Professional Documents
Culture Documents
BVK AN PH
PHC IU TR
KHOA KHM BNH
NM 2014
MC LC
Trang
1.
i tho ng ................................................................................................. 4
2.
3.
4.
5.
6.
7.
8.
9.
I.
-
II.
b. Dinh dng:
-
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
Ngng thuc l
Thuc chng kt tp tiu cu:
-
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%)
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.
Da mn, m, m, t m hi.
2. Cn lm sng:
-
Tr s bnh thng: TSH: 0.270 4.20 UIU/ml; FT4: 12.00 22.00 pmol/l
3. Nguyn nhn:
3.1. Nguyn nhn thng gp:
3.1.1. Bnh Basedow:
-
Lm sng:
Hi chng cng gip.
Bu gip lan ta.
Li mt.
Ph nim trc xng chy.
CLS: TSH gim, T3, T4, FT4 tng. Cng c khi ch c FT3 tng
Nhn c gip
Cng gip gi
III. IU TR:
A. iu tr ni khoa:
1. Thuc c tc dng nhanh:
1.1. Thuc c ch (beta):
-
+ 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:
-
Ngn s Iod hu c ha
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:
-
B. iu tr khc:
11
iu tr li mt bng corticoid.
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.
-
Vim sn c sn.
Zona.
13
Tng huyt p
Tui cao
Ht thuc l
Ri lon lipid mu
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
1 ln/ngy
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
130 139
85 89
THA 1(nh)
140- 159
90 99
160 -179
100-109
THA 3(nng)
180
110
THA tm thu n c
140
< 90
HA c o ti phng khm.
III.IU TR:
90% l THA tin pht, cn iu tr sut i.
16
Gim thc n c nhiu mui NaCl, tng cng thc n c nhiu Kali.
Gim stress.
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
18
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
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:
-
Tng huyt p
Bnh c 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:
CHN ON:
Hi bnh s v khm lm sng tht k gip hng chn on suy tim.
Tiu chun Framingham:
1. Tiu chun chnh:
-
Ran phi
Tim ln
Ph phi cp
Ting T3
Ph c chn
Ho v m
Kh th khi gng sc
Gan ln
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
III. IU TR:
Kt hp bin php khng dng thuc v dng thuc.
1. Khng dng thuc:
-
Hn ch mui
2. Dng thuc:
a) Digoxin:
-
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:
-
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
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 .
Khng tun th iu tr
Tng huyt p
Nhim trng
Qu ti dch
Dng nhiu ru
24
I.
-
NTTN ti pht: Do cng vi trng gy bnh ln trc, xut hin 1-3 tun sau t
nhim trng trc.
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.
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.
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
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:
-
27
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
- Protein mau
< 60g/l
- Albumin mau
< 30g/l
- 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
31
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
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 :
-
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.
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 :
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.
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.
35
Cc triu chng ri lon tiu ha: kh tiu, y hi, chng bng, bun nn, chn
n
Omeprazol 20
Pantoprazol 40mg
36
Rabeprazol 20mg
Esomeprazol 20mg
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
39
VIM I TRNG MN
I CNG:
I.
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 .
2. Cn lm sng:
-
Kho st phn.
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:
-
C. iu tr triu chng:
1. Tiu chy:
-
Actapulgite 1 gi x 3 ln/ngy
2. Thuc tr to bn:
-
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
45
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
48
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 +
HBV DNA
200.000 IU/ml
( 106 copies/ml)
v tin cn gia nh
lin quan HCC
HBeAg +
HBeAg -
HBV DNA
20.000 IU/ml
( 105 copies/ml)
HBV DNA
2.000 IU/ml
( 104 copies/ml)
Theo di
ALT, AST, SA/3 th x 1 nm
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
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:
-
HCV RNA trn ngng pht hin c thc hin bng k thut PCR
nhy cm nht (nh tnh, nh lng, nh genotype).
51
II.2. iu tr:
II.2.1. Ch nh iu tr:
Bnh nhn c cc biu hin sau:
-
Tui t 18 tr ln;
C bnh t min.
Ghp tng.
C bnh ni khoa nng: THA, Suy tim, bnh mch vnh, i tho ng
khng kim sot c, COPD.
Tr em di 2 tui, ph n c thai.
52
RBV
Peg-IFN 2a
Peg-IFN 2b
TG
iu tr
1, 4, 6
15 mg/kg/ ngy v
48 tun *
2, 3
800 mg/ngy
24 tun **
(nu d on p ng
km: 15mg/kg/ngy) v
IFN 2b.
TC < 25.000/ mm3 : Nn ngng Peg-IFN 2a.
-
54
HCV RNA c th xem xt thc hin sau sinh 1-2 thng nu mun
chn on sm.
-
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
15 - 29
Suy thn
< 15
Lc mu
55
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.
56
u ng
W4 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
Ngng iu tr
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
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:
-
Xt nghim:
Cng thc mu: C th c thiu mu nu c xut huyt tiu ha. c bit: S
Siu m bng: nh gi gan, lch, dch bng, huyt khi tnh mch ca.
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
% t vong/ nm
Giai on 1
1%
Giai on 2
10%
Giai on 3
20%
Giai on 4
50%
Lm sng
X gan cn b
X gan mt b
III. IU TR:
1. Trnh cc yu t lm tn thng gan:
60
61
THEO DI:
Nu bnh n nh theo di:
i.
ii.
iii.
Ni soi:
+ Nu khng c dn TMTQ: ni soi li sau 2 nm.
+ Nu c dn TMTQ: iu tr phng nga XHTH.
Feldman
et
all,
gastrointestinal
and
liver
disease
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
T > -1
T < -2.5
(severe osteoporosis)
gy xng gn y
66
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.
Trn dch khp: i khi thy khp gi do phn ng xung huyt v tit dch.
Nhm
Acetaminophen
(Paracetamol,
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.
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.
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:
-
Hi chng Reiter.
Cc bnh Sarcoidosis.
Vim ni tm mc bn cp.
*Cn lm sng:
-
VS tng.
X-quang quy c.
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.
Gim p lc khp bng cch ngh ngi, c nh khp bng np, dng cc
nng chng.
71
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:
-
Hon cnh khi pht: Sau khi ung ru n nhiu tht, nhim trng, gng sc.
iu tr:
76
77
Tien s gout
MOT CN GOUT
(CN AU TIEN)
Tuoi > 60
Co
Khong
80 ml/phut
CLCr
80 ml/phut
IU TR GIM AU
1.
Tm liu hiu qu nht, dung np cao nht (tn trng chng ch nh, tng tc
Paracetamol 500mg-1500mg/ngy
Meloxicam 7.5mg-15mg/ngy
Piroxicam 20mg/ngy
iu tr h tr
79
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.
-
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
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.
Bnh l khp hng: Hoi t v trng chm xng i, vim khp hng, thoi ha
khp hng.
Vim khp cng chu, vim ct sng dnh khp. long xng gy ln t sng.
Ngh ngi, trnh c ng mnh, khng mang xch nng, hn ch ng/ ngi
lu.
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.
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.
4.
84
AU U
I. NH NGHA:
-
III.
AU U MIGRAINE:
1. C IM AU U MIGRAINE:
Du hiu bo trc :
m im chi sng
Bn manh ng danh
T tay v mt mt bn
Thng mt bn u
Cng tng dn v d di
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).
IV.
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
V.
AU U TNG CM:
1. c im lm sng:
-
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):
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
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
25 50 mg
Tn thuc
Liu dng
Metoclorperamide
(Primperan)
10 20 mg/ ngy
Gh
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)
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
-
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
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
99
Loi cn
Thuc hng u
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
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
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:
-
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)
-
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).
-
Chc nng tuyn gip; ng huyt, ion , chc nng gan, thn, v cc bnh
t min khc.
3. Chn on phn bit:
-
Sarcodosis.
Nhc c + lymphoma.
Ossermann
I: Nhc c th mt
1. Nhc c th mt
* 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
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;
108
109
* 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
M n M
-
Bnh tim gy lp mch no, c bit l rung nh, ngoi ra cn c cc lon nhp
Bnh l v mu.
ngi trung nin v ln tui, tng huyt p l nguyn nhn chnh, ngi gi
lon ng mu.
112
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
Chng mt: Thng gp trong nhi mu tiu no hoc thn no, XH hoc thiu
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.
-
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
).
-
vi lit ngi.
-
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
-
114
II.
1. LM SNG:
-
Bnh khi pht t ngt vi cc triu chng cc b hay cc thiu ht chc nng
thn kinh.
-
ri lon cm gic )
-
Khng thoi lui: Tin trin nng ln, t mc ti a m tnh trng XH hoc thiu
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
40 45%
Khong 15%
Du mng no
Cc
triu
chng
o
M cnh
o
Kh mu M, bo ha oxy.
III.
Thay i li sng: B thuc l, n gim mui, tp luyn thn th, gim cn, ch
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
3.2. Xu:
-
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)
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:
Ho
Nang ngc
Kho th
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:
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 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-
Hen
tha
Bac 2Hen
nhe
cham
ngay
-Khang
Leukotrien
thang
- PEF 80%,
PEF dao ong: 20-30%
Bac 3-
Hen
- PEF 60-80%,
trung
Lieu
thap
en -Lieu
trung
LABA(c) ht
bnh
Theophylline
cham, hoac
-Lieu
trung
LABA
uong, hoac
-Lieu cao ICS,
124
Bac 4-
Hen
nang
- PEF 60%,
ket
hp
thuoc
sau
neu
can:
-
Theophylline
cham
- LABA uong
-
Corticosteroid
uong
Chu thch:
(*)
(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.
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
Hen ph qun
Dn ph qun
Lao phi
Trieu chng
oan
I:
Nhe
II:
Trung
bnh
III:
Nang
FEV1%
gang sc
GTLT(**)
80 %
30 <50 %
IV:
Rat
nang
Kha nang
127
(*)
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
128
II
III
IV
(nhe)
(trung bnh)
(nang)
(rat nang)
Mc o kho Kho
th tng ng
khi
sc nang
FEV1 (sau khi 80%
dung
50 - <80%
30 - <50%
< 30%
thuoc
129
neu suy ho
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.
-
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.
-
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
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:
-
3. Cc th lm sng:
-
4. iu tr:
-
Khng cn dng khng sinh cho vim ph qun cp ngi bnh thng.
Loi b yu t kch thch: khng ht thuc, trnh khi bi trong ngoi nh,
mi trng nhim.
135
TT hot
cht
TT
thuc
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
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
130
133
134
149
152
153
Albendazol
Mebendazol
Metrifonat
4.2.Chng nhim khun
Ung
Ung
Ung
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
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
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
352
412
Ung
Alfuzosin
99
100
101
102
368
432
433
441
442
443
103
444
104
Ung
Ung
Ung
Ung
Ung
Ung
105
106
370
374
446
450
107
108
109
399
400
401
478
479
480
Deferasirox
Deferipron
Erythropoietin
Ung
Ung
Tim
484
485
486
Atenolol
Diltiazem
Glyceryl trinitrat
(Nitroglycerin)
Ung
Ung
Ung
407
487
Ung
114
115
116
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
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
192
193
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
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
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
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
248
697
843
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
Tim
255
850
Tim
256
851
Tim
257
852
Insulin chm
258
853
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
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
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
844
1029
Amitriptylin (hydroclorid)
Ung
292
845
1030
Clomipramin
Ung
293
846
1031
Fluoxetin
Ung
294
853
295
1038
1039
Budesonid
Dng ht
Budesonid + formoterol
Dng ht
Fenoterol + ipratropium
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
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
Ung
1059
Dextromethorphan
Ung
1063
N-acetylcystein
Ung
785
788
963
966
Betahistin
Fluticason propionat
318
Ung
Dng ngoi; kh dung,
phun m, dng xt ,
dng ht
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
Ung
Ung
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
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