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S Y T AG

BVK AN PH

CNG HA X HI CH NGHA VIT NAM


c lp T do Hnh phc

PHC IU TR
KHOA KHM BNH
NM 2014

MC LC
Trang
1.

i tho ng ................................................................................................. 4

2.

Cng gip ....................................................................................................... 8

3.

Thiu mu c tim ........................................................................................... 13

4.

Tng huyt p ................................................................................................. 16

5.

Suy tim mn ................................................................................................... 20

6.

Nhim trng tit niu ..................................................................................... 24

7.

Hi chng thn h.......................................................................................... 27

8.

Vim cu thn mn ........................................................................................ 31

9.

Vim lot d dy t trng v Dit Helicobacter Pylori .................................. 35

10. Vim i trng mn ........................................................................................ 39


11. Vim gan siu vi ............................................................................................ 41
12. X gan ............................................................................................................ 58
13. Long xng .................................................................................................. 62
14. Thoi ho khp v thoi ho ct sng ........................................................... 64
15. Vim khp dng thp ..................................................................................... 68
16. Gout................................................................................................................ 72
17. iu tr gim au ....77
18. au thn kinh to ........................................................................................... 79
19. au u .......................................................................................................... 83
20. Chng mt t th kch pht lnh tnh 91
21. Mt ng . 92
22. ng kinh . 94
23. Parkinson .. 98
24. Nhc c .. 101
25. Lit VII ngoi bin 105
26. Cn thiu mu no thong qua ..107
27. Tai bin mch mu no ..109
28. Vim phi cng ng ngi ln 115
2

29. Hen ph qun .118


30. Bnh phi tc nghn mn tnh (COPD)..122
31. Vim ph qun cp .129
32. Danh mc thuc..131

BNH I THO NG TYPE 2


CHA C BIN CHNG
I CNG:

I.
-

T l mc bnh i tho ng (T) trong c nc c tnh trn 5%, tc


khong 4,5 triu ngi b T.

Bnh T gy nhiu bin chng nng n ln cc c quan nu khng c chn


on v iu tr thch hp.

II.

CHN ON V PHN LOI I THO NG:


A. Tiu ch chn on T theo ADA 2013: C T da vo 1 trong 4 tiu ch:
1. Glucose huyt tng lc i > 126mg% (7,0mmol/l) vi iu kin bnh nhn
phi nhn n (ch c dng nc lc t nht 8 gi).
2. Glucose huyt tng sau 2 gi lm nghim php dung np glucose > 200mg/dl
(11,1 mmol/l).
3. Bnh nhn c triu chng kinh in ca tng glucose huyt tng bt k
200mg% (11,1mol/l)
4. HbA1C

6,5% (xt nghim ny phi c thc hin ti phng th nghim c

chun ha theo tiu chun quc t).


Tiu ch 1,2,4 cn c thc hin lp li ln 2 nu khng c triu chng kinh
in, (n nhiu, ung nhiu, tiu nhiu, st cn khng r nguyn nhn).
* Cc tnh trng ri lon glucose huyt c xp vo nhm tin T
- Ri lon glucose huyt i: Glucose huyt 100 - 125 mg/dl (5,6-6,9 mol/l)
- Ri lon dung np glucose:

140 -199 mg/dl (7,8-11,0 mol/l)

- HbA1C t 5,7%- 6,4%


Nhng tnh trng ri lon glucose huyt cha chn on T nhng khng
hon ton l bnh thng v c nguy c xut hin cc bin chng mch mu ln ca
T v trong tng lai c nhiu kh nng din tin thnh T tht s.
III. IU TR- THEO DI:
1. iu tr khng dng thuc:
a. Luyn tp th lc thng dng v d p dng nht l i b tng cng 150 pht/
tun. ngi ln tui c th chia i b 2 ln ngy, mi ln 10-15 pht.
4

b. Dinh dng:
-

Nn dng thc n c lng carbohydrat hp thu chm nhiu cht x.

m 1gam/kg/ngy ngi khng c suy thn, n c t nht 3 ln tun.

M - du: nn dng du lt, m c, du m, du oliu tt hn b m V.

Hn ch ru bia.

Ngng ht thuc l.

2. iu tr bng thuc:
Sulfunylure
Gliclazide

Biguanid
Metformin

Khi u

Ti a

S ln dng / ngy

30
80mg

120mg
320mg

1 ln
2 ln

500mg
500mg
50mg

2550
2000
300mg

1- 3 ln
1 2 ln
1 3 ln

45mg

1 ln

100mg
5mg
50 100mg
5mg

1 ln
1 ln
1 2 ln
1 ln

c ch glucosidase
Acarboz (glucarbose)
15 30mg
TZD (Pioglitazol)
c ch DPP4
Sitaglitin
100mg
Saxaglitin
5mg
Vidagliptin
50mg
Linagliptin
5mg
3. Insulin (Tim di da):
Loi Insulin TDD
Insulin phng (Bolus) tc dng
rt nhanh Lispro aspart glulisin
Tc dng nhanh Actrapid
humulin
Insulin nn (Basal)
Tc dng trung bnh
Tc dng di
Glarglin (Lantus)
(Detemin)
Insulin
Mitard 30/70, Humudin 30/70,
Scillin 30/70, Insulin analog
trn sn, Insulin aspard pha
(Novomix)

Mu
sc

TG bt u
tc dng

TG tc dng
nh

TG tc dng
ko di

Trong

15 30 pht

0,5 1,5 gi

3 5 gi

Trong

30 pht

2 4 gi

6 8 gi

c
c

1 2 gi
3- 8 gi
4- 6 gi
3 4 gi

6 12 gi
14 24 gi

18 24 gi
24 40 gi
24 gi
24 gi

Trong

Mt l hay bt c cha sn 2 loi insulin theo t l


nht nh tc dng nhanh so vi chm. Vit Nam
t l l 30/70.
5

Cc phc phi hp vi Insulin:


-

Kt hp thuc ung 1 2 hoc 3 thuc + insulin nn 1 ln/ngy dng vo


bui chiu hoc bui n ti.

Kt hp thuc ung vi insulin pha hn hp nhanh v chm chia 2


ln/ngy hoc phi hp insulin nn v insulin tim bolus nu HbA1C cao
> 9%.

Kim sot v phng nga tim mch:


-

Tng huyt p: Thuc u tay - c ch men chuyn, c ch angiotentin II

K tip chn knh canxi v li tiu.

Cn phi hp nhiu thuc h p t c mc tiu h huyt p.

iu tr ri lon lipid mu:


-

Kim tra bilan lipid mu t nht mi nm 1 ln gm LDL-cholesterol,


HDL-cholesterol, cholesterol ton phn, triglycerid.

Thay i li sng, tng hot ng th lc.

Thuc u tay l statin

Nu c triglycerid tng c th dng nhm fibrate.

Ngng thuc l
Thuc chng kt tp tiu cu:
-

iu tr Aspirin liu thp 75 165mg phng nga th pht bnh nhn


c bnh tim mch km theo.

C th dng Clopidogrel 75mg/ngy bnh nhn c bnh tim mch v d


ng vi Aspirin.

Thm khm bn chn: Ch cc bt thng v cu trc, bnh l thn kinh,


mch mu, vt lot nhim trng bn chn. Ty theo bnh l m kt hp thuc
km theo.
Thm khm mt mi nm 1 ln, sau ty tn thng mt c th kt hp
vi thuc chuyn khoa.
Bnh l khp v bnh l ng tiu ha: T c bit l bnh nhn ln tui
c th kt hp khm v iu tr long xng v iu tr ri lon ng tiu ha
km theo.
6

Mc tiu iu tr:
HbA1C
< 7,0%
Glucose mu (lc i)
70 130 mg/dl (3,8 7,2)
Glucose mu (2h sau n)
< 180 mg% (10mmol/l)
Huyt p
< 140/90 mmHg
HDL-C
< 100 mg/dl (< 2,6 mmol/l)
Mc tiu iu tr mi c th c th khc nhau:
-

Bnh nhn tr, mi chn on, khng c bnh l tim mch, nguy c h
ng huyt thp (HbA1C < 6,5%)

HbA1C t 7,5 8% bnh nhn ln tui, i tho ng lu, c nhiu


bnh l i km, c tin s h glucose huyt trc .

nh gi cn thit cho bnh nhn i tho ng:


Huyt p, cn nng, vng eo
HbA1C

Mi ln khm
Mi 3 thng
Nu ng huyt n nh 6 thng / 1 ln
Bilan lipid mu
Nu khng iu tr mi 6 thng 1 nm/ 1 ln
nu c iu tr m mu ty theo quyt nh ca
BS
Chc nng thn, o creatinin Lc mi chn on, mi nm kim li 1 ln nu
v c tnh lc cu thn
c suy thn ty theo quyt nh ca BS.
ECG
Mi nm nu > 40 tui
Nu c bnh l tim mch ty theo quyt nh ca
bc s chuyn khoa.
Ti liu tham kho:
- Albecti KG Zimmet PN Definition, Diagnosis and classification of diabetes
melitus and its complication. Diabet. Med 2010 Jul, 157 (539-53).
- Hng dn, chn on v iu tr i tho ng typ2 cha c bin chng.
Hi Ni tit T Vit Nam 2012 2013.

CNG GIP
I. I CNG:
Cng gip c xem ng ngha vi nhim c gip l mt hi chng bao gm
cc bnh cnh lm sng gy nn do hormone gip tng nhiu v thng xuyn
trong mu.
II. CHN ON:
1. Lm sng:
a. Triu chng c nng: Hi hp, mt khi gng sc, nng ny, d gin, d cu
gt, mt ng, run ry, st cn d n ung bnh thng, khng chu c nng,
m hi nhiu, yu c, i tiu nhiu ln.
b. Triu chng thc th:
-

Tim: Nhp tim nhanh thng >100 ln/pht. Tim p mnh, T1 anh, c th
nghe c m thi tm thu tim.

C th c ri lon nhp tim thng gp rung nh.

Da mn, m, m, t m hi.

Run ch yu u chi, bin nh u, i khi run ton thn.

C yu, c teo r rt thi dng, c t u i. i khi c tnh trng lit


chu k.

Tc d rng, mng tay d gy.

nh mt sng, c th c triu chng co ko c nng mi trn.

Trng bnh nhn Basedow c bu gip lan ta.

2. Cn lm sng:
-

FT4, FT3, T4, T3 ton phn u tng; TSH gim

Tr s bnh thng: TSH: 0.270 4.20 UIU/ml; FT4: 12.00 22.00 pmol/l

Xt nghim TSH siu nhy vi mc gi hn 0.01UI/ml cho php phn bit


TSH gim do bnh l tuyn gip v bnh l ngoi tuyn gip.

a s bnh nhn cng gip lm sng c mc TSH gim di 0.01UI/ ml.

Bnh l ngoi tuyn gip: TSH c gim nhng khng t c mc trn.

3. Nguyn nhn:
3.1. Nguyn nhn thng gp:
3.1.1. Bnh Basedow:
-

L bnh t min lin h n h thng HLA.

C s hin din ca t khng th khng th th TSH thuc nhm globulin


min dch kch thch tuyn gip v t khng th khng microsom.

Bnh c th kt hp vi cc bnh t min khc nh: nhc c, suy thng


thn, bch bin.

Lm sng:
Hi chng cng gip.
Bu gip lan ta.
Li mt.
Ph nim trc xng chy.

ngi ln tui c th bnh v cm, hoc biu hin tim mch ni bt


- Cn lm sng:
Echo tuyn gip: tng sinh mch mu tuyn gip.
Kch thc tuyn gip ln hn bnh thng.
TSH gim, FT4, T3, T4 ton phn tng cao.
3.1.2. Bu gip a nhn c:
-

Thng gp ph n ln tui, c bu gip t lu, gn y mi xut hin


cng gip.

CLS: TSH gim, T3, T4, FT4 tng. Cng c khi ch c FT3 tng

Siu m tuyn gip: bu gip a nhn.

3.3. Nguyn nhn khng thng gp:


-

Nhn c gip

Cng gip thong qua trong cc trng hp vim tuyn gip

Cng gip gi

Cng gip do qu ti Iod

III. IU TR:
A. iu tr ni khoa:
1. Thuc c tc dng nhanh:
1.1. Thuc c ch (beta):
-

Thuc c tc dng rt tt iu tr cc triu chng nh hi hp, lo lng,


run tay, m hi, tim nhanh Ngoi ra Propanolol cn c tc dng
gim s chuyn T4 thnh T3 ngoi vi. Cho n nay thuc Propanolol
c s dng nhiu nht, sau l Atenolol liu thng thng 40
120mg chia lm 4 6 ln/ung v tc dng ca Propanolol nhanh nhng
ngn.

Chng ch nh: hen suyn, lot d dy t trng, Block nh tht.

i vi suy tim, kin cha thng nht v n lm gim tc dng co bp


ca tim. Cng c kin cho l vn c th dng nhng cn d dt.

Thuc c ch thng c ch nh trong cc trng hp:

+ Phi hp thuc khng gip tng hp lm gim cc triu chng kh chu cho
BN.
+ Sa son tin phu, trc khi iu tr Iod 131.
+ Cn bo gip trng.
1.2.

Corticoid:
-

Corticoid c xem c th ngn chn s tit hormone bi tuyn gip v


c ch s chuyn T4 thnh T3 ngoi vi.

Corticoid c ch nh trong cc trng hp: cn bo gip, cng gip


nng, li mt nng.

2. Thuc c tc dng ko di:


Thuc khng gip tng hp. l nhng dn xut ca Thionamid gm 2 phn
nhm l:
-

Nhm Thiouracid: MTU, PTU, BTU.

Nhm Imidazol: Methimazol v Carbimazol

Tc dng ch yu l ngn cn s tng hp hormone gip nhiu khu:


10

Ngn s Iod hu c ha

Ngn s hnh thnh v kt hp ca DIT

Ngn s chuyn T4 thnh T3 ngoi vi

Liu lng cch s dng:


Hm lng

Liu tn cng

Liu duy tr

mg/ vin

mg/ ngy

mg/ ngy

50mg

200 - 400 mg

50 - 100 mg

15 - 30mg

5 - 10mg

30 - 45mg

5 - 10 mg

Nhm
Thiouracil
PTU (PTU,proracil)

Imidazol
Carbimazol(Neomercazole,
carbimazol)

5mg

Khi chn on chc chn cng gip th nn s dng ngay liu cao c hiu
qu.
Thuc khng gip tng hp thng dng vi cc liu lng khc nhau cc giai
on iu tr:
-

Giai on tn cng: 6 8 tun.

Giai on duy tr: c khi ko di 18 24 thng, giai on ny liu lng


gim dn dn mi 1 2 thng da theo s ci thin cc triu chng.

Tai bin ca thuc khng gip tng hp:


-

Gim bch cu: thng gp.

Ri lon tiu ha: t gp

Hi chng vng da do tc mt hoc vim gan. Nu c, thay bng liu php


Iod, dung dch Lugol tm thi hoc vnh vin.

B. iu tr khc:

11

Khng c ch nh no l l tng cho mi trng hp. Cn phi cn nhc cho


mi trng hp c th: ty theo tui, tnh trng c th, iu kin kinh t, tnh trng
bnh tt m quyt nh.
1. Bnh Basedow:
Bu gip nh v va:
Bnh nhn di 50 tui: iu tr ni khoa trong 18 thng theo di:
-

Nu ti pht sau ngng thuc cho iu tr ni khoa li n t c bnh gip


iu tr ngoi khoa.

Bnh nhn trn 50 tui; iu tr bng Iod ng v phng x.


2. Bu gip nhn hoc bu gip lan ta:
iu tr ni khoa v bnh gip sau phu thut tuyn gip.
3. Biu hin mt nng (li mt c tnh):
-

Khng nn iu tr bng Iod phng x.

iu tr ni khoa bng khng gip tng hp.

C th phu thut khi bnh gip.

iu tr li mt bng corticoid.

TI LIU THAM KHO


1. GS Mai Th Trch PGS Nguyn Thy Kh Ni tit hc i cng 2007 (trang
160 161)
2. Catherins Deneux Tharaux Patrick Darmou- Endocrinologie 2000 (p146 160)
3. Wayne Bardin MD Current Therapy in Endocrinology and Metabolish -2000 (p73
77)
4. GS Mai Th Trch- Ni tit hc Bnh bu c-2002 (trang 62 69)
5. GS. PTS Thi Hng Quang - Bnh ni tit Hc vin Qun Y (trang 117 125)

12

THIU MU C TIM
I. I CNG:
Khi c tim b thiu mu biu hin trn lm sng bng nhng cn au tht ngc
(TN), i khi ch biu hin trn ECG.
II. CHN ON: AU THT NGC N NH (TNO) (Bnh c tim thiu
mu cc b mn tnh hay suy vnh)
Chn on cn au tht ngc in hnh gm 3 yu t:
au tht ngc sau xng c, lan ln c, vai tay tri c th xung ti ngn 4-5,
hm di, thng v, sau lng vi tnh cht (tht li, nght, rt, nng, cm
gic but. i khi kh th, mt, nhc u bun nn v v m hi ) v thi
gian in hnh l vi pht nhng khng qu 20 pht.
Xut hin khi gn sc hoc cm xc
Gim au khi ngh hoc dng nitrate
TN khng in hnh ch gm 2 yu t trn.
Khng phi TN ch c mt yu t hoc khng c yu t no ni trn.
-

ECG: thay i ca ST v T: ST , T m hoc dt. i khi ST , T cao nhn i


xng. Tuy nhin khong 60% TNO ECG bnh thng.

Siu m tim : c hnh nh ri lan vn ng vng.

C th chuyn tuyn trn lm in tm gng sc, x hnh tim, chp mch


vnh nu cha xc nh r.

* Chn on phn bit:


-

Vim sn c sn.

Vim thn kinh lin sn.

Zona.
13

Vim lot d dy t trng.

Vim thc qun tro ngc hay co tht thc qun.

au khp b vai cnh tay.

Vim mng ngoi tim.

Khi chn on TNO cn nh gi yu t nguy c bnh MV:


-

Tng huyt p

Tui cao

Ht thuc l

Phi nam, ph n mn kinh

Ri lon lipid mu

Tin s gia nh c bnh MV sm, nam

i tho ng.

55 tui, n

65 tui.

III. X TR:
-

Ngh ngi yn tnh, trnh gng sc, trnh nhng kch thch khng cn thit

Aspirin 75- 325 mg/ ngy. Nu khng dung np aspirin th dng clopidogrel
75mg/ngy.

Chn :

Bisoprolol 5-10mg

1 ln/ngy

Metoprolol 50- 200mg

1 ln/ngy

Carvedilol 12.5- 25mg chia 2 ln/ngy


1 ln/ngy.

Nebividol 2,5- 10mg

* C th phi hp thm ivabradine( procoralan) nu vn cn au tht ngc v


nhp tim >70 ln /pht vi liu: 2,5 7,5mg 2 ln/ ngy
-

H lipid mu: khi LDL-C > 100mg%, triglycerid tng


Atorvastatin 10mg 20 mg/ ngy
Rosuvastatin 10mg 20 mg/ ngy

Fenofibrat 200 300 mg/ ngy


Dn mch vnh: nitrate c tc dng ko di nh Isosorbid mononitrat 60mg
(ISMN 60mg) /ngy, nitroglycerin : 2,5-6,5mg 2-3 ln/ ngy.
14

C th dng c ch canxi c tc dng ko di (nifedipin retard, amlodipin,


diltiazem) nu c km THA hoc c chng ch nh c ch .

Dng thm c ch men chuyn nu c i tho ng (T), sau nhi mu c


tim, ri lon chc nng tht tri hoc tng huyt p (THA).

iu chnh yu t nguy c c th thay i c: THA (a HA di


130/80mmHg, nu c T th HA dui 125/80 mmHg), T, ri lon lipid
mu, ht thuc l.
Nu iu tr ni khoa tht bi, chuyn tuyn chp v can thip mch vnh

THIU MU C TIM IM LNG


I. nh ngha: L biu hin du thiu mu c tim cc b trn ECG, m khng biu hin
cn au tht ngc trn lm sng.
II. Chn on:
Thng c pht hin qua thm khm sc khe (o ECG) hoc trn lm sng
c biu hin ca ri lon nhp tim (cn nhp nhanh hay ngai tm thu) m ngi
bnh khng c biu hin TN
Theo di ECG thy ST hoc thay i ca sng T thng xy ra vo bui sng.
III. X tr: Tng t nh TNO.
Ti liu tham kho:
1. PGS-TS Trng Quang Bnh - Bnh Hc Ni Khoa - i Hc Y Dc TPHCM2009 (trang 62-87)
2. Gs. Nguyn Huy Dung- Bnh mch vnh - i Hc Y Dc TPHCM 2002.
3. PGS TS V Thnh Nhn - iu Tr Hc Ni Khoa - i Hc Y Dc TPHCM 2009 (Trang 87-99)
4. GS TS Phm Gia Khi v cng s. Khuyn co v cc bnh l tim mch v
chuyn ha, giai an 2006-2010 ca HI TIM MACH HC VIT NAM
(Trang 329-348).

15

TNG HUYT P
I. I CNG:
THA khi HA >= 140/90 mmHg c o t nht 2 ln ti phng khm.
Hoc khi HA >= 135/85 mmHg ( o ti nh vi ln)
Hoc khi HA >= 125/80 mmHg c o bng Holter.
II. PHN V CHN ON: theo JNC VI
Phn loi

HA tm thu (mmHg)

HA tm trng (mmHg)

(HATT)

(HATTr)

HA ti u

< 120

< 80

HA bnh thng

< 130

< 85

HA bnh thng cao

130 139

85 89

THA 1(nh)

140- 159

90 99

THA 2(trung bnh)

160 -179

100-109

THA 3(nng)

180

110

THA tm thu n c

140

< 90

Ch : - Khi tr s HATT v HATTr khng tng xng, chn huyt p cao hn


phn loi.
-

HA c o ti phng khm.

III.IU TR:
90% l THA tin pht, cn iu tr sut i.

16

5 - 10% l THA th pht: Thng gp ngi tr, cn tm nguyn nhn (thn a


nang, hp ng mch thn, u ty thng thn, hi chng Cushing, do thuc)
iu tr bao gm: Thay i li sng v dng thuc.
Mc tiu chung l a HA < 140/90 mmHg. Nu THA km vi mt s bnh l
khc c th a HA thp hn.
1. Thay i li sng:
Ch n ung:
-

Gim thc n cha nhiu m bo ha: M heo, m b, m g, m vt. Nn


n nhiu c.

Gim thc n c nhiu mui NaCl, tng cng thc n c nhiu Kali.

Ngng thuc l, gim ru, gim caf.

n nhiu rau qu, tri cy ti.

Gim stress.

Tp luyn:Tp th dc gi cho cn nng l tng, BMI (18.5 22.9)


2. S :
Thay i li sng
Khng t HA mc tiu(< 140/90
mmHg) (<130/80 mmHg BN
T hay bnh thn mn tnh

Thuc la chn ban u

Khng c C bt buc

THA 1
LT thiazide
C th dng: UCMC,
UCTT, chn , UC canxi
hay phi hp thuc

C C bt buc

THA 2
Kt hp 2 loi thuc
(thng l LT thiazide)
C th dng UCMC,
UCTT, chn, UC canxi
17

- Thuc ch nh bt buc
- Thuc iu tr THA khc
(LT, UCMC, UCTT, chn,
UC canxi).

Khng t HA mc tiu

Dng liu ti a hay kt hp thuc cho n khi t HA mc tiu


Xin kin trng ph khoa.
UCMC: c ch men chuyn; UCTT: c ch th th AT1; LT: li tiu; UCCA: : c ch canxi.

Hng x tr nhm bnh nhn THA c bit:


1. Ngi cao tui: LT thiazide v UC Canxi. C th phi hp 2 loi
2. Ngi tr: Nn tm nguyn nhn nh thn a nang, hp M thn, u ty thng
thn
3. THA v t qu: UCMC, (peridopril, losartan, +/- indapamide)
4. THA v i tho ng (T): UCMC, UCTT- AT1, UCCA, LT thiazide. i
khi cn phi hp 3 th thuc. HA mc tiu < 130/80mmHg.
5. THA v bnh thn mn:
- Cha suy thn: UCMC, UCTT-AT1, +/- LT thiazide
- suy thn:
* CL creatinin> 15 ml/pht: UCMC, UCTTAT, LT quai, UC 2 TW
(methyldopa).
* CL creatinin< 15ml/pht: LT quay v UCCA
- HA mc tiu<130/80mmHg, HA ti u< 125/75 mmHg.
6. THA v hi chng chuyn ha (IDF- 2005): thay i li sng l ch yu. Thuc:
UCMC, UCTT-ATI.
7. THA v bnh mch vnh: UC l ch yu, UCCA (DHP tc dng ko di hoc
non- DHP), UCMC. Khng h HA TTr<60mmHg.
8. THA v ph i tht: UCMC, UCTT-AT1, c th dng LT thiazide, UCCA, UC
9. THA v thai k:
-

C 4 dng:THA mn tnh, tin sn git (TSG), THA thai k, TSG/THA mn


tnh

18

iu tr khi HA tm thu > 150mmHg hoc HA tm trng >100mmHg hoc


c tn thng c quan ch.

Thuc: methyldopa, hydralazin, c ch

10. THA / bnh nhn cho con b:


-

Nu THA I nn ngng thuc trong vi thng.

Cc thuc c th dng: Methyldopa, hydralazin, propanolol, labetolol

11. THA khng tr: Cn tm nguyn nhn


12. THA cp cu, THA khn trng:
-

THA khn trng: Khi HA TTr>120mmHg, khng tn thng c quan ch:


C th iu tr ngoi tr, cho BN dng thuc ng ung hoc ngm di
li: Captoril 25mg( 6,26-50mg), Nitroglycerin 0.4mg NDL. H HA trong
vi gi, HATTr (100-110mmHg)

THA cp cu: khi HA>180/120mmHg, c tn thng c quan ch. Cho BN


nhp vin ngay v dng thuc ng TM.

Mt s thuc thng dng trn lm sng:

Li tiu

Chn

UMCM

Tn thuc

Liu (mg/ngy)

S ln/ngy

Idapamide

1,25 2,5

Furosemide

20 80

Spironolacton

20 50

Bisoprolol

2,5 10

Metoprolol

50 100

Carvedilol

12,5 50

Enalapril

5 40

12

Lisinopril

10 40

Perindopril

48

11

19

UCTT.AT1

UC Ca+

Uc 2TW

Candesartan

8 32

Losartan

25 100

12

Irbesatan

150 300

Amlodipin

2,5 10

Felodipin

2,5 20

Nifedipine, Nifedipine LP

10 20

12

Methyldopa

250 1000

Ghi ch: UCMC: c ch men chuyn; UCTTAT: c ch th th angiotensin;


LT : li tiu; UC2TW: c ch 2 trung ng
Ti liu tham kho:
1. Hi tim mch hc Vit Nam. Khuyn co 2008 v cc bnh l tim mch v chuyn
ho. NXB Y hc, 2008 (235 291).
2. GS. ng Vn Phc. Tng huyt p trong thc hnh lm sng. NXB Y hc, 2008.
3. Daniel H. Cooper, MD The Washington manual of medical therapeutics. Lippincott
Williams & Wilkinss, 2007 (102 118).

20

SUY TIM MN
I.

I CNG:
Suy tim l s mt kh nng ca tim duy tr cung lng tim p ng nhu
cu chuyn ho c th.
NGUYN NHN:
-

Bnh ng mch vnh

Tng huyt p

Bnh van tim

Bnh c tim

Cc nguyn nhn khc: ru, nhim trng, thuc

Cha r nguyn nhn.

PHN SUY TIM:

II.

I:

Khng hn ch vn ng th lc

II:

Hn ch nh vn ng th lc

III:

Hn ch nhiu vn ng th lc

IV:

Khng vn ng th lc no m khng gy kh chu.

CHN ON:
Hi bnh s v khm lm sng tht k gip hng chn on suy tim.
Tiu chun Framingham:
1. Tiu chun chnh:
-

Cn kh th kch pht v m hoc kh th phi ngi.

Phng tnh mch c

Ran phi

Tim ln

Ph phi cp

Ting T3

p lc tnh mch h thng >16cm nc

Thi gian tun hon >25 giy

Phn hi gan tnh mch c.


21

2. Tiu chun ph:


-

Ph c chn

Ho v m

Kh th khi gng sc

Gan ln

Trn dch mng phi

Dung tch sng gim 1/3 so vi ti a

Tim nhanh >120 ln/pht.


3. Tiu chun chnh hay ph:

Gim 4,5 5kg/ngy khi iu tr suy tim.


Chn on xc nh suy tim:
-

C 2 tiu chun chnh

Hoc 1 tiu chun chnh + 2 tiu chun ph.

Cc cn lm sng gip h tr chn on, xc nh nguyn nhn v nng ca suy tim.


-

ECG: cho thy nhp tim nhanh, rung nh, nhi mu c, thiu mu c tim

X quang ngc: bng tim to, ti phn phi tun hon phi

Siu m tim: pht hin cc bnh l van tim, c tim, bnh tim bm sinh, phn
sut tng mu gim

nh lng BNP: khi BNP<100pg/ml c gi tr loi tr suy tim.

III. IU TR:
Kt hp bin php khng dng thuc v dng thuc.
1. Khng dng thuc:
-

Trnh gng sc.

Hn ch mui

Tp th dc khi tnh trng suy tim n nh: 30 45ph/ngy, 3-5 ngy/tun.

Ngng thuc l, gim ru bia.

2. Dng thuc:
a) Digoxin:
-

Thng dng cho suy tim c km theo rung nh.


22

Liu khi u 0,125-0,25 mg/ngy (ung 1 ln) sau khong 1 tun chuyn
sang liu duy tr:
+ i vi NB cn tr: 0,125-0,25 mg/ngy (ung 1 ln)
+ i vi NB ln tui: 0,0625-0,125 mg/ngy (ung 1 ln).
Nu NB c suy gim chc nng thn cn gim liu.

b) Li tiu:
-

Furosemide: 20 600mg /ngy (ung 1-2 ln)

Indapamide: 2,5 5mg /ngy (ung 1 ln)

Spironolacton: 25 50mg /ngy (ung 1 ln)

c) c ch men chuyn (UCMC):


Tn thuc

Khi u

Duy tr

S ln/ ngy(ung)

Enalapril

2,5mg

10mg

Lisinopril

2,5-5mg

20mg

Perindopril

2mg

4mg

Ramipril

1,25- 2,5mg

5mg

Catopril

6,25mg

50mg

d) Chn th th AT1: (khi khng dung np UCMC)


- Candesartan: khi u 4-8mg 1ln, ti a 32mg 1ln/ngy
- Valsartan : khi u 20-40mg 2 ln, ti a 160mg 2ln/ ngy
- Losartan : khi u 25mg- 50mg 1 ln/ ngy,ti a 50- 100mg 1ln/ngy
e) Dn mch:
-

Nitroglycerin (nitroco, nitromin, sustonic): 2,5 6,5mg x 2-3 ln/ngy.

Isosorbide mononitrate (imdur, vasotrol): 30-60mg x 2ln / ngy.

f) Chn : (khi tnh trng suy tim n nh).


- Carvedilol : khi u 3,125mg2 ln/ ngy tng dn ti 25mg2 ln/ ngy
trong 6 tun.
- Bisoprolol: khi u 1,25mg/1 ln/ngy tng dn mi 2-4 tun ti 10mg/ ngy.
- Metoprolol : khi u 12,5mg-25mg / ngy tng dn ti 200mg/ngy trong 7
tun.
23

- Nebividol : khi u 1,25mg/1 ln/ngy tng dn mi 2-4 tun ti 10mg/


ngy.
* C th phi hp thm ivabradin(procoralan) 2,5-5mg2 ln/ ngy, khi vn cn
au ,nng ngc v nhp tim >70 ln/pht

S phi hp thuc tu theo mc suy tim:


-

Suy tim II: Li tiu+ UCMC (hoc chn th th AT1)+ dn mch+ chn

Suy tim III, IV: Digoxin + li tiu + UCMC (hoc chn th th AT1) +
dn mch + chn .

Khi iu tr cn tm cc yu t lm nng thm suy tim:


-

Khng tun th iu tr

Tng huyt p

Lon nhp tim

Nhim trng

Bnh l tuyn gip

S dng thuc khng ph hp

Qu ti dch

Dng nhiu ru

TI LIU THAM KHO:


1. Hi Tim Mch HcVit Nam. Khuyn co 2008 v cc bnh l tim mch
v chuyn ha. Nh xut bn y hc, 2008:439-471.
2. GS. ng Vn Phc. Suy tim trong thc hnh lm sng. i hc quc
gia TP.HCM, 2001:33-63.
3. Daniel H. cooper, MD. The Washington manual of medical therapeutics.
Lippincott Williams & Wilkins, 2007:167-176.
4. MIMS . Ben Yeo, 2012:71

24

NHIM TRNG TIT NIU


I CNG:

I.
-

Nhim trng tit niu (NTTN) l s xm nhp ca vi sinh vt vo bt c ni no


ca h tit niu t l niu o n v thn.

NTTN ti pht: Do cng vi trng gy bnh ln trc, xut hin 1-3 tun sau t
nhim trng trc.

Vi trng gy bnh ch yu l Ecoli.

NTTN khng bin chng: l mt t vim bng quang, niu o do vi trng xm


nhp vo nim mc bng quang niu o nhng khng gy ra nhng hu qu
nghim trng.

NTTN bin chng: Thng gp trong nhim trng nhu m nh vim b thn
hoc tin lit tuyn v c yu t nguy c nh tc nghn ng tiu, d ti pht.

II.

CHN ON:
1. Vim b thn cp:
-

Lm sng:
St cao, lnh run, c th bun nn
Tiu kh, tiu gt, tiu nhiu ln
Nc tiu c, c th c mu
au hng lng, gc ct sng, khm c th thy thn to au

Cn lm sng:
Phn tch nc tiu nhiu bch cu, hng cu, vi trng
Cy nc tiu c vi trng
Cng thc mu: Bch cu tng cao, ch yu l bch cu a nhn
Chn on hnh nh: Siu m, Xquang tm du hiu tc nghn do si.

2. Vim bng quang cp:


-

Lm sng:
Tiu kh, tiu gt, tiu nhiu ln
Nc tiu c, c th c mu
25

au h v
Thng khng c triu chng nhim trng ton thn.
-

Cn lm sng:
Phn tch nc tiu nhiu bch cu, hng cu, vi trng
Cy nc tiu c vi trng.

3. Vim tin lit tuyn:


-

Lm sng:
Thng tui trung nin
St cao, lnh run, c th bun nn
au vng di lng, y chu.
Tiu kh, tiu gt, tiu nhiu ln
Khm trc trng tin lit tuyn cng to, au
Nc tiu c c th c mu
au hng lng, gc ct sng, khm c th thy thn to au.

Cn lm sng:
Phn tch nc tiu nhiu bch cu, hng cu, vi trng
Cy nc tiu c vi trng.
Cng thc mu: Bch cu tng cao, ch yu l bch cu a nhn

III. IU TR:
1. Vim bng quang cp khng bin chng ph n:
-

Phc 7 ngy:
Fluoroquinolone:
Ciprofloxacin 250 500mg ung 2 ln/ngy
Ofloxacin 200 400 mg ung 2 ln/ngy
Levofloxacin 0.75g 1 ln / ngy

Phc 7 14 ngy: p dng cho bnh nhn c cc yu t nguy c sau:


Triu chng ko di trn 7 ngy
Nhim trng tiu ti pht
Tui trn 65
i tho ng
26

iu tr bng:
Fluoroquinolone
Cephalosporin (Cephalexin 250mg ung 4 ln/ngy, Cefuroxim
250mg ung 3 ln/ngy hoc Cefixim 200mg ung 2 ln/ngy).
2. Nhim trng tiu ti pht ph n:
Nn ko di thi gian iu tr trn 2 tun.
3. Nhim trng tiu nam:
o t gp, nn iu tr 7 14 ngy
o Fluoroquinolone
o Amoxicillin a.clavulanic: Curam, Augmentin 1g ung 2 ln/ngy.
o Cephalosporin. ( cefuroxim250mg ung 3 ln/ngy)
4. Nhim trng tiu khng c triu chng:
-

Ch iu tr vi ph n c thai hoc phu thut tit niu

Ph n c thai: iu tr 7 ngy vi Amoxicillin 250 500mg ung 3


ln/ngy hoc Cephalexin 250mg ung 4 ln/ngy.
5. Vim tin lit tuyn:

Vim cp: Fluoroquinolone ung 14 ngy

Vim mn: ko di thi gian iu tr Quinolon trong 1 thng.


6. Nhim trng tiu do vi khun khng in hnh (Mycoplasma Chlamydia):
o Doxycycline 100mg:
+ Ngy u: 2 vin/ngy
+ Ngy k tip: 1 vin/ngy/ 5 7 ngy.
o Azithromycin 500mg 1 vin/ngy/ 5 7 ngy.
o Spiramycin (Ery, Rova) 1,5 3 MUI / 2 3 ln/ngy/ 5 7 ngy.

TI LIU THAM KHO:


1. Phc iu tr Bnh vin Ch Ry nm 2009.
2. Thn hc cn bn JICA nm 2007.

27

HOI CHNG THAN H


I. AI CNG:
Hoi chng than h la biu hin lm sng ca bnh cu thn do nhieu
nguyen nhan, bao gom phu, tieu am

3,5g/24h, giam am mau < 25g/l

va tang lipid mau, gan 90% hoi chng than h la nguyen phat, chu yeu do
sang thng cau than toi thieu.
II. CHAN OAN:
1. Trieu chng lam sang:
+ Phu: phu toan than, phu nhieu keo dai, co the phu d doi, ngoai ra
con co the co cac dau hieu tran dch mang phoi, mang bung, mang tim,
mang tinh hoan.
+ Tieu t, nc tieu thng < 500ml/ngay
2. Can lam sang:
+ Protein nieu

3,5g/24h

+ Protein mau

< 60g/l

+ Albumin mau

< 30g/l

+ Tang cholesterol mau


+ Tang triglyceride mau
3. Chan oan xac nh:
a/ Tieu chuan chnh:
- Protein

3,5g/24h va keo dai

- Protein mau

< 60g/l

- Albumin mau

< 30g/l

b/ Tieu chuan phu:


- Phu
28

- Cholesterol mau
- Triglyceride mau
* CHAN OAN PHAN BIET:
1. Viem cau than cap:
Phu, cao huyet ap, tieu hong cau, am mau bnh thng
Cholesterol mau bnh thng
2. Phu do giam am mau:
Phu
Nc tieu bnh thng
Cholesterol mau bnh thng
III. IEU TR:
1. Nguyen tac ieu tr:
+ ieu tr ac hieu dung thuoc c che mien dch
+ ieu tr trieu chng
+ ieu tr bien chng
+ Nhng bien phap chung e kiem soat am nieu neu benh khong
ap ng vi ieu tr thuoc c che mien dch
2. ieu tr ac hieu:
a) ieu tr lan au:
- Lieu tan cong: Prednison 1mg/kg/ngay en khi het am nieu (co
the keo dai 12 tuan), ti a 80 mg/ ngy.
- Cung co: Prednisone 1mg/kg/cach ngay/4 tuan.
- Giam dan Prednisone dung cach ngay giam lieu dan, moi thang
giam 0,2mg/kg( gim 2 vin prednisone/ 1 thng/ ngi 50 kg)
- Gim liu dn t 6-8 thng
- Ngng ot ngot corticoid hoac giam lieu nhanh khi lui benh co the
gay tai phat.
29

b) Tai phat khong thng xuyen:


- ieu tr nh lan au
c) Neu tai phat xay ra trong khi ang giam lieu: phai tang lieu
prednisone ti mc tao c lui benh. Sau o, giam lieu nhanh ti mc tai
phat xay ra th giam cham lai e tranh tai phat.
d) Tai phat thng xuyen hoac le thuoc corticoid:
ieu tr nh lan au sau o dung prednison lieu thap cach ngay lau
dai e duy tr lui benh.
e) Khang corticoid:
- t gap, thng do x cau than khu tru tng vung, can sinh thiet
than, ieu tr nh tai phat thng xuyen.
3. ieu tr trieu chng:
a) Phu:
- Han che muoi va nc trong giai oan phu (2 - 3g muoi/ngay)
- Li tieu:
+ Ch nh li tieu:
Phu khong ap ng vi tiet che muoi
Phu nhieu, bang bung to, tran dch mang phoi, phu phoi gay kho
th
Phu i kem vi nhiem trung nang
+ Thuoc li tieu dung trong hoi chng than h: Spironolacton,
Furosemide
b) ieu tr tang lipid mau:
- Ch ieu tr nhng benh nhan co roi loan lipid keo dai va nhng
benh nhan co nguy c cao cua benh tim mach
- Thuoc la chon la nhom statin (lovastatin, simvastatin)
c) Bien phap ho tr khac:
30

- Cho them Vitamin D


- Cho them Calcium
4. ieu tr bien chng:
a. Nhiem trung:
- Khi nghi ng nhiem trung phai ieu tr khang sinh pho rong
b. Tac mach: Nhp vin iu tr ni tr.
5. Nhng bien phap chung lam giam am nieu:
- Neu HCTH khong ap ng vi ieu tr thuoc c che mien dch va
benh nhan b suy than th dung cac bien phap khong ac hieu e lam giam
am nieu:
+ Che o an han che protein
+ Dung thuoc c che men chuyen
IV. THEO DOI VA TAI KHAM:
- Hen tai kham moi 2 4 tuan
- Theo doi am nieu 24 gi va theo doi tac dung phu cua thuoc.
TI LIU THAM KHO:
1. TS. Trn Th Bch Hng - Than hoc can ban Benh vien Ch Ray
2004 (Trang 75-105)
2. TS. Trn Th Bch Hng - Benh hoc noi khoa H Y Dc TP. Ho Ch
Minh 2009 (Trang 319-329)
3. TS. Trn Th Bch Hng - iu tr ni khoa H Y Dc TP H Ch
Minh-2009 (Trang 404-424).

31

VIEM CAU THAN MAN


(CHRONIC GLOMERULONEPHRITIS)
I. AI CNG:
1. nh ngha : Viem cau than man (VCTM) la mot benh ly ton thng tieu cau
than, tien trien t t, keo dai nhieu nam. Bieu hien lam sang co the co tien s
phu, protein nieu, hong cau nieu, tang huyet ap, nhng cung co the ch co hong
cau nieu, protein nieu n oc.
2. Nguyn nhn :
-

Do viem cau than cap (10-20%)

Do viem cau than co hoi chng than h.

Do cac benh toan than nh :Lupus ban o he thong, ban dang thap ScholeinHenoch.

Hoac do benh chuyen hoa nh ai thao ng, benh cau than di truyen

Khong ro nguyen nhan.

3. Tin trin v tin lng :


-

Tien trien am , phu tai phat nhieu lan, roi en suy than.

Trong qua trnh tien trien co the xuat hien nhieu t co hoi chng than h.

Tien lng tuy theo the benh : Co the keo dai 5-10 nam, co trng hp tren 20
nam mi co suy than nang.

Tien lng con tuy thuoc cac yeu to gay benh nang nh tang huyet ap ac tnh, cac
t nhiem khuan, co thai,.
III. CHN ON :
3.1. Lm sng:
- Phu.
- Tang huyet ap : Tren 80 % benh nhan co tang huyet ap.

32

- Thieu mau : La trieu chng thng gap, khi a co suy than th trieu chng cang
nang.
3.2. Cm lm sng:
- Hong cau nieu : Thng co, t khi co ai mau ai the. Neu sau ieu tr protein
nieu am tnh nhng hong cau nieu dng tnh th nguy c benh tai phat van con.
- Protein nieu : Trong 24 gi gan nh thng xuyen dng tnh va giao ong trong
khoang 0.5-3 g/ngay. Protein nieu (+++ ) thng gap mau nc tieu luc sang
sm. Nhng mau nc tieu ke tiep sau o co the am tnh; protein nieu cach hoi.
Khi protein nieu am tnh th phai lam protein nieu 24 gi.
- Tru nieu : Tru hong cau, tru trong, tru hnh hat.
* Chan oan xac nh :
Da vao phu, tang huyet ap, Ure, Creatinin mau tang, protein nieu, hong cau
nieu, tru nieu.
* Chan oan phan biet :
-

Tang huyet ap ac tnh

Viem than- be than man tnh :

Protein nieu lanh tnh :

III. IEU TR :
1. ieu tr :
1.1 ieu tr trieu chng :
-

Chong nhiem khuan : Nhiem khuan co the la nguon cung cap khang nguyen
hoac la yeu to khi phat. V vay s dung khang sinh la can thiet. Dung khang
sinh t oc tnh vi than, dung ng uong la chu yeu. Cac khang sinh thng
dung la : Ampicillin, Azithromycin, Rovamycin. Thi gian dung khang sinh t
7-10 ngay.

ieu tr phu : Dung cac thuoc li tieu quai nh Lasix Furosemide).


33

Lasix 40mg x 2-4 vien/ ngay, tuy theo khoi lng nc tieu 24 gi ieu chnh
lieu Lasix cho hp ly, lng nc tieu 24 gi phai tren 1000ml, neu lng nc
tieu t hn phai tang lieu li tieu.
-

ieu tr tang huyet ap : Phai s dung cac thuoc ha ap khong anh hng en
chc nang than, cac nhom thuoc thng dung la :

+ Thuoc c che Canxi : Dung 1 trong nhng thuoc sau :


++ Nipedipin 30mg x 1-2 vien/ ngay.
++ Amlordipin 5mg x 1-2 vien/ ngay.
++ Felodipin 5mg x 1-2 vien/ ngay.
+ Thuoc c che beta : Dung 1 trong nhng thuoc sau :
++ Bisoprolol 5mg x 1-2 vien/ ngay.
++ Carvedilol 25mg x 1-2 vien/ ngay.
+ Li tieu quai : Furosemid.
Co the ket hp 2 loai thuoc li tieu khac nhom, than trong khi s dung cac thuoc
c che men chuyen, Hypothazid.
1.2 . Corticoid lieu phap :
1.2.1 Ch nh :
-

VCTM tien phat co HCTH.

Ton thng than trong cac benh he thong : Lupus ban o he thong, viem dac, benh to chc lien ket hon hp.

Cac benh mach mau : Viem mach mau dang nut, benh u hat Wegener.

Hoi chng Goodpasture.

Viem cau than tang sinh ngoai mao mach.

1.2.2 Thuoc va lieu dung :


-

Corticoid :

34

+ Prednisolon 1-1,5mg/ kg/ ngay, uong 1 lan sau khi an sang ( 6-7 gi sang ).
Dung thuoc keo dai cho en luc protein nieu am tnh hoac protein nieu di 0,5 g/
ngay, sau o giam lieu dan. Thi gian ieu tr la 06 thang.

TAI LIEU THAM KHAO


1- Brenner B.M., Mackenzie H.S., (1998) Distubances of renal function ,
Harrisons principles of internal medicine, 14 th ED, Mc Graw- Hill, New
York, pp. 1498- 1513.
2- Hoang an (2002 ) Viem cau than man, giao trnh giang day ai hoc va sau
ai hoc, Hoc vien Quan Y Ha Noi. (trang269-294)
3- GS.TS Nguyen Van Xang, TS. o Th Lieu (2004) Viem cau than man, bai
giang benh hoc noi khoa , Trng ai Hoc Y Ha Noi. (trang199-205).

35

VIM LOT D DY T TRNG


I. I CNG:
-

Vim d dy: Tn thng nim mc d dy do tc ng ca qu trnh vim.

Lot d dy- t trng l tnh trng lp nim mc d dy- t trng b khuyt do s


tn cng hip ng ca acid v pepsin ph v lp hng ro bo v ca nim mc
d dy- t trng.

II. CHN ON:


1. Chn on da vo:
-

au vng thng v, au c chu k (mang tnh cht gi ) hoc c bin chng.

Cc triu chng ri lon tiu ha: kh tiu, y hi, chng bng, bun nn, chn
n

X-quang: Chp d dy t trng c cn quang.

Tt nht: Ni soi d dy t trng v lm CLO test, c th test hi th tm


H.pylori (vi nhy v c hiu l 95%).

2. Chn on phn bit:


Ri lon tiu ha chc nng, GERD khng in hnh, vim ty cp, nhi mu c
tim vng honh
III. IU TR:
A. Ch n ung v ngh ngi:
-

n thc n mm d tiu, n trc khi ng 3 gi.

C chua, cay, thuc l, c ph, ru, thc n cn nng, nc c gas, du m

Ngi bnh c ngh ngi nm vin: Khi c au rm r, cn ct cn au v yu


t stress, khi c bin chng.

B. iu tr vim lot d dy t trng:


c ch tit acid l thuc chnh trong iu tr vim lot d dy- t trng, iu tr 8
tun i vi lot t trng, 12 tun i vi lot d dy.
1. Cc thuc c ch bm proton (PPI) vi liu chun:
-

Omeprazol 20

Pantoprazol 40mg
36

Rabeprazol 20mg

Esomeprazol 20mg

Ung trc khi n t nht 30 pht


* Bnh nhn bnh tim mch c dng Clopidogel, nn dng Rabeprazol,
Pantoprazol (khng c ch men C2P19)
2. Cc thuc khng th th H2:
-

Ranitidin 300mg: 1-2 ln/ ngy

Famotidine 40 mg: 1- 2 ln/ ngy

Nizatidin 300 mg: 1- 2 ln/ ngy

Ung trc n sng v ti t nht 30 pht hoc ung 1 ln trc khi i ng.
3. Antacid khng ha tan nh: Aluminium hydroxide (Phosphalugel, gastropugite,
trimafort, tenamyd gel ) Thng dng 3-4 ln/ngy:Cho ung sau ba n t 30
pht- 1gi. Dng 3 ln theo ba n v 1 ln vo bui ti trc khi i ng.
C. iu tr dit H.pylori:
1. PPI liu chun x 2 ln/ ngy kt hp vi
+ Amoxicillin 1g x 2 ln/ngy
+ Clarithromycin 500mg x 2 ln/ngy
ung trc khi n, lin tc t 10 14 ngy.
2. PPI liu chun x 2 ln/ ngy kt hp vi
+ Clarithromycin 500mg x 2 /ngy
+ Tinidazole hoc Metronidazol 0.5g x 2 /ngy
ung trc khi n, lin tc t 10 14 ngy.
3. PPI liu chun x 2 ln/ ngy kt hp vi
+ Amoxicillin 1g x 2 /ngy
+ Metronidazol 0.5g x 2 /ngy
ung trc khi n, lin tc, t 10 14 ngy.
4. PPI liu chun x 2 ln/ ngy kt hp vi
+ Amoxicillin 1g x 2 /ngy + Tinidazole 0.5g x 2 /ngy
ung trc khi n, lin tc, t 10 14 ngy.

37

5. Phc theo trnh t: 10 ngy


5 ngy u: PPI liu chun x 2 ln/ ngy + Amoxicillin 1g x 2 /ngy ung trc
khi n (lc bng i).
5 ngy k tip: PPI liu chun x 2 ln/ ngy kt hp vi
+ Clarithromycin 500mg x 2 ln/ngy + Tinidazole 0.5g x 2 /ngy
ung trc khi n (lc bng i).
6. Phc theo trnh t + Probiotics:
5 ngy u: PPI liu chun x 2 ln/ ngy + Amoxicillin 1g x 2 /ngy ung trc
khi n (lc bng i) + Probiotic (3.108 Lacobacillus acidophilus).
5 ngy k tip: PPI liu chun x 2 ln/ ngy kt hp vi
+ Clarithromycin 500mg x 2 ln/ngy
+ Tinidazole 0.5g x 2 /ngy
+ Probiotic (3.108 Lacobacillus acidophilus)
7. PPI liu chun x 2 ln/ ngy kt hp vi
+ Amoxicillin 1g x 2 /ngy
+ Clarithromycin 500mg x 2 /ngy
+ Tinidazole hoc Metronidazol 0.5g x 2 /ngy
ung trc khi n, lin tc, t 10 14 ngy.
D. Thuc iu tr triu chng:
1. Thuc iu ha vn ng d dy:
Domperidon (Motilium M, Ocupal, Pymepelium .) 10 - 20mg x 2-3 ln/
ngy ung trc n 30 pht.
Trimebutin 100 200 mg x 3 ln/ ngy ung trc n 30 pht.
2. Thuc gim au, chng co tht:
Alvrine citrate 40 mg (Spasmaverin 40 mg) 1- 3 vin x 3 ln/ngy.
Alvrine citrate 60 mg (Meteospasmyl 60 mg) 1vin x 2- 3 ln/ngy
Hyoscine-N-butylbromide 10 mg, 1-2 vin x 3-5 ln/ ngy
3. Thuc chng y hi:
Simethicone 40 mg 1-2 vin x 3- 6 ln ung sau n.
4. Thuc tr chng kh tiu:
38

Pancrelase 100 mg 1 vin x 2 ung u bui n.


5. Tiu chy: Diosmectite 1 gi x 3ln/ngy
TI LIU THAM KHO:
1. BSCK2 Trn Kiu Min - Bnh hc Ni khoa - B mn Ni i Hc Y Dc
TPHCM 2009 (Trang 242-257)
2. BSCK2 Trn Kiu Min - Ths Quch Trng c - Bnh hc Ni khoa - B
mn Ni i Hc Y Dc TPHCM 2009 (Trang 163-190).
3. BS CKI Trng Vn Lm - So snh phc iu tr nhim H. pylori theo
trnh t vi phc b ba chun: Mt th nghim i chng ngu nhin.
4. BS CKI Trng Vn Lm - So snh phc tun t cng thm Probiotics v
tit tr H. pylori vi phc tun t vi: Mt th nghim i chng ngu
nhin.
5. Phc iu tr ca Bnh vin Ch Ry nm 2013.
6. Harrisons Priciples of Internal Medicin 1999.
7. Mirzaee V, Rezahosseini O (2012).Randomized control trial: Comparison of
Triple Therapy plus Probiotic Yogurt vs. Standard Triple Therapy on
Helicobacter Pylori Eradication.Iran Red Crescent Med J;14(10):657-66. Epub
2012 Oct 30.
8. Mukai T, Asasaka T, Sato E, Mori K, MATsumoto M, Ohori H (2002).
Inhibition of binding of Helicobacter Pylori to the glycolipid receptors by
probiotic Lactobacillus reuteri. FEMS Immunol Med Microbiol ;32:105-110
9. Medeiros JA, Pereira MI (2013).The use of probiotics in Helicobacter pylori
eradication therapy.J Clin Gastroenterol;47(1):1-5.

39

VIM I TRNG MN
I CNG:

I.

1. Vim i trng mn c nhiu nguyn nhn:


* Cc bnh nhim: Nhim khun lao, Salmonella, Shigella.
-

Nhim k sinh trng: Amide, Giardia.

Nhim nm Candida.

* Khng r nguyn nhn: Vim i trc trng xut huyt (vim lot i trng).
2. Cn phi chn on phn bit cancer i trng.
CHN ON:

II.

1. Lm sng:
-

au bng kiu au dc khung i trng h chu (P) (T), hng (P) (T) ngang rn
au qun tht tng cn trn nn au m .

Ri lon i cu: Lc bn, lc chy.

2. Cn lm sng:
-

Kho st phn.

Ni soi, sinh thit.

III. IU TR:
A. Ch n ung:
King n cc thc n nhiu du m, hp, sa, rau sng, cc gia v chua cay. Nu
tiu chy nn dng thc n lng; nu to bn nn n c tng nhu ng rut.
B. iu tr nguyn nhn:
1. Amip ng rut:
a. Lm sng: au bng m , gim au sau khi i cu, phn cha m ln mu, khng tt.
b. Xt nghim phn c kyste Entamoeba.
c. X-quang i trng tng nhu ng.
d. Soi trc trng: Nim mc c nhiu vt lot nh.
e. Thuc: Metronidazol: 20-30 mg/kg/ngy : 3 ln x 7 10 ngy.
Tinidazol 0,5 g: 2 g/ngy x 3- 5 ngy.
Secnidazol 0,5g: 2g liu duy nht.
40

2. Giun ng rut:
-

Mebendazol 0,1g (Vermox) 1 vin x 2 ln/ngy x 3ngy, lp lai ty theo


loi giun.

Mebendazol 0,5 g 1vin/ ln, lp lai ty theo loi giun.

Albendazol 0,4g/ ngy, lp lai ty theo loi giun.

C. iu tr triu chng:
1. Tiu chy:
-

Diosmectite 1 gi x 3 lm/ ngy

Actapulgite 1 gi x 3 ln/ngy

Loperamid 2 mg, 1 vin/4-6h (nu cn tiu chy)


Vi khun thay th: Lactobacillus 1 gi x 2, Bacillus clausii 1 vin/ng x 2
ln/ngy

2. Thuc tr to bn:
-

Lactulose 10 g/15ml: 1 3 gi/ ngy

Bisacodyl 5 mg, 1-2 vin ung ti

Macrogol 10g, 1- 2 gi/ ngy ung bui sng

3. Thuc iu ha nhu ng rut:


Trimebutin 100 200 mg x 3 ln/ ngy ung trc n 30 pht.
4. Thuc chng co tht:
Alvrine citrate 40 mg (Spasmaverin 40 mg) 1- 3 vin x 3 ln/ngy.
Alvrine citrate 60 mg (Meteospasmyl 60 mg) 1vin x 2- 3 ln/ngy
Hyoscine-N-butylbromide 10 mg, 1-2 vin x 3-5 ln/ ngy
5. Thuc chng y hi:
Simethicone 40 mg 1-2 vin x 3- 6 ln ung sau n.
6. Thuc tr chng kh tiu:
Pancrelase 100 mg 1 vin x 2 ung u bui n.
TI LIU THAM KHO:
1. Ths V Th M Dung - Bnh Hc Ni Khoa i Hc Y Dc TPHCM - 2009
2. Ths V Th M Dung iu tr hc ni khoa - i hc Y Dc TPHCM - 2009
3. Phc iu tr ca Bnh vin CH Ry 2013.
41

VIM GAN SIU VI

Vim gan siu vi (VGSV) l tt c nhng biu hin lm sng do nhiu loi siu
vi c i tnh vi t bo gan gy ra hi chng vim v hoi t.
Da vo biu hin lm sng v bin i xt nghim, VGSV c chia lm 2 loi:
- VGSV cp: triu chng lm sng v bt thng v xt nghim chc nng gan
ko di khng qu 6 thng.
- VGSV mn: triu chng lm sng v bt thng v xt nghim chc nng gan
ko di trn 6 thng.
A. VIM GAN SIU VI CP
Hin nay, c rt nhiu loi siu vi gy vim gan, nhng trong iu kin ca Bnh
vin a khoa trung tm An Giang c th xc nh c VGSV A (HAV), VGSV B
(HBV), VGSV C (HCV).
I. CHN ON.
I.1 . Chn on s b.
I.1.1. Dch t.
- Tin cn gia nh: c ngi thn b vim gan.
- Tin cn c nhn: c quan h tnh dc khng bo v, dng chung kim tim, th
thut xuyn qua da, truyn mu t 2 tun n 6 thng trc khi c triu chng u tin
ca bnh.
I.1.2. Lm sng
- Vng mt, vng da- nim khng qu 28 ngy.
- Khng st hoc st nh.
- Mt mi, u oi,
- Ri lon tiu ha: nn i, chn n, au h sn phi.
- Gan to v au
- i vi cc th nng c th pht hin ri lon tri gic, xut huyt da nim,
gan teo nh.

42

I.1.3. Cn lm sng
AST (SGOT) v ALT (SGPT) gia tng ti thiu l gp 2 ln tr s cao nht
ca gii hn bnh thng. Thng thng, trong VGSV cp, AST v ALT gia tng t 510 ln, c khi > 20 ln tr s cao nht ca gii hn bnh thng.
I.2. Chn on xc nh da vo xt nghim huyt thanh v c thc hin ln
lt nh sau:
- u tin nn lm IgM anti-HAV, IgM anti-HBc v HBsAg
+ IgM anti-HAV (+): VGSV A cp.
+ IgM anti-HBc (+): VGSV B cp.
+ HBsAg (+) n thun: khng kt lun c VGSV B (c th l ngi
mang mm bnh cng c th l VGSV B cp v mn).
- Sau , nu IgM anti-HAV v IgM anti-HBc (-), chn on tm thi l
VGSV cp A khng B v lm tip anti-HCV
+ Anti-HVC (+): VGSV C, nu c thm bng chng v chuyn huyt
thanh th kt lun l VGSV C cp. Trong trng hp anti-HVC (-), c th lm HCV
RNA xc nh chn on.
II. IU TR
Bnh nhn nghi ng VGSV c cc du hiu nng sau y cn c nhp vin
ngay theo di v iu tr:
- Ri lon tri gic.
- Xut huyt.
- Ri lon h hp
- Try tim mch
- Nn i nhiu
- Khng n ung c
- St cao
Cn loi tr nhiu bnh l ni, ngoi khoa c vng da nim

43

II.1. Ch n ung
- Khu phn nhiu m, nhiu ng, t m
- Khng bia ru
- Khng nn king n thi qu, khuyn khch bnh nhn n nhiu ln, mi ln
mt t, nu cn, i ba n chnh vo lc sng v tra, chiu ti nn n nh.
II.2. S dng cc loi thuc
- Hn ch cc loi thuc c th gy c gan: Khng dng corticoid, cn thn
khi s dng phenobarbital, thuc khng lao, khng sinh nhm cyclin...
- Vitamin K1 10 mg/ngy tim bp, 3-5 ngy khi prothrombin gim <60%
- Cholestyramin: 1 gi (4g) x 2-3 ln/ngy khi bnh nhn c du hiu nga.
- Cc loi thuc c ngun gc dc tho nh Silymarin, Biphenyl dimethyl
dicarboxylat khng gy c v gim transaminases c th xem xt s dng trong
VGSV cp.
- Xem xt dng Lamivudine 100mg/ngy, nu nh bnh vim gan siu vi B
cp din tin nng hoc ri vo vim gan ti cp. Cha c bng chng v li ch ca
Tenofovir v Entecavir trong vim gan B ti cp.
- i vi vim gan siu vi C cp, xem xt dng Peginterferon alfa 2a/2b
hoc Interferon alfa. Nn bt u iu tr t nht l 8 tun sau khi c triu chng u
tin hay sau 12 tun m HCV RNA vn cn trn ngng pht hin. Liu dng thng l
Peginterferon alfa 2a: 180mcg/tun, hoc Peginterferon alfa 2b 1.5mcg/tun ko di 24
tun. Khng cn phi hp vi Ribavirin.
II. 3. Ngh ngi
- Khng cn thit ngh ngi tuyt i v hon ton ti ging nhng lm vic
nng gng sc lm cho bnh din bin phc tp v ko di
- Thi gian ngh ngi nn ko di cho n khi ht vng da - mt v
transaminases <2 ln so vi ch s cao nht ca gii hn bnh thng.
- Khng nn lao ng nng, gng sc t nht l 3 thng k t khi ht giai
on ngh ngi.

44

II.4. Theo di thng xuyn v lm sng v xt nghim


II. 4.1. V lm sng.
Din tin ca vng da mt, ri lon tiu ha, tnh trng u oi, mt mi, c
hay khng xut huyt, ph chi, bng bng, ri lon tri gic...
II. 4.2. V xt nghim.
- AST v ALT hng tun cho n khi <2 ln so vi tr s cao nht ca gii
hn bnh thng, sau mi thng mt ln, t nht trong 6 thng. Nu AST, ALT tip
tc tng hoc ko di >6 thng, bnh nhn c biu hin ca bnh vim gan mn tnh.
- HBsAg, anti HBs, anti HCV mi 3 thng. Nu sau 6 thng k t khi c
biu hin vin gan cp, bnh nhn vn cn HBsAg(+), hoc anti HCV(+) c ngha l
bnh vim gan siu vi cp chuyn sang giai on mn tnh. Nu anti HBs(+), IgM
anti HBc tr thnh (-) c ngha l bnh nhn VGSV B cp c biu hin phc hi.
- Prothrombin trong cc th nng.
- Siu m bng pht hin cc bnh gy tc mt.

45

B. VIM GAN SIU VI MN


I. CHN ON V IU TR VGSV B MN TNH
I.1. Chn on
I.1.1.Dch t : ging nh VGSV cp .
I.1.2. Lm sng.
Chn n, mt mi, au nhc h sn phi, hoc khng c triu chng.
I.1.3. Cn lm sng
- AST, ALT gia tng v ko di >6 thng.
- HBsAg(+)v ko di >6 thng
- IgM anti HBc(-).
I.2. iu tr
I.2.1. Ch nh iu tr c hiu.
Cn 2 tiu chun sau:
- Bnh VGSV B mn tnh tin trin vi ALT (SGPT)>2 ln tr s cao nht ca
gii hn bnh thng.
- Siu vi ang tng sinh c xc nh trong 2 trng hp sau:
+ HBsAg(+), HBeAg(+) v HBV DNA (+) 20.000 IU/ml (105 copies/ml).
+ Hoc HBsAg(+), HBeAg(-) v HBV DNA (+) 2.000 IU/ml (104 copies/ml).
Da vo s tng sinh ca siu vi B, thun tin cho vic iu tr, c th chia
ta lm 2 loi VGSV B mn: VGSV B mn tnh vi HBeAg(+) v VGSV B mn vi
HBeAg (-).
I. 2.2. Phc iu tr.
- Bnh nhn mi cha iu tr bng cc thuc chng siu vi B:
+ Thuc: c th chn mt trong 2 nhm thuc : thuc ung gm Tenofovir (TDF),
Entecavir (ENT) l hai thuc u tin chn la hng u (v t l khng thuc thp),
Telbivudine (LdT), Adefovir (ADV), Lamivudine (LAM) hoc thuc tim Peg-interferon
alfa 2a (Peg-IEN 2a).

46

+ Liu dng:
Tenofovir (TDF): 300 mg/ngy ung.
Entecavir (ENT): 0.5 mg/ngy ung.
Telbivudine (LdT): 600 mg/ngy ung.
Adefovir (ADV): 10 mg/ngy ung.
Lamivudin 100mg/ngy ung.
Peg-IFN alfa 2a 180 g/tun, tim di da (bng), trong 48 tun. Interferon
alfa c in, c th s dng 5MIU/ ngy hoc 10 MIU/ln, 3 ln/tun, tim di da t
6-12 thng. u im dng nhm thuc ny ph n tr mun c con, nng HBV
DNA <107 copies/ml, hoc theo yu cu ca bnh nhn.
+ Thi gian iu tr
VGSV B mn tnh c HBeAg(+):Thuc ung ko di t nht l 12 thng.
Ngng thuc khi HVB DNA <15IU/ml (khong 80 copies/ml) v khong 6-12 thng
sau khi chuyn i huyt thanh (HBeAg dng tnh tr thnh m tnh hoc xut hin
anti-HBe dng tnh).
VGSV B mn tnh c HBeAg(-); thi gian iu tr kh xc nh v ngng
thuc rt d b tt pht, c th ko di n khi mt HBsAg.
- Bnh nhn iu tr thuc khng virus Lamivudine (LAM) 100mg/ngy v
hoc adefovir (ADV) 10mg/ngy, khng p ng [sau 6 thng dng LAM nng HBV
DNA> 200 IU/ml (103 copies/ml) hoc sau 1 nm dng ADV c nng HBV DNA >
200.000 IU/ml (106 copies/ml), hoc khng thay i] hoc nng HBV DNA >10 ln
so vi ln trc (cch nhau 3-6 thng): c th chuyn sang TDF LAM.
- VGSV B bin chng x gan cn b, nu nng HBV DNA trn ngng pht
hin nn ch nh iu tr k c ALT bnh thng, c th dng thuc ung (Tenofovir,
Entercavir) hoc thuc tim (Interferon, Peg-IFN 2a). Trong trng hp dng
Interferon alfa c in, c th s dng 5MIU/ ngy hoc 10 MIU/ln, 3 ln/tun, tim
di da t 6-12 thng.
- VGSV B mn tnh bin chng x gan mt b, nn dng TDF hoc ENT
(1mg/ngy), chnh liu khi thanh thi Creatinin <50ml/pht (chng ch nh s dng
Interferon/Peg- interferon).Cn phi ghp gan.
47

- Tr em<12 tui: nn dng Lamivudine 3 mg/kg/ngy, khng vt qu


100mg/ngy hoc Interferon alfa 2a 6MIU/m2( khng vt qu 10MIU/ln), 3 ln/tun.
- Trng hp ALT trong khong 1-2 X ULN, nng HBV DNA cao
(>106copies/ml), c tin s gia nh lin quan n HCC, nu bnh nhn chp nhn v
tun th iu tr lu di, cn cn nhc iu tr thuc khng virus cho bnh nhn. Nn
xem xt sinh thit gan, hoc Fibroscan, hoc cc xt nghim nh gi mc x ha
quyt nh iu tr.
- Ph n VGSV B ang c iu tr bng thuc ung v c thai: Nn tip tc cc
thuc nhm B trong bng phn loi ca FDA (nh Tenofovir, Telbivudine). Thn trng v
khng khuyn co dng tip Lamivudine, Adefovir, Entecavir (nm trong bng C ca
FDA). Chng ch nh dng Interferon/Peginterferon cho ph n c thai.
Bn cnh iu tr c hiu, khuyn bnh nhn nn sp xp cng vic ngh
ngi, trnh lao ng nng, hn ch cc thuc gy hi cho gan, khng ung ru bia.
i vi bnh nhn c nng ferritin trong huyt thanh cao nn gim cc thc n c
cht st (tht b, bin, rau mung, rau dn, cc loi ci xanh...).
I.2.3. Theo di.
- Trc iu tr:
ALT, AST, GGT, Bilirubin, Albumin, Globuline, T l Prothrombin (TQ),
CTM, Siu m bng; AFP (nu c ch nh), nh lng HBV DNA; Anti HAV (nu m
tnh, nn chng nga VGSV A); AntiHCV, Anti HIV (xc nh ng nhim); Creatinin;
Chc nng tuyn gip (nu dng IFN/ Peg-IFN); Nu c iu kin nn sinh thit gan/
Fibroscan.
* i vi ngi mang HBV khng hot tnh (HBsAg+ > 6 thng, HBeAg
-, AntiHBe +, HBV DNA <2.000 IU/ml hoc <104 copies/ml, ALT-AST thng xuyn
mc bnh thng, sinh thit gan khng phn ng vim ng k): Theo di ALT, AST,
siu m bng mi 3 thng trong nm u, sau mi 6 12 thng, nu ALT, AST tng
th cn nh lng HBV DNA v loi tr cc bnh gan khc.

48

- Trong thi gian iu tr:


+ Cc triu chng lm sng, ALT, AST, creatinine, HBsAg, HBeAg, antiHBe mi 3 thng. Creatinine cn theo di st hn cc bnh nhn c thanh thi
Creatinine < 60 ml/pht.
+ nh lng HBV DNA mi 6 thng.
- Sau khi ngng iu tr: Triu chng lm sng, xt nghim ALT, AST,
HBsAg, HBeAg, anti-HBe, nh lng HBV DNA mi 3-6 thng nh gi ti pht.

49

PHC
IU TR VGSV B mn
HBsAg + (> 6 th)
ALT 2 ULN

HBV DNA
< 2.000 IU/ml
(< 104 copies/ml)
v HBeAg
AntiHBe +

W12 HCV RNA

HBV DNA
200.000 IU/ml
( 106 copies/ml)
v tin cn gia nh
lin quan HCC

ALT > 2 ULN (> 6 th)

HBeAg +

HBeAg -

HBV DNA
20.000 IU/ml
( 105 copies/ml)

HBV DNA
2.000 IU/ml
( 104 copies/ml)

iu tr bng thuc khng virus

Theo di
ALT, AST, SA/3 th x 1 nm

ALT, AST, SA/6-12


th

Trc iu tr ty iu kin cn nh gi thm: ALT, AST, GGT, Bilirubin,


Albumin, Globulin, t l prothrombin (TQ), CTM, siu m bng; AFP (nu
cn), HBV DNA nh lng; Anti HAV (nu m tnh, nn chng nga VGSA
A); Anti HCV, Anti HIV (xc nh ng nhim), Creatinin, Chc nng tuyn
gip (nu dng IFN/Peg-IFN); Nu c iu kin nn sinh thit gan/Firoscan

HBV DNA nh lng


v tm nguyn nhn

Theo di trong khi iu tr:


- LS, ALT, AST, Creatinin,
HBsAg, HBeAg, AntiHBe/3th
- HBV DNA nh lng/6th

Keeffe E et al. Clin Gastroenterol Hepatol 200


Thuc iu tr
Tenofovir (TDF): 300 mg/ngy ung.
Entecavir (ENT): 0.5 mg/ngy ung.
Telbivudine (LdT): 600 mg/ngy ung.
Adefovir (ADV): 10 mg/ngy ung.
Lamivudin 100mg/ngy ung.
Peg-IFN alfa 2a 180 g/tun, tim
di da (bng), trong 48 tun. Interferon
alfa c in, c th s dng 5MIU/ ngy
hoc 10 MIU/ln, 3 ln/tun, tim di
da t 6-12 thng

Ngng iu tr khi
Trng hp HBeAg +:
HBV DNA < 15 IU/ml
(80 copies/ml) v chuyn
HT HBeAg 6 12 th

Trng hp HBeAg -:
n khi mt HBsAg

Theo di sau ngng iu tr:


LS, ALT, AST, HBsAg, HBeAg, AntiHBe,
HBV DNA nh lng/3-6th
50

II. CHN ON V IU TR VIM GAN C SIU VI MN


Vim gan siu vi C mn (VGSV C) c th iu tr khi, nu khng iu tr s c
nguy c chuyn thnh x gan (5 25%), ung th gan v bnh gan mt b (1 3% mi
nm).
II.1. Chn on:
II.1.1. Dch t hc:
-

Tin cn gia nh: C ngi thn b VGSV C

Tin cn c nhn: C quan h tnh dc khng bo v, dng chung kim


tim, th thut xuyn da, truyn mu t 2 tun n 6 thng trc khi
c triu chng u tin.

II.1.2. Lm sng:
Cc triu chng c th gp: Chn n, mt mi, au tc h sn phi hoc
khng c triu chng.
II.1.3. Cn lm sng:
-

ALT/AST tng v ko di trn 6 thng.

Anti HCV (+)

HCV RNA trn ngng pht hin c thc hin bng k thut PCR
nhy cm nht (nh tnh, nh lng, nh genotype).

Nu c iu kin, nn thc hin cc k thut khng xm ln nh


gi tnh trng x ha hoc x gan trc khi iu tr. Nn lm sinh thit
gan (nu c th) xc nh thay i m hc, gp phn tin lng v
chn on phn bit.

Cc xt nghim nh gi v theo di iu tr khc: Huyt ,


creatinin, chc nng tuyn gip v cc xt nghim AFP, siu m
bng khi c ch nh.

51

II.2. iu tr:
II.2.1. Ch nh iu tr:
Bnh nhn c cc biu hin sau:
-

ALT, AST tng hoc bnh thng;

Anti HCV (+);

HCV RNA trn ngng pht hin;

Gan cn b (khng bng bng, khng c bng chng bnh no do gan,


Bilirubin ton phn < 1.5g/dL, Albumin > 34g/L, TC > 75.000/ mm 3, INR <
1.5 hoc Prothrombin bnh thng );

Xt nghim sinh ha, huyt hc chp nhn c ( Hb > 13g/dl i vi nam/


Hb > 12g/dL i vi n, Neutrophil > 1.500/ mm3, Creatinin < 1.5 mg/dL)

Tui t 18 tr ln;

Bnh nhn sn sng iu tr v tun th iu tr;

Khng c chng ch nh.

II.2.2. Chng ch nh:


-

Bnh nhn khng tun th.

C bnh t min.

Ghp tng.

C bnh tuyn gip.

C du hiu suy nhc thn kinh.

C bnh ni khoa nng: THA, Suy tim, bnh mch vnh, i tho ng
khng kim sot c, COPD.

D ng vi thuc trong phc iu tr.

Tr em di 2 tui, ph n c thai.

Thn trng i vi ngi trn 70 tui v tr em 2 17 tui.

52

II.2.3. Phc iu tr:


Trc khi dng thuc cn t vn 3 vn chnh: hiu qu, an ton v gi thnh
cho bnh nhn v gia nh.
Phc : Interferon chun (IFN) 3M UI x 3 ln/tun + RBV 1 - 1.2 g/ngy ung.
Hoc phc chun (theo EASL 2011 HCV guideline): Peg- Interferon (PegIFN) + Ribavirin (RBV), liu v thi gian iu tr thay i ty theo Genotype v p
ng ca bnh nhn, trung bnh l 48 tun, c th rt ngn cn 24 tun hoc phi ko di
n 72 tun, c th
Genotype

RBV

Peg-IFN 2a

Peg-IFN 2b

TG
iu tr

1, 4, 6

15 mg/kg/ ngy v

180 g/ tun hoc

1.5 g/kg/ tun

48 tun *

2, 3

800 mg/ngy

180 g/ tun hoc

1.5 g/kg/ tun

24 tun **

(nu d on p ng
km: 15mg/kg/ngy) v

(*) C th rt ngn thi gian iu tr cn 24 tun nu nng HCV RNA trc iu tr


thp (< 400.000 800.000 IU/mL hoc < 2.106copies/mL) v t c p ng virus
nhanh (RVR: Rapid vilologic response) tc l nng virus tun l th 4 sau khi bt
u iu tr di ngng (< 50IU/mL hoc <300 copies/ mL).
(**) C th rt ngn thi gian iu tr cn 12 16 tun nu t c p ng virus
nhanh (RVR: Rapid vilologic response).
II.2.4. Theo di:
II.2.4.1.Trc iu tr:
- Nu Anti HCV (+) v HCV RNA nh tnh (+): VGSV C cp hoc mn ty tnh
hung lm sng, cn lm tnh HCV RNA nh lng v nh genotype iu tr.
- Nu Anti HCV (+) v HCV RNA nh tnh (-): Nhim HCV giai on hi phc
hoc nhim HCV cp c nng siu vi thp, cn lp li HCV RNA nh tnh sau 6
12 thng.
53

- Nu Anti HCV (-), HCV RNA nh tnh (+):


+ C a bnh gan/ Suy gim min dch: Nhim cp hoc mn, cn lm tnh
HCV RNA nh lng v nh genotype iu tr.
+ C a bnh thng: HCV RNA nh tnh dng gi.
- Nu Nu Anti HCV (-), HCV RNA nh tnh (-): Khng nhim HCV.
II.2.4.2.Trong qu trnh iu tr:
-

Lm sng, huyt , Ure, creatinin, ALT, AST mi thng;

T3, T4, FT4, TSH, ng huyt v hoc HbA1C mi 03 thng;

nh lng HCV RNA vo tun l th 4, 12, 24, 48 v 24 tun sau khi kt


thc iu tr.

Khm chuyn khoa tm thn, ECG, X- quang khi cn;

K hoch ha gia nh trong sut thi gian iu tr, c bit i vi ph n


trong la tui sinh .

II.2.4.3. Ch gim liu RBV v Peg-IFN:


-

Hb < 10g/dL: Gim liu RBV 200mg/ ngy.


Hb < 8.5 g/dL: ngng RBV.

TC < 80.000/ mm3 : Gim 50% liu Peg-IFN 2b.


TC < 50.000/ mm3 : Gim liu Peg-IFN 2a cn 90 g/ liu, nn ngng Peg-

IFN 2b.
TC < 25.000/ mm3 : Nn ngng Peg-IFN 2a.
-

BC < 1.500/ mm3 : Gim 50% liu Peg-IFN 2b.


BC < 1.000/ mm3 : Nn ngng Peg-IFN 2b.

Hoc da vo Neutrophile < 750/ mm3 : Nn gim liu Peg-IFN 2a cn 135


g/ liu hoc gim 50% liu Peg-IFN 2b.
Neutrophile < 500/ mm3 : Nn ngng Peg-IFN 2a v Peg-IFN 2b.

* C th dng thm GSF 300 g/ ln khi Neutrophile < 800/ mm3,


Erythropoietin 40.000 n v/ tun tim di da d phng gim nguy c thiu
mu do dng IFN hoc Peg-IFN.

54

II.2.4.4. IU TR VIM GAN SIU VI C CC I TNG C BIT:


TR EM:
1. Anti HCV khng nn thc hin tr s sinh c m nhim HCV v khng th
ny c th di chuyn t m sang con.
-

HCV RNA c th xem xt thc hin sau sinh 1-2 thng nu mun

chn on sm.
-

Anti HCV nn lm khi tr 18 thng.

2. Tr em 2 17 tui c th xem xt iu tr theo tiu chun ging nh ngi


ln.
Phc : Peg-IFN 2b 1.5 g/ 1.73 m2/ tun + RBV 15mg/kg/ngy.
BNH NHN C BNH THN:
M t

iu tr c ngh

GFR,
mL/pht /1.73 m2

Tn thng thn vi 90
GFR

bnh

iu tr thng quy

thng

hoc tng
Tn thng thn vi 60 - 90
GFR gim nh
GFR gim trung bnh

30 - 59

Peg-IFN 2b 1 g/ kg/ tun

GFR gim trm trng

15 - 29

hoc Peg-IFN 2a 135 g/ tun

Suy thn

< 15

+ RBV 200 800 mg/ngy (bt


u bng liu thp v tng t t
nu kim sot c tc dng ph)

Lc mu

Liu chun IFN 3m U x3/ tun


hoc Peg-IFN 2b 1 g/ kg/ tun

55

hoc Peg-IFN 2a 135 g/ tun


gim liu hng ngy RBV

NG NHIM HCV/HIV: Ch nh iu tr VGSV C khi CD4 > 200/ mm3 , lu


c tnh gan cng nh phi hp RBV DDI.
NG NHIM HCV/HBV: Xem xt dng Peg-IFN 2a v RBV ( ging nh iu tr
VGSV C)
VGSV C CP:
-

Nn xem xt iu tr bng IFN.

Nn bt u iu tr mun, khong 8 12 tun sau khi pht (15% t loi tr


virus).

iu tr vi IFN chun 3m U x 3 ln/tun, n tr liu. Xem xt dng PegIFN v tin dng: Peg-IFN 2a 180 g/ tun hoc Peg-IFN 2b 1.5 g/ kg/
tun.

Thi gian iu tr ti u cha xc nh, c th 12 tun (24 tun c nhiu


ngi ng h).

Vn dng RBV: ty trng hp.

Ti liu tham kho:


1. EASL Clinical practice guidelines 2011: Management hepatitis C virus infection.
2. EASL Clinical practice guidelines 2009: Management hepatitis B virus infection.
3. Quyt nh s 599/Q-BV.BN, ngy 02/11/2011 ca Gim c Bnh vin Bnh
Nhit i v vic ban hnh Hng dn chn on v iu tr bnh vim gan siu vi.

56

PHC IU TR VGSV C mn genotype 1, 4, 6


Peg interferon 2a 180 g/tun TDD + Ribavirin 15 mg/kg/ ngy ung
Peg interferon 2b 1.5 g/kg/tun TDD + Ribavirin 15 mg/kg/ ngy
Interferon chun (IFN) 3M UI x 3 ln/tun + RBV 1 1.2 g/ngy ung.

u ng

W4 HCV RNA

W4 HCV RNA dng


((d ng W12 HCV RNA

W4 HCV RNA m
(< 50IU/ml): RVR

W12

Thi gian
iu tr 24 w nu nng
HCV trc iu tr thp
< 400.000 800.000 IU/mL
hoc < 2log 10

HCV RNA

W 12
HCV RNA dong
d ng

W 12 HCV RNA m:
cEVR

Thi gian
iu tr 48 w
2 log 10
so vi ban u:
pEVR
Thi gian

W 24 HCV RNA
iu tr 24 w

W 12 HCV RNA m:
DVR

Thi gian
iu tr 72 w

< 2 log 10
so vi ban u:
Non EVR

Keeffe E et al. Clin Gastroenterol Hepatol 200

W 12 HCV RNA dng

Ngng iu tr

Theo di: LS, huyt , Ure, creatinin, ALT, AST mi 4 tun;


T3, T4, FT4, TSH, ng huyt v hoc HbA1C mi 12 tun;
57 12, 24, 48 v 24 tun sau ngng tr
nh lng HCV RNA vo cc tun 0, 4,

PHC IU TR VGSV C mn genotype 2, 3


Peg interferon 2a 180 g/tun TDD + Ribavirin 15 mg/kg/ ngy ung
Peg interferon 2b 1.5 g/kg/tun TDD + Ribavirin 15 mg/kg/ ngy
Interferon chun (IFN) 3M UI x 3 ln/tun + RBV 1 1.2 g/ngy ung

W4 HCV RNA
W4 HCV RNA dng
dd d ng
W12 HCV RNA

W4 HCV RNA m
(< 50IU/ml): RVR

W12

Thi gian
- iu tr 12 16 w
(ti pht cao, nht l genotype
3 vi nng RNA HCV cao)
- iu tr 24 tun

HCV RNA

W 12
HCV RNA dng
d ng

W 12 HCV RNA m:
EVR
Thi gian
iu tr 48 w

< 2 log 10
so vi ban u hoc vn
dng tun 24

> 2 log 10
so vi ban u:
DVR

Thi gian
iu tr 24 w

DVR
Ngng iu tr

Keeffe E et al. Clin Gastroenterol Hepatol 200

Theo di: LS, huyt , Ure, creatinin, ALT, AST mi 4 tun;


T3, T4, FT4, TSH, ng huyt v hoc HbA1C mi 12 tun;
nh lng HCV RNA vo cc tun 0, 4, 12, 24, 48 v 24 tun sau ngng iu tr

58

X GAN
I. I CNG:
X gan l bnh thng gp v do nhiu nguyn nhn gy ra. Tn thng gii phu
bnh gm vim v thoi ha hoi t t bo gan, ti to v tng sinh t bo gan dng nt,
x ha t chc lin kt.
II. CHN ON:
1. Lm sng:
-

Bnh cnh lm sng ca x gan rt a dng, ph thuc vo bnh cn gy x gan.

Biu hin lm sng bng hai hi chng chnh:

+ Hi chng suy t bo gan; giai on sm triu chng: Mt mi, chn n, ri


lon tiu ha. Mun hn st cn, ph chn, ph mm n lm, vng da xm da, c
th c xut huyt di da, chy mu cam, ri lon tiu ha, y bng chng hi,
n ung km.
+ Hi chng tng p lc tnh mch ca: C chng, lch to, tun hon bng h
ca ch, xut huyt tiu ha gan thng teo nh i vi cc nguyn nhn x gan
sau ngoi t, gan to i vi cc nguyn nhn x gan ng, gan mt chc, c
th thy mt gan g gh.
2. Cn lm sng:
-

Xt nghim:
Cng thc mu: C th c thiu mu nu c xut huyt tiu ha. c bit: S

lng tiu cu gim, s lng bch cu c th gim.


Ri lon ng mu: TQ, TCK, ko di ( hoc PT, INR ko di).
Albumin gim, A/G <1
mt: Billirubin TT v bilirubin GT, Phsphatase kim tng.
AST, ALT bnh thng hoc tng do hoi t t bo gan, nu AST/ALT >2
ngh n x gan do ru. GGT tng.
St, Ferritine huyt thanh c th tng.
Gradient albumin dch bng v huyt thanh (SAAG) >1.1g/l
Ch im huyt thanh siu vi B, C c th dng tnh.
FP theo di K ha.
59

Siu m bng: nh gi gan, lch, dch bng, huyt khi tnh mch ca.

Fibro scan: nh gi x gan.

Ni soi: Gip chn on mc dn tnh mch thc qun.

CT scan gip nh gi x gan, K gan, huyt khi tnh mch ca.

Phn Child- Pugh Turcotte:


1 im

2 im

3 im

Bnh no gan

Khng

1, 2

3, 4

Bng bng

Khng

Nh

Cng

Bilirubin mu (mg%)

<2

2-3

>3

Albumin mu (g%)

> 3.5

2.8 3.5

<2.8

PT (giy)

<4

46

>6

hoc INR

<1.7

1.7 2.3

>2.3

Child Pugh A (5 6 im), B (7 9 im), C (10 15 im)


Giai on:
nh ngha

% t vong/ nm

Giai on 1

Khng dn TMTQ, khng bng bng

1%

Giai on 2

C dn TMTQ, khng bng bng

10%

Giai on 3

Bng bng dn TMTQ

20%

Giai on 4

XHTH do v dn TMTQ bng bng

50%

Lm sng
X gan cn b

X gan mt b

III. IU TR:
1. Trnh cc yu t lm tn thng gan:
60

- Khng ung ru v hn ch ht thuc l.


- Chng bo ph: Thay i li sng, tp th dc.
- Chng nga vim gan siu vi A, B; cm.
- Trnh cc thuc c hi cho gan: NSAIDs, Isoniazid, Valproic acid,
Erythromycine, Aminoglycoside, Ketoconazol, Chlopromazine, Acetaminophen liu
cao.
2. iu tr nguyn nhn (nu c):
- Ngng ung ru.
- iu tr vim gan siu vi B, C: C ch nh khng virus (xem phc iu tr
Vim gan siu vi B, C).
- Vim gan t min: Corticoid + Azathioprine;
- Bnh Wilson: Trientine + km
3. iu tr h tr:
- Ch dinh dng: n ung iu , khng n qu nhiu m ng vt, nn
dng cht bo cha bo ha, tri cy, rau qu, trnh to bn.
- Bnh nhn n km c th dng:
+ L-ornithin L aspartat: 400 1.200 mg/ ngy: 2-3 ln
+ Arginine tidiacicate hoc Arginine aspartate.
- Thuc tr gan:
+ B sung acid amin phn nhnh: Isoleucin, leucin, valin.
+ Phosphatidylcholin 300 mg: 1 vin x 3 ln/ ngy.
+ Silymarin 70 mg: 3-6 vin/ngy
- Chng to bn: Lactulose 15 ml 1-3 gi/ngy ung sao cho i cu 2 ln/ngy
4. iu tr bng bng:
1.1. Ch n:
- Hn ch mui: Dng 2g mui hoc 88 mmol Na+/ ngy.
- Khng hn ch dch, ch hn ch khi Na+ < 120 mmol/L
1.2. Li tiu:

61

- Mc tiu: Gim 1 kg/ngy i vi BN bng bng+Ph, 0,5 kg/ngy i


vi BN khng ph. Ngng li tiu khi Creatinin mu tng.
- u tin chn Spironolactone, khi u 50 100mg/ ngy, tng 50 100
mg/7 ngy n khi t mc tiu iu tr, liu 400 mg/ngy. Tc dng ph thng
gp l tng K+/ mu, n ha tuyn v nam.
- Furosemide: Khi u 20 40 mg/ ngy, 160 mg/ngy.
- Phi hp Spironolactone + Furosemide t l 4/1.
- Theo di ion .
5. Phng nga nhim trng dch bng:
Norfloxacin 0,4 g/ ngy
6. iu tr tng p lc tnh mch ca: Phng nga xut huyt tiu ha do v tnh
mch thc qun.
1.1. c ch beta+ Ni soi tht tnh mch thc qun
+ Propranolol: liu khi u 20 mg x 2 ln/ngy, tng dn n khi nhp tim 55
ln/ pht.
+ Nadolol: liu khi u 40 mg x 1 ln/ngy, tng dn n khi nhp tim 55 ln/
pht.
1.2. BN khng ng tht TMTQ: c ch beta+ Isosorbide mononitrate
Isosorbide mononitrate Bt u bng 10 mg ung bui ti, ti a 20 mg x 2
ln/ ngy.
1.3. BN khng dung np hoc chng ch nh vi c ch beta: Ni soi tht tnh
mch thc qun.
IV.

THEO DI:
Nu bnh n nh theo di:
i.

CTN, t l Prothrombin, chc nng gan, thn, ion /3 thng.

ii.

Siu m bng, FP/6 thng.

iii.

Ni soi:
+ Nu khng c dn TMTQ: ni soi li sau 2 nm.
+ Nu c dn TMTQ: iu tr phng nga XHTH.

Ti liu tham kho:


62

1. TS Nguyn Quc nh, PGS TS Ng Qu Chu v cng s.(2011). Hng dn


chn on v iu tr bnh ni khoa.
2. Mark

Feldman

et

all,

gastrointestinal

and

liver

disease

pathology/diagnosis/management. Sauders Elsevier, 8 th edition


3. C. haslett et all, Davison- medicine interne pricipes et pratique, 19 eme edition.
Maloine.
4. Phc iu tr ca bnh vin Ch Ry nm 2013.

63

LONG XNG
I. I CNG :
Long xng l mt hi chng vi c im sc bn ca xng b suy gim dn
n gia tng nguy c gy xng. Sc bn ca xng phn nh s kt hp ca mt
xng cht khong trong xng v cht lng xng.
II. Chn on long xng
2.1. Lm sng
a- Biu hin lm sng:
- au mi m h ct sng , au dc cc xng di, au mi c bp, n lnh, hay
b chut rt cc c
- au thc s ct sng, au khi ngi lu. C th au mn tnh hoc cp tnh sau
chn thng
- y bng chm tiu, nng ngc kh th
- G lng, gim chiu cao
b- Bin chng ca long xng:
- au ko di do chn p thn kinh
- G vo ct sng, bin dng lng ngc
- Gy xng c tay, gy ln t sng, gy c xng i
- Gim kh nng vn ng
2.2. Cn lm sng
- Chp X quang xng
- o mt khong xng (BMD)
- Xt nghim:
Mu: Osteocalcin, alkaline phosphatase
Nc tiu: Deoxy lysyl pyridinoline
* Tiu chun chn on long xng do WHO 1994:
Chn on

Tiu chun

Bnh thng- Normal

T > -1

Thiu Xng- Osteopenia

-2.5 < T < -1.1


64

Long xng- Osteoporosis

T < -2.5

Long xng nghim trng

Long xng + Tin s

(severe osteoporosis)

gy xng gn y

* Ch nh o mt xng cho ph n theo NOF ngh:


1/ Tt c ph n sau mn kinh, di 65 tui v c mt trong nhng yu t nguy c :
Tin s gy xng sau tui 30.
C thn nhn tng b gy xng (cha m, anh ch em).
Ngi da trng
Cao tui
Ph n # 46 tui.
Mt tr nh (dementia).
Sc khe yu
Ht thuc l.
Trng lng thp ( <56 Kg).
Thiu ni tit t n: mn kinh sm( trc 45 tui hay do phu thut), thi gian
tin mn kinh (ko di hn 5 nm).
Thiu canxi
Nghin bia ru
Suy yu th lc
Hay b t ng
Thiu vn ng c th.
2/ Tt c ph n 65 tui tr ln.
3/ Ph n sau mn kinh vi tin s gy xng.
4/ Ph n mun c iu tr phng chng long xng v nu xt nghim MX
cho thy h c MX thp.
5/ Ph n tng c iu tr bng liu php thay th hormon trong mt thi gian
di hn 10 nm.
III/ IU TR:
4.1. Thay i cc thi quen xu v np sng.
65

4.2. iu chnh s thiu canxi v sinh t D:


- Lng calci cn dng 1000 1200mg/ngy.
- Lng sinh t D ti thiu 400UI/ngy.
4.3. Cc thuc chng hy xng:
- Nhm hormon v cc thuc ging hormon
Estrogen Replacement 0.625 mg ung/ngy
Raloxifen 60 mg/ung/ngy
- Nhm Bisphosphonates
Alendronat: 10 mg ung/ngy hoc 70 mg ung/tun
Risedronat: 5mg ung/ngy hoc 35mg ung/tun
4.4. iu tr gim au theo bng hng dn s dng thuc gim au ca WHO
* i tng cn iu tr:
Theo T chc long xng Hoa K (NOF):
Nu ch s T ca mt xng trn (-1): khng cn iu tr.
Nu T nm trong khong (-1) n (-2.4) c gy xng th nn iu tr.
Nu T di (-2.5) : cn iu tr.
N thi k sau mn kinh hn 20 nm.
N trn 75 tui.
Ti liu tham kho:
1. Long xng, nguyn nhn, chn on, iu tr, phng nga. NXB y hc 2007

2. Bnh long xng v mt s quan nim iu tr. Bi ging cao hc nm 2001


3. Bnh thp khp. Nh xut bn y hc H Ni 1998 :22- 32
4. Meryls Le Boff, Bi ging, Bnh long xng th k 21
5. Bnh long xng v cc bin php iu tr. TS.BS L Anh Th-BV Ch Ry.

66

THOI HA KHP V THOI HA CT SNG


I. I CNG:
Thoi ha khp l nhng bnh ca khp v ct sng mn tnh, au v bin dng,
khng c biu hin vim. Tn thng c bn ca bnh l tnh trng thoi ha ca sn
khp v a m (ca ct sng), phi hp vi nhng thay i phn di sn v mng
hot dch.
II. CHN ON:
A. LM SNG:
1. au:
-

Kiu c gii au khi vn ng v gim khi ngh ngi.

V tr: thng i xng 2 bn, au v tr ca khp hoc on ct sng b thoi


ha, t lan xa (tr khi c chn p r v dy thn kinh).

Tnh cht: au m , c th c cn au cp ( ct sng ) xut hin v tng khi


vn ng, thay i t th, au nhiu vo bui chiu, gim au v m v khi
ngh ngi.

au din tin thnh tng t, di ngn ty trng hp, ht t c th ht au,


sau ti pht t khc, c th lin tc tng dn.

au khng km theo vi cc biu hin nh: St, vim, sng, nng .

2. Hn ch vn ng:
Hn ch mt phn cc ng tc ca khp v on ct sng thoi ha.
Hn ch nhiu do cc phn ng co c km theo.
Khng lm c mt s ng tc: Quay c, ci st t, ngi xm.
Cng khp vo bui sng.
3. Bin dng:

67

Khng nhiu nh cc bnh khp khc: Bin dng do mc gai xng, do lch trc
khp hoc thot v mng hot dch ngn tay b thoi ha, cc gai xng to nn hnh
ht li ln khp ngn xa.
4. Cc du hiu khc:
-

Teo c: do t vn ng cc c b tn thng.

Ting lo so khi vn ng t c gi tr v c th thy ngi bnh thng hoc


cc bnh khc.

Trn dch khp: i khi thy khp gi do phn ng xung huyt v tit dch.

5. Du hiu ton thn: Khng c biu hin ton thn.


B. CN LM SNG:
1. X-quang: c 3 du hiu c bn
a. Hp khe khp khe khng ng u, ct sng chiu cao a m gim, khng bao
gi dnh khp.
b. t xng di sn: Phn u xng hm khp, mm t sng c hnh m c,
cn quang nhiu, trong phn xng c thy mt s hc nh sng hn.
c. Mc gai xng: phn tip gip gia xng, sun v mng hot dch; ra ngoi
ca thn t sng, gai xng c hnh th v m c, mt s mnh ri ra nm
trong khp hay phn mm quanh khp.
2. Ni soi khp (nu c iu kin): Thy nhng tn thng thoi ha ca sn khp,
pht hin cc mnh xng ri trong khp
III. IU TR V PHNG BNH:
A. iu tr:
Khng c thuc cha qu trnh thoi ha, iu tr triu chng v phc hi chc
nng l quan trng, phi phi hp ni khoa, vt l v ngoi khoa.
1. Ni khoa:
2. 1.1. Thuc gim au thng dng t 2-4 tun: Chn mt trong cc thuc theo bc
thang gim au ca t chc Y t th gii (WHO)
-

Nhm

Acetaminophen

(Paracetamol,

Paracetamol 0,5g liu t 1-3vin / ngy.


68

Efferalgan),

Efferalgan

codein,

- Aspirin 1- 2 g/ ngy.
- Nhm khng vim nonsteroid:
+ Diclofenac (voltaren) vin 50mg x 2 vin/ ngy hoc
vin 75mg 1vin / ngy sau n no.
+ Hoc c ch chn lc COX 2:
Celecoxib 100 200mg/ngy.
Piroxicam 10mgx2ln/ngy
Meloxicam(Mobic) 7,5mgx2ln/ngy
Edosic (Etodolac) 600-1.200mg/ngy
Nabumetone (Korum, Novidol) 1- 2 g/ngy
1.2. Thuc tng cng dinh dng sn, thng dng t 4-6 thng.
-

Glucosamin 1500mg/ngy.

Tinh cht sn ng vt.

Thuc c ch Interleukin 1: Diacerein 50 100 mg/ ngy

2. Cc phng php vt l
Cc bi tp th dc cho tng v tr thoi ho
iu tr bng tay : Xoa bp, ko nn, n huyt: tp vn ng th

ng.

iu tr bng nhit: Hng ngoi , bn nng, parafin.


iu tr bng nc: Nc khong , nc nng.
S dng cc dng c chnh hnh
3. iu tr ngoi khoa
Chnh li cc d dng ca khp bng cch c v khot xng.
iu tr thot v a m bng ct vng cung sau hay ly phn thot v
Lm cng dnh khp t th c nng
Ghp khp nhn to
B. Phng bnh:
Phng bnh rt quan trng bng cch ngn nga v hn ch cc tc ng c gii
qu mc khp v ct sng, ta c th d phng c kt qu cc bnh thoi ha khp,
ct sng.
TI LIU THAM KHO:
69

1. PGS.TS.BS Trn Ngc n. Bnh thp khp Nh xut bn Y Hc 1998.


2. TS BS L ANH TH. Chn on v iu tr bnh thoi ha khp- BV Ch Ry
2006
3. TS inh Hiu Nhn - Bnh Hc Ni Khoa i Hc Y Dc TPHCM - 2009 .

VIM KHP DNG THP


(Rheumatoid Arthritis)
I.

I CNG:
Vim khp dng thp l bnh t min c biu hin ton thn, c c im l

vim mng hot dch ca nhiu khp. Vim khp dng thp c c trng bi cc
biu hin cc khp i xng hai bn.
II. CHN ON:
Chn on vim khp dng thp cn da vo biu hin ca mt tp hp cc du
hiu lm sng v xt nghim trong tiu chun chn on ca vin thp khp hc M
1987.
A. Tiu chun chn on vim khp dng thp ca vin thp khp hc M
1987 (American college of Rheumatology ACR).
1) Cng khp bui sng mt khp no trong khong thi gian 1 gi, trc khi
gim ti a.
2) Sng m mm ba khp tr ln.
3) Vim khp khp lin t ngn xa bn tay, khp bn ngn tay v chn, khp c
tay, khp c chn, khp gi, khp khuu.
4) Vim khp i xng.
5) Cc nt di da.
6) Xt nghim yu t dng thp (RF) dng tnh.
7) Tn thng n mn, long xng cc khp bn tay v c tay trn X-quang
(tiu chun c nhy 91,2%; c hiu 89,3%).
chn on xc nh cn c t nht 4 trong 7 tiu chun nu trn, tiu chn 1 4 tn ti t nht trong 6 tun.
B. Chn on phn bit:
-

Vim khp vy nn.


70

Vim khp phn ng.

Hi chng Reiter.

Vim ct sng dnh khp.

Lupus ban h thng.

Cc bnh Sarcoidosis.

Vim ni tm mc bn cp.

Vim khp nhim khun.

*Cn lm sng:
-

Yu t dng thp (Rheumatoid factor RF) dng tnh.

CRP ( C Reactive Proteine) tng.

VS tng.

X-quang quy c.

Trong vim khp dng thp:


-

Mi mc X-quang bnh thng

Tip theo c hnh nh tn thng n mn kinh in (Erosion) cnh khp.

Mun hn na l hnh nh n mn lan rng ra sn khp, hp khe khp, bn


trt khp, lch trc khp.

III. iu tr:
-

Bnh vim khp dng thp l bnh cha c kh nng cha khi. Mc ch
cao nht ca iu tr l t c s lui bnh, ngn chn cc bin chng.

V nguyn tc, vic iu tr phi ko di sut i nu khng c tc dng ph


buc phi ngng thuc.
1) Cc bin php khng dng thuc:

Gim p lc khp bng cch ngh ngi, c nh khp bng np, dng cc
nng chng.

Mi iu tr vt l tr liu v tp luyn u khng c qu mc.

Ch n ung dinh dng tng cng cht m, vitamin v cc khong


cht.
2) Thuc:

71

a. Thuc gim au:

Chn mt trong cc thuc theo bc thang gim au

ca t chc Y t th gii (WHO)


3. Nhm Acetaminophen (Paracetamol, Efferalgan), Efferalgan codein,
Paracetamol 0,5g liu t 1- 3 vin/ngy.
4. Aspirin 500 mg x ln/ ngy
- Nhm khng vim nonsteroid:
+ Diclofenac (voltaren) vin 50mg x 2 vin/ ngy hoc
vin 75mg 1vin / ngy sau n no.
+ Hoc c ch chn lc COX 2:
Celecoxib 100 200mg x 2 ln/ngy.
Piroxicam 10mgx2ln/ngy
Meloxicam (Mobic) 7,5mgx2ln/ngy
Edosic (Etodolac) 600-1.200mg/ngy
Nabumeton (Korum, Novidol) 1 2g/ngy
b. Nhm Corticosteroid:
-

Prednisolon 7,5mg/ngy lc 8h sng.

Methylprednisolone 5-10mg/ngy lc 8h sng.

c. Nhm thuc chng thp khp (DMARDS Disease Modifying Anti


Rheumatic Drugs):
- Methotrexat:
Liu dng: 10-20mg/tun, tim bp hoc ung. Thng
dng ng ung bt u bng liu 10mg; ung 4 vin (vin 2,5mg) vo
mt ngy nht nh trong tun. Thuc c hiu qu sau 1-2 thng. C th
chnh liu tu theo p ng ca bnh. Trong trng hp thuc km hiu
qu hoc km dung np bng ng tim bp (ng tim 10 hoc 15mg)
mi tun mt mi duy nht.
Chng ch nh: H bch cu, suy gan thn, tn thng phi
mn tnh.
Tc dng khng mong mun: Thng gp lot ming, nn,
bun nn. C th gy c t bo gan v tu.
72

Nhm hn ch tc dng khng mong mun ca methotrexat


cn b sung acid folic, liu bng liu methotrexat (vin 5mg, 02 vin/tun
chia 2 ngy trong tun khi dng liu 10mg methotrexat/tun).
- Hydroxychloroquin 200 400 mg/ ngy
- Sulfasalazin (Sulfasalazine-SZZ) 500 mg x 2 ln/ ngy ung sau n
* iu tr phi hp:
Ty tnh trng bnh trng thi c th hon cnh ca mi bnh nhn m c
th dng n tr hoc phi hp tr liu khi dng n tr khng hiu qu.
Phi hp 2 hoc 3 loi thuc l Methotrexat, Sulfasalazin v
hydroxychloroquin i vi bnh vim khp dng thp dai dng.
Lu : Tc dng ph c hi ca thuc iu tr vim khp dng thp trn: Tiu
ha, huyt hc, tim mch, gan, thn, phi. V vy cn kim tra thng xuyn cc
chc nng trn trc khi iu tr v sau mi thng, ba thng, hay t xut theo
din bin ca bnh.
Ti liu tham kho:
1) American college of Rheumatology Subcommittee on Rheumatoid Arthritis 2002.
2) ABC of Rheumatology fourth edition 2010.
3) Current Diagnosis Treatment in Rheumatology 2007.
4) Kellys textbook of Rheumatology 2008.
5) Bnh vim khp dng thp NXBYH 2007.
6) The Washington Manual of Medical Therapeutics 33RD edition 2010.

73

BNH GOUT
I. I CNG:
Gout l tnh trng ri lon chuyn ha acid uric. Bnh xy ra ch yu do tng to
qu mc acid uric trong mu v trong m hoc do gim o thi aid uric trong c th
hoc phi hp c hai c ch. Bnh c c trng bi nhng t vim khp cp v sau
din tin thnh mn tnh, gy tn thng m mm v thn.
II. CHN ON:
1. Chn on xc nh da vo cc c im:
-

Gii: >90% l nam

Tui: Nam gii a s khi bnh sau tui dy th.


N gii khi bnh sau thi k mn kinh.

Hon cnh khi pht: Sau khi ung ru n nhiu tht, nhim trng, gng sc.

V tr: a s bt u khp bn ngn chn ci t l 75%. Thnh thong cng


gp 1 s khp khc nh c chn, cc ngn chn.

Tnh cht ca t vim khp cp. au d di, sng, nng v rt cng mt


khp khng i xng, thng xy ra ban m khong 1-2 gi sng, cn ko di
n sng th gim dn. Triu chng vim khp tng ti a trong 24 - 48 gi ko
di vi tun, c th t khi khng li di chng.

Ton thn st 380-390C c th rt run.

Nt Tophi tm thy khong 20% in hnh loa tai. Ngoi ra cn c mm


khuu tay, trc xng bnh ch, gn c.

*Tiu chun chn on Gout ca Ilar v Omeract (2000).


- C tinh th Urate c trng trong dch khp v hoc: Tophi c chng minh c cha
tinh th urate bng phng php ha hc hoc knh hin vi phn cc v hoc:
C 6/12 trng thi lm sng, xt nghim v x-quang sau:
C hn 1 cn vim khp cp.
Vim khp mt khp.
vng khp.
74

Sng, au khp bn ngn chn 1.


Vim khp bn ngn chn 1 1 bn.
Vim khp c chn 1 bn.
Tophi nhn thy c.
Sng khp khng i xng.
Tng acid uric mu: 7mg/dl nam, 6mg/dl n.
Nang di v xng hc khuyt xng.
Cy vi sinh m tnh.
2. Chn on phn bit:
* Cn vim khp gout cp vi:
Vim khp nhim trng.
Bnh gi gout (vi ha sn khp).
Lao khp.
* Vim khp gout mn vi: Vim khp dng thp, thoi ha khp.
III.

iu tr:

Nguyn tc: iu tr lin tc, lu di kt hp gia iu tr v phng bnh.


1. t vim khp gout cp:
* Nhm Thuc gim au:
Gim au chn mt trong cc thuc theo bc thang gim au ca t chc Y
t th gii (WHO):
5. Nhm Acetaminophen (Paracetamol, Efferalgan), Efferalgan codein,
Paracetamol 0,5g liu t 1-3vin / ngy.
- Nhm khng vim nonsteroid:
+ Diclofenac (voltaren) vin 50mg x 2 vin/ ngy hoc
vin 75mg 1vin / ngy sau n no.
+ Hoc c ch chn lc COX 2:
Celecoxib 100 200mg/ngy.
Piroxicam 10mg x 2ln/ngy
Meloxicam(Mobic) 7,5mg x 2ln/ngy
Etodolac (edosic) 600-1.200mg/ngy
75

Nabumeton (korum, novidol) 1 2g/ngy


* Colchicin: Hin ti t s dng do c nhiu tc dng ph, ch s dng khi
NSAIDS v glucocortinoids chng ch nh hoc khng dung np.
-Liu 2-6mg/ ngy u tin.
1-2mg/ngy, vi ngy sau.
1mg/ngy, cho n khi ht au.
* Corticosteroids: Dng khi cc thuc trn khng hiu qu hoc chng ch nh.
- Prednisolon ung 40-60mg/ngy trong 3-5 ngy ri gim liu dn v ngng
thuc trong 7-10 ngy.
- Thng dng cho bnh nhn suy thn, suy gan.
2. Lm gim v duy tr acid uric mu mc cho php (<300mol/l hay
<5mg/dl)
+ Bt u liu thp, tng dn ti liu iu tr, s dng lin tc.
- Thuc chng tng hp acid uric:Nu Acid uric niu >800mg/24h v chc
nng thn bnh thng.
*Allopurinol.
- Khi u 100mg/ngy, tng liu mi tun.
- Thng dng 300mg/ngy/1 ln ung nhiu nc.
- Bnh nhn suy thn.
Nu lc cu thn -GFR<40ml/P150mg/ngy, GFR<20ml/P 100mg/72 gi.
**Lu cc tc dng ph c hi ca thuc iu tr gout.
3. iu tr khng dng thuc:
- Tp th dc, gim cn.
- King thc phm giu Purin: tht (tht tru, b, d,.) ph tng ng vt (
tim, gan, thn, c,)
- King n hi sn, tht rng.
- Khng ung ru, bia.
- Khng ht thuc l.
- Ung nhiu nc (2,5-3l nc/ngy) nc khong khng c gas, c kim cao

76

Ti liu tham kho:


1. Bnh hc ni khoa Trng HYD TPHCM 2009
2. Phc iu tr gout Bnh vin ch Ry TPHCM.
3. Kellys textbook of Rheumatology 2008.
4. Manual of Rheumatology and out patient Orthopedic Disorders. Diagnosis and
Therapy 2009.
5. The Washington Manual of Medical Therapeutics 33RD edition 2010.

77

HNG DN IU TR TNG ACID URIC MU


TANG ACID URIC MAU

Tien s gout

Khong trieu chng


Thay oi loi song :
.Giam can nang
.Han che Protid
.Han che uong ru

MOT CN GOUT
(CN AU TIEN)

CN GOUT TAI PHAT


Tuoi < 60

Tuoi > 60

Tien s co soi he nieu


Khong

Co

Cac u cuc quanh khp (Tophi)


Co

Khong

Mc loc cau than


CLCr

80 ml/phut

CLCr

80 ml/phut

Acid uric nieu 24 gi


< 800mg

> 800 mg (che o an bnh thng)

GIAM TONG HP ACID URIC


ALLOPURINOL / FEBUXOSTAT

TANG THAI ACID URIC


(PROBENECID/SULFINPYRAZONE)

Tiep tuc neu co ket qua


Neu khong, chuyen dung ALLOPURINOL
78

IU TR GIM AU
1.

Nguyn tc s dng thuc gim au:

Cn kt hp iu tr nguyn nhn gy au (iu tr c hiu, iu tr bnh c bn).

Tn trng s bc thang ca T chc Y t th gii WHO.

Dng ng ung l chnh nhm n gin ha cch thc s dng.

Tm liu hiu qu nht, dung np cao nht (tn trng chng ch nh, tng tc

thuc, tng dn liu, lu s ph thuc thuc)


-

C th kt hp cc iu tr h tr nh trng hp au c ngun gc thn kinh nn

kt hp thuc vitamin nhm B v cc thuc gim au thn kinh. C th kt hp cc


thuc chng trm cm cc trng hp au ko di, au do ung th vv.
2. S bc thang ch nh thuc gim au theo khuyn co ca t chc Y t th
gii: Bc 1: Thuc khng c morphin (paracetamol, thuc chng vim khng steroid
liu thp, noramidopyrin, floctafenin)
- Bc 2: Morphin yu (codein, dextropropoxyphen, buprenorphin, tramadol).
- Bc 3 : Morphin mnh
Bng liu mt s thuc gim au bc 1-2 theo khuyn co ca T chc Y t
th gii (WHO)
Thuc gim au bc 1
-

Paracetamol 500mg-1500mg/ngy

Diclofenac 50mg, 2 vin/ngy, hoc 75mg/ngy

Meloxicam 7.5mg-15mg/ngy

Piroxicam 20mg/ngy

Celecoxib 200 - 400mg/ngy

Etoricoxib 60-90mg/ngy ung 1 ln

Thuc gim au bc 2 Paracetamol kt hp vi codein hoc tramadol


-

Paracetamol 500mg + codein 30mg (Eferalgan- codein) 1-3 vin/ngy

Paracetamol 325mg + Tramadol 37.5 mg (Ultracet) 1-2 vin x 4 -6 ln/ngy,


khng qu 8 vin/ ngy

iu tr h tr
79

* Trng hp au c ngun gc thn kinh:


-

Thuc gim au thn kinh


+ Cytidine 5mg + Uridine 3mg (Nucleo e.m.p forte) 1-2 vin x 2 ln/ngy
+ Gabapentin 25 - 35 mg/kg/ ngy: 3 ln, khi u 10 mg/kg/ngy
+ Pregabalin 150- 300mg/ngy chia 3 ln.

Ch nh: au do nguyn nhn thn kinh nh au thn kinh ta, hi chng chn p
r thn kinh (thoi ha ct sng c hoc thot v a m, hi chng ng c tay, hi
chng ng c chn), au x c (fibromyalgia)
Cch dng: Nn ung vo bui tra v ti. Cn tng liu dn. Khi u bng liu
cao ngay t u c th gy chng mt, bun nn.
-

Vitamin nhm B (B1, B6, B12)


+ Neurobion (vitamin B1, B6, B12): tim hoc ung
+ Neurolaxan B (vitamin B1, B6, B12): ung
+ Methycobal (vitamin B12): tim hoc ung 1500g/ngy

Ch nh: au c ngun gc thn kinh nh au thn kinh ta, hi chng chn p


r thn kinh (thoi ha ct sng c hoc thot v a m, hi chng ng c tay, hi
chng ng c chn), au thn kinh lin sn
Cch dng: Nn dng liu cao.
* Trng hp au mn tnh:
- Thuc chng trm cm ba vng (tricyclic antidepressssant), chng lo u
+ Amitriptylin (Laroxyl: vin 25mg)
Ch nh: au mn tnh, au c ngun gc thn kinh, c ri lon gic ng,
c yu t tm l, hoc au do ung th.
Cch dng:Nn khi u bng liu thp: vin/ngy. Liu: 25-75mg. C
th gy chng mt
+ Dogmatil (Sulpirid: vin 50mg)
Ch nh: au c ri lon gic ng, c yu t tm l.
Cch dng: Liu 50-150mg/ngy. Nn khi u bng liu thp:
50mg,ngy. Khng qu 4 tun.
Ti liu tham kho: Hng dn s dng thuc gim au ca T chc Y t Th gii.
80

AU THN KINH TA
I. I CNG:
1. au thn kinh ta l au theo ng i ca dy thn kinh ta t im khi u
cho n im kt thc ca n.
2. Nguyn nhn thng gp nht l do thot v a m L4/L5, hay L5/gy chn p
cc r thn kinh tng ng. Cc nguyn nhn khc c th gp nh vim nhim,
bnh l ct sng, u thn kinh, ung th xm ln chn p thn kinh ta.
II. CHN ON:
Chn on au thn kinh ta da vo biu hin lm sng c trng, chn on
nguyn nhn da trn cn lm sng, ch yu l MRI hoc CT ct sng tht lng.
1. Biu hin lm sng:
- au dc theo ng i ca thn kinh ta:
+ au r L5: au vng hng lan n phn gia ca mng, pha sau v bn ca
i, mt ngoi cng chn, mt mu ca bn chn, tn cng l ngn chn ci v 3 ngn
gia ca bn chn.
+ au r S1: au vng hng lan n phn gia ca mng, mt sau ca i, mt
sau cng chn, gt chn, gan bn chn v tn cng l ngn t (ngn 5) ca bn chn.
- Khm lm sng:
+ Du Lasgue (+) cc khc nhau ty mc chn p r thn kinh.
+ n cc im au dc theo ng i ca thn kinh ta (im Valleix) bnh
nhn s au tng ln.
+ Du n dy chung (+).
+ Ri lon cm gic (t b, kin b, nng rt) vng thn kinh ta chi phi.
+ Gim vn ng hoc lit nhm c tng ng chi di do thn kinh ta chi
phi.
+ Gim hoc mt phn x gn xng bn thn kinh ta b au.
+ Ri lon c trn: Mt s trng hp thot v a m chn p chm ui nga
a n ri lon cm gim vng tng sinh mn v trc trng, tiu kh hoc b tiu,
i tin kh.
81

+ Teo c bn chn au: Nu au thn kinh ta lu.


Lu : Mt s triu chng gi nh hng cc nguyn nhn khc (ngoi thot v a
m) nh st, gy st, au nhiu v m, nh hng tng trng, au ct sng tht
lng cao L1- L3 hoc thp S1 S3, bnh nhn c mt s cc biu hin khc ngoi
du hiu au thn kinh ta
2. Cn lm sng: Cc xt nghim huyt hc, sinh ha, ch s vim thng trong
gii hn bnh thng i vi au thn kinh ta do thot v a m. Mt s bt thng
v huyt hc v hoc sinh ha gip nh hng cc nguyn nhm vim hoc bnh c
tnh.
-

Chp X quang ct sng tht lng: Gip chn on phn bit cc bt thng khc:
trt t sng, vim thn sng a m, du hiu hy xng hoc c xng bt
thng.

Chp CT scanner: Gip chn on c nguyn nhn gy au thn kinh ta l do


thot v a m hay do nguyn nhn khc.

MRI ct sng: Gip chn on chnh xc v tr, mc , dng thot v a m,


cng nh gip chn on cc nguyn nhn khc (vim, nhim, u thn kinh, K di
cn )

* CHN ON PHN BIT:


-

au thn kinh i, au thn kinh b i, au thn kinh bt.

Bnh l khp hng: Hoi t v trng chm xng i, vim khp hng, thoi ha
khp hng.

Bnh l c tht lng chu: Vim, p xe, u.

Vim khp cng chu, vim ct sng dnh khp. long xng gy ln t sng.

III. IU TR: Ty theo nguyn nhn


1. iu tr au thn kinh ta do thot v a m:
1.1. iu tr ni khoa:

iu tr khng dng thuc:


-

Ngh ngi, trnh c ng mnh, khng mang xch nng, hn ch ng/ ngi
lu.

Vt l tr liu: Massage, ko dn ct sng, n ct sng


82

iu tr bng thuc:
Gim au chn mt trong cc thuc theo bc thang gim au ca t chc Y
t th gii (WHO):
+ Nhm Acetaminophen (Paracetamol, Efferalgan), Efferalgan codein,
Paracetamol 0,5g liu t 1-2vin x 3-4 ln / ngy.
+ Paracetamol 500mg + codein 30mg (Eferalgan- codein) 1-3 vin/ngy
+ Paracetamol 325mg + Tramadol 37.5 mg (Ultracet) 1-2 vin x 4 -6 ln/ngy,
khng qu 8 vin/ ngy
+ Nhm khng vim nonsteroid:
Diclofenac (voltaren) vin 50mg x 2 vin/ ngy hoc
vin 75mg 1vin / ngy sau n no.
c ch u th COX 2:
Piroxicam 10mg x 2 ln/ngy
Etodolac (edosic) 600-1.200mg/ngy
Nabumeton (korum, novidol) 1 2g /ngy
c ch chn lc COX 2:
Celecoxib 200 400mg/ngy.
Meloxicam(Mobic) 7,5mg x 2 ln/ngy
Thuc dn c chn mt trong cc thuc sau:
+ Thiocolchicosit (Coltramyl 4 mg): 2 vin x 2 ln/ ngy
+ Mephenesin (Decontractyl): 500 1000 mg x 3 ln/ ngy
+ Tolperisone (Mydocalm 50 mg, 150 mg): 50 - 150mg x 3 vin / ngy
+ Eperison (Myonal) 50mg x 3 vin/ ngy
+ Tizanidine 2 4 mg x 3 4 ln/ ngy
+ Nhm Benzodiazepin: Diazepam 5 15 mg/ ngy, Temazepam 7,5 30
mg/ ngy
Trng hp c au r thn kinh nhiu, au mn tnh, c th dng:
+ Vitamin B12 (Methylcobalamin): 500 mcg x 3 ln/ ngy (ung)
+ Gabapentin 25 - 35 mg/kg/ ngy: 3 ln, khi u 10 mg/kg/ngy
+ Pregabalin 150- 300mg/ngy chia 3 ln.
83

+ Cytidine 5mg + Uridine 3mg (Nucleo e.m.p forte) 1-2 vin x 2 ln/ngy
1.2. Can thip ngoi khoa:
Ch nh ngoi khoa cho cc trng hp: Thot v a m mc nng: Hi
chng chm ui nga, mt cm gic vng tng sinh mn, biu hin tng au, hp ng
sng nng, lit chi di. Tht bi vi iu tr ni khoa bo tn (iu tr ni khoa ng
phng php trn 8 tun m khng c kt qu)
2. iu tr au thn kinh ta do cc nguyn nhn khc:
+ Cc nguyn nhn do vim nhim: Ty do vi trng thng, vi trng lao hay
k sinh trng m c ch nh cho ph hp.
+ Cc nguyn nhn khc: U thn kinh, ung th khm chuyn khoa c
hng iu tr thch hp.
Ti liu tham kho:
1.

TS Nguyn Quc nh, PGS TS Ng Qu Chu v cng s.(2011). Hng dn


chn on v iu tr bnh ni khoa.

2.

Malmivaara and et al (1995), the treatment of acute low back pain- best rest,
exercises or ordinary activety. N Engl Med. 1995, 332:351-5

3.

Mark P.Arts, MD and et all(2009), tubular diskectomy vs conventional


microdiskectomy for sciatica, vol. 302, No, July 8.

4.

Phc iu tr ca Bnh vin Ch Ry nm 2013.

84

AU U
I. NH NGHA:
-

au u l cm gic au u v cm gic au ny khng c s phn b theo


cc vng ca thn kinh

au u l cm gic rt thng gp trong thc hnh y khoa, l triu chng ca


nhiu bnh khc nhau.

II. PHN LOI AU U:


-

Bng phn loi au u quc t ln II 2004 (ICHP-II: The International


Classification of Headache Disorder II Edition 2004) c nh gi l phn loi
tt nht hin nay.

Bng phn loi au u quc t ln II 2004:

Phn 01: au u nguyn pht: (khng c nguyn nhn khc)


1. Migraine
2. au u dng cng thng
3. au u tng cm
4. Cc au u nguyn pht khc: au u khi gng sc, au u khi ng, au na
u lin tc.
Phn 02: au u th pht.
1. au u sau chn thng u v c.
2. au u do bnh mch mu trong s
3. au u lin quan bnh ni s khc khng do nguyn nhn mch mu, tng p
lc ni s t pht, au u sau co git ng kinh.
4. au u do thuc
5. au u do nhim trng thn kinh trung ng
6. au u do ri lon cn bng ni m: tng huyt p, thiu oxy m
85

7. au u do bnh c, mt, tai mi hng


8. au u do ri lon tm thn.

III.

AU U MIGRAINE:
1. C IM AU U MIGRAINE:
Du hiu bo trc :

Trong vi gi hoc mt ngy trc khi c cn au u, bnh nhn c cc triu chng


v tm thn hoc thn kinh thc vt.
Tin triu:
-

m im chi sng

Bn manh ng danh

T tay v mt mt bn

Mt ngn ng thong qua


au u:

Thng mt bn u

au theo nhp mch

Cng tng dn v d di

Thi gian 4-72 gi


Triu chng i km: Nn, s ting ng, s nh sng, chng mt
2. IU TR AU U MIGRAIN:
a. iu tr ct cn:
Thuc gim au;
6. Gim au chn mt trong cc thuc theo bc thang gim au ca t chc
Y t th gii (WHO):
+ Nhm Acetaminophen (Paracetamol, Efferalgan), Efferalgan codein,
Paracetamol 0,5g liu t 1-2vin x 3-4 ln / ngy.
+ Paracetamol 500mg + codein 30mg (Eferalgan- codein) 1-3 vin/ngy
+ Paracetamol 325mg + Tramadol 37.5 mg (Ultracet) 1-2 vin x 4 -6 ln/ngy,
khng qu 8 vin/ ngy
86

+ Nhm khng vim nonsteroid:


Diclofenac (voltaren) vin 50mg x 2 vin/ ngy hoc
vin 75mg 1vin / ngy sau n no.
c ch u th COX 2:
Piroxicam 10mg x 2 ln/ngy
Etodolac (edosic) 600-1.200mg/ngy
Nabumeton (korum, novidol) 1 2g /ngy
c ch chn lc COX 2:
Celecoxib 200 400mg/ngy.
Meloxicam(Mobic) 7,5mg x 2 ln/ngy
Thuc chng nn: Metoclopramide 10 mg - 1 vin x 3 ln/ ngy gip tng
tc dng ca thuc gim au thng thng.
Thuc c hiu Migrain :
Dihydroergotamin (Tamik) 3mg 1vin x 3 ln / ngy
b. .Thuc nga cn:
+ Thuc c ch beta:
-

Propranolol 20-80mg/ ngy x 2 ln/ngy

Metoprolol 50-100 mg/ ngy x 2 ln/ngy

Atenolol 25 100 mg/ ngy x 2 ln/ngy

* Lu tc dng ph v chng ch nh ca thuc


+ Thuc chng trm cm: Amitryptylin 10 50 mg/ ngy, khi u bng liu
thp, tng 10 mg/ 2 tun cho n khi kim sot c triu chng.
+ Thuc chng ng kinh:
-

Topiramate khi u 25 mg ung ban m, sau 1-2 tun tng 25 -50 mg/ngy :
2 ln/ ngy, liu ch 100 200 mg/ ngy (khng qu 500 mg/ngy).

Valproate sodium 300 1.000 mg x 2 ln/ngy


+ Thuc c ch knh calcium: Flunarizine 5 mg (<65 tui: 2 vin/ ngy, >65
tui: 1 vin/ ngy, ung vo bui ti)
87

* Cc thuc iu tr d phng dng t nht 6 thng, sau gim liu v ngng


thuc nu c th.
Trnh cc yu t khi pht cn:
-

Trnh cc thuc dn mch , thuc nga thai

Sinh hot n ung ngh ngi iu

Trnh cc cng thng tm l

Trnh cc thc n cha ru bia

Gii hn s dng cafe

IV.

AU U DNG CNG THNG:


1. c im lm sng:

Cn au u m ko di vi pht n nhiu ngy.

Cm gic au nh sit cht, nng u c 2 bn.

au khng theo nhp mch

Cng au trung bnh

Khng nn i nhng c th c triu chng s nh sng hoc ting n.


2. iu tr:

Thuc gim au:


+ Nhm Acetaminophen (Paracetamol, Efferalgan), Efferalgan codein,
Paracetamol 0,5g liu t 1-2vin x 3-4 ln / ngy.
+ Paracetamol 500mg + codein 30mg (Eferalgan- codein) 1-3 vin/ngy
+ Paracetamol 325mg + Tramadol 37.5 mg (Ultracet) 1-2 vin x 4 -6 ln/ngy,
khng qu 8 vin/ ngy
+ Nhm khng vim nonsteroid:
Diclofenac (voltaren) vin 50mg x 2 vin/ ngy hoc
vin 75mg 1vin / ngy sau n no.
c ch u th COX 2:
Piroxicam 10mg x 2 ln/ngy
Etodolac (edosic) 600-1.200mg/ngy
Nabumeton (korum, novidol) 1 2g /ngy
88

c ch chn lc COX 2:
Celecoxib 200 400mg/ngy.
Meloxicam(Mobic) 7,5mg x 2 ln/ngy
-

Thuc gin c:
+ Thiocolchicosit (Coltramyl 4 mg): 2 vin x 2 ln/ ngy
+ Mephenesin (Decontractyl): 500 1000 mg x 3 ln/ ngy
+ Tolperisone (Mydocalm 50 mg, 150 mg): 50 - 150mg x 3 vin / ngy
+ Eperison (Myonal) 50mg x 3 vin/ ngy
+ Tizanidine 2 4 mg x 3 4 ln/ ngy
+ Nhm Benzodiazepin: Diazepam 5 15 mg/ ngy, Temazepam 7,5 30
mg/ ngy

Chng trm cm:


+ Amitryptyline 25 100 mg/ngy
+ Etifoxine chlorhydrate 50 mg x 3- 4 ln/ ngy
+ Sulpiride ( dogmantin, sulpiride stada) 50 150mg / ngy.

Thuc chng ng kinh:


+ Topipramate 100 mg/ ngy
+ Valproate sodium 500 mg/ ngy

Khng dng thuc:


Nm ngh yn tnh
Trnh ung nhiu ru
Trnh cng thng.

V.

AU U TNG CM:

1. c im lm sng:
-

Cng rt d di, au tp trung mt bn hc mt, cn ko di 15 180 pht


nu khng iu tr.

au u phi hp vi t nht mt trong nhng triu chng sau y pha bn


au:
Sung huyt kt mc mt
Chy nc mt
89

Chy nc mi
V m hi vng trn v mt
Ph mi mt
2. iu tr:
-

iu tr ct cn:
Dyhydroergotamin dng ung: Tamik 3mg ung 1 vin x 3 ln/ ngy.

iu tr nga cn:
Cn tip tc iu tr cho n khi bnh nhn ht au u t nht 2 tun, khi ngng
thuc gim liu t t, trnh ngng thuc t ngt.
Nhm thuc ng kinh:
+ Topipramate 100 mg/ ngy
+ Valproate sodium 500 mg/ ngy
Nhm c ch knh calcium: Flunarizine, Verepamil, Nimodipin
Corticosteroide: Prednison 0,5 mg/kg (s dng 3 tun)
Nhm thuc Gim au:
Gim au chn mt trong cc thuc theo bc thang gim au ca t chc
Y t th gii (WHO):

Thuc gim au:


+ Nhm Acetaminophen (Paracetamol, Efferalgan), Efferalgan codein,
Paracetamol 0,5g liu t 1-2vin x 3-4 ln / ngy.
+ Paracetamol 500mg + codein 30mg (Eferalgan- codein) 1-3 vin/ngy
+ Paracetamol 325mg + Tramadol 37.5 mg (Ultracet) 1-2 vin x 4 -6 ln/ngy,
khng qu 8 vin/ ngy
+ Nhm khng vim nonsteroid:
Diclofenac (voltaren) vin 50mg x 2 vin/ ngy hoc
vin 75mg 1vin / ngy sau n no.
c ch u th COX 2:
Piroxicam 10mg x 2 ln/ngy
Etodolac (edosic) 600-1.200mg/ngy
Nabumeton (korum, novidol) 1 2g /ngy
90

c ch chn lc COX 2:
Celecoxib 200 400mg/ngy.
Meloxicam(Mobic) 7,5mg x 2 ln/ngy
TI LIU THAM KHO:
1. PGSTS. V Anh Nh - Thn kinh hc i Hc Y Dc TPHCM - 2006
(Trang 135-147).
2. PGSTS. V Anh Nh - Lm sng v thn kinh hc - i Hc Y Dc TPHCM
-2004 (trang 257-267).

91

CHNG MT T TH KCH PHT LNH TNH


I. I CNG:
Chng mt t th kch pht lnh tnh l nguyn nhn thng gp nht ca chng
mt tin nh ngoi bin, chim t 80% bnh nhn chng mt, thng gp la tui t
30-50, mc d c th gp trong bt c nhm tui no, n thng gp hn nam, cn
khong 1-2 pht, c th t khi (sau vi tun- vi thng), kh nng ti pht cao (1 nm:
18%, 3 nm: 30%).
II. CHN ON:
Loi chng mt ny c th nh hng bnh nhn tui 30 50 tui. Cn xy
ra t ngt khi u c t v tr no (nh khi nm trn ging hoc khi lm vic
di xe hi v quay u vo mt pha ). Chng mt quay trn xy ra, ko di 1- 2
pht v c th nng lm cho bnh nhn cm thy bun nn, nhng him khi nn.
Khm lm sng tt c cc du hiu lm sng bnh thng ngoi tr nghim php
Dix- Hallpike dng tnh.
NGHIM PHP DIX- HALLPIKE :
A. Xoay u bnh nhn sang bn t 30 n 45 (hnh A)

B. Bnh nhn m mt nhn thng vo mt hay trn thy thuc, sau thy thuc
92

gi u cho bnh nhn nm nga nhanh xung trong 2 giy, c dui nh ra sau v thp
hn mt ging khm t 20 n 30 (Hnh B)

Sau khong 2 n 20 giy xut hin git nhn cu xoay nh ln hay git ngang,
c th ko di t 20 n 40 giy. Git nhn cu thay i hng khi bnh nhn ngi
thng ln. Nu git nhn cu khng xy ra cho bnh nhn ngi ln 30 giy sau lp li
xoay u sang i bn.
Da vo git nhn cu phn loi tn thng ng bn khuyn:
1. ng bn khuyn sau: nh ln hay xoay theo kim ng h.
2. ng bn khuyn trc: nh xung c hay khng xoay theo kim ng h
3. ng bn khuyn ngang: Ngang (Horizont)
Dng thng gp nht ca chng mt t th kch pht lnh tnh: L do si ng
bn khuyn sau (95%); ngang (3%) ; trc (2%).
III. IU TR:

1. iu tr triu chng :
a). Thuc iu tr chng mt :
Tn thuc

Liu dng

Ghi ch

Betahistine 8;16; 24 mg 16 72 mg/ ngy Tc dng ph: Lon V. CC TE


v thai k
Flunarizine (Sibelium) 5-10mg/24 gi
Cinnarizine

Chn knh canxi. Khng dng cho


bnh nhn trm cm, Parkinson

25 50 mg

b). Thuc chng nn:


93

Tn thuc

Liu dng

Metoclorperamide
(Primperan)

10 20 mg/ ngy

Promethazine (Phenergan) 25-50mg/ngy

Gh

Tc dng ph: iLon vn


ng. CC TE
ch v thai k
Bun ng

Domperidone

20 30 mg/ ngy

C th dng cho TE

Dimenhydrinate

25-50mg/ngy

Bun ng

c) Cc thuc iu tr h tr:
- Gii lo u: Diazepam, Lorazepam; Etifoxine HCl 50mg (3-4 vin/ ngy); Sulpiride 50
mg (1-3 vin/ngy)

- H tr suy gim nhn thc tin nh:


+ Piracetam 400 800 mg x 3 ln/ ngy
+ Ginko biloba 40 80 mg x 2 3 ln/ ngy
+ Vinpocetine 10 mg x 3 ln/ ngy
- Thuc khc:
Acetyl-DL-Leucine (Tanganil) 500mg: 1 vin x 3 -4 ln/ ngy
TI LIU THAM KHO:
1. S tay lm sng thn kinh (Sau i hc), nm 2007, PGS.TS V Anh Nh;
2. S tay lm sng thn kinh (Sau i hc), nm 2013, PGS.TS V Anh Nh;

94

PHC IU TR MT NG
I. I CNG:
Mt ng khng phi l mt bnh m l mt triu chng, c nh ngha nh
kh khi u gic ng, kh duy tr gic ng, gic ng b ngt qung, hay thc dy
sm, hay gic ng khng hi phc ko di t nht 1 thng, xy ra t nht 3 ln/tun, gy
ra kh chu hay cc bin chng trong ngy.
30% ngi ln M thnh thong b mt ng, 10 20% mt ng mn tnh,
nhng ch c < 5% ngi mt ng khm chuyn khoa. Ph n, ngi ln tui, trnh
hc vn v kinh t x hi thp, stress gn y, lm dng ru hay thuc d mt ng
hn.
Nguyn nhn: c th l
-

Yu t c a: Chu k thc ng c bn ca mi ngi, nhp sinh hc, nhn


cch, c ch thch nghi v tui;

Cc yu t thc y: Bnh ni khoa hay thn kinh, dng thuc k toa v


khng k toa, cc yu t tm l, tm thn, hon cnh, mi trng, thai k,
mn kinh dng hormon hoc thuc nga thai;

Cc yu t duy tr: Hnh vi thch nghi, v sinh gic ng km, lo u, lm dng


thuc.

II. CHN ON:


Chn on mt ng phi tp trung vo cc yu t c th gy mt ng cng nh
thi gian bnh. Thy thuc cn ghi nhn thi gian mt ng:
-

Mt ng thong qua (tm th): Ch vi ngy, thng do stress cp tnh hay

thay i mi trng (l ch, du lch sang nc c mi gi khc).


-

Mt ng ngn hn: Di 4 tun thng khi pht do cc thay i hon cnh

nng n.
- Mt ng mn tnh: Ko di trn 4 tun, cc yu t thc y gm bnh thc th
hay tm l (bnh ni khoa: GERD, trm cm, h hp, xng khp), dng
thuc (chng trm cm, kch thch h thn kinh trung ng, glucocorticoid),
ru, caffein, thuc l.
95

III. X TR V IU TR MT NG:
1. Cn xc nh kiu mt ng:
- Kh bt u gic ng (mt ng u hm, ngi tr)
- Thc gic qu sm (ngi cao tui)
- Kh duy tr gic ng
2. Xc nh nguyn nhn gy mt ng.
3. Thc hin cc Bin php khng dng thuc gip ng tt:
- Nn ng v thc gic vo mt gi nht nh.
- Hn ch vic ng tra (nu cn ch nm ngh nu kh ng vo ban m).
- Chun b ging ng thch hp (thong, ti, yn tnh). Cn xem ging ng l
ni ch ng (Khng c sch bo, xem ti vi hoc hc hnh trn ging).
- Trnh ung c ph, tr m vo ti trc khi ng.
- Trnh i ng vi bng no qu hoc i qu.
- Thng xuyn tp th dc nhng khng nn tp t nht 4 gi trc khi ng.
- Luyn tp phng php th gin, chng stress (nh yoya, th dng sinh).
4. Dng dc tho theo kinh nghim dn gian c tc dng an thn: lc tin (nhn
lng), tm sen (l mm ht sen), trinh n (mc c), l vng nem
5. Thuc t dc tho: Rotunda (c Bnh vi)
6. Dng thuc khng histamin (loi OTC): Doxylamin, promethazin, alimemazin,
diphenhydramin, pyrilamin.
7. Dng thuc an thn gy ng (theo ch nh ca bc s)
- Nhm barbiturat (amobarbital, butabarbital, immenoctal, secobarbital...): rt t
dng.
- Nhm benzodiazepin : Diazepam (Seduxen, Valium), flurazepam (Dalmane),
estazolam (Prosom, Nucfalon), tetreazepam (Normison, Restoril), triazolam (Halcion)
quazepam (Doral): thng dng hin nay.
- Cc thuc khc: Cloral hydrat, meprobamat, chng trm cm (amitriptylin).
zolpidem (Ambien), zaleplon (Sonata), zopiclon c li im T ngn (1-2 gi),
khng c ch gic ng REM, t tim nng gy nghin.
96

8. Thuc chng lo u : Etifoxine chlorhydrate 50mg (1-4 vin/ngy), Sulpiride 50 mg (1-3


vin/ngy)
9. Thuc khc: Rotundin

TI LIU THAM KHO:


1. S tay lm sng thn kinh (Sau i hc), nm 2007, PGS.TS V Anh Nh;
2. S tay lm sng thn kinh (Sau i hc), nm 2013, PGS.TS V Anh Nh;
3. Mt ng - TS DS nguyn Hu c.

97

NG KINH
I. I CNG:
Cn co git (seizure) l tnh trng bnh l no, c trng bi s phng lc qu
mc, ng b v tm thi ca mt nhm cc neuron trong no; biu hin lm sng
tng ng vi vng no b kch thch. Bnh ng kinh (epilepsy) c c trng bi
cc cn ng kinh ti pht. Thng thng mt bnh nhn c chn on l ng kinh
khi c t nht hai cn ng kinh t khi pht cch nhau ti thiu 24 gi, nu ch c mt
cn duy nht th cha th gi l ng kinh.
Trng hp bnh nhn c cc cn ng kinh trong khun kh bnh l cp tnh
(vim no, nhim c no cp, ri lon chuyn ha ) th khng c gi l bnh
ng kinh. T l dn s b ng kinh khong 1- 2%.
* PHN LOI: Theo Hip hi Chng ng kinh Quc t nm 1981
1. ng kinh cc b:
ng kinh cc b n gin: Vi triu chng vn ng, cm gic, gic quan hay
tm thn.
ng kinh cc b phc tp: C nh hng ti tri gic, c th khi u l ng
kinh cc b n gin sau mt thc hay mt thc ngay.
ng kinh cc b n gin hay phc tp ton th ha.
2. ng kinh ton th
Cn vng thc;
Cn vng khng in hnh;
Cn git c;
Cn co git;
Cn co cng;
Cn mt trng lc;
Cn co cng co git.
4. ng kinh khng phn loi: Gm cc cn m cc d liu lm sng khng cho
php phn loi vo hai loi trn.

98

II. CHN ON:


Chn on da vo hi bnh s cn thn, khm thn kinh v lm mt s CLS.
A. LM SNG:
Khi pht bt cht.
C xu hng lp li
Cn ko di khong vi pht.
B. CN LM SNG:
CT u: l xt nghim cn thit vi cc trng hp sau (cn cc b, cn khi pht
tui nh nhi, cn khi pht sau 20 tui, cn ton th khng p ng iu tr, c du
hiu thn kinh cc b) s cung cp cc thng tin chi tit v cu trc bnh thng ca
no, nhng bt thng cu trc: mu t, nang, u, m so c lin quan n ng kinh.
MRI no ngoi cc thng tin nhn c nh chp CT scan, n cn gip pht hin
cc d dng bm sinh, x cng thy thi dng.
in no gip nhn bit c hot ng bt thng trong no m sinh ra cn
ng kinh. N gip nhn bit v tr, nng v loi cn ng kinh.
C. CHN ON NGUYN NHN:
60 75% cc trng hp ng kinh l khng r nguyn nhn. Cc nguyn nhn
c th pht hin: tn thng no trong bo thai, chn thng lc sinh (do thiu oxy),
ng c, nhim trng h thn kinh trung ng, chn thng u, u no, tai bin mch
mu no
D. CHN ON PHN BIT:
Co git do nguyn nhn tm l; ngt; migrain; h ng huyt; bnh no do bin
dng; cn thiu mu no thong qua; ri lon tin nh; ri lon trong gic ng; cn
qun ton b tm thi; ri lon vn ng; co tht na mt; cn hong lon; tc dng
ph ca thuc v c cht.
III. IU TR:
Thuc chng ng kinh c chn la ty theo loi cn, v thuc ch c tc dng
vi mt s th lm sng.

99

Loi cn

Thuc hng u

Thuc hng th nh La chn khc

Cn cc b n gin hay
phc tp

Carbamazepine
Phenytoin

Gapapentin
Valproic acid
Lamotrigine
Gapapentin
Lamotrigine
Phenobarbital
Lamotrigine
Clonazeopam

Phenobarbital
Primidone
Topiramate
Topiramate
Clonazeopam

Lamotrigine

Ethosuximide

Cn co cng co git Carbamazepine


nguyn pht hay th pht Valproic acid
Phenytoin
Valproic acid
Cn vng thc
Cn vng thc khng Valproic acid
in hnh, cn mt trng
lc, cn git c
Valproic acid (Depakin vin 500mg)

Khi u liu 200 400mg/ngy, tng 5 10mg/kg mi 3 7 ngy.


Liu duy tr 10 40mg/kg/ngy.
Topiramate ( Topamax vin 25, 50mg)
Liu khi u 50mg/ngy sau tng 50 mg mi 1- 2 tun cho ti liu 200
600mg/ngy. Liu duy tr 200 600mg/ngy.
Gabapentin: vin 300mg
Khi u 300mg mi ngy v mi ngy tng 300mg chia lm 3 ln.
Liu ti a 4800mg/ngy. Liu duy tr 900 4800mg/kg/ngy.
Phenobarbital vin 100mg
Khi u 0,5 1mg/kg/ngy( ngi ln 30 -60mg/ngy), tng liu 0,5 -1mg mi 3-4
tun. Duy tr 1- 3 mg/kg/ngy( 60 240mg/ngy)

Carbamazepine vin 200mg (tegretol,)


Liu khi u 400mg/ngy v tng 200mg mi tun
Liu duy tr 8 20 mg/kg/ngy (400 1800mg/ngy)
TI LIU THAM KHO:
1. S tay lm sng thn kinh (Sau i hc), nm 2007, PGS.TS V Anh Nh;
2. S tay lm sng thn kinh (Sau i hc), nm 2013, PGS.TS V Anh Nh;
3. Phc iu tr 2013 - Bnh vin Ch Ry;

100

BNH PARKINSON
I - I CNG
Bnh Parkinson l nguyn nhn thng gp nht ca Hi chng Parkinson. Theo
y vn t l mc bnh l 187/100.000 dn (nguy c sut i 1/40). La tui khi pht t
50 70, mc d bnh c th xy ra t 20 tui (khong 10%). Tui t vong ca bnh
nhn Parkinson tng t vi nhm chng. Sa st tr tu c khuynh hng xy ra trong
giai an mun ca bnh trong khong 30% s bnh nhn.
Cn nguyn gy bnh hin khng c bit, c th c vai tr ca stress oxy ha
v cc ri lon chc nng ty lp th.
Yu t di truyn: Nguy c di truyn khi tin cn gia nh mc bnh trc 50 tui.
Yu t mi trng: Tip xc vi thuc tr su cc vng nng thn.
Triu chng chnh l run tremor cn gi l tnh trng lit run shaking palsy.
Triu chng run c th ngng khi bnh nhn cm a hay cm t bo. Hu qu sau
cng ca bnh l mt thng bng hay cng c.
II- CHN ON.
Chn on bnh Parkinson i hi cc iu kin:
1. Hin din 2 trong nhng biu hin ch yu ca hi chng Parkinson: Run khi
ngh, chm vn ng, cng , t th khom gp, ng cng v mt phn x t
th.
2. Khng c bnh s, tin s ca nhng nguyn nhn khc gy hi chng
Parkinson (Vim no, phi nhim vi c cht, mi dng thuc chng lon thn
gn y, chn thng u, bnh l mch mu v tr ph hp)
3. Khng c tht iu tiu no, lit vn nhn dc, cc biu hin tn thng thn
kinh thc vt nng.
4. MRI khng c nhi mu l khuyt, u nc p lc bnh thng, teo tiu no v
hoc thn no.
5. p ng r vi Levodopa.
Ni chung cn ngh n bnh Parkinson nu bnh nhn c hi chng Parkinson
vi run khi ngh, khi pht khng i xng v p ng r vi Levodopa, vi
101

iu kin khng c nhng du chng bt thng tiu no, tn thng b v gai,


mt phn x t th sm, ri lon chc nng thc vt nng v sa st tr tu sm.
* CHN ON PHN BIT
1) Lit trn nhn tin trin.
2) Thoi ha v no nhn nn.
3) L ln lan ta vi th Lewy Bodies.
4) Teo a h thng gm teo tiu no cu v nhn trm v hi chng Shy-Drager
5) Bnh Parkinson vi x cng teo c ct bn.
III-TR LIU NI KHOA BNH PARKINSON
Mc tiu:
Ci thin cc ri lon bnh l lm cn tr sinh hot hng ngy
Gi cho bnh nhn duy tr c hot ng cng lu cng tt. Hn ch ti a cc
bin chng ca bnh.
Bnh lun tin trin, khng c phng php no lm chn li c; nn iu tr
sm, ng v .
Dopamine l thuc c hiu qu nht lm gim triu chng bnh Parkinson.
Tt c nhng thuc tr liu chng bnh Parkinson nn dng liu thp v gia tng t t
trnh nhng phn ng ph.
* CC THUC U TIN:
1. L-DOPA phi hp CARBIDOPA:
Sinemet(Carbidopa kt hp levodopa ) vin( 10/100, 25/100,25/250) :
Khi u 100 150mg levodopa/ngy, chia lm 2 3 ln sau ba n. Tng
100mg mi tun, liu nn gi mc ti thiu lm ci thin triu chng.
Stalevo ( Carbidopa plus levodopa plus entacapone ): vin (mg): 12.5/50/200;
18.75/75/200; 25/100/200; 31.25/125/200; 37.5/150/200; 50/200/200; khi u liu
thp 1 ln/ngy nn gi mc ti thiu lm ci thin triu chng.
2. C CH MEN COMT: Catechol-O-Methyltransferase
Tolcapone(Tasmar) khi u 100mg 3 ln/ngy. khi u liu thp 1 ln/ngy
nn gi mc ti thiu lm ci thin triu chng.

102

3. CHT NG VN DOPAMINE:
Bromocriptine( parlodel ) vin 2,5mg, 5mg khi u 1,25mg tng dn mi 2 4
tun cho n khi t hiu qu v duy tr 2,5 10mg, 3 ln/ngy.
Pergolide khi u 0,5mg, duy tr 1mg 3ln/ngy.
* THUC CHN TH HAI
1. Thuc khng cholinergic: Gip ci thin triu chng run
Artan( trihexylphenidyl) 0,5 - 2mg x3 ln/ngy
2. Amantadine (symmetrel) vin 100mg khi u 100mg bui sng, c th tng
liu n 100mg x 3/ngy.
3. Thuc chn Beta (Propanolol, Metoprolol ): C hiu qu hn nhng thuc
khng cholinergic trong iu tr run, nn dng liu thp tng dn, cn lu huyt p v
chng ch nh.
4. Thuc khc: Pramipexol
V-KHUYN CO
Hin din ca run, cng c v lon ng bnh nhn l nhng yu t ca khi pht
sm ca bnh Parkinson, nu khng c triu chng thn kinh no khc, v nu bnh
nhn khng dng thuc gy ra hi chng parkinson, chn on chc chn bnh
Parkinson. Cn:
Gii thch cho bnh nhn r bnh tnh.
Khuyn khch bnh nhn luyn tp th lc u n.
Triu chng nh khng cn tr liu.
Nu bnh nhn c nhng than phin cn tr chc nng, cn xem xt tr liu. Nu
bnh nhn nh hn 70 tui, tr tu cn minh mn nn khi ng tr liu vi ng
vn dopamine non-ergot bi v t c nguy c bin chng v vn ng trong nm
nm u. K levodopa c th cho thm vo nu khng c p ng vi ng
vn dopamine.
TI LIU THAM KHO:
1. S tay lm sng thn kinh (Sau i hc), nm 2007, PGS.TS V Anh Nh;
2. S tay lm sng thn kinh (Sau i hc), nm 2013, PGS.TS V Anh Nh;

103

BNH NHC C
I. I CNG:
Bnh nhc c l ri lon thn kinh c t min do s sn xut t khng th khng th
th acetylcholine nicotinic. Khong 80 90% bnh nhn nhc c c khng th khng th
th acetylcholine nicotinic. Tn sut mc bnh 1/20.000 - 1/10.000 dn. T l nam: n
khong 1:2. Cc triu chng c th xut hin bt c la tui no, nhng thng gp nht l
t 20 30 tui 073 n, 50 60 tui nam. Cc bnh t min khc kt hp nh: Vim khp
dng thp, lupus v thiu mu c tnh gp 5% bnh nhn; Bnh tuyn gip gp 10% bnh
nhn, thng kt hp vi khng th khng tuyn gip. Khong 10 -15% bnh nhn nhc c
c u tuyn c.
II. CHN ON:
1. Tiu chun chn on:
-

Lm sng: Du hiu chnh ca bnh nhc c l yu c dao ng v d mt

mi. Cc triu chng vn nhn xy ra 50% bnh nhn (25% khi u bng song th,
25% khi u bng sp mi) v khi bnh hn 1 thng th 80% c bt thng v vn
nhn. Cc triu chng hu hng (ni kh, nut kh) xy ra 10%, yu chn (i li kh)
10% v yu ton thn 10%. Suy h hp gp 1%. Bnh nhn lun than phin cc triu
chng do yu c khu tr nh song th, sp mi, ni kh, nut kh, mt kh nng nng
cnh tay qu u hoc i li kh khn. Bnh nhn nhc c khng than phin yu
chung chung, mt chung chung, bun ng hoc au c. Trong trng hp in hnh,
yu c dao ng, xu hn khi gng sc v ci thin khi ngh ngi. Cc triu chng c
khuynh hng nng vo cui ngy. Mt s yu t khc c th thc y yu c bao gm
cng thng tinh thn, nhim trng, thuc (succinylcholine, khng sinh nhm
aminoglycoside, quinidine, c t botulinum)
-

Test thuc Telsilon (Edrophonium) hoc Prostigmine (+)

Cn thc hin test ni c iu kin cp cu h huyt p, ngt, suy h hp. Nu


bnh nhn c kh th nng phi hon test cho n khi tnh trng h hp n nh. Phi
chun b 0.4 mg Atropine tim tnh mch trong trng hp c tc dng ph ca thuc
(nhp tim chm). Chn 1 hoc 2 nhm c (c nng mi, c vn nhn ngang, c hu
104

hng) quan st. Chun b ng tim 1 ml (10 mg) Telsilon (Edrophonium), tim mch
0,1 ml (1 mg) test s nhy cm ca thuc (theo di nhp tim v tc dng ph ca
thuc). Sau 1 pht, nu khng c tc dng ph xy ra, tim thm 3 mg v quan st s
ci thin ca bnh nhn. Mt s bnh nhn nhc c ci thin tt trong 30 -60 giy sau
tim 4 mg, khi ngng test. Nu sau 1 pht, vn cha ci thin, tim thm 3 mg v
ch thm 1 pht na, nu vn khng ci thin, tim 3 mg cui cng. Nu bnh nhn c
triu chng muscatinic (nh tit m hi nhiu, tit nc bt) bt c lc no trong khi
ang lm test chng t liu thuc ci thin triu chng v nn ngng test. Thi
gian ci thin yu c ca Edrophonium ch ko di vi pht. Nu yu c ci thin r
rng th kt lun test (+). Nu khng ci thin r rng nn kt lun test (-). C th tin
hnh m i vi gi dc (nc mui sinh l) so snh. Cng c th lp li test vi
ln. nhy 90%, c hiu kh xc nh v thuc cng ci thin yu c trong cc
bnh thn kinh c khc: Hi chng Eaton Lambert, botulism, hi chng Guilliain
Barre, bnh neuron vn ng, cc tn thng thn no v xoang cnh.
Neostigmine c thi gian tc dng ko di hn, cng c th dng lm test, liu 0,04
mg/kg IM hoc 0,02 mg/kg IV (ch duy nht 1 ln).
-

in c: Test kch thch dy thn kinh lp li (+) khong 60%. in c si n

c c kt qu (+) trong 77 100% trng hp ty nng ca bnh.


-

Khng th khng th th Acetylcholine (+) 50 75%.

2. Chn on nguyn nhn: Do bt thng min dch mc phi. Cc cn lm sng


gip chn on nguyn nhn v h tr iu tr.
-

X quang ngc nghing

CT scan ngc c cn quang: nh gi tuyn c (bnh thng, tng sinh, u)

Chc nng tuyn gip; ng huyt, ion , chc nng gan, thn, v cc bnh

t min khc.
3. Chn on phn bit:
-

Vim a c: Yu c gc chi lin tc, c th p ng vi test Prostogmine.

Bnh c do cng gip: Lit vn nhn li mt- xm ln m m vo mt.

Hi chng nhc c: Nhc c do thuc, nhc c do ng c botulinum

Bnh c ty th: Lit vn nhn tin trin km sp mi v yu c.


105

Sarcodosis.

Nhc c + lymphoma.

Bin chng thn kinh c ca nhim HIV.

Lit chu k h Kali mu.

4. Chn on phn loi:


Ossermann ci tin

Ossermann
I: Nhc c th mt

1. Nhc c th mt

IIA: Nhc c ton thn nh, p ng tt vi thuc 2. Nhc c ton thn nh


khng cholinesterase
IIB: Nhc c ton thn mc trung bnh, nh hng 3. Nhc c ton thn trung
nng n h c xng v h c thuc hnh no, c p ng bnh
vi thuc khng cholinesterase nhng khng y
III: Nhc c nng, suy h hp

4. Nhc c ton thn nng

IV: Nhc c nng giai on cui. Hnh nh ging ht 5. Cn suy h hp.


nh III, nhng tin trin t I sang II mt hn 2 nm

* 4 5: nn nhp vin

III. IU TR:
1. Nguyn tc:
- Phc iu tr nhc c nn c thit lp ring cho tng bnh nhn v ph
thuc vo nng ca bnh, tui, c hay khng c ph i tuyn c v cc bnh l ni
khoa km theo.
- Mc ch ci thin sc c, u tin m bo h hp y cho bnh nhn.
2. iu tr c hiu:
2.1. Nhc c th mt: Nn bt u bng Pyridosigmine bromide (Mestinon 60 mg)
30 -60 mg/ 4-6h, chnh liu ty theo p ng 120 mg/3h, nu vn cn triu chng,
iu tr t ngn (2-3 thng) Corticoides vi liu tng dn.
2.2. Cn nhc c: iu tr ti khoa Hi sc.

106

2.3. Thuc c ch men cholinesterase: Pyridosigmine bromide v Neostigmin


bromide l nhng thuc thng s dng.
- Pyridosigmine bromide (Mestinon 60 mg) 30 -60 mg/ 4-6h, chnh liu ty theo
p ng 120 mg/3h. Tc dng ph: Ri lon tiu ha (kh chu, tiu phn lng, bun
nn, nn, au qun bng, tiu chy), tng tit trong ph qun v trong ming.
- Neostigmin bromide (Prostigmine 15 mg) 7,5 15 mg/ 3-4h.
2.4. Coticoides: Ci thin ng k triu chng >75% bnh nhn (trong 6 8 tun u).
Prednisone liu 1-1,5 mg/kg/ ngy, 1/3 bnh nhn c yu c tm thi trong 7-10 ngy
u iu tr. Nn s dng cch ngy gim tc dng ph v gii thch r cho bnh
nhn trnh ngng thuc.
2.5. Thc c ch min dch:
- Azathioprine ci thin triu chng phn ln bnh nhn, nhng chm (4-8
thng sau iu tr). Cc bnh nhn tht bi vi Corticoides c th p ng vi
Azathioprine hoc ngc li. Tc dng ph: Mt mi, gim t bo mu (thng nhchnh liu)
- Mycophenolate mofetil: S dng cho nhc c khng tr hoc do tc dng ph
ca thuc c ch min dch khc. Liu 0,5g x 2 ln ung/ ngy, sau 2 tun c th tng
ln 1g x 2 ln/ ngy. Tc dng ph: gim t bo mu, lot d dy, xut huyt tiu ha.
2.6. Ct tuyn c: ngh cho hu ht bnh nhn nhc c. p ng tt nht ngi
tr v giai on sm ca bnh (bnh khi pht sau 60 tui , bnh nhn c u tuyn c
khng p ng tt nh bnh nhn khng u tuyn c).
2.7. Thay huyt tng.
2.8. Truyn Globulin min dch.
3. iu tr h tr: B sung Kali, Calci khi dng Corticoides; thuc chng trm cm;
khng sinh khi c tnh trng nhim trng.
IV. THEO DI:
Theo di cng thc mu, ion v nh lng khng th khng th th
acetylcholine nh k iu chnh liu thuc c ch min dch. Trnh tng, gim liu
thuc khng men hoc c ch min dch t ngt (thc y cn nhc c).
TI LIU THAM KHO:
107

1. S tay lm sng thn kinh (Sau i hc), nm 2007, PGS.TS V Anh Nh;
2. S tay lm sng thn kinh (Sau i hc), nm 2013, PGS.TS V Anh Nh;
3. Phc iu tr 2013 - Bnh vin Ch Ry;

LIT VII NGOI BIN


I. I CNG
Lit dy thn kinh s VII ngoi bin ( hay con gi Bells Palsy ) l mt tn
thng cp tnh, thng t gii hn lin quan n ch mt dy thn kinh mt thn
kinh s VII.
Cho n nay vn cha xc nh c nguyn nhn ca lit VII ngoi bin. Mt
s yu t c cho l c th gy ra Lit VII ngoi bin l :
Herpes simplex virus type 1 ( HSV 1 ) c xc nh trong a s cc
trng hp
Herpes Zoster
Nhim HIV cp tnh
Bnh Lyme
Vim tai gia cp hoc mn tnh
Bnh c
Khi u vng mt : u tuyn nc bt,
II. CHN ON :
Chn on bnh ch yu da vo lm sng. Bnh thng xy ra t ngt khi di
tu xe hoc thng sau ng dy pht hin :
- Khun mt mt cn xng : M hoc mt cc np nhn t nhin: Np nhn
trn, rnh mi m. Ming v nhn trung b ko v bn lnh (khi nhe rng s mt cn
xng cng r hn.)
- Mt bn lit khng nhm kn Du Charles Bell (+)
- Cm gic t mt bn mt
- Mt v gic 2/3 trc li
- Kh mt hoc chy nc mt

108

III. IU TR : Khng c iu tr c hiu :


1) Corticosteroids: Prednisolon: 20mg - 60mg/ ngy chia lm 2 3 ln / ngy (c th
n 80mg / ngy ) duy tr 1 2 tun, gim liu khi lm sng ci thin. Nn cho trong
vng 72 gi sau khi khi pht
Methylprednisolon: 16 48 mg/ngy
2) Thuc khng virus: Acylovir 200mg 5 ln / ngy t 7 n 10 ngy
3) Kt hp khng virus v corticoide: 1000mg/ngy x 5 ngy kt hp prenisolone

4) 60mg/ngy x 5 ngy sau 30mg/ngy x 3 ngy sau 10mg/ngy x 2 ngy


5) Vitamin nhm B (B1, B6, B12): 1 vin x 2 ung/ngy x 7 ngy
6) Chm sc mt : Nn eo knh rm chng gi bi, ra mt thng xuyn bng nc
mt nhn to, nc mui sinh l ( NaCl 9 ) hay Cloramphenicol 0,4 %.
7) Vt l tr liu : Cc bi tp trn khun mt c th lm gim thi gian phc hi
hoc di chng
8) Phng php khc : Hiu qu ca chm cu cn ang c xem xt

TI LIU THAM KHO:


Phc iu tr Khoa Ni thn kinh Bnh vin KTT An Giang.

109

CN THIU MU NO THONG QUA


I. I CNG:
Cn thiu mu no cc b thng qua l mt ri lon chc nng thn kinh. Bnh
c c im xut hin t ngt, c triu chng thn kinh cc b, tn ti trong thi gian
di 24 gi, phc hi triu chng hon ton v c xu hng lp li nhiu ln
* NGUYN NHN:
C ch thiu mu cc b thong qua vn cha r, ngi ta ngh do cc nguyn
nhn sau:
1. X va ng mch:
2. Cc bnh tim gy thuyn tc: Rung nh, hp van 2 l, van tim nhn to,..
3. Cc nguyn nhn gy thuyn tc mch khc: Mng x va t ng mch n
ng mch c ng knh nh hn, huyt khi tnh mch phi
II. CHN ON:
2.1. Lm sng:

Cn thiu mu cc b thong qua c triu chng ty theo s phn b mu nui


ca ng mch. Cn thiu mu no cc b thong qua c th ko di vi giy n 12
24 gi thng 10 15 pht. Da trn cc c im ca cn thiu mu no thong qua
c th nh khu c ng mch lin quan
1. Cc biu hin thuc h ng mch cnh: M tm thi mt mt, lit nh na
ngi, ri lon cm gic na ngi, ri lon ngn ng
2. Cc biu hin thuc h ng mch ct sng thn nn: Biu hin lm sng rt
a dng cc triu chng vn ng, cm gic hai bn lun chuyn, tht iu vn ng
bn ny hoc bn kia, cm gic chng mt lm bnh nhn phi nhm mt, i lon
chong, rung git nhn cu, cc ri lon vn nhn hay vn ngn
2.2. Cn lm sng:
- CT scan u t c gi tr chn on
- MRI u pht hin sm tn thng c kch thc nh
- Siu m xuyn s: o tc dng mu ni s
- Cng thc mu, ion , ure, creatinin, SGOT, SGPT, lipid mu, tng phn tch
nc tiu, ECG,.
110

* CHN ON:
Da vo cc triu chng lm sng, hi bnh s v tm sot nguyn nhn, cha c
tiu chun chc chn xc nh cc cn thiu mu no thong qua
Phn bit: ng kinh, migraine, ngt, h ng huyt, h huyt p t th
III. IU TR: nhm nga t qu trong tng lai
1. Ni khoa:
Gim thiu cc nguy c t qu: H huyt p nu bnh nhn tng huyt p, kim
sot ng huyt bnh nhn i tho ng, iu chnh lipid mu nu c ri lon lipid
mu
Chng kt tp tiu cu:
Aspirin 160 300mg/ngy
Clopidrogel( plavix, pidocar,) 75mg/ngy
Cc thuc chng kt tp tiu cu s dng lu di
2. Ngoi khoa: Khi c hp hn 70% ng knh ng mch cnh
TI LIU THAM KHO:
1. S tay lm sng thn kinh (Sau i hc), nm 2007, PGS.TS V Anh Nh;
2. S tay lm sng thn kinh (Sau i hc), nm 2013, PGS.TS V Anh Nh;

111

TAI BIN MCH MU NO


I. I CNG:
Tai bin mch mu no (TBMMN) hay t qu no l mt hi chng lm sng,
c trng bi hin tng mt chc nng no cc b cp tnh v ko di trn 24 gi, c
th gy t vong v nguyn nhn do mch mu no. t qu no c nh ngha l tnh
trng no t ngt b tn thng cc b do nguyn nhn mch mu (thiu mu no cc
b hoc chy mu no) gy ra triu chng thn kinh khu tr (i khi ton th), khng
do chn thng.
TBMMN gm cc th lm sng:
- Xut huyt (chy mu) trong s (15 20%)
+ Xut huyt trong no (Xut huyt no no tht);
+ Xut huyt khoang di nhn.
- Thiu mu cc b no cp hay cn gi l nhi mu no (NMN) (80 85%)
Khi nim TBMMN khng bao gm: Chy mu t di mng cng, mu t ngoi
mng cng, hoc cc chy mu hay NMN do nguyn nhn chn thng, nhim trng
hay u.
* NGUYN NHN:
1. Thiu mu no cc b (NMN)
-

Huyt khi x va ng mch (M) ln gy tc mch ti ch hoc lp mch t

M n M
-

Bnh tim gy lp mch no, c bit l rung nh, ngoi ra cn c cc lon nhp

khc, hp van 2 l, van nhn to


-

Bnh l mch mu nh (NMN l khuyt) ch yu do tng huyt p.

Bnh l v mu.

2. Xut huyt: Mt s nguyn nhn chnh


-

ngi trung nin v ln tui, tng huyt p l nguyn nhn chnh, ngi gi

nguyn nhn c th l thoi ha dng bt, u no.


-

ngi tr, nguyn nhn ch yu l d dng ng tnh mch, phnh mch, ri

lon ng mu.
112

3. Xut huyt khoang di nhn:


-

Nguyn nhn ch yu l v ti phnh M;

Ngoi ra cn c th do: d dng ng tnh mch, ri lon ng mu, chn

thng.
* Bnh s chi tit c th chn on khong 80% cc trng hp TBMMN vi:
1. Khi pht t ngt: Bnh cnh in hnh l khi pht t ngt, tin trin vi cc
khim khuyt thn kinh lin quan n tn thng mt vng no theo phn b ti
mu ca mt M.
2. Cc triu chng thng gp:
au u: t ngt, nng n, t cng au nng ngy t nhng pht u, gi

+ Trong XH di nhn: Bnh nhn m t au u nh ba b, nh mun n


tung, thng km nn i, cng gy v du mng no, 20 30% c au u khng in
hnh, mt s t khng au.
+ Trong Xut huyt no, khi pht au u cng t ngt km khim khuyt thn
kinh tin trin v bin i thc, him c du mng no tr trng hp XH no
mng no hay lt no tht v khoang di nhn.
+ Trong NMN t khi c au u (20%) hoc au mc nh v thong qua.
NMN do lp mch t tim thng gp au u hn do x va ng mch
-

Chng mt: Thng gp trong nhi mu tiu no hoc thn no, XH hoc thiu

mu cc b M sng- nn thong qua. Thng rt hay km theo ri lon chc nng


thn no hoc tiu no: nystagmus, ri lon vn nhn, tht iu vn ng v cc bt
thng ca cc dy s khc.
-

Ri lon th gic: Thng gp l m, c th m thong qua, do tc M cnh

trong cng bn hoc tc M mt, m mt bn t ngt do tc M vng mc trung


tm, hoc m v no do tn thng v no thy chm 2 bn, thng do tc nh M
thn nn (BN khng nhn thy, nhng phn x nh sng vn nhy do chc nng thn
no cn nguyn, bn manh (thng l bn manh ng danh hoc gc manh ng danh)
do tn thng tia th hoc v no 1 bn v nhn i do nhiu nguyn nhn, nhn i
xut hin t ngt l in hnh ca XH hoc nhi mu thn no cp, nhn i tin trin
113

chm tng dn do phnh mch hoc u, nhn i c lin quan n au mt hoc xung
quanh mt c th do huyt khi tnh mch xoang hang, do phnh mch ca M cnh.
-

Ri lon ngn ng:


+ Mt ngn ng din t (mt kh nng ni thnh li, nhng cn bn vn gi

c kh nng thng hiu li ni) do tn thng vng Broca nm phn sau hi trn
di.
+ Mt ngn ng tip nhn (mt ngn ng Wernicke: Mt kh nng hiu li ni,
nhng kh nng ni khng b nh hng, BN vn c th ni lu lot nhng khng
thnh cu, khng r ngha v hon ton khng ph hp vi ch , vi cu hi, BN
thng ni nhiu v ni qu tha- mt ngn ng lu lot), do tn thng vng
Wernicke nm phn sau ca hi thi dng trn.
+ Mt ngn ng ton b: Khng hiu li ni v khng ni c, vn tnh to,
linh hot, p ng vi mi trng xung quanh tt tr p ng v ngn ng (git mnh
vi ting ng, quay v ni c m thanh, nhn v tip xc bng mt vi ngi i din
).
-

Cc ri lon cm gic: Thng gp nht l t, gim hoc mt cm gic, thng i

vi lit ngi.
-

Yu v lit na ngi: L du hiu thng gp nht, phn b v mc lit

gip nh khu tn thng. Lit ngi khng ng u (gia tay v chn) trong tn
thng v no; tn thng bao trong th lit ngi ng u; lit ngi km bt
thng dy thn kinh s bn kia c th gp trong cc tn thng thn no: Hi chng
Weber, Milard Gubler
-

Ri lon thc hn m: Do tn thng h thng li hot ha hoc hot ng

chc nng ca 2 bn cu no b tn thng, c 3 dng tn thng ch yu gy hn m


thng gp:
+ Tn thng cc b gy nh hng cu trc su ca gian no, chn p bn cu
cn li, hoc chn p trung no; nguyn nhn do mu t trong s, nhi mu din rng
trn liu, u no, p xe
+ Cc tn thng thn no trc tip nh hng vo h thng li thn no.

114

+ Qu trnh ri lon chc nng thn no v hoc nh hng c hai bn v no, gp


trong cc nguyn nhn chuyn ha, thiu oxy no, bnh no.
CHN ON LM SNG:

II.

1. LM SNG:
-

Bnh khi pht t ngt vi cc triu chng cc b hay cc thiu ht chc nng

thn kinh.
-

Tin trin nhanh n thiu ht thn kinh ti a (lit, hn m, ri lon vn ngn,

ri lon cm gic )
-

Khng thoi lui: Tin trin nng ln, t mc ti a m tnh trng XH hoc thiu

mu no cp c th gy ra. Nu triu chng thoi lui sm trong vng 24 gi (a s


trong vng 1 gi) th cha phi l t qu no tht s m l cn thiu mu no thong
qua.
2. CHN ON PHN BIT:
2.1. Bnh no do nguyn nhn chuyn ha: H ng huyt, tng ng huyt, h
natri mu, bnh no do gan, ng c thuc hay ru.
2.2. Cn ng kinh vi lit Todd sau cn hoc cn ng kinh khng c co git.
2.3. Migraine c triu chng lit ngi.
2.4. Sang thng trong s no v cu trc (mu t di mng cng, u no, d dng
ng tnh mch).
3. CHN ON TH LM SNG:
-

XH di nhn c bnh cnh ring vi au u d di v du mng no, thng

khng c du thn kinh nh v, nn d phn bit vi XH no v NMN.


-

Phn bit XHN v NMN:


+ Bnh khi pht vi cc triu chng au u, nn i v cng gy thng l do

XH. Mt BN t qu c gim thc sm thng l XH (Nhi mu no din rng cng


biu hin bng gim thc nhng thng mun hn).
+ Cc du thn kinh nh v ca NMN thng khu tr theo vng chi phi ca
mt M no, trong khi XHN c th biu hin cc vng M khc nhau.

115

c tnh

Xut huyt no

Nhi mu no

Khi pht t qu

< 30 pht

> Vi gi - 24 gi

Din tin

Nhanh (+++)

T t (+)

au u

80 90%

Him

Nn i

Him

Him gp

Ri lon thc hay hn m

40 45%

Khong 15%

Du mng no

XH mng no, XH Him gp


no no tht

Cc
triu
chng

Tuy nhin, mt s trng hp trn lm sng kh phn bit c XH no v


NMN, cn phi c CT scan hoc MRI.
4. CN LM SNG:
Trong giai on cp ty trng hp, c th thc hin cc CLS sau:
CT scan v hoc MRI, ECG, X quang phi, siu m tim, siu m

o
M cnh
o

CTM, PT/ INR, aPTT

ng huyt, HbA1C, bilan lipid mu, ion , ur, creatinin, Men

tim, ALT, AST


o

Kh mu M, bo ha oxy.

Chc d DNT (nu nghi ngh XH di nhn)


IU TR:

III.

1. Trong giai on cp: iu tr ni tr (xem phc Khoa Ni Thn kinh)


2. Phng nga th pht (Qun l bnh nhn sau ra vin): Chung cho c xut
huyt no v nhi mu no
-

Thay i li sng: B thuc l, n gim mui, tp luyn thn th, gim cn, ch

n t m, nhiu rau qu;


-

Tp vt l tr liu Phc hi chc nng;


116

n nh huyt p (xem phc iu tr Tng huyt p);

n nh ng huyt (xem phc iu tr i tho ng)

n nh bilan lipid: u tin s dng nhm Statin (Atorvastatin, Simvastatin,

Lovastatin, Rosuvastatin, Fluvastatin, Pravastatin) hoc nhm Fibrat (Bezafibrat,


Ciprofibrat, Fenofibrat) hoc Gemfibrozil ty theo loi ri lon lipid.
-

Thuc bo v thn kinh:


+ Piracetam 400 800 mg x 3 ln/ ngy
+ Ginko biloba 40 80 mg x 2 3 ln/ ngy
+ Vinpocetine 10 mg x 3 ln/ ngy

3. Ring vi nhi mu no:


-

Chng kt tp tiu cu:


+ Clopidogel 75 mg/ ngy
+ Aspirin 75 325 mg/ngy

+ Dipyridamol + acetylsalicylic acid 200/50 x 2 ln/ ngy.


-

+ Cilostazol 0,1 g x 2 ln/ ngy


Nu rung nh: Chng ng ng ung (Acenocoumarol).

TI LIU THAM KHO:


1.

S tay lm sng thn kinh (Sau i hc), nm 2007, PGS.TS V Anh Nh;

2.

S tay lm sng thn kinh (Sau i hc), nm 2013, PGS.TS V Anh Nh;

117

VIM PHI CNG NG NGI LN


I. I CNG:
Vim phi mc phi cng ng l hin tng nhim khun nhu m phi xy
ra ngoi bnh vin, bao gm: Vim ph nang, ng v ti ph nang, tiu ph qun tn
cng hoc vim t chc k ca phi. Tc nhn gy vim phi c th l vi khun, virus,
k sinh trng, nm, nhng khng phi l trc khun lao.
II. CHN ON:
Trn bnh nhn ang sng ngoi cng ng hoc khng bnh vin trong
vng 2 tun l t nht trc , mi xut hin v c t nht 3 trong 4 du hiu sau:
1. C 1 trong cc biu hin ton thn: Mt mi, n lnh (hoc st), chn n, sa st
tri gic mi xut hin.
2. C 1 trong cc biu hin c nng h hp: Nng ngc, kh th, ho, khc m c.
3. Cc biu hin thc th khi khm phi: Ting th bt thng, ran n.
4. Xquang ngc: Hnh nh thm nhim (tn thng lp y ph nang) mi.
* CHN ON PHN BIT:
1. Lao phi:
2. Trn dch mn phi:
3. Nhi mu phi:
4. Ung th phi:
5. Dn ph qun bi nhim:
III. IU TR:
1. Nguyn tc chung:
- La chn khng sinh theo cn nguyn gy bnh nhng ban u thng theo
kinh nghim lm sng, yu t dch t, mc nng ca bnh, tui bnh nhn,
cc bnh km theo, cc tng tc, tc dng ph ca thuc.
- Thi gian dng khng sinh: T 7-10 ngy nu do cc tc nhn khng in hnh.
118

- iu tr triu chng nu cn:


Gim au, h st bng Paracetamol 0.5g x 4 ln/ngy nu st trn 380C. Hi
phc nc in gii, Vitamin B1, B6 liu cao cho ngi nghin ru, m bo dinh dng.
2. iu tr:
-

Amoxicillin/A.Clavulanic (Curam, Augmentin, Klamentin)1gx 3 ln/ ngy

Hoc Clarythromycin 0.5g2 ln/ ngy

Hoc Azithromycin N1: 0,25g ung 2 vin /1ln/ ngy.N2-N5:0,25g x 1 vin


ung/1 ln/ ngy

Hoc Levofloxacin 0,75g 1 ln /ngy

Hoc Cephalosporin th h 2, 3 (Cefuroxim 0,5mg x 3 ln/ngy hoc


Cefpodoxim 200mg x 2 ln/ngy).

Khi ho khan nhiu gy mt ng, c th cho cc thuc gim ho nh:


+ Terpin codein (bit dc Acodin) 15 - 30mg / 24gi
+ Dextromethophan 10 20mg / 24gi.

Khi ho m nhiu c th kt hp vi thuc long m:


Acetyl Cystein 200mg x 3gi / 24gi.

3. TIU CHUN NH GI KT QU IU TR:


3.1. Tt:
-

Triu chng c nng v ton thn tt ln (c bit l st gim hoc ht st)

C-Reactive Protein (CRP) gim.

C hay khng triu chng thc th ti phi gim.

C hay khng bch cu mu gim.

C hay khng tn thng trn X-quang ngc gim.

3.2. Xu:
-

Triu chng c nng v ton thn din bin xu hn (c bit l st khng


gim).

CRP khng gim.

Triu chng thc th ti phi (+/-)

119

C hay khng bin chng (p-xe phi, m mng phi, nhim trng huyt, vim
phc mc, vim mng no, vim ni tm mc)

Tng bch cu (+/-)

C hay khng tn thng trn X-quang ngc.

TI LIU THAM KHO:


1. B Y t. Hng dn iu tr. Tp 1, NXB Y hc 2005.(Trang199-205)
2. TS Nguyn Vn Thnh. Phc iu tr v quy trnh mt s k thut trong thc
hnh ni khoa bnh phi. i Hoc Y Cn Th. NXB Cn Th 2006. (Trang 1-13)
3. TS Trn Vn Ngc - Bnh Hc Ni Khoa - i Hc Y Dc TPHCM - 2009
(Trang 289-300)
4. TS Trn Vn Ngc - iu Tr Hc Ni Khoa - i Hc Y Dc TPHCM - 2009
(Trang 290-307).

120

HEN PH QUN

I.

I CNG:
Hen ph quan la tnh trang viem man tnh ng th, vi s tham gia cua nhieu

thanh phan te bao va te bao trong c che sinh benh. Tnh trang viem man tnh noi
tren la nguyen nhan gay tang phan ng cua ng th vi cac tac nhan kch thch.
Bieu hien bang hien tng phu ne niem mac, tang tiet, co that c trn phe quan va co
the dan en bien oi man tnh cau truc phe quan. Benh canh lam sang la cac cn ho,
kho th, nang ngc, th kho khe lap i lap lai, thng xay ra vao ban em va sang
sm. Cac cn nay xay ra vi mc o khac nhau, co the hoi phuc t nhien hoac khi co
ieu tr.
II.

CHN ON:

1. Chan oan xac nh:


Ve lam sang, can ngh en hen phe quan khi co mot trong bon trieu chng sau:
-

Ho

Nang ngc

Kho th

Th kho khe hay th rt

Cac trieu chng tren co ac iem la thng xuat hien hay nang len ve em,
sang sm, sau khi gang sc, sau khi tiep xuc vi cac yeu to kch thch ng th (d
nguyen, khoi, bui, thay oi thi tiet). Benh thng khi phat t luc nho. Ban than
benh nhan hay gia nh co mac cac benh d ng, hen phe quan. Thong thng cn

121

kho th hay cac trieu chng cai thien ro khi s dung thuoc dan phe quan hay
corticosteroid.
Chan oan c cung co them khi o chc nang ho hap co tang FEV 1 12%
(hay 200mL) hoac PEF > 60L (hay 20%) sau khi ht thuoc dan phe quan
(salbutamol 400mcg trong 10-20 phut), dao ong PEF sang chieu tren 20%
- Bng kim chn on HPQ:

A. Triu chng lm sng

D. Chc
nng
phi

B. Yu t kch
pht

PEF

hen
PEV1

:
Co it nht 2 trong 4 triu ch ng : A7, C6, D1, D2.

122

Ho c Co it nht 3

ch ng sau: A7 + 1C + 1B, C6 + 1A + 1B, D1 + 1A + 1B, D1 +

1A + 1C, D2 + 1A + 1B, D2 +1A + 1C (1A, 1B, 1C co nghia la co it nht 1 triu ch ng


trong nhom cac

ch ng A,B,C).

* S dung thuoc thng xuyen: a s dung co hieu qua (thng mang thuoc theo
ngi hoac phai s dung hang ngay).
anh gia: c phep chan oan hen khi co t nhat hai cau trong noi dung A va t nhat
mot cau trong noi dung B hoac C.
2. Chan oan phan biet:
Cn kho th thng phai chan oan phan biet vi kho th do tac nghen ng
th cao (d vat ng th, u noi long kh - phe quan, kho th thanh quan), viem phe
quan cap co trieu chng giong cn hen, t cap benh phoi tac nghen man tnh
(COPD), hen tim. Trong a so cac trng hp, chan oan phan biet can da tren hoi
ky tien s va benh s.
III. IU TR:
anh gia mc o nang va ieu tr theo phan bac nang:
Tat ca benh nhan kham lan au eu can anh gia mc o nang va co ke hoach
ieu tr theo phan bac mc o nang. Nhng lan tai kham sau can anh gia mc o
kiem soat va ieu tr theo mc o kiem soat hen.
Bang 2. Phan bac mc o nang va ieu tr theo bac ngi ln va tre em tren 5 tuoi (*)
tat ca cac mc o:
- Ngoai thuoc khuyen cao s dung hang ngay, thuoc SABA(a) nen s dung khi can
nhng khong nen qua 3-4 lan / ngay.
- Can giao duc ky lng benh nhan ve phong benh va cach s dung thuoc.
- Tnh trang hen c xem la a khong che khi trieu chng lam sang on nh
trong t nhat 2-3 thang va ieu tr tiep theo duy tr mc thap nhat e co the duy
tr kiem soat c trieu chng
123

Bac

Mc o

Thuoc

Cac la chon

trieu chng

hang ngay

khac

Bac 1-

- Cac trieu xuat hien trong thi Khong can thiet

Hen

gian ngan va di mc mot lan /

tha

tuan. Benh nhan hoan toan bnh


thng ve trieu chng va chc
nang ngoai cn
- PEF dao ong: < 20%

Bac 2Hen
nhe

- Cac trieu chng co t nhat mot Lieu thap (bang -Theophylline


(b)
lan / tuan nhng khong hang 2) ICS

cham

ngay

-Khang

- Trieu chng ban em >2 lan /

Leukotrien

thang
- PEF 80%,
PEF dao ong: 20-30%
Bac 3-

- Cac trieu chng co hang ngay

Hen

- PEF 60-80%,

trung

Lieu

thap

en -Lieu

trung

trung bnh (bang bnh ICS ket


2) ICS ket hp hp

PEF dao ong: > 30%

LABA(c) ht

bnh

Theophylline
cham, hoac
-Lieu

trung

bnh ICS ket


hp

LABA

uong, hoac
-Lieu cao ICS,

124

Bac 4-

- Cac trieu chng ton tai lien Lieu cao (bang 2)

Hen

tuc, hoat ong the lc anh hng. ICS

nang

- PEF 60%,

ket

hp

LABA(c) ht, ket


hp mot trong cac

PEF dao ong: > 30%

thuoc

sau

neu

can:
-

Theophylline

cham
- LABA uong
-

Corticosteroid

uong

Chu thch:
(*)

Theo GINA 2004

(a) SABA : Thuoc kch thch beta2 tac dung ngan (Short-acting beta2 agonist)
(b) ICS: Corticosteroid dang ht (Inhaled-corticosteroid)
(c): LABA:Thuoc kch thch beta2 tac dung dai (Long-acting beta2 agonist)
Thuc thng dng Khoa Khm Bnh:
Ventolin (MDI): SABA. Xt 2 nht khi cn
Berodual( MDI): SABA kt hp vi khng cholinergic. Xt 2 nht khi cn
Seretide 25/125 (MDI): LABA kt hp corticoid ht.2 nht x 2 ln/ngy.
Symbicort 4.5/160 (MDI): LABA kt hp corticoid ht. 2 nht x 2 ln/ngy.

BNH PHI TC NGHN MN TNH (COPD)


I. I CNG:
Benh phoi tac nghen man tnh (tieng Anh: Chronic Obstructive Pulmonary
Disease COPD) la tnh trang benh ly c ac trng bang hien tng han che lu
thong kh tren ng th khong hoi phuc hoan toan. Hien tng han che lu thong
125

kh nay thng tien trien tang dan va ket hp vi mot qua trnh viem bat thng cua
phoi di tac ong cua o nhiem kh th keo dai.
II. CHN ON:
1. Chan oan xac nh:
Can ngh en COPD khi:
- Ho man tnh: Thng lien tuc trong ngay, t khi xuat hien va nang ve em.
- Khac am man tnh.
- Co nhng t viem phe quan cap tai dien.
- Kho th: Tien trien tang dan theo thi gian, ton tai lien tuc, tang len khi gang sc
va sau moi t nhiem khuan ho hap.
- Tien s hut thuoc (thng t 20 goi - nam tr len) va/ hoac song trong moi trng
o nhiem kh th.
n v goi nam = (So ieu thuoc hut trung bnh mot ngay: 20) So nam hut thuoc
b. Kham lam sang va can lam sang:
Trieu chng thc the:
Cac trieu chng tuy theo mc o, giai oan nang thng co:
- Bien dang long ngc kieu hnh thung, giam di ong.
- Noi ngan hi, co keo c ho hap phu ca luc ngh ngi.
- Giam thong kh phoi.
- Cac trieu chng cua suy tim phai.
Xquang ngc: Co the thay hnh anh kh phe thng, tang ap ong mach phoi.
ECG: Co the thay dau hieu day nh phai, that phai.

Kh mau ong mach: Co the phat hien giam oxy, co hay khong kem theo

tang CO2
c. Chc nang ho hap:
ay la tieu chuan vang e chan oan xac nh, nen thc hien nhng ni co
ieu kien: FEV1/ FVC < 70% sau dung thuoc dan phe quan.
126

2. Chan oan phan biet:


Nen phan biet COPD vi cac benh thng gap sau:
o

Hen ph qun

Suy tim xung huyt

Dn ph qun

Lao phi

PHN GIAI ON:


Bang 1. Phan giai oan COPD (theo GOLD 2007)(*)
Giai

Trieu chng

Chc nang ho hap

oan

I:

Co hay khong kem theo trieu chng khac:

Nhe

ho, khac am nhng khong thng xuyen.

II:

Co trieu chng kho th khi gang sc nhe.

Trung

giai oan nay benh nhan thng i kham

bnh

III:
Nang

FEV1%

gang sc

GTLT(**)
80 %

Benh nhan thng khong cam thay kho th.


50 <80 %

benh v trieu chng ho hap hoac v cac t


cap.
Co trieu chng kho th thng xuyen, giam

30 <50 %

kha nang gang sc, co nhieu t cap hn va


chat lng cuoc song giam sut.

IV:

Benh nhan kho th nang thng xuyen. Cac

Rat

t cap luon e doa t vong. Co the co bieu

nang

Kha nang

hien tam phe man tnh. Chat lng cuoc


song giam nang.

< 30% hoac


< 50% kem
theo suy ho
hap man(***)

127

(*)

GOLD: Chien lc x tr toan cau COPD (Global Initiative for Chronic

Obstructive Lung Disease do Vien Huyet hoc va Tim, Phoi My ket hp vi WHO
khuyen cao). GOLD t 2006 bo giai oan O (nguy c) ra khoi bang phan loai mc o
nang.
(**)

GTLT: Gia tr ly thuyet c tnh theo tuoi, chieu cao, gii va sac toc.

(***)

Trieu chng suy ho hap man, PaO2 <60mmHg th kh phong hoac suy tim phai.
2013

BN

mMRC

CAT

GOLD 1-2

0-1

< 10

GOLD 1-2

10

GOLD 3-4

0-1

< 10

GOLD 3-4

10

Nguy c cao
D

III. X TR COPD GIAI ON N NH:


anh gia mc o nang (giai on) va ieu tr theo giai on:
Tat ca benh nhan kham lan au eu can anh gia mc o nang va co ke hoach
ieu tr theo mc o nang c xc nh

128

Bang 3. X tr COPD on nh theo giai oan (theo GOLD 2006)


Giai oan

II

III

IV

(nhe)

(trung bnh)

(nang)

(rat nang)

Mc o kho Kho
th tng ng

khi

th Kho th khi Kho th khi Kho th ngay trong cac


gang gang sc nhe

sc nang
FEV1 (sau khi 80%
dung

i lai bnh c ong nhe


thng

50 - <80%

30 - <50%

< 30%

thuoc

dan phe quan)


Tranh tiep xuc cac yeu to nguy c, vaccin phong cum
Them: Dan phe quan tac dung ngan (khi can)
Them:
- Ket hp ieu tr lien tuc vi 1 hoac nhieu thuoc dan
phe quan tac dung keo dai (khi can).
- Phuc hoi chc nang ho hap
Them: Ket hp tr lieu corticosteroid
ht lien tuc neu co nhieu t cap

129

Them: Tr lieu oxy


keo dai

neu suy ho

hap man tnh.


Xem xet kha nang
phau thuat

Phc iu tr COPD giai on n nh:


Ke hoach ieu tr can phai thiet ke cho tng ngi benh tuy theo kha nang s
dung thuoc cua ngi benh (th du: benh nhan co biet cach s dung cac che pham
dang ht khong, dung nap c thuoc khong, benh nhan co kha nang mua thuoc hay
c bao hiem tra tien thuoc khong). Nh vay se co nhieu phac o ieu tr COPD.
Cac phac o can phai thiet ke theo trnh t u tien: theo hieu qua ieu tr, theo tien
ch ieu tr, theo gia chi ph ieu tr, theo kha nang cung cap thuoc. Da tren khuyen
cao cua GOLD, chung ta co the co cac phac o ieu tr theo tng bc vi trnh t u
tien nh tren.
Bng 4: Phc iu tr COPD theo giai on v theo th t thuc u tin chn
la.
( Tt c giai on km theo trnh tip xc yu t nguy c (thuc l), tim nga cm)
Giai on 1
Tnh hung lm sng
Bnh nhn ch kh th khi
gng sc nng, cha cn
dng thuc DPQ tc dng
di

Thuc s dng
Dng dn ph qun tc dng ngn khi cn
1.a. Berodual MDI 2 hoc Ventolin MDI nht khi cn.
1.b. Salbutamol 2- 4mg khi cn.

130

Giai on 2
Tnh hung lm sng
Nn dng DPQ tc dng ko
di khi tnh trng kh th
phi dng DPQ tc dng
ngn 3 4 ln/ ngy.

Thuc s dng
2.a. Spiriva 18 g ht 1 ln/ ngy
+ Berodual MDI 2 hoc Ventolin (MDI) 2 nht khi cn.
2.b. Ventolin CR 4mg ung 1- 2 ln/ngy, hoc
Bambuterol 10 mg 1 v/ngy
+ Berodual MDI 2 nht hoc Ventolin MDI khi cn.
2.c. Theophylline vin phng thch chm 200-400 mg x
2 ln/ngy (khng qu 10 mg/kg/ngy)
+ Salbutamol 2 - 4mg ung khi cn.

Giai on 3
Tnh hung lm sng
- Xem xt dng phi hp cc
thuc DPQ tc dng ko di
lm gim tnh trng kh
th. Dng 1, 2 hay 3 loi
DPQ ty vo mc kh th
ca mi bnh nhn v din
bin bnh.
- Cc trng hp c t cp
lp i lp li, hay c biu
hin tng phn ng ph qun
xem xt dng corticoid ht

Thuc s dng
3.a. Titotropium 18 g ht 1 ln/ ngy
Seretide 25/125 (MDI) 2 nht x 2
Hay Symbicort 4.5/160 2 nht x 2 ln/ngy
Theophyllin vin phng thch chm 20-400mg x 2
ln/ngy
+ Berodual MDI 2 nht hoc Ventolin (MDI) 2 nht
khi cn.
3.b. Ventolin CR 4-8mg ung 1-2 ln/ngy, hoc
Bambuterol 10 mg 1 v/ngy
Theophyllin 200-400mg x2 ln/ngy
+ Berodual MDI 2 nht hoc Ventolin MDI khi cn.
3.c. Theophyllin 200-400mg x2 ln/ngy
+ Salbutamol 2-4mg ung khi cn.
+ Prednisolone liu thp nht c hiu qu khi c ch
nh dng corticoid.

Giai on 4
Tnh hung lm sng
Thuc s dng
-Mc kh th tng dn v xut - iu tr nh bc 3
hin bin chng
- Oxy tr liu ko di ti nh khi c ch nh
- iu tr cc bin chng nu c: Tm ph mn,
a hng cu.
Theo GOLD 2013

131

1: LABA/ICS or LABA

1: LABA/ICS or LAMA

2: LABA + LAMA

2: LAMA + LABA/ICS
or LABA/ICS + PDE4
or LAMA+ LABA
or LAMA+ PDE4

1: SAMA or SABA

1: LAMA or LABA

2: LAMA or LABA

2: LAMA + LABA

Or SAMA + SABA
c

1 < 40%

132

VIM PH QUN CP
I. I CNG:
Vim ph qun cp l tnh trng vim nhim cp tnh ca cc ph qun.
Nguyn nhn thng do virus, vi khun hoc c virus vi khun. Bnh thng tin
trin lnh tnh.
II. CHN ON:
Th in hnh: Vim ph qun cp do virus.
1. Lm sng:
Thng gp vo ma ng . Tin trin thng bt u t t, khi pht bng vim
hng ng h hp trn vi st nh, vim mi hng (ht hi, s mi, au rt hng)
c th vim mi nc, vim xoang, vim Amydal, vim tai gia sau lan xung kh
qun - ph qun.
-

i khi bnh bt u mt cch rm r: st cao, ho nhiu, ho khc m, c th


m dnh mu.

Tn thng ph qun qua 2 giai on:

Giai on kh:
+ Bnh nhn thng c cm gic rt bng sau xng c, cm gic ny tng ln khi
ho.
+ Ho khan, ho tng cn dai dng, c th khn ting.
Triu chng ton thn: thng st mc trung bnh khong 380C. Nhc u,
mt mi, bing n, au mi lng, au u, au ngc c ngun gc do c v
nhng cn ho lin tc.
-

Khm phi: lc u bnh thng, sau c th nghe ran rt v ran ngy.


Giai on ny ko di 3 - 4 ngy th chuyn sang giai on t.

Cm gic au rt bng sau xng c gim dn ri ht, kh th nh, ho


khc m nhy, m vng m hoc dnh mu.

G khng thy vng c, nghe phi c th thy ran ngy, ran m. Giai
on ny ko di 4 - 5 ngy v khong 10 ngy l khi.

133

Mt s trng hp ho khan ko di nhiu tun (do tng tnh phn ng


ph qun sau nhim khun).

Trng hp nng:
Ngoi nhng triu chng trn cn thy kh th r rt, co ko lng ngc tm ti,
nhp th nhanh trn 25 ln/pht ngi ln.
2. Cn lm sng:
-

X-quang phi: Bnh thng hoc c th thy thnh ph qun dy.

Xt nghim: C th thy s lng bch cu v tc mu lng tng.

3. Cc th lm sng:
-

Th co tht dng hen ph qun

Th ho ra mu: Ho mu t do ph n, xung huyt nim mc ph qun.

4. iu tr:
-

ngi ln bnh thng, a s cc trng hp vim ph qun cp t khi


khng cn iu tr.

Ch yu iu tr triu chng vi ngh ngi ti ging, cho lng nc ung,


cc thuc gim au, khng vim, khng phi corticoid.

Khi ho khan nhiu gy mt ng, c th cho cc thuc gim ho nh:


++ Codein 15 - 30mg / 24gi
++ Dextromethophan 10 20mg / 24gi.

Mt t corticoid ng ung: Prednisolon 0.5mg/kg/ngy trong 5 7ngy.

Trong trng hp co tht ph qun, c th dng cc thuc gin ph qun cng


2 ng ht nh ventoline, Bicarnyl hoc kh dung Ventoline 5mg x 2-4 nang
kh dung trong 24h hoc Salbutamol 4mg ung ( 2- 4 vin/24h).

Khng cn dng khng sinh cho vim ph qun cp ngi bnh thng.

Nu ho ko di v khc m m trn 7 ngy, c a bnh phi tc nghn mn


tnh hoc c vim mi m, vim Amydal, vim tai gia phi hp th s dng
thuc:
Khng sinh nhm betalactam nh:
Amoxicillin liu 2-3g/ 24h
134

Hoc Macrolid nh:


Azithomycine 0.5g ung 1 ln /ngy.
Clarythomycine 250- 500mgx 2ln/ ngy
Hoc:
Spiramycine 1.5 3MUI x 3 ln/ ngy
Cephalexin 250 500mg/ 6h/1ln; Hoc 500mg - 1g/ 12h/ 1ln. Khng
qu 4g/ngy.
Kt hp vi thuc long m: Acetyl Cystein 200mg x 3gi/ 24gi.
Ngng ht thuc l, thuc lo.
Phng bnh:
-

Loi b yu t kch thch: khng ht thuc, trnh khi bi trong ngoi nh,
mi trng nhim.

Gi gn sc khe, gi m nht l ma lnh.

Ti liu tham kho:


1. Hng dn iu tr - Tp I B Y T (NXB Y hc) 2005. (Trang196-199).
2.TS Trn Vn Ngc - Bnh Hc Ni Khoa - i Hc Y Dc TPHCM Nm 2009
(Trang 289-377).

135

DANH MC THUC S DNG TI KHOA KHM BNH


DA TRN THNG T 31/2011/TT-BYT
STT
theo TT 31
STT

TT hot
cht

TT
thuc

Tn thuc hay hot cht

ng dng, dng
dng

3
4
I. THUC GIM AU, H ST, CHNG VIM
KHNG STEROID, THUC IU TR GT V
CC BNH XNG KHP
1.1.Thuc gim au; thuc h st; chng vim khng
steroid
Celecoxib
Ung
Ung
Diclofenac
DL-Lysin-Acetylsalicylat
Ung
(Acetylsalicylic acid)

27
29
30

28
30
31

31
32
39
41
44

Etodolac
Etoricoxib
Meloxicam
Nabumeton
Paracetamol (acetaminophen)
Paracetamol + codein phosphat

45
48

33
34
42
47
50
52
57
60

12
13
14
15

49
50
51
52

61
62
63
64

Allopurinol
Ung
Benzbromaron
Ung
Colchicin
Ung
Probenecid
Ung
1.3. Thuc chng thoi ha khp

16
17
18

53
55
56

65
67
68

Diacerein
Glucosamin
Leflunomid
1.4.Thuc khc

Ung
Ung
Ung

19

57

69
70

Alendronat
Alendronat natri +
cholecalciferol (Vitamin D3)

Ung
Ung

1
2
3
4
5
6
7
8
9
10
11

20

Piroxicam
Tramadol
1.2. Thuc iu tr gt

136

Ung
Ung
Ung; Dng ngoi
Ung
Ung
Ung
Ung
Ung

60

73

21

Cytidin-5-monophosphat
disodium + uridin

Ung

II. THUC CHNG D NG V DNG TRONG


CC TRNG HP QU MN
67
70
71

80
83
84

72
76
77
79
83

85
89
90
92
96
97
100

32

120

137

Alimemazin
Ung
Cinnarizin
Ung
Clorphenamin (hydrogen
Ung
maleat)
Desloratadin
Ung
Diphenhydramin
Ung
Ebastin
Ung
Fexofenadin
Ung
Loratadin
Ung
Loratadin + Pseudoephedrin
Ung
Promethazin (hydroclorid)
Ung
III. THUC CHNG CO GIT, CHNG NG
KINH
Carbamazepin
Ung

33
34
35

121
124

138
141

Gabapentin
Phenobarbital

Ung
Ung

125

142

Phenytoin

Ung

36
37
38
39

126

143

Pregabalin

Ung

127

144
145
146

Valproat magnesi

Ung

Valproat natri
Valproat natri + valproic acid

Ung
Ung

40
41

128
129

147
148

Valproic acid
Valpromid

Ung
Ung

22
23
24
25
26
27
28
29
30
31

IV. THUC IU TR K SINH TRNG, CHNG


NHIM KHUN
4.1.Thuc tr giun, sn
42
43
44

130
133
134

149
152
153

Albendazol
Mebendazol
Metrifonat
4.2.Chng nhim khun

Ung
Ung
Ung

4.2.1.Thuc nhm beta-lactam


45
46

139

158
159

Amoxicilin
Amoxicilin + acid clavulanic
137

Ung
Ung

Ung
Ung
Ung

143
144
145
150
152
153
160
161
164
167

160
162
165
166
167
172
174
175
184
185
188
193

Amoxicilin + sulbactam
Ampicilin + sulbactam
Cefaclor
Cefadroxil
Cefalexin
Cefdinir
Cefetamet pivoxil

59
60
61

185
186
187

220
223
224

Metronidazol
Secnidazol
Tinidazol
4.2.3.Thuc nhm macrolid

Ung
Ung
Ung

62
63
64

189
190
194

227
228
233

Azithromycin
Clarithromycin
Spiramycin
4.2.4.Thuc nhm quinolon

Ung
Ung
Ung

65
66
67
68
69
70
71

196

236
238
241
242
243
244
245

Ciprofloxacin
Levofloxacin
Moxifloxacin

Ung
Ung
Ung

Nalidixic acid
Norfloxacin
Ofloxacin
Pefloxacin

Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Tim
Ung
Ung

47
48
49
50
51
52
53
54
55
56
57
58

200
201
202
203

Ung
Ung
Ung
Ung

Cefixim
Ung
Cefpodoxim
Ung
Cefradin
Ung
Ceftibuten
Ung
Ung
Cefuroxim
4.2.2.Thuc nhm nitroimidazol

72

210

254

4.2.5.Thuc nhm sulfamid


Sulfasalazin
4.3.Thuc chng virut

73
74
75
76
77
78

226
227
230
234
235
238

270
271
274
278
279
282

Aciclovir
Adefovir dipivoxil
Entecavir
Interferon (alpha)*
Lamivudin
Oseltamivir
138

79
80
81

239
240
244

283
284
288

82

185

313

83
84
85
86
87

254
256
257
258
260

298
300
301
302
304

88
89
90

282
284
285

342
344
345

Peginterferon*
Ribavirin
Tenofovir (TDF)

Tim
Ung
Ung

4.4. Thuc iu tr bnh do amip


Metronidazol
Ung
4.5. Thuc chng nm
Fluconazol
Ung
Griseofulvin
Ung
Itraconazol
Ung
Ketoconazol
Ung
Nystatin
Ung
V. THUC IU TR AU NA U, CHNG
MT
Dihydro ergotamin mesylat
Ung
Ergotamin (tartrat)
Ung
Flunarizin
Ung
VI. THUC CHNG PARKINSON

91
92
93
94
95
96
97

360
361
363
364
365
366

421
422
423
425
426
427
428

Entacapon
Levodopa + carbidopa
Levodopa + benserazid
Pramipexol
Tolcapon
Topiramat
Trihexyphenidyl (hydroclorid)

Ung
Ung
Ung
Ung
Ung
Ung
Ung

VII. THUC IU TR NG TIT NIU


98

352

412

Ung

Alfuzosin

VIII. THUC TC DNG I VI MU

99
100
101
102

368

432
433
441
442
443

103
444
104

8.1.Thuc chng thiu mu


St fumarat
St fumarat + acid folic
St sulfat (hay oxalat)
St sulfat + folic acid
St sulfat + folic acid + km
sulfat
St sulfat + vitamin B1+
vitamin B6+ vitamin B12
139

Ung
Ung
Ung
Ung
Ung
Ung

105
106

370
374

446
450

8.2. Thuc tc dng ln qu trnh ng mu


Ung
Acenocoumarol
Cilostazol
Ung
8.3.Thuc khc

107
108
109

399
400
401

478
479
480

Deferasirox
Deferipron
Erythropoietin

Ung
Ung
Tim

IX. THUC TIM MCH


9.1.Thuc chng au tht ngc
404
405
406

484
485
486

Atenolol
Diltiazem
Glyceryl trinitrat
(Nitroglycerin)

Ung
Ung
Ung

407

487

Ung

114
115
116

Isosorbid (dinitrat hoc


mononitrat)

408
409

488
489

Nicorandil
Trimetazidin
9.2. Thuc chng lon nhp

Ung
Ung

117
118
119
120
121
122

410
411
415
418
419
420

490
491
495
499
500
501

Adenosin triphosphat
Amiodaron (hydroclorid)
Ivabradin
Propranolol (hydroclorid)

Ung
Ung
Ung

123
124
125
126
127
128
129
130
131
132
133

421
422
423
424

502
503
504
505
506
507
508
509
510
511
513

Acebutolol
Amlodipin
Benazepril hydroclorid
Bisoprolol
Bisoprolol + hydroclorothiazid

Ung
Ung
Ung
Ung

110
111
112
113

425
426
427
428
429
431

Ung
Sotalol
Ung
Verapamil (hydrochlorid)
Ung
9.3.Thuc iu tr tng huyt p

Candesartan
Captopril
Carvedilol
Cilnidipin
Clonidin
Doxazosin
140

Ung
Ung
Ung
Ung
Ung
Ung
Ung

134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159

432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
450

451
452
453
454

514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
534
535
536
537
538
539
540
541

Enalapril
Felodipin
Hydralazin

Ung
Ung
Ung

Imidapril
Indapamid
Irbesartan
Irbesartan + hydroclorothiazid
Labetalol
Lacidipin

Ung
Ung
Ung
Ung
Ung
Ung

Lercanidipin (hydroclorid)
Lisinopril
Losartan
Losartan + hydroclorothiazid
Methyldopa
Metoprolol
Moxonidin
Nebivolol
Nicardipin
Nifedipin
Perindopril
Perindopril + amlodipin
Perindopril + indapamid
Quinapril
Ramipril
Rilmenidin
Telmisartan
Telmisartan +
hydroclorothiazid
Valsartan
Valsartan + hydroclorothiazid
9.4.Thuc iu tr suy tim

Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung

160
161
162

455

542
543

163
164

458
459

547
548

Carvedilol
Digoxin
9.5.Thuc chng huyt khi

Ung
Ung

165
166
167

464

555
556
558

Acenocoumarol
Acetylsalicylic acid

Ung
Ung

Clopidogrel

Ung

466

141

Ung
Ung

560

Dipyridamol + acetylsalicylic
acid
9.6. Thuc h lipid mu

Ung

Atorvastatin
Bezafibrat
Ciprofibrat
Fenofibrat
Fluvastatin
Gemfibrozil
Lovastatin
Pravastatin
Rosuvastatin
Simvastatin
9.7.Thuc khc
Buflomedil (hydroclorid)
Citicolin
Ginkgo biloba
Nimodipin
Piracetam
Vinpocetin

Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung

168
169
170
171
172
173
174
175
176
177
178

473
474
475
476
477
478
479
480
481
482

566
567
568
569
570
571
572
573
574
575

179
180
181
182
183
184

483
486
489
492
495
500

576
579
582
587
590
596

185
186
187

575
576
578

687
688
690

Ung
Ung
Ung
Ung
Ung
Ung

X. THUC LI TIU
Furosemid

Ung

Hydroclorothiazid
Spironolacton

Ung
Ung

XI. THUC NG TIU HA

188

189
190
191

580
581

692
693

585
587
588

697
699
700

Famotidin
Ung
Lanzoprazol
Ung
Magnesi carbonat + nhm
hydroxit + atropin sulfat + calci Ung
alumina carbonat

701

Magnesi hydroxid + nhm


hydroxid

192
193

11.1.Thuc khng acid v cc thuc chng lot khc


tc dng trn ng tiu ha
Aluminum phosphat
Ung
Atapulgit hot ha + hn hp
magnesi carbonat-nhm
Ung
hydroxid

142

Ung

702
194
703
195
196
197
198
199
200
201
202
203
204
205
206
207
208

590
591
592
593
594
595
596

Magnesi hydroxid + nhm


hydroxid + simethicon
Magnesi trisilicat + nhm
hydroxyd
Nizatidin
Omeprazol
Esomeprazol
Pantoprazol
Rabeprazol
Ranitidin
Rebamipid
Ranitidin + bismuth + sucralfat
Sucralfat
Ranitidin
11.2.Thuc chng nn

Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung

597
595

707
708
709
710
711
712
714
713
715
712

600
601
603

718
719
721

Dimenhydrinat
Domperidon
Metoclopramid

Ung
Ung
Ung

11.3.Thuc chng co tht


Alverin (citrat)
Alverin (citrat) + simethicon
Hyoscin butylbromid
Mebeverin hydroclorid
Papaverin hydroclorid
11.4. Thuc ty, nhun trng

Ung
Ung
Ung
Ung
Ung

209
210
211
212
213

606
610
611
613

724
725
730
731
733

214
215

617
622
624

737
743
745

216

Bisacodyl
Lactulose
Macrogol (polyetylen glycol
hoc polyoxyethylen glycol)

Ung
Ung
Ung

746
Macrogol (Polyetylen glycol) +
natri sulfat + natri bicarbonat + Ung
natri clorid + kali clorid
217
628

752

629

753

11.5.Thuc iu tr tiu chy


Atapulgit mormoiron hot
ha
Bacillus subtilis

754

Bacillus claussii

218
219
220

143

Ung
Ung

Ung

221

631

756

Dioctahedral smectit

Ung

222

632

757

Diosmectit

Ung

223

635

761

Lactobacillus acidophilus

Ung

224

636

762

Loperamid

Ung

225

639

767

226

640

768

Racecadotril
Saccharomyces boulardii

Ung
Ung

770

11.6.Thuc iu tr tr
Cao ginkgo biloba +
heptaminol clohydrat +
troxerutin

Ung

771

Diosmin

Ung

772

Diosmin + hesperidin
11.7.Thuc khc

Ung

Arginin
Arginin citrat
Arginin hydroclorid
Biphenyl dimethyl dicarboxylat
L-Ornithin - L- aspartat
Pancreatin
Phospholipid u nnh
Simethicon

Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung

Simethicon + phloroglucinol
Silymarin

Ung
Ung

641
227
228

642

229
230
231
232
233
234
235
236
237
238

645

239

657

776
777
778
779
784
787
788
789
790
791

240

660

794

Trimebutin maleat

Ung

241

662

796

Ursodeoxycholic acid

Ung

242
243
244
245

646
651
654
655
656

666
676

802
803
818
819
820

677

821

246
247

XII. HOCMON V CC THUC TC NG VO


H THNG NI TIT
12.1. Hocmon thng thn v nhng cht tng hp
thay th
Budesonid
Dng ht
Budesonid/formoterol
Dng ht
Methyl prednisolon
Ung
Prednisolon acetat
Ung
Prednisolon
Ung
metasulfobenzoat natri
Prednison
Ung
144

248

697

843

12.2. Insulin v nhm thuc h ng huyt


Acarbose
Ung

249

698

844

Clorpropamid

Ung

250

699

845

Glibenclamid

Ung

251

700

846

Gliclazid

Ung

252

701

847

Glimepirid

Ung

253

702

848

Glipizid

Ung

254

703

849

Insulin tc dng trung bnh (I)

Tim

255

850

Insulin tc dng ngn (S)

Tim

256

851

Insulin trn (M)

Tim

257

852

Insulin chm

258

853

Insulin tc dng ko di (L)

Tim
Tim

854

Metformin

Ung

855

Metformin + glibenclamid

Ung

259

704

260
261

705

856

Pioglitazon

Ung

262

706

857

Repaglinid

Ung

263

707

858

Voglibose

Ung

264
265
266
267
268

708
709

859
861

710
711

862
863

712

864

12.3.Hocmon tuyn gip, cn gip v thuc khng gip


trng tng hp
Benzylthiouracil
Ung
Carbimazol
Ung
Ung
Levothyroxin (mui natri)
Ung
Propylthiouracil (PTU)
Thiamazol
Ung
12.4. Thuc iu tr i tho nht
Ung

269

714

866

Desmopressin

270

716

868

271

724

876

Vasopressin
Ung
XIII. THUC GIN C V C CH
CHOLINESTERASE
Eperison
Ung

272

726

878

273

880

Mephenesin
Neostigmin bromid

Ung
Ung

274

730

883

Pyridostigmin bromid

Ung

275

733

886

Tizanidin hydroclorid

Ung

145

276

734

887

Tetrazepam

Ung

277

736

889

Tolperison

Ung

XIV. THUC CHNG RI LON TM THN


14.1.Thuc an thn
278

816

1000

Diazepam

Ung

279

817

1002

Ung

280

818

1003

Etifoxin chlohydrat
Hydroxyzin

281

819

1004

Ung

282

821

1006

Lorazepam
Rotundin

Ung
Ung

283
284

822
823

1007
1008

14.2.Thuc gy ng
Zolpidem
Ung
Zopiclon
Ung
14.3.Thuc chng ri lon tm thn

285

824

1009

Amisulprid

Ung

286

826

1011

Ung

287

832

1017

Clorpromazin (hydroclorid)
Levosulpirid

288

835

1020

289

836

1021

Paroxetin
Prazepam

Ung
Ung

290

839

1024

Sulpirid

Ung

Ung

14.4.Thuc chng trm cm


291

844

1029

Amitriptylin (hydroclorid)

Ung

292

845

1030

Clomipramin

Ung

293

846

1031

Fluoxetin

Ung

XV. THUC TC DNG TRN NG H HP

294

853

295

1038

15.1. Thuc cha hen v bnh phi tc nghn mn


tnh
Bambuterol
Ung

1039

Budesonid

Dng ht

Budesonid + formoterol

Dng ht

Fenoterol + ipratropium

Thuc xt mi, hng

296
297

854

1042

Dng kh dung

298
299

855

1043

Formoterol fumarat

Kh dung; nang

300

856

1044

Ipratropium

Kh dung, ung

146

301

1046

Salbutamol (sulfat)

302

1047

Salbutamol + ipratropium

Ung
Kh dung

858

1048

Salmeterol
+ fluticason propionat

Kh dung; Dng ht; bt


ht

859

1049

Terbutalin

Ung; Kh dung

1050

Terbutalin sulfat
+ guaiphenesin
Theophylin

Ung

303
304
305
306

860

1051

307
308

861

1052

Tiotropium
15.2. Thuc cha ho

1053

Alimemazin

Ung

309

Ung
Ung (vin gii phng
chm)
Ung, kh dung

310

862

1054

Ambroxol

311

863

1055

Bromhexin (hydroclorid)

Ung
Ung

312

864

1056

Carbocistein

Ung

865

1057

313
314
315

866

316

Codein camphosulphonat
+ sulfoguaiacol + cao mm
Grindelia

1058

Codein + terpin hydrat

Ung

1059

Dextromethorphan

Ung

1063

N-acetylcystein

Ung

15.3. Thuc khc


317

785
788

963
966

Betahistin
Fluticason propionat

318

Ung
Dng ngoi; kh dung,
phun m, dng xt ,
dng ht

XVI. DUNG DCH IU CHNH NC, IN


GII, CN BNG ACID-BASE V CC DUNG
DCH TIM TRUYN KHC
319

875

1072
1073

320
876
321

1074

Kali clorid
Kali glutamat
+ magnesi glutamat
Magnesi aspartat
+kali aspartat
147

Ung
Ung
Ung

1075
322
1076
323

Natri clorid + kali clorid


+ natri citrat + natri bicarbonat
+ glucose (Oresol)

Ung

Natri clorid + kali clorid


+ natri citrat + glucose khan

Ung

XVII.KHONG CHT V VITAMIN


884
324
325
326

1094
1095
1097
1098

327
1099
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346

1102
1103
1108

885
886
889
891

894
895

896
898
900

1110
1113
1114
1120
1123
1124
1125
1126
1129
1130
1131
1132
1137
1140
1143

Calci + vitamin D3 + km
+ ng + magnesi
Calci acetat
Calci carbonat
Calci carbonat
+ calci gluconolactat

Ung
Ung
Ung
Ung

Calci carbonat + vitamin D3

Ung

Calci folinat
Calci lactat
Calci glucoheptonat
+ Vitamin D3
Calci gluconolactat
Calcitriol
Mecobalamin
Tricalcium phosphat
Vitamin B1
Vitamin B1 + B6 + B12
Vitamin B1 + B6 + B12 + St
Vitamin B1 + B6 + C + PP
Vitamin B5
Vitamin B6
Vitamin B6 + magnesi (lactat)
Vitamin B12
Vitamin C + rutine
Vitamin E
Vitamin PP

Ung
Ung

148

Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung
Ung

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