Trng DDH Y Dc Cn Th

Khoa Dc

Lp Dc K37 Nhm B2 T 3

Bo Co Thc Tp Dc Lm Sng II
Ca Lm Sng Lot D Dy T Trng

A. TRNH BY & PHN TCH CA LM SNG (SOAP)
1. Thng tin ch quan (S):
Thng tin bnh nhn (BN): Mt ph n tn A, 86 tui c a n khoa cp cu.
Triu chng bnh: Mt tun trc BN b mt mi suy nhc au vng thng v, bun nn.
Trc khi nhp vin mt ngy BN i phn nha en, cht nn c mu ging b
c ph.

Tin s bnh: Vim xng khp

Gut
Tng huyt p
Run khi ngh do chng lo u
D ng thuc: Khng c tin s d ng thuc.
2. Thng tin khch quan (O):
Sinh hiu ca bnh nhn:
Mch: 155 nhp/pht (Bt: ngi gi 60 70 nhp/pht)
Nhp th: 24 ln/pht (Bt: 16 - 20 ln /pht)
Huyt p: 115/59 mmHg (Bt: 120/70 mmHg)
Kt qu xt nghim:
Kt qu xt nghim sinh ha mu khi nhp vin:
Cc ch s xt nghim
Kt qu
Hemoglobin (g/dL)
8.3
PCV
0.275
MCV (fL)
75
MCH (pg)
25
9
Platelets (x10 /L)
264
Haenatocrit
0.31
C creactive protein (mg/L)
45
NR
1.01
Na+ (mmol/l)
141
+
K (mmol/L)
4.0
Creatinin (mcg/l)
105
Urea (mmol/L)
20.3
Cc thuc bnh nhn ang s dng:
Propranolol 40mg n 3 ln/ngy khi cn.
Indometacin 25 mg 3 ln/ ngy.
Arthrotec (diclofenac 50mg + misoprostol 200 mcg) 2 ln/ ngy.
Allopurinol 100 mg 1 ln/ ngy.
Ramipril 10mg 1 ln/ ngy.
Simvastatin 40 mg vo bui ti.

Bnh thng
11 - 13
0.36 -0.47
80 -100
27 -32
150 -400
0.36 -0.46
0-4
135 -145
3.5 -5
45 -84
1.7 -8.3

3. nh gi (A):
GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc
Lp Dc K37 Nhm B2 T 3
Sinh hiu ca BN:
- B A c nhp th nhanh, mch p nhanh, huyt p ch gim nh.
- Nhit c th ca bnh nhn khng co ghi nhn.
Kt qu xt nghim: Da vo kt qu sinh ha mu ca bnh nhn khi nhp vin c th nhn nh s b:
- BN c nhng ch s bt thng lin quan n tnh trng xut huyt nh: Haemoglobin, PCV, MCV,
MCH v Haematocrit u gim so vi bnh thng.
- BN c ch s Urea v Creatinin tng bt thng:
Urea ca bnh nhn tng l do BN b bnh Gut.
Creatinin tng cao so vi ch s bnh thng nhng cha n mc chn on suy thn, BN ch c s
gim lc cu thn. (Ch s Creatinin/ huyt thanh t 130 mcmol/l tr ln c chn on l suy thn mc
nh)
Thuc bnh nhn ang s dng:
V tng tc gia cc thuc m BN ang s dng ng ch nht l s tng tc gia nhm thuc iu tr tng
huyt p ( Propranolol, Ramipril) vi cc thuc thuc nhm NSAID (Indomethacin, Diclofenac).
V liu s dng cho BN: BN A l ngi ln tui cn phi da vo h s thanh thi Clearance Creatine tnh
liu thuc cho bnh nhn.
Chn on: b A b xut huyt tiu ha trn do lot d dy t trng. Da vo nhng du hiu sau:
Trn lm sng:
Nn ra mu, tin phn nha en.
Mch nhanh, nhp th nhanh huyt p tt nh c du hiu sc mt mu.
au vng thng v.
Dng thuc gim au NSAID.
Cn lm sng:
Hng cu gim, huyt sc t gim v Hematocrit gim.
Cn nh gi tnh trng xut huyt ca bnh nhn c hng x l ph hp, c th nh gi da trn
thang im sau:
Thang im Rockall (Rockall score): gip tin lng nguy c xut huyt v t vong
Yu t nh gi
Thang im
Rockall hon
chnh

im

Tui

Thang im
Rockall
lm sng

< 60 tui

60-79 tui

80 tui

Shock
Nhp tim > 100 ln/pht

Huyt p tm thu < 100 mmHg

B nh kem
Thiu mu c tim, suy tim huyt, cc b nh khc
kem theo

Suy th n, suy gan, ung th di cn

Chn on n i soi
GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc

Lp Dc K37 Nhm B2 T 3
Khng tm thy tn thng, rch nim mc tm v
(Mallory-Weiss tear)

Lot d dy - t trng, vim thc qun

Ung th tiu ha trn

N i soi nh gi nguy c xut huyt

Lot c y sch ho c v t mu en

C mu trong ng tiu ha trn, c tn thng chy

mu tin trin, l mch, cc mu ng

Cch tnh im: Cng tt c cc im tng mc.

Rockall lm sng: da vo 3 yu t (tui, bnh l i kem, v tnh trng shock)
Nguy c cao: 3 7 im
Nguy c thp: 0 2 im
Rockall chung: bao gm Rockall lm sng, bng chng chy mu qua ni soi, v chn on
Nguy c cao: > 8 im
Nguy c trung bnh: 3 8 im
Nguy c thp: 0 2 im.
T thang im rockall ta c th suy ra phn trm nguy c t vong (mortality) v ti xut huyt (rebleeding)
theo bng sau:

Da theo nhng thng tin t BN A ta c:

Rockall lm sng: nguy c cao (5 im)
Rockall chung: cha c th nh gi chnh xc c v BN cha thc hin ni soi. C th nm trong mc
nguy c trung bnh.(3 8 im).
GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc
Nguy c t vong khong 2,9%
Nguy c ti xut huyt 11%.

Lp Dc K37 Nhm B2 T 3

4. K hoch (P):
Trong trng hp ny, BN cn c:
H sc tch cc ngay t u.
Xt nghim cng thc mu, in gii ure, ng mu, xt nghim chc nng gan thn, nhm
mu, in gii .
Ni soi d dy, t trng chn on xc nh cm mu.
Dng thuc gim tit acid.
iu tr lin lot v chng ti pht do thuc.
Gio dc BN trong vic s dng thuc, n ung v c li sng lnh mnh.
B. TR LI CU HI:
Cu 1: La chn iu tr ngay cho b A l g? iu tr sc v iu tr triu chng cho b A th no?
Tr li: Da theo kt qu tnh im Rockall c th d on BN A c nguy c xut huyt v t vong
loi trung bnh (khong 11%). Vy cn cp cu sc cho bnh nhn ng thi iu tr triu chng cho bnh nhn.
iu tr sc v iu tr triu chng cho BN theo nguyn tc: Hi sc tch cc, ni soi cm mu
v iu tr lin lot. C th:
Hi sc cho BN:
1) T th bnh nhn u thp.
2) m bo ng th: duy tr kh nng vaanj chyn oxy mu cho BN : cho th oxy qua xng mi 3-6l/pht. Nu
c nguy c tro ngc vo ng h hp hoc c suy h hp cn t ni kh qun.
3) u tin hng u trong hi sc l b li khi lng tun hon n nh huyt ng.
4) Tt c bnh nhn phi c t truyn tnh mch.
5) Bi ph th tch tun hon:
Bi ph th tch c bt u truyn tnh mch dch mui ng trng 20 ml/kg.
Nu sau khi truyn dch ng trng ti tng liu 50ml/kg m bnh nhn vn cn du
hiu sc cn truyn dch keo (500 -1000ml) m bo th tch trong lng mch.
6) Truyn mu cho BN duy tr mt mc hemoglobin >100g/l bnh nhn ln tui.
Truyn mu: thng khi hemoglobin < 7-8 g/dL. Mc d kt qu xt nghim l 8.3 g/dL
nhng bnh nhn A l ngi cao tui c bnh v tim mch nn cn truyn mu duy tr mc hemoglobin >
10g/dL.
Cm mu cho bnh nhn v theo di tnh trng mt mu ca bnh nhn:
Ni soi cm mu, c th s dng mt tronh nhng cch sau:
Tim cm mu: bng adrenalin 1/10000, cn tuyt i, nc mui u trng. Tin hnh tim 4 gc lot v
tim vo y lot.
Dng nhit: dng u d n cc hoc a cc,
Cm mu c hc: dng kp clip c tc dng tt trong cc trng hp ang chy mu t cc mch mu ln.
Thuc: s dng thuc c ch bm proton liu cao c chng minh lm gim chy mu ti pht v
gim t l phi phu thut.
iu tr ngoi khoa: khi s dng cc phng php cm mu trn u tht bi, c th xem xt iu tr
ngoi khoa hoc bng nt mch.
Cu 2: Nn ngng dng thuc no trong cc thuc iu tr gn y cho b A?
Tr li: Nn ngng vic s dng thuc NSAID v n lm nng thm tnh trng vim lot ca BN,
gm 2 thuc: Indomethacin v Arthrotec.
GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc
Lp Dc K37 Nhm B2 T 3
Bnh nhn ang trong tnh trng xut huyt tiu ha, huyt p gim nn ngng cc thuc
iu tr tng huyt p: Propranolol v Ramipril.
Cu 3: C ch gy lot d dy ca NSAID?
Tr li:
Nim mc d dy rut sn xut ra PG (c bit l PGE2), c tc dng lm tng to cht nhy v
c th l c kch thch phn bo thay th cc t bo b ph hy. Nh vy, vai tr ca PGE l bo v nim
mc ng tiu ha. Thuc NSAID vi mc khc nhau c ch COX lm gim tng hp PG, to iu kin
cho HCl v pepsin ca dch v gy tn thng cho nim mc khi hng ro bo v b suy yu.
Ngoi ra cc NSAID cn tc ng trc tip hy hoi cc t bo biu m tiu ha do phn ln
chng u l nhng acid. Cc NSAID cn c ch s phn chia ca t bo biu m ng tiu ha lm thay i
lu lng mu ti cc c quan tiu ha, lm gim thiu cc lp cht cung cp nng lng trong cc t bo nim
mc v hot ha men 5-lipoxygenase lm tng cc Leukotrien - l cht gy hy hoi t bo biu m ca h tiu
ha - gy thng lot.
Nhm thuc NSAID tc ng
trn d dy theo 2 c ch:
Trc tip ln lp nim mc:
lm tn thng cu trc t bo v lp bo v
nim mc b mng i.
Gin tip: c ch sn xut
prostaglandin E2 v I2 thng qua c ch c ch COX 1
lm gim lng mu nui dng bo, gim bi tieetd
cht nhy v gim tit NaHCO3.
Cu 4: Misoprostol c hiu qu th
no trong ngn nga lot do NSAID?
Tr li:
Misoprostol l cht tng t prostaglandin
E1, c tc dng c ch tit acid d dy v bo v nim
mc d dy. Khi dng vi liu ngn chn tit acid d dy,
misoprostol c tc dng
lnh vt lot d dy c hiu qu nh nhng thuc i
khng H2.
Misoprotol l thuc thuc nhm tc ng ln
cc yu t
bo v nim mc, l dng tng hp prostaglandin E 2
dng methyl
ester ha.C tc dng ngn nga lot do NSAID do:

Gia tng tng hp v gii phng prostagladin ti ch trn nim mc d dy.

c ch hot cht kh prostaglandin
Tng kch thch m ht nn lm tng kh nng lnh so .
Cu 5: ngh cht c ch no, liu v ng dng ?
Tr li: Cc thuc c ch bm proton ng tnh mch liu cao c chng minh l lm gim chy
mu ti pht v gim t l phi phu thut:
Liu dng: 80mg tim tnh mch chm sau 8mg/ gi truyn tnh mch lin tc trong 72h, sau
chuyn sang dng ung vi liu 40 mg/ngy ti thiu 28 ngy tip theo (esomeprazol, pantoprazol v
omeprazol).
i vi rabeprazol dng liu 40mg tim tnh mch chm + 4 mg/gi truyn lin tc trong 72 h,
sau chuyn sang dng ung liu 40mg /ngy ti thiu 28 ngy tip theo.
Trng hp khng c thuc dng ng tnh mch, c th s dng thuc vin gp 2 3 ln liu
tiu chun.

GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc
Lp Dc K37 Nhm B2 T 3
Hin nay th gii khng khuyn co s dng thuc c ch H 2 trong XHTH cp do khng c
nhng hiu qu iu tr cao v c nhiu tc dng ph. Nhng nu phi dng th dng ranitidin 50 mg tim tnh
mch chm, sau duy tr 6.25 mg/ gi trong 72 gi dng loi 50 mg tnh mch chm ngy 3 ln.
Cu 6: S nhim Hp c tng kh nng tn thng mng nhy do NSAID? Cc yu t c th dn n
lot v tng nguy c ti pht b A?
Tr li: Hp l xon khon Gram (-) c tr nim mc d dy t trng, ph hy nhiu t bo nim mc
d dy t trng bng nhng enzym: catalase, lipase, glycoprotein,.Trong s t bo D c chng minh b
ph hy nhiu v s ph hy ny c lin quan n bnh lot d dy t trng. T bo D tit somatostatin c ch
tb G tit gastrin, m gastrin c vai tr kch thch s bi tit H +, khi tb D b ph hy nhiu tc l lng
Somatostatin tit ra t s lm gia tng nng H+ trong dich d dy (tng yu t tn cng).
Cc thuc NSAID tc dng theo c ch c ch enzym COXs trong c th. Enzym ny c vai tr tng
hp PGI2, PGE2 c tc dng bo v nim mc d dy. Khi enzym ny b ph hy tc l PGI2, PGE2 c sn
sinh ra t hn lm gim cc yu t bo v d dy.
Trong trng hp bnh nhn ang b nhim con Hp m cn dng thm cc thuc NSAID s lm trm
trng thm tnh trng mt cn bng gia cc yu t tn cng v yu t bo v. Do lm tng s ph hy mng
nhy ca cc thc NSAID.
Cc yu t c th dn n lot v tng nguy c ti pht b A:
Tui tc: cng ln tui th chc nng sinh l trong c th cng b gim theo, cc yu t bo v c th cng gim
ng thi. Mt khc ngi gi thng c nhiu bnh kem theo, v vy phi dng nhiu thuc iu tr. iu
ny cng ng ngha vi vic b A chu nhiu tc dng ph ca thuc.
S dng thng xuyn cc thuc NSAID iu tr bnh.
Lo u.
Cu 7: Khi no bt u tit tr Hp? Bn ch nh pht no iu tr Hp?
Tr li: Nu c Hp th tit tr sau khi bng vt lot (xut huyt tiu ha n nh).

Phc tit tr H.pylori:

Triple therapy:
1. Omeprazole
+
Clarithromycin
+
Amoxicillin
20mg x 2 ln/ngy
20mg x 2 ln/ngy
1g x 2 ln/ngy
2. Omeprazole
+
Clarithromycin
+
Metronidazol
20mg x 2 ln/ngy
250mg x 2 ln/ngy
500mg x 2 ln/ngy
3. Ranitidin Bismuth citrate +
Clarithromycin
+
Amoxicillin
400mg x 2 ln/ngy
500mg x 2 ln/ngy
1g x 2 ln/ngy
Thi gian 7-10 ngy
Trng hp khng c Clarithromycin:
1. Omeprazole
+
Amoxicillin
+
Metronidazol
20mg x 2 ln/ngy
1g x 2 ln/ngy
50mg x 2 ln/ngy
Thi gian 7-10 ngy
2. Bismuth citrate
+
Metronidazol
+
Tetracyclin
120mg x 2 ln/ngy
500mg x 2 ln/ngy
500mg x 4 ln/ngy
Thi gian 14 ngy
iu tr bn:
Omeprazole
+
Bismuth citrate
+
20mg x 2 ln/ngy
120mg x 4 ln/ngy
Metronidazol
+
Tetracyclin
500mg x 2 ln/ngy
500mg x 4 ln/ngy
Thi gian 7-10 ngy
GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc
Cu 8: Lp k hoch iu tr bng thuc cho b
sau khi xut vin?
Tr li: Sau khi bnh nhn xut vin cn s
dng thuc iu tr nhng bnh c t trc ca
BN ng thi cng s dng thuc iu tr v phng
nga bin chng. C th s dng toa thuc sau:
1) Meloxicam 15mg
1 ln/ngy .
(Ung sau n)
2) Allopurinol 100mg
1 ln/ngy
(Ung sau n)
3) Gemfiprozil 600mg
2 ln/ngy.
(Ung bui sng, bui ti trc ng).
4) Omeprazole 20mg
1 ln/ngy.
(Ung vo bui sng trc n 30 pht)
5) Amlodipine 5mg
1 ln/ngy.
(Ung vo bui sng)

Lp Dc K37 Nhm B2 T 3

Cu 9: C nn b sung st cho b A? Nu c th trong bao lu?

Tr li: S dng cc ch phm b sung st cho bnh nhn l iu cn thit. Theo kt qu xt nghim,
Haemoglobin = 8.3 g/dL (<10g/dL), MCV, PCV v MCH gim -> b A b thiu mu mc trung bnh. BN
l ngi ln tui va tri qua tnh trng mt mu nhiu dn n thiu st v (chy mu do bt k nguyn nhn g
u dn ti thiu st, nu s mt mu xy ra th s thiu mu thiu st s xy ra sau ). V do bnh nhn
c iu tr bng PPIs, c th dn n thiu st. Do st phi c chuyn sang dng st ha tr 2 trong mi
trng acid hp thu, m PPIs lm gim tit acid d dy, nn lm gim hp thu st.

Cch tt nht l s dng cc ch phm tng hp sn c trn th trng do BN khng n c nhiu.

Liu dng: 10 50 mg st nguyn t mi ngy (i vi ngi gi).

Cho thuc khong 2 tun sau cho BN ti khm, kim tra li cc ch s ha sinh, nu bnh thng th
ngng s dng st, chuyn sang b sung t thc phm: Rau xanh (ci bp, ci xanh, ci xoong), tri cy
(hnh nhn, me)
GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc
Lp Dc K37 Nhm B2 T 3
Cu 10: Li khuyn cho bnh nhn khi chun b xut vin ti u ha hiu qu iu tr v m bo
tun th tr liu?
Tr li: Sau khi xut vin, BN cn s dng thuc ng gi theo s hng dn ca thy thuc. ng thi
bnh nhn cng cn thay i li sng, kt hp vi ch n ung hp l v trnh nhng yu t nh
hng n sc khe. C th:
Trnh khi thuc l.
Hn ch cng thng, stress
Trnh thc n chua , cay, vitamin C, c ph
n ung u n, khng vi v.
Ngh ngi khi au nhiu, khi c bin chng.
Nn lm vic theo thi kha biu n nh.
Ung thuc ng gi, ng thi im.
Ngi nh h tr bnh nhn tun th iu tr: nhc BN ung thuc
Trnh s dng cc thuc NSAID, corticoid.

GVHD: Ts. Phm Thnh Sul

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Trng DDH Y Dc Cn Th
Khoa Dc
Lp Dc K37 Nhm B2 T 3
TI LIU THAM KHO
1) Trng i Hc Y H Ni (2012), Bnh Hc Ni Khoa Tp 2, NXB Y Hc H Ni.
2) Trng i Hc Y Dc Tp HCM - B Mn Ni (2012), iu Tr Hc Ni Khoa, NXB Y Hc chi
nhnh Tp H Ch Minh.
3) Trng i Hoc Y Dc Cn Th- B Mn Dc Lm Sng (2015), Gio trnh Dc Lm Sng II,
Cn Th.
4) WebMD Health Network Professional, http://www.medscape.com
5) Trn Phng Phng & Trn Tr My, http://www.dieutri.vn

GVHD: Ts. Phm Thnh Sul

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