy nguy c tng ng huyt), do u tin h HA nn
b qua nguy c, v xt nghim thm: acid uric, cholesterol,
ng huyt
TUN 5:
CA HUYT P 2
Subjective: Thng tin ch quan
Thng tin bnh nhn: Nguyn Anh H, nam, 65 tui, cao
1m65, 60kg
Din bin bnh: huyt p dao ng t 140-155/80-85
mmHg
Bnh s: tiu ng type 2
Tin s gia nh: khng r
Li sng: BN thng xuyn ht thuc 5 iu/ngy
Tin s dng thuc: dng glucophage
Tin s d ng: khng r
1/14/2014
36
Objective: Thng tin khch quan
Cn lm sng:
Xt nghim BN Ch s chun
Ure 6.6 2.5 7.5 mmol/l
Creatinin 60 53 100 mol/l
HDL cholesterol 1.8 >1.68 mmol/l
LDL cholesterol 2.5 < 3.4 mmol/l
Total cholesterol 4.5 3.9 5.2 mmol/l
Triglycerid 1.5 0.46 1.88mmol/l
Assesment: nh gi tnh trng BN
Cc xt nghim vn bnh thng
Huyt p dao ng t 140 155/80 85 mmHg
Thng xuyn ht thuc l khong 5 iu/ngy lm tng nguy
c tim mch
Tui cao cho thy huyt p tm thu quan trng hn huyt p
tmtrng v nguy c tim mch
Mc bnh tiu ng type 2 v ang dng Glucophage
chn on l tng huyt p
Plan: K hoch iu tr
Mc tiu iu tr:
Gim t l tim mch, bnh thn v t l t vong
Gim huyt p <130/80mmHg v bnh nhn b tiu ng
type 2
t huyt p tm thu mc tiu cho bnh nhn
Li khuyn cho bnh nhn: nn thay i li sng, khng ht
thuc, ch n gim du m cc loi tht c mu ..
Tr li cu hi
1. nh gi nguy c tim mch ca bnh nhn trong vng 10
nm theo thang im Framingham
Tng im: 10 im 10 nm nam gii nguy c tim mch
25%, so snh nguy c chun trong dn s nguy c tim
mch mc trung bnh
Ch s im
Tui 65-69 6
Cholesterol ton phn 4.5 0
HDL -2
Huyt p 2
Tiu ng 2
Ht thuc 2
1/14/2014
37
Tr li cu hi
2. Bnh tng HA bnh nhn ny c g c bit? nn
bt u dng thuc iu tr tng HA cha?
Theo phc tr THA, th thay i li sng l u tin,
nhng trng hp ny BN ngoi THA c km thm i
tho ng dng thuc ngay t u v thay i li
sng.
Tr li cu hi
3. Nu quyt nh dng thuc th nhm thuc no nn
chn v nn trnh bnh nhn ny? Gii thch?
Liu?
Nhm thuc la chn cho bnh nhn H: nhm CCB d l
la chn th 2 nhng trng hp ny u tin cho BN
cao tui la chn u tay c th cho BN
ACEI l la chn 1 y l thuc u tin hng u cho
bnh nhn b tng huyt p km i tho ng, t tc
dng ph v c th khc phc, nhng do BN cao tui nn
dng CCB trc
Tr li cu hi
Liu: Captopril 25- 150mg/ngy
Thuc nn trnh bnh nhn H: nhm thuc li tiu c
bit l li tiu quai v li tiu thiazid v c tc dng ph
lm tng ng huyt m bnh nhn ang b tiu ng
typ 2
Tr li cu hi
4. Bnh nhn c ch nh dng Nifedipin, nhng bnh
nhn thng xuyn chng mt lc ngi dy hoc
ng dy, bnh nhn cm thy b hi hp. Gii thch l
do bnh nhn b triu chng trn? Cch khc phc?
L do: BN c triu chng b h HA t th. Nifedipin c T
ngn nn tc dng nhanh v mnh gy h HA nhanh
h HA t th
Cch khc phc: dng Nifedipin dng phng thch di hay
i thuc c T di nh Amlodipin
1/14/2014
38
Tr li cu hi
5. Mt ln tnh c c trn Internet, bnh nhn c c
thng tin rng Nifedipin lm tng nguy c nhi mu c
tim bnh nhn tng HA v vy bnh nhn n gp
bc s v ngh i thuc. C nn i thuc cho
bnh nhn ny khng?
Thng tin ny chnh xc, nhng nu BN ny dng CCB c
hiu qu th khng nn i thuc.
Tr li cu hi
6. Theo li dn ca bc s, bnh nhn gim ht thuc l,
vn ng v thay i ch n, king cht bo, ngt n
nhiu cht x v cc loi tri cy nh cam, chanh, bi,
chui, c chua..., cc loi c nhiu m thay v n tht. Tun
trc bnh nhn thy nhc u, nght mi, tai, st, i
khm th c chn on l vim xoang, BN c k
Clarithromycin v ung c 1 tun nhng cha khi.
Trong tun , bnh nhn cm thy thng xuyn b hi
hp, hay chong khi thay i t th? Gii thch l do bnh
nhn c cm gic nhu vy? Cch khc phc?
Tr li cu hi
Bnh nhn thy hi hp, hay chong khi thay i t th
H HA t th ng.
Clarithromycin
+ Nhm: khng sinh Macrolid
+ Ch nh: nhim trng a v tr (TMH, tiu ha,h
hp)
+ Tc dng ph: ri lon tiu ha,vim gan
+ Chng ch nh: mn cm, suy gan
C tc dng c ch men gan nn khi dng chung vi
Nifedipin s lm tng TDP Nifedipin h HA t th mnh
Tr li cu hi
Gii thch: v Clarithromycin c ch men gan khi dng
chung vi Nifedipin s lm tng tc dng ph H HA
1/14/2014
39
Tham kho
nh ngha huyt p: l p lc ca mu ln thnh mch
Tng huyt p: s tng dai dng ca huyt p ln ng
mch
Tham kho
Nhmthuc tim mch huyt p thng dng:
Nhm Thuc C TDP CC
Chn knh Ca2+ (CCB)
Thuc nhm DHP
(dihydropyridin):
Nifedipin
Amlodipin
Felodipin
- Tr tng HA
- D phng TN
- Hi chng Raynaud (thiu
mu u chi)
- H HA mnh
- Nhc u, chng mt, bun
nn, bng mt, ph mt c
chn, tim nhanh
- HA thp
- Sc tim suy tim
- Thn trng cho PNCT
c ch men chuyn (ACEI)
Captopril
Elanapril
Perinopril
- Tng HA c km thm
nhiu bnh: tiu ng
- L thuc u tay tr suy tim
sung huyt
- Dng sau NMCT phng
bin chng suy tim
- H HA liu u
- Ho khan (tc dng ny s
c dung np sau vi thng
s dng)
- Ph mch do d ng
- Tng ion K+ huyt
- Suy thn cp
- Mn cm
- PNCT
- Hp ng mch thn 2 bn
- Tin s ph mch d ng
- Tng K+ huyt
- V niu
Chn receptor angiotensin
2 (ARB)
Losartan
Telmisartan
Ging ACEI nhng t ho khan
v ph mch hn
Chn chn lc 1
(1 tim, 2 kh ph qun,
c ch: lm tim p chm,
gin mch)
Atenolol
Bisoprolol
Metoprolol
- Tng HA
- D phng TN
- Chng lon nhp
- Dng sau NMCT nga bin
chng tim nhanh
- Tim chm, tt HA, mt mi
- Co tht ph qun, gy khi
pht hen suyn
- Hi chng Raynaud
- Che lp du hiu h ng
huyt
- Lit dng
- Nhp tim chm
- Block tim 2 & 3
- Hen suyn, COPD
- PNCT
- Suy tim 4
Chn c 1 v 2
Propanolol
Nadolol
Timolol
- Nhp tim chm
- Block tim 2 & 3
- Hen suyn, COPD
- PNCT
- Suy tim 4
Tham kho
Li tiu thiazid Indapamid
- Tng HA
- Ph do suy tim sung huyt,
x gan
- Mt nc, mt mui, tng
acid uiric huyt, tng ng
huyt, tng cholesterol
- D ng (do thuc c cu
trc sulfamid)
- Thc y hn m gan
- Tt HA t th
- Mn cm sulfamid
- BN b gim th tch mu
- No gan, gout
- PNCT v cho con b
- V niu
Li tiu quai Furosemid
- Ph do suy tim sung huyt,
x gan
- Tng HA
Ging thiazid, thm:
- Gim thnh lc
Chn alpha Prazosin
THA km ph i tuyn tin
lit lnh tnh
Lit giao cm TW
(kch thch receptor 2 trn
trung tm vn mch)
Methyldopa
- Thuc u tay trong tng HA
thai k
- Tng HA trung bnh v nh
cho nhiu i tng
- Bun ng, trm cm
- Kh ming, to bn
- Tt HA t th
- Tim chm
- Lit dng
- Vim gan
- C th gy thiu mu tiu
huyt
- Trm cm
- Suy gan
- U ty thng thn
- BN ang dng IMAO hay
levodopa