Viêm khớp dạng thấp

  • View
    59

  • Download
    8

Embed Size (px)

Transcript

  • VIM KHP DNG THPThs. Bs. Nguyn Th Kim Lini hc Y H ni

  • I CNGL bnh hay gp nht trong cc bnh khp.L bnh mang tnh cht XH: thng c, din bin ko di, hu qu tn phNhiu tn gi: Thp khp teo t, VKDT, VK mn tnh tin trin, VKNK khng c hiu., VKDT.0,5-3% dn s . 20% iu tr ti vin.Ph n trung nin: 70% n, 60-70% >30 tuiC tnh cht gia nh

  • Nguyn nhnYu t tc nhn gy bnh: Vi rus ???Yu t c a: Gii, tuiYu t di truyn: c tnh cht gia nh, VKDT: 60-70% HLADR4Yu t thun li: suy yu, mt mi, bnh truyn nhim, lnh m ko di, phu thut.

  • C ch sinh bnh

    Tc nhn gy bnhC aKhng thT khng thPhc hp min dchThc boMen tiu thMng hot dch khpVim khp khng c hiuDnh bin dng

  • TRIU CHNG LM SNGVim khp1.1. Khi pht:- Vim 1 khp (2/3): khp nh bn tay (1/3), 1/3 khp gi, 1/3 cc khp khc.Tnh cht:sng au r, hnh thoi, cng khp bui sng 10-20%Din bin: 1 vi tun- vi thng

  • TRIU CHNG LM SNG1.2. Giai on ton pht:

    V trT lBn tayC tay90%Khp ngn gn90%Khp bn ngn80%Khp khuu60%Khp gi70%Bn chnC chn70%Ngn chn60%Cc khp khcHim gp

  • TRIU CHNG LM SNGTnh cht vim:

    i xng 95%Sng phn mu taySng, au, hn ch vn ng, t nng , c th c dch khp gi.Cng khp bui sng 90%au tng nhiu v m (gn sng)Cc ngn tay hnh thoi (ngn 2, 3, 4)

  • TRIU CHNG LM SNGDin bin:

    Vim khp nng dn, tng dn, pht trin thm cc khp khcDnh bin dng khp (bn tay gi thi, ngn tay hnh c c, dnh khp gi)

  • TRIU CHNG LM SNG

    2. Triu chng ton thn, ngoi khp:2.1. Ton thn:Gy st, mt mi, n ng km, da nim mc xanh, ri lon thn kinh thc vt

  • TRIU CHNG LM SNG2.2. Da:Ht di da: 10-20% (VN: 5%)+ cc ni ln khi mt da, chc, khng au, khng l r, khng di ng v dnh vo nn xng di, c kch thc 5-20mm+ V tr: xng tr gn khp khuu, xng chy gn khp gi, hoc khp khc, 1 n vi ht Da kh, teo v x (cc chi)Lng bn tay chn gin mch hng.Ri lon dinh dng v vn mch: lot v khun chn, ph chi (chi di)

  • TRIU CHNG LM SNG2.3. C, gn, dy chng, bao khp:- Teo c r rt vng quanh khp tn thng:+ C gian ct, c giun, c i, cng chn.Vim gn: Vim gn AchilleDy chng: Vim co rt, hoc gin dy chngBao khp: Phnh ra thnh kn hot dch (kn Baker)

  • TRIU CHNG LM SNG2.4. Ni tng: Rt him gpTim: kn oVMNgTim, ri lon dn truyn, t tn thng mng trong tim v van timH hp: Vim MF nh, x ph nangHch: ni to, v au mt trong cnh tay.Lch: Lch to, gim bch cu (HC Felty)Xng mt vi, gy xng t nhin

  • TRIU CHNG LM SNG2.5. Mt, thn kinh, chuyn ha:Vim gic mc, vim mng mt th miChn p dy thn kinh ngoi binThiu mu nhc scRi lon thn kinh thc vtNhim amyloid: thn, xut hin mun

  • Xt nghimXN chung:CTM: hng cu gim, nhc sc, bch cu c th tng hoc gim.VSS tngSi huyt tng, phn ng ln bng (+)in di Pr: alb gim, globulin tngHaptoglobin, seromucoid, orosomucoid, C pr(+)

  • Xt nghim

    2. XN min dch:Waaler- Rose v latex:+ Pht hin yu t dng thp (t KT)Cnh hoa hng dng thpT bo Hargraves, KTKN, KT khng acid nhn, KT khng quanh nhnAnti CCP: Anti-cyclic citrullinated peptideC c hiu cao, nhy kmCh VKDT

    Rheumatoid arthritis is both common and chronic, with significant consequences for multiple organ systems. Better understanding of its pathophysiology has led to the development of targeted therapies that have dramatically improved outcomes. The key to therapeutic success lies in identifying individuals who will have severe destructive disease as early as possible, so that effective treatment can be initiated before irreversible damage occurs. Anti-cyclic citrullinated peptide (anti-CCP) antibody testing is particularly useful in the diagnosis of rheumatoid arthritis, with high specificity, presence early in the disease process, and ability to identify patients who are likely to have severe disease and irreversible damage. However, its sensitivity is low, and a negative result does not exclude disease. Anti-CCP antibodies have not been found at a significant frequency in other diseases to date, and are more specific than rheumatoid factor for detecting rheumatoid arthritis. We discuss anti-CCP antibody testing in rheumatoid arthritis, with an emphasis on diagnostic performance, prognostic capability, and relevance to pathogenesis and new treatment paradigms in rheumatoid arthritis. *

  • Xt nghim3. Dch khp:Mucin gim, dich khp lng, gim nht, mu vng nht.Lng t bo tng nhiu: BC DDNTT, bo tng c nhiu ht nh (KN_KT)- ragocytesWaaler- Rose v latex: (+) sm hn cao hn so vi muLng b th trong dich khp gim

  • Sinh ThitSinh thit MHD:Tng sinh cc hnh lng ca MHDTng sinh lp TB ph hnh lngm hoi t ging t huytTng sinh nhiu mch mu tn to phn t chc m.Lymphocyst, Plasmocyst2. Sinh thit ht di da: gia: m ln hoi t dng t huytXung quanh: nhiu t bo Lympho, plasmocyst

  • X Quang1. Du hiu chung:u tin: Mt vi u xng, cn quang phn mm quanh khp.Hnh khuyt nh, bo mn xng gi sn khp v u xng, khe khp hp.Hy hoi sn khp, u xng gy nn dnh v bin dng khp.

  • X Quang2. Hnh nh c bit: Bn ngn tayKhe khp, ranh gii gia cc xng hp m, sau s dnh mt khi.u xng bn ngn tay: Hnh khuyt, khe khp hp ri dnhKhng thy tn thng khp ngn xa

  • TIN TRINDin bin ko di nhiu nm, t t tng dn, hoc tng t.Nng ln khi: lnh, chn thng, nhim khun, phu thut.4 giai on Steinbroker

    Giai on I: tn thng mi khu tr MHDSng au phn mmXQ cha c thay iCn V c gn nh bnh thng

    *

  • TIN TRINGiai on II: Tn thng 1 phn n u xng, sn khp.XQ: hnh khuyt, khe khp hp.V b hn ch: tay cn nm c, i li bng gy, nng

  • TIN TRINGiai on III:Tn thng nhiu n u xng, sn khp. XQ: Dnh khp mt phnV cn t:bnh nhn t phc v SHHN, khng i li cGiai on IV: Dnh khp v bin dng khp trm trngMt ht chc nng vn ng, tn ph hon tonThng sau 10- 20 nm

  • Bin chngNhim khun ph: LaoDo dng thuc iu tr VKDT: Steroid, NSAID, gim au, choloroquin, mui vng, c ch MDChn p TKTim, thn, v mt: Him

  • Tin lngBnh nng: tt ni tng, s khp vim, phn ng Waaler-Rose(-)Chn on v iu tr mun

  • Th lm sngTh bnh theo triu chngTh mt khp: hay khp gi, chn on kh, sinh thit MHDTh lch to: HC Felty: lch to, BC gim, gan to, ni hch, xm da3. Th km hi chng Sjogren GougerotVKDT + Teo tuyn nc bt, tuyn nc mt: HC kh mt, ming4. Th xut hin sau bnh bi phi (HC Caplan):bi than, silic

  • Th bnh theo tin trinTh lnh tnh: Tin trin chm, s lng khp vim t2. Th nng: nhiu khp, c st, c biu hin ni tng, tin trin rt nhanh, lin tc3. Th c tnh: st cao, trn dch khp gi, tin trin rt nhanh dn n dnh v bin dng khp.

  • Th theo c a Th nam gii: nh, khng in hnhTh ngi gi: sau 60 tui, bnh nh, d nhm vi thoi ha khpTh c phn ng Waaler- Rose (-): th huyt thanh (-).Bnh nng, kh iu tr

  • Chn on1. Tiu chun chn on ARA (1987):Cng khp bui sng ko di trn 1 giSng au ko di trn 6 tun, ti thiu 3 v tr trong s 14 khp: ngn tay gn (2), bn ngn (2), c tay (2), khuu (2), gi (2), c chn (2), bn ngn chn (2) Sng au 1 trong 3 v tr: khp ngn tay gn, khp bn ngn, khp c taySng khp i xngC ht di daDu hiu XQ: in hnh (bo mn u xng, hp khe)Phn ng Waaler- Rose, test latex (+)Chn on xc nh: >= 4 tiu chun

  • Chn on2. Tiu chun ca Vit namN, tui trung ninVim cc khp nh hai bn tay (c tay, n ngn, ngn gn), khp gi, c chn, khuu.i xngC du hiu cng khp bui sngDin bin ko di trn 2 thng.

  • Chn on phn bit Giai on uThp khp cpThp khp phn ng: xh sau cc bnh NK, VK khng i xng, khng li di chngHi chng Reiter: Vim khp, niu o v kt mc mt

  • Chn on phn bit2. Giai on sau:Hi chng Pierre Marie: Vim nhiu khp, c ngn tay, ngn chm di trng (U ph qun)Luput ban h thng, x cng bGoutVim CSDKThp khp vy nnBnh tiu ha c biu hin khp (vim i trc trng chy mu), bnh thn kinh (bnh tabes), bnh mu, ung th Thoi ha khp

  • IU TRNguyn tc chung:iu tr kin tr, lin tc Kt hp nhiu bin phpThi gian iu tr chia lm nhiu giai on: ni tr, ngoi tr, iu dngTheo di, qun l bnh nhn

  • IU TRThuc s dngChng vim : Corticoid, NSAIDGim au: Paracetamiu tr c bn: Cloroquin, Methotrexat, Cellcept (Mycophenolate, Transfonex)iu tr h tr: Calci, Kali, D dy

  • iu tr khng dng thucVLTLTp luyn

  • IU TRB. C th Giai on 1:Chlorquin 0,2g-0,4g/ ngyHydrocortison ti chVt l tr liuTrnh lnh, m, lm vic nh

  • IU TR2. Giai on 2: NSIADChloroquin 0,2-0,4g/ngySteroid 40mg/ngy VLTL

  • IU TR3. Giai on 3: nngSteroid 1,5mg/kg/ ngy hoc 100-200mg TMGim dn liu, duy tr liu ti thiu 5mg (1v prednisolon)S dng thm:Methotrexat 2,5mg x 3-5v / tun Hoc : Endoxan 1-2 mg/kg/ ngy Cellcept 2g/ngy- Tp luyn chng dnh khp

  • IU TR4. iu tr ngoi khoaCt b MHD, thay khp nhn to

  • PHC HI CHC NNGMt bin php quan trng v bt buc:trnh c thp nht cc di chng, tr li kh nng lao ng ngh nghip cho bnh nhn.Sau khi dng thuc iu tr bnh nhn gim au th phi kt hp vt l tr liu v vn ng liu php.

  • PHC HI CHC NNG+ Tm nc nng, nc m, b parafin, dng n hng ngoi, t ngoi chiu vo khp vim, tm bn...:* Gin mch, tng cng lu thng mu, tng tit m hi, gin c v gim au ti ch.+ Dng dng in mt chiu, xoay chiu, in cao tn, siu m vi cng v bc sng khc nhau.

  • PHC HI CHC NNG+ Xoa bp v bm huyt: thy thuc lm v hng dn bnh nhn thc hin, xoa bp c tc dng lm lu thng mu, gim au, tng tnh n hi ca da, gim x ho da v dy chng.+ Vn ng liu php v phc hi chc nng: hng dn bnh nhn vn ng thch hp:

  • PHC HI CHC NNGTp vn ng bng tay khng, tp vi cc dng c phc hi chc nng: tp bng gy, tp t, tp tro thang, co, ko, bn p.

    + Nc sui khong, nc bin v bn tr liu:- Nc khong: khi ngun nc c ho tan t mt gam cht rn tr ln trong mt lt nc, hoc nc nng > 30 C n nh.

  • Ca bnhBnh nhn n, 60 tui, b bnh hn 5 thng, sng au cc khp 2 gi, c chn, bn ngn chn 2 bn, c du hiu cng khp bui sng iu tr NSAID vn sng au cc khp

  • Rheumatoid arthritis is both common and chronic, with significant consequences for multiple organ systems. Better understanding of its pathophysiology has led to the development of targeted therapies that have dramatically improved outcomes. The key to therapeutic success lies in identifying individuals who will have severe destructive disease as early as possible, so that effective treatment can be initiated before irreversible damage o