1/14/2014

TUN 1
Ca 1: LOT DDTT

Hgb 10.3 g/dL (12-18 g/dL)

Plt 162.109/L (150 450.109/L

ng B, 57 tui, nhp vin v i ngoi phn en. Cch

y 2 ngy, ng b au d dy nng. Trong vi thng

INR 1.1 (0.8 1.2)

gn y ng thnh thong c triu chng kh tiu.

HR 87 nhp/pht

ng ht thuc l nhiu nm, suy tim mn tnh

BP 115/77 mmHg

nh v ang dng enalapril 5mg x 2 ln/ngy v

BN c truyn 1,5 lt dung dch sinh l

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:

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

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

2. BN nn dng thuc no kim sot lot t trng

xut huyt?
Dng PPI ng ung, do BN vn n ung c

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

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

Tr li cu hi

4. Thuc no nn c k toa khi BN xut

Tr li cu hi

5. BN cn c t vn g?
- n nhiu ba, khng qu no hay qu i

vin?

- Trnh: cay, chua, nng, kch thch

- Tim mch: thuc c

- B thuc l, ru bia: v l yu t nguy c

- Gi tinh thn lc quan

- Vim khp: paracetamol 500mg + codein 30mg dng ko

di n khi ht p ng, quay li cc thuc NSAIDs v

6. BN theo di iu tr nh th no?

nga lot
- Nga lot: dng misoprostol, antacid, PPI liu duy tr
thp

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
- Indomethacin 25mg: 1v x 3 ln/ngy

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

- Voltaren 50mg: 1v x 2 ln/ngy

- Cytotec 200g: 1v x 2 ln/ngy

thng v v bun nn. BN i ngoi phn en ngy hm

Tin s d ng: khng c g c bit

trc v nn ra cht nn m c ph hm nhp vin.

Sinh hiu:

BN c tin s bnh xng khp

- 51kg, cao 1m56

Tin s gia nh: khng c g c bit

- Mch: 101 ln/pht

Li sng: khng c g c bit

- Nhit : 36,5oC

Tin s dng thuc: BN dng cc thuc sau theo n ca

- Huyt p: 125/70 mmHg

bs khm iu tr cc bnh ang mc:

- Nhp th: 24 ln/pht

BN da xanh xao, nim mc nht, trng thi lo u, cng thng

1/14/2014

Xt nghim:

Kt qu chn on hnh nh: kt qu ni soi ngay ti

- Hemoglobin: 85g/l (125-145)

- Hematocrit: 0,3 (0,35-0,47)
- Protein-C: 4,5 mg/l (<5)
- MCV: 75fL (83-92)

thi im vo vin cho thy BN b lot mn v, c r mu

(Forrest Ib)

Thuc s dng trn BN:

- MCH: 25 PG (27-32)

- Cm mu qua ni soi bng adrenalin 1/10000

- INR: 1,01

- BN c k n Esomeprazol 80mg IV, sau truyn

- Na: 141 mmol/l (133-147)

tip liu 8mg/h trong 72h, tip tc ung liu 40mg/ln x 2

- K: 4,0 mmoll/l (3,4-4,5)

- Creatinin: 70 mol/l (40-80)

ln/ngy x 5 ngy. Mu XN H.pylori (+).

- Tiu cu: 264 x 109/l (150-450 x 109)

- Ure: 20,3 mmol/l (1,7-8,3)

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

TUN 2:
CA HEN SUYN

Subjective: Thng tin ch quan

Thng tin bnh nhn: L, nam, 18 tui

L do vo vin: kh th sau khi i b 200m

Lp 12CDSL04

Din bin bnh: gn y i tp th dc vo sng sm v

B quyt i i:
Cm in thoi ng gia tri ma sm chp.
Gi in thoi ln ht ln:
>Siu nhn Gao, bin hnh>!!

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

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

Objective: Thng tin khch quan

Tui

Ch s PEF

Gi tr o

18

420

80%

Tin s d ng: khng r

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

Assesment: nh gi tnh trng BN

Bnh nhn ang dng thuc:

Assesment: nh gi tnh trng BN

Bnh nhn c tnh trng kh th, cc bc iu tr hen

- Ventolin CR 4mg (salbutamol phng thch chm c kim

suyn theo GINA, u tin bnh nhn phi dng thuc ct

sot) 2 vin x 2 ln/ngy

cn 2-agonist tc ng nhanh, v cc thuc corticoid

- Becotide MDI (beclomethasone) 2 nht x 2 ln/ngy

(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

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

Salbutamol

- Tim nhanh, hi hp, run u chi

- Mn cm, PNCT

- 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
Beclomethasone

-Qu liu ko di: nh hng

chc nng thng thn
- Ti ch: nhim nm candida

- Mn cm

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

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

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.

sm.

Tr li cu hi

2. Cc yu t nguy c hen suyn? Bnh nhn L c yu
t nguy c no?

Tr li cu hi

Bnh nhn L c yu t nguy c:
- Thi tit: sng sm

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, SO3-

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

- Vn ng th lc: i b th dc

1/14/2014

Tr li cu hi

3. ngha lu lng nh (PEF) v m t cch o? Mt

Tr li cu hi

M t cch o PEF:

s phng php o chc nng h hp khc?

Bc 1: Di chuyn nt ch ti s 0 hoc s thp nht trn thc

- ngha PEF: L theo di bin thin ca lu lng nh

ca lu lng nh k.

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

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

Tr li cu hi

4. Ventolin v Becotide c cha hat cht g? C ch
tc ng v TDP?

- FEV1: th tch th ra gng sc trong 1 giy

Thuc

C ch

Ventolin (salbutamol)

Kch thch adrenergique c tc

ng chn lc ln th
th trn c ph qun

Becotide
(beclomethasone)

Khng vim

TDP

Tim nhanh, hi hp, run

u chi

Nhim nm candida
vng hng

1/14/2014

Tr li cu hi

5. M t cch dng MDI (meter dose inhaler):

Tr li cu hi

6. Nhn xt toa thuc ca bnh nhn L:

- M np bnh xt, gi thng ng, lc k

y bnh nhn c k toa salbutamol tc ng chm

- Ngm ming bnh xt gia hai hm rng, khp mi v th

l khng hp l, v khng c tc dng ct cn m ch kim

ra chm

sot cn.

- 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

Tr li cu hi

7 . Bnh nhn cn t vn kh nng dng Singulair cho

8. L c th dng Singulair khng? Dng phi hp hay dng

trng hp ca mnh?

n l? Theo di trong iu tr bnh hen ca L ra sao?

SINGULAIR (montelukast) c ch nh cho ngi bnh

ln tui v tr em trn 6 thng tui d phng v iu tr

- Bnh nhn L c th dng Singulair. Theo bc iu tr ca

hen ph qun mn tnh, bao gm d phng c cc triu

GINA th dng phi hp vi thuc ct cn, lc ny bnh nhn

chng hen ban ngy v ban m.

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

TUN 2:
CA VIM XOANG

Subjective: Thng tin ch quan

Thng tin bnh nhn: bnh nhn nam, 34 tui

Lp 12CDSL04

L do n khm: nght mi nng, au u v nhn m

Lng mn:

Din bin bnh: cc triu chng trn c trong 3 ngy

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:
......

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

> Mua khng em, ch c 5 ngn thi

Tin s d ng: thuc penicillin

Objective: Thng tin khch quan

Triu chng chnh

Bnh nhn

Assesment: nh gi tnh trng BN

Bnh nhn tng b cm cm mi y, iu tr bng 2 vin

au nhc vng u (khu vc xoang)

paracetamol, do iu tr khng ng mc nn cc xoang

Chy mi

tr nn vim tc, ph n v ngn tr dch nhy thot ra

Nght mi

xanh). iu ny l yu t thun li ca vim xoang.

Nga mi

Khng ngi c cc mi

mi, dn n nhim trng xoang (dch m mu vng

1/14/2014

Plan: K hoch iu tr

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

ngh dng thuc:

- Thuc co mch dng ung: pseudoephedrin 60mg 1 vin x 3
ln/ngy

khng sinh

Mc tiu iu tr: gii quyt nhim trng, lm cc triu

- Khng sinh chng nhim trng: clarithromycin 500mg 1 vin x

2 ln/ngy: 7 ngy; hay nhm cyclin

chng bnh nh hn v lnh bnh nhanh hn, trnh cc

- Gim au: paracetamol 500mg 1 vin x 3 ln/ngy

bin chng
- Khng histamin H1
- Nc mui sinh l: ra mi

Plan: K hoch iu tr

Plan: K hoch iu tr

Dn d:

Ch khi dng thuc:

Thuc

TDP

Ch

- 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.

Pseudoephedrin

Do dng chung vi
Kh ming, bun ng, h khng H1 nn cng
HA, tim nhanh
hng tc dng ph l
bun ng mnh

- Vic quan trng vn l trnh vim mi. Khng nn nhng

ni khng kh b nhim (bi, khi, thuc l...). Trnh thc n b

Ri lon tiu ha

d ng. n ung y c sc khng. V sinh thn th,

Paracetamol

Liu cao: suy gan

nng ra tay, ra mt, khng tm ni nc bn.

Khng H1

Bun ng

Clarithromycin

10

1/14/2014

Tr li cu hi

1. Cn hi bnh nhn nhng cu hi g gip cho vic

Tr li cu hi

2. ng A c m mu vng hi xanh trong 3 ngy gn

chn on bnh?

y cng nhng cn au vng mt quanh mt v mi.

- C au rng khng? ( nu c au rng, th c th do vim

ng b mt kh nng nhn bit mi v v, k t khi b

xoang hm)

cm lnh tun trc. Khng st. Nhng bnh m ng

- 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

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

trng vim nng)

xoang sng trc  do gy au khu vc mt v mi;

- C st v nn i khng?

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

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

nhim khun (vim mi, cm cm)

do bnh nhn c tin s d ng penicillin nn khng chn. Cng

- D ng, nhim mi trng

c th chn nhm cyclin

- Gim khng

- Khng histamin H1
- Gim au: paracetamol

11

1/14/2014

Tr li cu hi

5. Theo bn, ng A c cn s dng beclomethasone

Tr li cu hi

6. Mt tun sau, ng A quay li v cho bit cc triu

dng xt mi hay khng?

chng gim nh nhng n ngy hm qua th ng y

ng A khng cn dng beclamethasone dng xt, v c th

bt u st, chng mt, khng nghe r v au tai. Bn

gy trm trng thm tnh trng nhim khun trong xoang

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

Tr li cu hi

8. ng A quay li vi n thuc Doxycyclin 100mg 2

khng sinh no cn c k cho ng A?

vin/ngy x 7 ngy. Bn cn t vn cho ng A nhng g?

- Macrolid hay cyclin

- 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.

12

1/14/2014

Tham kho

Phn bit hen suyn v COPD

Tham kho
Khc nhau:

Ging nhau: u l bnh mn tnh - c tnh trng vim

Tui

Nguyn
nhn

Tin trin bnh

Chc nng
h hp

Hi phc

ng th - tc nghn ng th - tng tit nhy - co tht

cung phi - u lin quan n yu t mi trng. Nn

Hen

Xut hin t
khi nh

a dng

Gia cc cn,
BN khng c
triu chng g

dng nh:
C th r rt
khng nh
hng

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

biu hin lm sng cng c nhng im ging nhau nh

ho, khc m, nng ngc, kh kh, kh th...

TUN 2:
CA ECZEMA

Rt km hay
khng c

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

13

1/14/2014

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.

14

1/14/2014

Assesment: nh gi tnh trng BN

Thuc ang dng

TDP

CC

Plan: K hoch iu tr

Xt nghim cn lm thm:
- Sinh thit da ti ch vim ( loi tr nhim khun da do

Salbutamol

- Tim nhanh, hi hp, run u chi

- Mn cm, PNCT

virus, vi nm)

Beclomethasone

Betamethasone

Mc tiu iu tr: kim sot triu chng bnh eczema (da

-Qu liu ko di: nh hng chc

nng thng thn
- Ti ch: nhim nm candida

- Mn cm

- Teo da, mng da, gin mch mu

ti ch

- Vim da do virus,
vi khun, vi nm

phng rp, thay i mu, ng vy, nga)

Plan: K hoch iu tr

Thuc ngh cho bnh eczema bnh nhn:

Plan: K hoch iu tr

Trnh dng corticoid + khng sinh dng bi ti ch di

- Khi bnh nhn cha b nhim trng: c th dng corticoid

ngy. Sau mt thi gian nu triu chng khng gim, th

bi ti ch trong thi gian ngn (< 5 ngy).

phi chuyn sang khng sinh ng ton thn v ngng

- Khi bnh nhn c triu chng bi nhim (chc l, ):

dng corticoid ti ch.

khng sinh ng ung

15

1/14/2014

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

Tr li cu hi

2. Beclometason v betamethason thuc nhm thuc
no? Nu cc tc ng ca nhm thuc ny
Nhm Corticoid

Tc ng

- Khng histamin H1
- Khng vim corticoid
- Gi m da: vaselin, glycerin
- Nu nhim trng: dng khng sinh

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

16

1/14/2014

Tr li cu hi

3. Gii thch thut ng hot tnh glucocorticoid v

Tr li cu hi

Nu TDP ton thn v ti ch ca glucocorticoid?

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

Ton thn
-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)

Ti ch

-Mn trng c, teo da, bi nhim, chm

lin so
- Dng xt: khn hng, nhim candida
- Dng nh mt: c thy tinh th

 n nh HA v nhp tim.

Tr li cu hi

4. Thuc bi ngoi da Betnovate s dng nh th

Tr li cu hi

5. Nn ch nh khng sinh no cho bnh nhn? Ch phm

no? C s dng trong thi gian di c khng?

dng ngoi cha corticoid v khng sinh c hiu qu

Betnovate (betamethason): bi ti ch vng da b vim 2-3

khng?

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.

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)

17

1/14/2014

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 : 37oC

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

18

1/14/2014

Objective: Thng tin khch quan

Tr s cn lm sng
Na
K

Bnh nhn

Bnh thng

127 mEq/L

135-150

5 mEq/L

3,5-5

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

Cl

98 mEq/L

98-110

BUN

15 mg/dL

7-21

Creatinin

1,1 mg/dL

0,7-1,5

- H huyt p t th

Glucose

103 mg/dL

80-110

- Ri lon tiu ha

Cortisol

1,4 mcg/dL

8-25

ACTH

2096 pg/mL

0-130

- Mt mi

Plan: K hoch iu tr

Mc tiu iu tr: gim triu chng bnh, a ch s cortisol
mu v ACTH v li bnh thng

- St cn

Cn lm sng:
- nh lng cortisol mu v ACTH khc hn bnh thng

Plan: K hoch iu tr

Theo di dng thuc: do dng corticoid di ngy trn ph
n, nn theo di s mt xng

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

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).

hp nhp sinh l c th
- Mineralcorticoid (fludrocortison) 0,05 0,2mg/ngy: duy tr

B sung calci trong thi gian dng thuc 1000 mg/ngy, vit
D 400 n v/ngy.

cn bng Na v K trong c th, do TDP ca cortisol

19

1/14/2014

Tr li cu hi

1. Bnh Addison (suy thng thn mn tnh) l g?

Tr li cu hi

Nguyn nhn:

Suy thng thn mn (bnh Addison) l tnh trng tuyn

+ Lao thng thn

thng thn gim tit ton b cc hormon (ch yu l cc

+ Ri lon t min (qu trnh t min dch c th ph hy nhiu

hormon ca v thng thn, glucocorticoid, aldosterol,

t chc nh tuyn ty, tuyn gip...).

+ Di cn ung th, nhim nm, giang mai...

androgen)

+ 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

Tr li cu hi

Triu chng lm sng:
- Sm da v nim mc

gim th tch mu lu thng, gim huyt p v cung lng tim.

- Mt mi

+ Gim tit cortisol (hormon chuyn ho ng) s dn n gim d tr

- H huyt p v h huyt p t th

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,

- St cn v mt nc

gim bch cu N, tng bch cu i toan v bch cu lympho (L).

- Ri lon tiu ha

+ Gim tit androgen (hormon sinh dc): dn n teo tinh hon hoc

- C cc biu hin h ng huyt

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.

- Triu chng tm thn kinh: gim tr nh, l m, nhc u

- Thay i khu v

20

1/14/2014

Tr li cu hi

Tr li cu hi

Triu chng cn lm sng:

Triu chng cn lm sng:

+ Thiu mu ng sc, mu c, hematocrit tng do mt nc.

+ Xt nghim c hiu chn on: nghim php kch thch bng ACTH:

+ Bch cu gim, bch cu a nhn trung tnh gim, tng bch cu lympho v bch cu i
toan.

- Ngy th nht: ly nc tiu 24h nh lng 17-cetosteroid v 17-hydrocortico- steroid.

+ Gim Na+, tng K+ mu, tng canxi mu.

- Ngy th hai: ly mu m bch cu E (bch cu i toan). Sau truyn ACTH 25 n v

+ Tng ur, creatinin nguyn nhn c th do mu ti thn gim dn n suy thn chc nng.

pha vi 500- 1000 ml thanh huyt mn 0,9% vi tc 3 n v / gi / truyn lin tc / 8-

+ ng mu thp.

10 h. Sau khi truyn ht dch m li s bch cu i toan.

+ in tm : in th thp.

- Ly nc tiu 24 h nh lng 17-cetosteroid v 17-hydroxycortico-steroid.

+ X quang tim-phi: trn phim chp thng tim nh nh hnh git nc.

- Kt qu:

+ X quang bng: c th thy nt vi ho thng thn (c th gp trong lao).

. Ngi bnh thng: bch cu i toan gim 70-90%, 17-cetosteroid tng trn 50%,

+ Cortisol huyt tng gim.

17-hydroxycortico-steroid tng trn 200%.

+ Aldosterol mu v nc tiu gim, androgen gim.

.Trong bnh Addison: bch cu i toan v steroid nc tiu khng thay i.

+17- cetosteroid nc tiu/24h gim.

+ 17- hydroxycortico-steroid nc tiu/24h gim.

Tr li cu hi

Tr li cu hi

2. So snh Addison vi suy thng thn cp tnh? Nu cc biu

hin ca hai dng?
nh ngha

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)

3. bnh nhn H ny c cc triu chng no gi bnh

Addison?

Biu hin 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

Lm sng:
- Sm da, thay i sc t da
- Mt mi
- St cn
- H huyt p t th

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

- Ri lon tiu ha
Cn lm sng:
- nh lng cortisol mu v ACTH khc hn bnh thng
- H Na, tng K

21

1/14/2014

Tr li cu hi

4. Gii thch cch hot ng ca trc HPA (h i

Tr li cu hi

5. Mc tiu iu tr ca bnh nhn ny l g?

tuyn yn tuyn thng thn), t cho bit bnh

- n nh nng cortisol

nhn b suy thng thn nguyn pht hay th pht

- a cc ch s XN v mc n nh

- Trc HPA hot ng theo c ch iu ha ngc, cortisol

- V lu di, phi kim sot c tnh trng bnh

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

6. Trnh by phc iu tr Addison cho bnh nhn

Tr li cu hi

7. Gii thch ti sao dng hot cht trong phc iu

ny, nu c th cch dng, liu dng?

tr trn? C nn dng Dexamethason thay th cho hot cht

- Cortisol hay Prednisolon 20mg 30mg: dng mt ln

khng? V sao?

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

- 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

22

1/14/2014

Tr li cu hi

8. Trong qu trnh iu tr di hn, bnh nhn xut hin cn suy

TUN 2:
CA I THO NG TYPE 1

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.

Subjective: Thng tin ch quan

Subjective: Thng tin ch quan

Thng tin bnh nhn: A, n, 18 tui, nng 50kg, cao 1,63m

Tin s gia nh: khng c bnh i tho ng

L do vo vin: mt nc nng v chuyn ha ceton nh

Li sng: khng r

Din bin bnh: t 4 tun tr li y, c triu chng kht

Tin s dng thuc: khng r, hin khng dng thuc no

nc nhiu, tiu m nhiu (6 ln/m), mt mi, st

Tin s d ng: khng r

5,5kg

Bnh s: 6 thng va qua, b vim h hp trn ti pht, 3
ln vim m o do candida

23

1/14/2014

Objective: Thng tin khch quan

Assesment: nh gi tnh trng BN

BN c cc nguy c v triu chng rm r in hnh ca T

Tr s

Bnh nhn

Bnh thng

nh gi

ng huyt
lc i

280 mg/DL

126 mg/DL

Cao

HbA1c

14%

7%

Cao

type 1:

- C vt ceton huyt nh

- St cn
- Ung nhiu
- Tiu nhiu
- Mt mi

Assesment: nh gi tnh trng BN

Cc yu t tham kho:

Assesment: nh gi tnh trng BN

Thuc

Tc dng

TDP

CC

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

- 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

Insulin

H ng huyt, n nh
nng ng huyt

tng trn 9% (14%) nn xt ch nh dng ngay insulin dng tim.

24

1/14/2014

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

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

- a mc HbA1c v mc bnh thng %): lm gim triu

vin y t

chng v kim sot bin chng

Vn ng nh nhng mt mn th thao.
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.

Tr li cu hi

1. Bng chng no cho thy BN mc i tho ng type
1?

Lm sng: t ngt

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

- Ung nhiu

- a mc HbA1c v mc bnh thng (<7%): lm gim

- Tiu nhiu

triu chng v kim sot bin chng

- 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

25

1/14/2014

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.

Tr li cu hi
- Ko da ln v tim qua da mt gc 450

5. Theo di iu tr nh th no?

- Sau tim nn gi kim li khong 10 giy insulin c

- Theo di ng mu thng xuyn bng my o

hp thu ht, khng xoa bp ch st ch tim trnh tnh

- Khi tm c liu tim thch hp th 3-6 thng phi ti

trng insulin hp thu nhanh gy h ng huyt qu mc.

khm xem liu c cn thch hp khng, nu c bin

- Cn xoay vng v thay i vng tim trnh bin

chng phi iu tr bin chng

chng lon dng m (lu : v tr tim gn rn: thuc hp

- Theo di HbA1c mi 3 thng

thu nhanh  coi chng h ng huyt t ngt)

26

1/14/2014

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

Objective: Thng tin khch quan

Sinh hiu:
- Mch 90 ln/pht

Li sng: ung ru (1-2 ln/tun), rt t vn ng

- Huyt p: 130/85 mmHg

Tin s dng thuc: metylprednisolon, bactrim

- Thn nhit: 37oC

Tin s d ng: bactrim

- Nhp th: 15 nhp/pht

27

1/14/2014

Objective: Thng tin khch quan

Tr s

Assesment: nh gi tnh trng BN

Bnh nhn

Bnh thng

Na

137 mEq/L

135 - 150

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

nh gi
Bnh thng

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

34 UI/L

< 35

Bnh thng

ALT

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

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.

- Gim cn
- BN nn dng nhm Biguanid (metformin): liu khi u
500mg/ngy, ung sau ba n. Liu ti a 2500mg/ngy chia 3
ln.

28

1/14/2014

Plan: K hoch iu tr

BN cn xt nghim ng mu thng xuyn, theo di ch s

Ch khi dng thuc:

Thuc

Plan: K hoch iu tr

TDP

CC

HbA1c mi 3 thng.

n nhiu:
- Tri cy.

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

- 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?

Tr li cu hi

2. Bin chng c th xy ra khi b T type 2 nhng
khng iu tr l g?

- Tin s b tin i tho ng

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

- 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

29

1/14/2014

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

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

ng bng nghim php dung np glucose. ngha

sng sau khi nhn i qua m ca t nht 8 gi.

HbA1c?

- Rt mu o ng huyt. Sau bnh nhn c cho ung

Lm sng: mt mi, tng cn

75g Glucose. o li ng huyt sau khi ung 2 gi.

Cn lm sng: Glucose huyt i, glucose huyt ngu

- <140mg/dL l dung np glucose bnh thng.

- 140mg/dL v <200mg/dL l ri lon dung np glucose.

nhin, glucose sau n (nghim php dung np glucose)

- 200mg/dL: chn on tm thi l i tho ng (cn lp li

HbA1c

ln hai chn on xc nh).

Tr li cu hi

ngha HbA1c? (hemoglobin + glucose)

Tr li cu hi

4. Mc tiu iu tr BN ny l g?

nh gi mc glucose trung bnh trong mu 2-3 thng

- a lng glucose mu v mc n nh hay mc ti

qua.

- a tr s HbA1c v 5-7% trong vng 3 thng, nu thp

Dng tr s ny xem c kim sot c bnh khng:

qu h ng huyt mnh

- 5-7%: bnh thng

- >10%: ng huyt cha c kim sot tt

- Ngn nga v kim sot bin chng

- Gim cn

30

1/14/2014

Tr li cu hi

Tr li cu hi

5. Nn khi u nhm thuc iu tr no cho BN (men

6. BN cn lu g v ch n v luyn tp?
n nhiu:

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

- Tri cy.
- Rau.
- Cc loi ng cc.

(tng cn). Nhm Thiazolidinedion v c ch -

- Nhng thc phm c nhiu cht dinh dng v t cht bo v

glucosidase gy c gan nn cng khng chn.

calo. Cng cn n sn phm ng vt v ngt t hn.

- BN nn dng nhm Biguanid (metformin): liu khi u

Vn ng: iu v va sc, mc tiu gim cn nng xung.

500mg/ngy, ung sau ba n. Liu ti a 2500mg/ngy

Thuc:
- Khng dng metylprednisolon, nu vim khp th dng

chia 3 ln.

NSAIDs v bo v d dy.

Tham kho
T type 1
-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

T type 2
-Khng ph thuc insulin
- khng insulin
-Khi pht chm

Tham kho
T thai k
2-5% PNCT mc T
thai k, trong 40% c
nguy c T type 2 sau
ny

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

-C di truyn
-Ln tui (>40)
-Bo ph
-Ceton (-)
-Dng thuc, nu thuc
khng p ng mi dng
insulin

Xc nh T lc i: >126mg/Dl

Biu hin ceton niu (+): bun nn, au bng, kht, hi
th c mi ceton

31

1/14/2014

TUN 5:
CA HUYT P 1

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

Subjective: Thng tin ch quan

ng Trn Vn A. 53 tui, c chn on tng huyt p

Subjective: Thng tin khch quan

Phn loi theo JNC7

Huyt p tm thu
(mmHg)

Huyt p tm trng
(mmHg)

<120 v

<80

cch y 1 thng. Hm nay ng i khm li, vi kt qu

Bnh thng

nh sau:

Tin THA

120 -139 hoc

80 89

THA giai on 1

140 -159 hoc

90 99

- Huyt p ti phng khm: 176/108 mmHg

THA giai on 2

160 hoc

100

- Ph i tht tri (xc nh qua im tm ECG)

THA tm thu n c

140 v

100

- Bnh s: khng r

Kt lun: 176/108 mm Hg. ng A tng huyt p giai on 2

- Bn thn: ht thuc l, cao 1m6 nng 75 kg, hay ung

bia vi bn

32

1/14/2014

Objective: Thng tin ch quan

Ty theo cch o m ngng cao huyt p khc nhau:
 Phng khm, bnh vin:

Assesment: nh gi tnh trng BN

 ng A mc bnh ph i tht tri tng nguy c bnh tim

140/90 mmHg

 Bnh nhn t o huyt p: 135/85 mmHg

mch.

 o huyt p lin tc 24 gi: 125/80 mmHg

 Ht thuc l, hay ung ru bia.

i vi bnh nhn A:

 Cng vi huyt p hin ti ca ng th nguy c tim mch

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.

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

Tr li cu hi
1. C th s dng bin php no gip chn on
tng HA, hng dn bnh nhn ra sao?

v CCB

Nu vn khng t mc tiu chng ta c th tng liu,
thm thuc ph hp vi tnh trng bnh nhn.

 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

Thng xuyn ti khm.

Kim tra acid uric, cholesterol, ng huyt

- Khng dng cht kch thch (c ph, ht thuc, ru bia)

trc 2 gi

33

1/14/2014

Tr li cu hi
- T th o chun: BN ngi gh ta, cnh tay dui thng

Tr li cu hi
2. Huyt p o ti nh l 155/97mgHg? Hy gii thch cho

trn bn ngang mc vi tim. Ngoi ra, c th o cc t

bnh nhn c s chnh lch gia HA phng khm v

th nm, ng. i vi ngi cao tui hoc c bnh i

HA ti nh

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

 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

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
3. nh gi bnh nhn?
 Cn nng: 75kg
 Chiu cao: 1m60

Tr Li Cu Hi
4. ngh thuc tr liu khi u, cn cn dn BN iu

BMI = 29,3 (bo ph)

g?
 THA 2, phi hp 2 nhm: ACEI v CCB: do THA c ph i tht tri
ACEI: Enalapril 5mg/ln/ngy

 Mc bnh ph i tht tri  tn thng c quan ch

 Ht thuc l,thng ung ru bia.

c ch men chuyn (ACEI)

 Tng huyt p giai on 2.

Captopril
Elanapril
Perinopril

- Tng HA c km thm
nhiu bnh: tiu ngz
- 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

=> Nguy c tim mch ca ng tng gp i. V vy ng A

CCB: Amlodipin 5mg/ln/ngy

phi tch cc thay i li sng v tun th theo di iu tr

ca bc s.

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

34

1/14/2014

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

35

1/14/2014

Objective: Thng tin khch quan

Cn lm sng:
Xt nghim

Assesment: nh gi tnh trng BN

Cc xt nghim vn bnh thng

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

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
tm trng 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:

Tr li cu hi
1. nh gi nguy c tim mch ca bnh nhn trong vng 10
nm theo thang im Framingham

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 ..

Ch s

im

Tui 65-69

Cholesterol ton phn 4.5

HDL

-2

Huyt p

Tiu ng

Ht thuc

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

36

1/14/2014

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

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

sng.

 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

Tr li cu hi
4. Bnh nhn c ch nh dng Nifedipin, nhng bnh
nhn thng xuyn chng mt lc ngi dy hoc

bit l li tiu quai v li tiu thiazid v c tc dng ph

ng dy, bnh nhn cm thy b hi hp. Gii thch l

lm tng ng huyt m bnh nhn ang b tiu ng

do bnh nhn b triu chng trn? Cch khc phc?

typ 2

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

37

1/14/2014

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

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

bnh nhn ny khng?

khm th c chn on l vim xoang, BN c k

Thng tin ny chnh xc, nhng nu BN ny dng CCB c

Clarithromycin v ung c 1 tun nhng cha khi.

hiu qu th khng nn i thuc.

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.

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

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

38

1/14/2014

Tham kho

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

Nhm thuc tim mch huyt p thng dng:

Nhm

Thuc

Chn knh Ca2+ (CCB)

Thuc nhm DHP

(dihydropyridin):
Nifedipin
Amlodipin
Felodipin

c ch men chuyn (ACEI)

Captopril
Elanapril
Perinopril

Chn receptor angiotensin

2 (ARB)

Losartan
Telmisartan

Chn chn lc 1
(1 tim, 2 kh ph qun,
c ch: lm tim p chm,
gin mch)

Atenolol
Bisoprolol
Metoprolol

Chn c 1 v 2

Propanolol
Nadolol
Timolol

C
- Tr tng HA
- D phng TN
- Hi chng Raynaud (thiu
mu u chi)

- 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

TDP
- H HA mnh
- Nhc u, chng mt, bun
nn, bng mt, ph mt c
chn, tim nhanh
- 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

CC

- HA thp
- Sc tim suy tim
- Thn trng cho PNCT

- Mn cm
- PNCT
- Hp ng mch thn 2 bn
- Tin s ph mch d ng
- Tng K+ huyt
- V niu

Ging ACEI nhng t ho khan

v ph mch hn

- 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
- 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

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

Methyldopa

- Thuc u tay trong tng HA

thai k
- Tng HA trung bnh v nh
cho nhiu i tng

Lit giao cm TW
(kch thch receptor 2 trn
trung tm vn mch)

- 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

- Mn cm sulfamid
- BN b gim th tch mu
- No gan, gout
- PNCT v cho con b
- V niu

- Trm cm
- Suy gan
- U ty thng thn
- BN ang dng IMAO hay
levodopa

39