I.

Tm tt ca lm sng : X gan
1 Thng tin chung v bnh nhn
Tn : V Vn Qung
Gii : Nam
Tui : 39
Cn nng : 65 kg
Chiu cao: 163 cm
2

L do vo vin:

Mt mi, chng bng, ho nhiu.

3 Din bin bnh:
Khi vo vin, bnh nhn mt mi, chng bng, n ung km, i ngoi phn nt, khng
st => vo vin.
4 Bnh s
- i tho ng: 5 nm
- X gan: 6 nm
5 Tin s gia nh:
Bnh thng.
6

Li sng:

- Ru: 12 nm.
- khng ht thuc.
7

Tin s dng thuc

- Bnh n khng ghi. Bnh nhn khng nh dng thuc g. C s dng

thuc iu tr d dy v insulin tim di da.

8 Tin s d ng :
Khng c d ng
9 Khm bnh khi nhp vin
- Ton thn : Bnh nhn tnh, tip xc tt.

Da nim mc vng.
Mt mi.
Hch ngoi vi khng s thy.
+ Mch : 80 ln/pht
+ Nhit : 36.5C
+ Huyt p: 130/80 mmhg
+ Nhp th : 16 ln/pht
- Khm c quan :
+ Tun hon: tim u, T1, T2 r: khng c du hin bnh l.
+ H hp: Thng kh tt, khng kh th.
+ Tiu ha: Bng chng, tun hon bng h (+)
Hi chng suy t bo gan (+)
+ Thn kinh: bnh thng.
10 Cn lm sng
1 Xt nghim huyt hc.

11

Yu cu xt
nghim
RBC
HGB
HCT
MCV
MCH
MCHC
PTL
RDW-SD
RDW-CV
PDW
MPV
P-LCR
Th tch
khi tiu cu
(PCT)
WBC
NEUT%
NEUT#
LYM%
LYM#
MONO%
MONO#
EO%

Kt qu
28/8
3.08
110
29.4
95.5
35.7
374
83
54.5
17
14.2
11.3
35.6
0.09

2/9
3.21
116
31.5
98.1
36.1
368
100
68.9
20.8
12.9
10.6
30.9
0.11

5.88
66.2
3.89

8.49
63.5
5.4

22.4

7/9
3.25
119
33.1
101.8
36.6
369
154
79.8
23.3
14
11.1
33.7
0.17

11.54
88.3
10.2

23.6

Tr s bnh
thng

n
v

4.3 - 5.8
140 160
38-50
83 - 92
28 - 32
320 - 356
150 - 450
35 46
10 - 15

T/l
g/l
%
Fl
Pg
g/l
G/l
Ft
%
Ft
Ft
%
%

5 20

4.0 - 10.0
45 - 75
1.8 7.5

G/l
%
G/l

25 - 45

1.32
8.8
0.52
2.4

2
9.8
0.83
2.7

0.92
3.6
0.41
0

1 4.5
08
0 0.8
08

G/l
%
G/l
%

EO#

0.14

0.23

0 0.8

G/l

BASO%

0.2

0.4

0.1

01

BASO#

0.01

0.03

0.01

0 0.1

G/l

2. xt nghim sinh ha

Yu cu xt
nghim

Kt qu
28/8

XN sinh ha
Glucose
Ure
Creatinin
AST
ALT
Bilirubin
T,P
Bilirubin T.T
Albumin
in gii
Na+
K+
ClCRP hs
Ck-MB
Amoniac

25

2/9

Tr s bnh
thng

n v

Mmol/l
Mmol/l
Umol/l
u/l
u/l
Umol/l
Umol/l
g/l
Ln
Mmol/l
Mmol/l
Mmol/l
Mg/l
u/l
Umol/l

16/10
25

2.3
111
268
94
336.8

8.5
5.1
74
137
52
484.7

1.3
111
268
94
336.8

3.9 6.4
2.5 7.5
62 120
0 37
0 40
1 17

172.5
29.4

246.7
6.1

172.5
29.4

1 4.3
35 50

125.57 129.23 125.57

2.6
2.4
2.6
79
85
79
40
46.5
40
44.2
38.2
44.2
140
140

135 145
3.5 5
98 106
16
0 24
12 47

29/8

11h
17h
7h
22h

30/8

20mmol.l
14 mmol.l
7.5 mmol.l
22.4 mmol.l
3. Cc xt nghim min dch

Yu cu xt
nghim

Kt qu
28/8

XN
Troponin
XN
AFP

Tr s bnh thng

7/9

0.0327
34

0 0.3

Ng/ml

0 -9

Ng/ml

4. Siu m (28/8 ): Hnh nh si ti mt. vim gan.

5. Phiu xt nghim vi sinh (8/9): Nm +++
6. Chp Xquang s ha 1 phim lng ngc thng(28/8): Hnh
nh bnh thng.
7. Ni soi: Lot tin mn v. test Hp dng tnh.
8. Xt nghim nc tiu
Yu cu xt
nghim

Kt qu

Tr s bnh
thng

n v

30/8
33
1.025
Ncg
Ncg
6

Ncg
5.5
50 leu/ul

n
v

0 16.9
1.015 1.025
05
0 0.1
4.8 7.4
00
05
0 0.8
0 3.4
0 10

Ln
Umol/l
Mmol/l
g/l
Ul
Mmol/l
Umol/l
ul

9. Xt nghim ng mu
Yu cu xt
nghim
12

Kt qu
28/8

2/9

Tr s bnh
thng

n
v
Ch

16/10

XT
NGHIM
NG
MU
Yu t 1
436
405
(Frbrogen)
Thi gian
Prothrombin
bng my bn
t ng, t
ng
Prothrombin Xin kim 22.6
19.5
s
tra li
Prothrombin
49
59
%
Prothrombin
1.76
1.49
NR
APTT
APTTs
43.7
37.5
28.8
APTT
1.47
1.27
0.97
bnh/chng

180 450

Mg/dl
Ln

Giy
70 100

0.85 1.2

28 33
0.85 1.2

Ln
s

on bnh trong bnh n: X gan tin trin.

13 Thuc s dng trn bnh nhn.
Thuc

28
/8
+

NaCl
0.9%
Glucose
+
Furosemid +
ng
tim tnh
mch
20mg

29/ 30
8 /8
+ +

31
/8
+

1/ 2/ 3/ 4/
9 9 9 9
+ + + +

++

5/ 6/ 7/ 8/
9 9 9 9
+ + + +

++

+
+

+
+

9/
9
+

10
/9
+

11/
9
+

++ ++ ++ ++

Tnh trng bnh nhn

28/8: Bnh nhn chng
mt, mt mi, da v nim
mc vng, khng ph,
TALTMC (+), THBH
(+), Suy TB gan (+), i
ngoi phn nt.
29/8: ng mu mao

Furosemid
ng
ung
glycyrrhiz +
in
Gradogen +
Vitamin
+
KCl
Scilin
30/70
Scilin R
Domever
Sorbitol
Omeprazo
l
Medrol
Ciprofloxa
cin
sezol
Klino

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mch tng cao.

1/9: i ngoi phn lng
nhiu ln.
2/9: Ri lon tiu ha
trn nn x gan tin
trin, cc triu chng
cha ci thin=>tin
lng nng.
4/9: Tiu tin 1l/24h, i
ngoi phn nt.
8/9: Ni soi dy dy c
lot d dy, nhim nm.
9/9: C chng (+)

1. PHN TCH S DNG THUC TRN BNH NHN

+ Thuc la chn vi cc vn ca b nh nhn:
NaCl 0.9%
Glucose
Furosemid
ng tim tnh
mch 20mg
Furosemid
ng ung
glycyrrhizin

dung dch tim truyn b sung nc v in gii

Tng p lc keo nhm gi nc, dch v iu tr hn ng huyt
L thuc li tiu quai.

L thnh phn ca cam tho, c tc dung nh bi virus gy ra vim gan v

phng nga cha tr tnh trng loetsdaj dy t trng.

Giadogane
L thuc tng t thuc ng dc Boganic, Boganic l thuc c tc dng
tng cng chc nng gan - mt, chng d ng, thng tiu, gii c, nhun
trng, kch thch tiu ho.

Vitamin

Phng v iu tr s thiu ht vitamnin nhm B ( B1, B6, B12) do ch

n ung khng y .
- iu tr gii c do nghin ru.

KCl
Scilin 30/70

dung dch tim truyn b sung nc v in gii

Thuc c tc dng h ng huyt trong vng 30pht, hiu qu ti a
t c sau 2- 8 gi tim . Tc dng thuc c ko di trong
24h .

Scilin R

Thuc c tc dng h ng huyt trong vng 30pht , hiu qu ti a t

c sau 1 3 gi tim. Tc dng thuc c ko di trong 8h
Thuc li tiu gi Kali.
L thuc li mt.
Sorbitol c dng trong iu tr triu chng to bn v kh tiu

Domever
Sorbitol

Omeprazol

Medrol
Ciprofloxacin

sezol

Klino

iu tr lot d dy- t trng, Ngn nga ti pht lot t trng

L thuc chng vim, chng d ng.

khng sinh dit khun ph rng,ph thuc
nng , c ch DNA gyrase, tc dng tt vi cc vi khun khng
khng sinh thuc nhm khc, hp thu tt qua ng tiu ha, dng
cho cc nhim khun n ng m cc khng sinh thng thng khng tc
dng. ADR di ng ch yu ln thn kinh trung ng, da, d dy-rut.
Nn ung thuc 2h sau ba n, ngi bnh cn c d n ung nhiu
nc v khng ung chng toan d dy, thng iu tr 1-2 tun( t
nht 48 h sau khi khng cn triu chng, liu gi 500-700mg x 2)
iu tr chng mt nc v cc cht in gii trong cc trng hp tiu
chy,nht l tr em (web)
Mtronidazole l thuc khng khun thuc h nitro-5 imidazole. - iu tr
d v phng nhim trng do vi khun k kh trong cc trng hp phu
thut c nguy c cao.

+ Thuc la chn phu hp vi hng dn iu tr:

- Bnh X gan c c chng v tng p lc tnh mch ca:
iu tr c trng (o Hng dn iu tr bnh vin Bch Mai)

Ch chc tho c trng khi cng to, mi ln chc c th t 1 - 3 lt.

Thuc li tiu c 2 nhm thuc c ch nh l: li tiu khng aldosteron v nhm
furosemid. Cch dng c th la chn dng tng loi li tiu n c hay kt hp 2 loi.
Dng n c nn bt u bng nhm khng aldosteron liu 100 - 300mg.
Dng kt hp: li tiu khng aldosteron/furosemid liu 100mg/40mg nu khng p ng
c th tng liu cng vi t l ny s hn ch ri lon in gii. Liu ti a 300mg/120mg.
C th dng ko di v cn theo di in gii mu in gii niu.
Khi p ng c th gim liu li tiu cng theo t l, p ng tt li tiu furosemid nn
dng trc.
Theo di p ng iu tr bng cn nng v s lng nc tiu: cn nng cho php gim
0,5-1 kg/ ngy, s lng nc tiu 1500ml - 2000ml/ngy.
=> Bnh nhn c s dng Furosemid v Spirolacton. Ngay khi mi vo vin nng
KCl ca bnh nhn gim, c bit sau khi s dng cc thuc li tiu, nng
cng gim hn nn bc s cho bnh nhn truyn thm dung dch KCl.
B dch ngay lp tc (Gm c Glucose v NaCl 0.9 % vo 28/8 v NaCl vo cc ngy
tip theo): c gii thch da vo vic chc nng gan b nh hng nn dn n C
trng=> gim th tch tun hon => gim dng mu ti thn => gim chc nng lc ca
thn tm thi. do vy cn b dch m bo an ton cho thn.
Tuy nhin, l do ca nhm l cn ch - Trnh truyn qu nhiu dung dch mui
do tng c trng, tng dch cc t chc khc , lm cho c trng cng nng.
D phng vim mng bng t pht (slide bi ging X gan)
Bnh nhn xut huyt tiu ha cp tnh:
Nguy c nhim khun (c SBP) cao: 25-65% BN lm tng t l

tht bi cm mu, ti XH v t vong

Yu t nguy c: BN x gan tin trin, XH nng
Bnh nhn c nng protein ton phn trong dch c trng thp
m trc cha c t SBP:
BN c protein ton phn/dch c trng thp (<10g/L) v/hoc c
bilirubin ton phn/ huyt thanh cao: c nguy c SBP
Ch nh khng sinh (norfloxacin 400mg/ngy) d phng di hn
cho BN c protein ton phn/dch c trng thp (<15g/L) lm gim
nguy c SBP v t vong. Cha r thi gian d phng.
Ch nh khng sinh
+ Hng u: norfloxacin 400mg/ngy d phng di hn
+ Thay th: ciprofloxacin 750 mg/tun hoc co-trimoxazol 960mg/ngy
- iu tr i tho ng:
o Mc tiu iu tr(Bv Bch Mai):
a HbA1c v 6.5-7.0% trong vng 3 thng
Glucose mu lc i 3,9-7,2 mmol/l
Glucose mu sau n 2h < 10 mmol/l
iu tr cc yu t nguy c i km
Bnh nhn trc khi nhp vin ang dng thuc chng T Insulin nhng khi nhp
vin, do phi truyn Glucose nn ng huyt khng c kim sot. Ngay 29/8 c
ch nh iu tr bng phc 2 mi insulin hn hp mt ngy, 1 bui sng , 1 bui
chiu, vi mc ch loi nhanh lm gim glucose mu sau n, loi chm tc dng c
ngy( mi ban ngy) v sut m n sng ( mi ban m). Liu ban u v vic iu
chnh liu ty thuc vo xt nghim Glucose huyt tng v ch s HbA1c, phc iu
tr hng dn chnh liu 3,4 ngy 1 ln ho c 2 ln/1 tun.
- iu tr tiu chy:
iu tr ban u khi cha xc nh c nguyn nhn tiu chy (Hng dn bch
Mai)
- B nc v in gii, bng Oresol, hay dch truyn.
Tuy nhin, theo nhn nh ca nhm, bc s nghi ng c nh hng ca vi khun k
khi nn cho bnh nhn s dng Metroniazol.
- iu tr triu chng:
Bnh nhn mt mi, chn n => Bc s nghi ng c tn thng ng dn mt nn s dng
cc thuc iu tr triu chng gm:
-Cc thuc li mt: Sorbitol.
- Thuc chng vim Corticoid (Medrol)
- hn ch tc dng trn d dy ca bnh nhn (c tin s d dy) ca Corticoid bc s
b sung thm Omeprazol.
- B sung cc thuc b gip liu php tm l cho bnh nhn gm: Vitamin 3B,
Giadogane v Glycyrrhizin.