5-PHAC DO KHOA KB

1CNG HA X HI CH NGHA VIT NAM S Y T AG BVK AN PH c lp T do Hnh phc

PHC IU TR

KHOA KHM BNH

NM 2014

2MC 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

329. Hen ph qun .118

30. Bnh phi tc nghn mn tnh (COPD)..122

31. Vim ph qun cp .129

32. Danh mc thuc..131

4BNH I THO NG TYPE 2 CHA C BIN CHNG

I. I CNG:

- 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.

5b. 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:

Khi u Ti a S ln dng / ngy

Sulfunylure

Gliclazide 30

80mg

120mg

320mg

1 ln 2 ln

Biguanid

Metformin 500mg

500mg

2550

2000

1- 3 ln 1 2 ln

c ch glucosidase Acarboz (glucarbose)

50mg 300mg 1 3 ln

TZD (Pioglitazol) 15 30mg 45mg 1 ln

c ch DPP4

Sitaglitin 100mg 100mg 1 ln

Saxaglitin 5mg 5mg 1 ln

Vidagliptin 50mg 50 100mg 1 2 ln

Linagliptin 5mg 5mg 1 ln

3. Insulin (Tim di da):

Loi Insulin TDD Mu

sc

TG bt u

tc dng

TG tc dng

nh

TG tc dng

ko di

Insulin phng (Bolus) tc dng rt nhanh Lispro aspart glulisin

Trong 15 30 pht 0,5 1,5 gi 3 5 gi

Tc dng nhanh Actrapid humulin

Trong 30 pht 2 4 gi 6 8 gi

Insulin nn (Basal)

Tc dng trung bnh c 1 2 gi 6 12 gi 18 24 gi

Tc dng di c 3- 8 gi 14 24 gi 24 40 gi

Glarglin (Lantus)

(Detemin) Trong

4- 6 gi 3 4 gi

24 gi 24 gi

Insulin

Mitard 30/70, Humudin 30/70,

Scillin 30/70, Insulin analog

trn sn, Insulin aspard pha (Novomix)

c 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.

6

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.

7

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 Mi ln khm

HbA1C 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 v c tnh lc cu thn

Lc mi chn on, mi nm kim li 1 ln nu 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.

8

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.

93. 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

10

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:

11

- 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:

Nhm Hm lng

mg/ vin

Liu tn cng

mg/ ngy

Liu duy tr

mg/ ngy

Thiouracil

PTU (PTU,proracil)

50mg

200 - 400 mg

50 - 100 mg

Imidazol

Carbimazol(Neomercazole,

carbimazol)

5mg

15 - 30mg

30 - 45mg

5 - 10mg

5 - 10 mg

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:

12

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)

13

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.

14

- 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 55 tui, n 65 tui.

- i tho ng.

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

Nebividol 2,5- 10mg 1 ln/ngy.

* 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.

15

- 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 TPHCM-

2009 (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).

16

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

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.

Phn loi HA tm thu (mmHg)

(HATT)

HA tm trng (mmHg)

(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

17

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) (

18

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

19

- 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:

Tn thuc Liu (mg/ngy) S ln/ngy

Li tiu Idapamide

Furosemide

Spironolacton

1,25 2,5

20 80

20 50

1

2

1

Chn Bisoprolol

Metoprolol

Carvedilol

2,5 10

50 100

12,5 50

1

1

2

UMCM Enalapril

Lisinopril

Perindopril

5 40

10 40

4 8

1 2

1

11

20

UCTT.AT1 Candesartan

Losartan

Irbesatan

8 32

25 100

150 300

1

1 2

1

UC Ca+ Amlodipin

Felodipin

Nifedipine, Nifedipine LP

2,5 10

2,5 20

10 20

1

1

1 2

Uc 2TW Methyldopa 250 1000

2

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).

21

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:

- 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.

II. 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.

22

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

23

- 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 2

Lisinopril 2,5-5mg 20mg 1

Perindopril 2mg 4mg 2

Ramipril 1,25- 2,5mg 5mg 1

Catopril 6,25mg 50mg 3

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.

24

- 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

25

NHIM TRNG TIT NIU

I. I CNG:

- 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:


Nc tiu c, c th c mu

26

au h v

Thng khng c triu chng nhim trng ton thn.

- Cn lm sng:


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.


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:


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

27

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.

28

HHOOII CCHHNNGG TTHHAANN HH

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

29

- 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.

30

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:

31

- 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).

32

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 Scholein-

Henoch.

- 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.

33

- 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).

34

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 da-

c, 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 :

35

+ 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).

36

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

37

- 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.


+ Clarithromycin 500mg x 2 /ngy

+ Tinidazole hoc Metronidazol 0.5g x 2 /ngy

ung trc khi n, lin tc t 10 14 ngy.


+ Amoxicillin 1g x 2 /ngy

+ Metronidazol 0.5g x 2 /ngy

ung trc khi n, lin tc, t 10 14 ngy.


+ Amoxicillin 1g x 2 /ngy + Tinidazole 0.5g x 2 /ngy


38

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)


+ Amoxicillin 1g x 2 /ngy

+ Clarithromycin 500mg x 2 /ngy

+ Tinidazole hoc Metronidazol 0.5g x 2 /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:

39

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.

40

VIM I TRNG MN

I. I CNG:

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.

II. CHN ON:

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.

41

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.

42

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.

43

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 5-

10 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

44

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

45

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 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.

46

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).

47

+ 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

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

48

- Tr em106copies/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

49

- Trong thi gian iu tr:

+ Cc triu chng lm sng, ALT, AST, creatinine, HBsAg, HBeAg, anti-

HBe 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.

50

Keeffe E et al. Clin Gastroenterol Hepatol 2007; 5: 89097.

ALT > 2 ULN (> 6 th)

HBsAg + (> 6 th)

W12 HCV RNA

HBV DNA

200.000 IU/ml

( 106 copies/ml)

v tin cn gia nh

lin quan HCC

HBV DNA

20.000 IU/ml

( 105 copies/ml)

PHC

IU TR VGSV B mn

HBV DNA

2.000 IU/ml

( 104 copies/ml)

ALT 2 ULN

HBeAg -

HBV DNA nh lng v tm nguyn nhn

HBeAg +

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

ALT, AST, SA/6-12 th

HBV DNA

< 2.000 IU/ml

(< 104 copies/ml)

v HBeAg AntiHBe +

iu tr bng thuc khng virus


Ngng iu tr khi

Theo di trong khi iu tr: - - LS, ALT, AST, Creatinin,

HBsAg, HBeAg, AntiHBe/3th

- - HBV DNA nh lng/6th

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

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

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

51

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.

52

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/ mm3, 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.

53

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 (Peg-

IFN) + 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

(nu d on p ng

km: 15mg/kg/ngy) v

180 g/ tun hoc 1.5 g/kg/ tun 24 tun **

(*) 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

54

- 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.

55

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 GFR,

mL/pht /1.73 m2

iu tr c ngh

Tn thng thn vi

GFR bnh thng

hoc tng

90 iu tr thng quy

Tn thng thn vi

GFR gim nh

60 - 90

GFR gim trung bnh 30 - 59 Peg-IFN 2b 1 g/ kg/ tun

hoc Peg-IFN 2a 135 g/ tun

+ RBV 200 800 mg/ngy (bt

u bng liu thp v tng t t

nu kim sot c tc dng ph)

GFR gim trm trng 15 - 29

Suy thn < 15

Lc mu Liu chun IFN 3m U x3/ tun

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

56

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 Peg-

IFN 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.

57


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 m (< 50IU/ml): RVR

W4 HCV RNA dng

((d ng

W12 HCV RNA

Thi gian iu tr 24 w nu nng HCV trc iu tr thp

< 400.000 800.000 IU/mL

hoc < 2log 10

W 12

HCV RNA dong

d ng

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

2 log 10 so vi ban u:

pEVR

Thi gian iu tr 24 w

W 12 HCV RNA m:

cEVR

< 2 log 10 so vi ban u:

Non EVR

Ngng iu tr

W4 HCV RNA

W12 HCV RNA

W 24 HCV RNA

Thi gian iu tr 48 w

Thi gian iu tr 72 w

W 12 HCV RNA m:

DVR W 12 HCV RNA dng

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 tr

58


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 m

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

dd d ng

W12 HCV RNA

Thi gian - iu tr 12 16 w

(ti pht cao, nht l genotype 3 vi nng RNA HCV cao) - iu tr 24 tun

W 12

HCV RNA dng

d ng

PHC IU TR VGSV C mn genotype 2, 3

< 2 log 10 so vi ban u hoc vn

dng tun 24

DVR

Thi gian iu tr 24 w

W 12 HCV RNA m:

EVR

> 2 log 10 so vi ban u:

DVR

Ngng iu tr

W4 HCV RNA

W12 HCV RNA

Thi gian iu tr 48 w

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

59

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 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.

60

- 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 2.3

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

Giai on:

Lm sng nh ngha % t vong/ nm

X gan cn b

Giai on 1

Giai on 2

Khng dn TMTQ, khng bng bng

C dn TMTQ, khng bng bng

1%

10%

X gan mt b

Giai on 3

Giai on 4

Bng bng dn TMTQ

XHTH do v dn TMTQ bng bng

20%

50%

III. IU TR:

1. Trnh cc yu t lm tn thng gan:

61

- 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:

62

- 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:

63

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.

64

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

65

Long xng- Osteoporosis T < -2.5

Long xng nghim trng

(severe osteoporosis)

Long xng + Tin s

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 (

66

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.

67

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:

68

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, Efferalgan), Efferalgan codein,

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

69

- 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:

70

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.

71

- 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:

72

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





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.

73

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.

74

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.

75

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.





Celecoxib 100 200mg/ngy.

Piroxicam 10mg x 2ln/ngy

Meloxicam(Mobic) 7,5mg x 2ln/ngy

Etodolac (edosic) 600-1.200mg/ngy

76

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 (

77

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.

78

HNG DN IU TR TNG ACID URIC MU

TANG ACID URIC MAU

Khong trieu chng

Tien s gout

MOT CN GOUT

(CN AU TIEN)

CN GOUT TAI PHAT

Thay oi loi song :

.Giam can nang

.Han che Protid

.Han che uong ru

Tien s co soi he nieu

Cac u cuc quanh khp (Tophi)

Mc loc cau than

Acid uric nieu 24 gi

GIAM TONG HP ACID URIC

ALLOPURINOL / FEBUXOSTAT

TANG THAI ACID URIC

(PROBENECID/SULFINPYRAZONE)

Tiep tuc neu co ket qua

Neu khong, chuyen dung ALLOPURINOL

Tuoi < 60 Tuoi > 60

Co Khong

Co Khong

CLCr 80 ml/phut CLCr 80 ml/phut

< 800mg > 800 mg (che o an bnh thng)

79

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

80

* 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.

81

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.

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