TH DLS tong hop

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<p>1/14/20141TUN 1Ca 1: LOT DDTT ng B, 57 tui, nhp vin v i ngoi phn en. Cch y 2 ngy, ng b au d dy nng. Trong vi thng gn y ng thnh thong c triu chng kh tiu. ng ht thuc l nhiu nm, suy tim mn tnh nh v ang dng enalapril 5mg x 2 ln/ngy v furosemid 40mg/ngy c 2 nm. Gn y, ng vim khp v dng naproxen 500mg x 2 ln/ngy. Hm qua, BN lm XN v c kt qu nh sau: Hgb 10.3 g/dL (12-18 g/dL) Plt 162.109/L (150 450.109/L INR 1.1 (0.8 1.2) HR 87 nhp/pht BP 115/77 mmHg BN c truyn 1,5 lt dung dch sinh l BN va c ni soi ng tiu ha sng nay v c chn on lot t trng xut huyt. Ngy mai BN s c k toa cc thuc ng ang dng nu BN n ung bnh thng.Tr li cu hi 1. Cc triu chng gi ni soi ng tiu ha? Lit k cc nguy c ca ng B i vi bnh lot t trng? Ch tr liu ca BN n thi im ny thch hp cha? - Triu chng gi : kh tiu, phn en, au d dy nng- Nguy c: cao tui, ht thuc, dng NSAIDsch tr liu cha thch hpTr li cu hi 2. BN nn dng thuc no kim sot lot t trng xut huyt?Dng PPI ng ung, do BN vn n ung c 3. Chin thut k tip trong iu tr bnh lot t trng xut huyt ca BN l g?- Ngng dng NSAIDs- PPI lansoprazol 20mg x 3 ln/ngy 4-6 tun- Nu c xut huyt: PPI 6-8 tun1/14/20142Tr li cu hi 4. Thuc no nn c k toa khi BN xut vin?- Tim mch: thuc c- Vim khp: paracetamol 500mg + codein 30mg dng ko di n khi ht p ng, quay li cc thuc NSAIDs v nga lot- Nga lot: dng misoprostol, antacid, PPI liu duy tr thpTr li cu hi 5. BN cn c t vn g?- n nhiu ba, khng qu no hay qu i- Trnh: cay, chua, nng, kch thch- B thuc l, ru bia: v l yu t nguy c- Gi tinh thn lc quan6. BN theo di iu tr nh th no?Nu sau 4-6 tun, triu chng khng gim, th xt nghim tm H.pylori, trc khi lm XN phi ngng PPI t nht 2 tunTUN 1Ca 2: LOT DDTT Trn Th H, n, 80 tui, BN i ngoi phn en v nn cht nn mu c ph. Mt tun nay mt mi, yu kh chu vng thng v v bun nn. BN i ngoi phn en ngy hm trc v nn ra cht nn m c ph hm nhp vin. BN c tin s bnh xng khp Tin s gia nh: khng c g c bit Li sng: khng c g c bit Tin s dng thuc: BN dng cc thuc sau theo n ca bs khm iu tr cc bnh ang mc:- Indomethacin 25mg: 1v x 3 ln/ngy- Voltaren 50mg: 1v x 2 ln/ngy- Cytotec 200g: 1v x 2 ln/ngyTin s d ng: khng c g c bitSinh hiu:- 51kg, cao 1m56- Mch: 101 ln/pht- Nhit : 36,5oC- Huyt p: 125/70 mmHg- Nhp th: 24 ln/phtBN da xanh xao, nim mc nht, trng thi lo u, cng thng1/14/20143 Xt nghim:- Hemoglobin: 85g/l (125-145)- Hematocrit: 0,3 (0,35-0,47)- Protein-C: 4,5 mg/l ( 2 ln b giD ng nguyn Phn hoa, lng th, nm mcThuc, ha cht Aspirin, NSAIDs, SO3- nhim Khi thuc l, mi trngNgh nghip Nha, thuc ty, Pt, CrNhim trng h hp VirusVn ng th lc p xe, bng, chy bTm l Ci ln, khc, lo sTr li cu hi Bnh nhn L c yu t nguy c:- Thi tit: sng sm- Vn ng th lc: i b th dc1/14/20147Tr li cu hi 3. ngha lu lng nh (PEF) v m t cch o? Mt s phng php o chc nng h hp khc?- ngha PEF: L theo di bin thin ca lu lng nh th ra theo thi gian nhm xc nh:Cc du hiu bo trc s xu i ca bnh hen nng ca bnh hen.p ng vi thuc trong cn hen.Chn k hoch hnh ng ph hpTr li cu hi M t cch o PEF: Bc 1: Di chuyn nt ch ti s 0 hoc s thp nht trn thc ca lu lng nh k.Bc 2: ng thng ngi hoc ngi thng lng, ht vo tht su.Bc 3: Ngm l thi ca lu lng nh k vo ming; th ra tht mnh v tht nhanh mt ln (thi ht kh nng), trong 1 hay 2 giy..Bc 4: Kim tra ch s o c trn lu lng nh k v ghi li. o 3 ln, chn ch s cao nhtTr li cu hi Mt s phng php o chc nng h hp khc:- o th tch h hp bng ph dung k- FEV1: th tch th ra gng sc trong 1 giyTr li cu hi 4. Ventolin v Becotide c cha hat cht g? C ch tc ng v TDP?Thuc C ch TDPVentolin (salbutamol)Kch thch -adrenergique c tc ng chn lc ln th th trn c ph qunTim nhanh,hi hp, run u chiBecotide (beclomethasone)Khng vimNhim nm candida vng hng1/14/20148Tr li cu hi 5. M t cch dng MDI (meter dose inhaler):- M np bnh xt, gi thng ng, lc k- Ngm ming bnh xt gia hai hm rng, khp mi v th ra chm- Nga nh u, n bnh xt ng thi ht chm v tht su, cng nhiu cng tt.- Nn th trong khong 10 giy cho thuc hp thu.Tr li cu hi 6. Nhn xt toa thuc ca bnh nhn L: y bnh nhn c k toa salbutamol tc ng chm l khng hp l, v khng c tc dng ct cn m ch kim sot cn.Tr li cu hi 7 . Bnh nhn cn t vn kh nng dng Singulair cho trng hp ca mnh?SINGULAIR (montelukast) c ch nh cho ngi bnh ln tui v tr em trn 6 thng tui d phng v iu tr hen ph qun mn tnh, bao gm d phng c cc triu chng hen ban ngy v ban m.Tr li cu hi 8. L c th dng Singulair khng? Dng phi hp hay dng n l? Theo di trong iu tr bnh hen ca L ra sao?- Bnh nhn L c th dng Singulair. Theo bc iu tr ca GINA th dng phi hp vi thuc ct cn, lc ny bnh nhn khng dng corticoid MDI thm na. - Theo di iu tr: n ung y , trnh nhng thc n tng gy d ng cho bnh nhn. Vn ng hp l, va sc, trnh thi tit lnh bui sng sm.1/14/20149TUN 2: CA VIM XOANGLp 12CDSL04Lng mn:Anh n bn Em trong mt bui chiu, tri ang ma tm t!!! Nh nhng ly o ma ra, tht du dng anh th th:......</p> <p>..</p> <p> Mua khng em, ch c 5 ngn thiSubjective: Thng tin ch quan Thng tin bnh nhn: bnh nhn nam, 34 tui L do n khm: nght mi nng, au u v nhn m Din bin bnh: cc triu chng trn c trong 3 ngy gn y Bnh s: hen suyn lc nh, va mi b cm lnh Tin s gia nh: khng r Li sng: khng r Tin s dng thuc: 2 vin paracetamol khi b cm lnh Tin s d ng: thuc penicillinObjective: Thng tin khch quanTriu chng chnh Bnh nhnau nhc vng u (khu vc xoang) CChy mi CNght mi CNga miKhng ngi c cc mi CAssesment: nh gi tnh trng BN Bnh nhn tng b cm cm mi y, iu tr bng 2 vin paracetamol, do iu tr khng ng mc nn cc xoang tr nn vim tc, ph n v ngn tr dch nhy thot ra mi, dn n nhim trng xoang (dch m mu vng xanh). iu ny l yu t thun li ca vim xoang.1/14/201410Plan: K hoch iu tr Xt nghim cn lm thm: ni soi mi xoang kim tra tnh trng vim, nu c iu kin th chc ht dch lm khng sinh Mc tiu iu tr: gii quyt nhim trng, lm cc triu chng bnh nh hn v lnh bnh nhanh hn, trnh cc bin chngPlan: K hoch iu tr ngh dng thuc:- Thuc co mch dng ung: pseudoephedrin 60mg 1 vin x 3 ln/ngy- Khng sinh chng nhim trng: clarithromycin 500mg 1 vin x 2 ln/ngy: 7 ngy; hay nhm cyclin- Gim au: paracetamol 500mg 1 vin x 3 ln/ngy- Khng histamin H1- Nc mui sinh l: ra mi Plan: K hoch iu tr Ch khi dng thuc:Thuc TDP Ch PseudoephedrinKh ming,bun ng, h HA, tim nhanhDo dng chungvi khng H1 nn cng hng tc dng ph l bun ng mnhClarithromycin Ri lon tiu haParacetamol Liu cao: suy ganKhng H1 Bun ngPlan: K hoch iu tr Dn d:- Khi b cm cm, phi i khm c iu tr ng v dt im, trnh lm khi pht yu t thun li gy vim xoang.- Vic quan trng vn l trnh vim mi. Khng nn nhng ni khng kh b nhim (bi, khi, thuc l...). Trnh thc n b d ng. n ung y c sc khng. V sinh thn th, nng ra tay, ra mt, khng tm ni nc bn.1/14/201411Tr li cu hi 1. Cn hi bnh nhn nhng cu hi g gip cho vic chn on bnh?- C au rng khng? (nu c au rng, th c th do vim xoang hm)- Chy nc mi trong hay c? (vim d ng: nc mi trong, vim nhim khun: nc mi xanh vng)- C nght mi khng?- C nga mi khng? (nu c, c th do vim d ng)- C ngi c mi khng? (nu khng ngi c, l tnh trng vim nng)- C st v nn i khng?Tr li cu hi 2. ng A c m mu vng hi xanh trong 3 ngy gn y cng nhng cn au vng mt quanh mt v mi. ng b mt kh nng nhn bit mi v v, k t khi b cm lnh tun trc. Khng st. Nhng bnh m ng A c th mc phi v chn on bnh cui cng ca bn?- Nhng triu chng ca ng A c lin quan n bnh vim xoang cp do nhim khun (vim xoang trn v xoang sng trc do gy au khu vc mt v mi; nc mi mu xanh vng, v b mt khu gic tm thi)Tr li cu hi 3. Nh c s hin din ca mt s triu chng nht nh, bn tin rng ng A b vim xoang cp tnh. Hy k cc yu t nguy c dn n vim xoang?- ng dch trong xoang khng thot ra c, dn n nhim khun (vim mi, cm cm)- D ng, nhim mi trng- Gim khngTr li cu hi 4. La chn iu tr ban u cho ng A?- Ra mi: NaCl 0,9%- Co mch dng xt ti ch: xylomethazolin, oxymethazolin dng trong 3-5 ngy- Khng sinh nhm macrolid: u tin l nhm B-lactam, nhng do bnh nhn c tin s d ng penicillin nn khng chn. Cng c th chn nhm cyclin- Khng histamin H1- Gim au: paracetamol1/14/201412Tr li cu hi 5. Theo bn, ng A c cn s dng beclomethasone dng xt mi hay khng?ng A khng cn dng beclamethasone dng xt, v c th gy trm trng thm tnh trng nhim khun trong xoangTr li cu hi 6. Mt tun sau, ng A quay li v cho bit cc triu chng gim nh nhng n ngy hm qua th ng y bt u st, chng mt, khng nghe r v au tai. Bn ngh ng y iu g?- i n bc s ti khm, v c th c du hiu nhim trng: st, auTr li cu hi 7. Mt bc s thc tp gi n cho bn v nh t vn khng sinh no cn c k cho ng A?- Macrolid hay cyclinTr li cu hi 8. ng A quay li vi n thuc Doxycyclin 100mg 2 vin/ngy x 7 ngy. Bn cn t vn cho ng A nhng g?- Phi ung vi ti thiu mt cc nc y, v t th ng, trnh lot thc qun, v gim kch ng ng tiu ha.- Khng ung thuc cng lc vi sa (gy gim hp thu), cc cht chua, antacid- Trnh nh nng ti a.- Tun th iu tr.1/14/201413Tham kho Phn bit hen suyn v COPDGing nhau: u l bnh mn tnh - c tnh trng vim ng th - tc nghn ng th - tng tit nhy - co tht cung phi - u lin quan n yu t mi trng. Nn biu hin lm sng cng c nhng im ging nhau nh ho, khc m, nng ngc, kh kh, kh th...Tham khoKhc nhau:TuiNguynnhnTin trin bnhChc nng h hpHi phcHenXut hin t khi nha dngGia cc cn, BN khng c triu chng g dng nh: khng nh hngC th r rtCOPDXut hin khi trn 40 tuit, ch yu tin s l BN ht thuct cp ca c tn s v trm trng ngy cng tngNgy cng nng hnRt km hay khng cTUN 2: CA ECZEMASubjective: Thng tin ch quan Thng tin bnh nhn: A, nam, 27 tui L do vo vin: bnh eczema Din bin bnh: sau khi bi kem Betnovate, vng da bi thuc b v chc l Bnh s: hen suyn t nm 15 tui, thnh thong b eczema vo ma ng v khi b stress Tin s gia nh: khng r Li sng: khng r Tin s dng thuc: salbutamol xt v beclometason xt Tin s d ng: khng r1/14/201414Objective: Thng tin khch quan Assesment: nh gi tnh trng BN Sau khi bi Betnovate (betamethason), bnh nhn c triu chng nhim trng ti ch bi kem. Bnh nhn ang dng thuc hen suyn:- Salbutamol dng xt (ct cn hen)- Beclometason dng xt (kim sot cn hen) Bnh nhn ang dng thuc eczema:- Betamethason dng bi ti chAssesment: nh gi tnh trng BN Bnh nhn c 2 yu t nguy c c th khi pht bnh eczema: do c tin s hen suyn (yu t c a) v b cng thng (yu t ri lon thn kinh)Assesment: nh gi tnh trng BN y bnh nhn c k toa cho iu tr hen suyn l hp l. iu tr bnh eczema, bnh nhn bi lin tc betamethason l khng hp l, bi v s lan rng tim n ca nhim trng c th xy ra do tc dng che du nhim trng ca corticoid.1/14/201415Assesment: nh gi tnh trng BNThuc ang dng TDP CCSalbutamol - Tim nhanh,hi hp, run u chi - Mn cm, PNCTBeclomethasone-Qu liu ko di: nh hng chc nng thng thn- Ti ch: nhim nm candida- Mn cmBetamethasone- Teo da, mng da, gin mch mu ti ch- Vim da do virus, vi khun,vi nmPlan: K hoch iu tr Xt nghim cn lm thm: - Sinh thit da ti ch vim ( loi tr nhim khun da do virus, vi nm) Mc tiu iu tr: kim sot triu chng bnh eczema (da phng rp, thay i mu, ng vy, nga) Plan: K hoch iu tr Thuc ngh cho bnh eczema bnh nhn:- Khi bnh nhn cha b nhim trng: c th dng corticoid bi ti ch trong thi gian ngn (&lt; 5 ngy).- Khi bnh nhn c triu chng bi nhim (chc l, ): khng sinh ng ungPlan: K hoch iu tr Trnh dng corticoid + khng sinh dng bi ti ch di ngy. Sau mt thi gian nu triu chng khng gim, th phi chuyn sang khng sinh ng ton thn v ngng dng corticoid ti ch.1/14/201416Plan: K hoch iu tr Nu sau khi dng thuc m triu chng khng gim th phi quay li bc s xem xt v ti khm. Trnh: gi nga, thc n d ng, tm nhiu, x phng, gi da m, cng thngv kim sot tt bnh hen suyn.Tr li cu hi 1. Bnh eczema l nh th no? Cc nguyn nhn chnh gy eczema? iu tr nh th no?Eczema l tnh trng vim da mn tnh tin trin thnh tng t hay ti phtNguyn nhn: bnh t min, khng ly- ngoi: x phng, thi tit, ha cht, d ng lng th, phn hoa, bi- trong: hormon, stress, di truynTriu chng: nga, ni trn daTr li cu hi iu tr nh th no? Khng th tr dt im, do l bnh t min nn ch iu tr theo triu chng- Khng histamin H1- Khng vim corticoid- Gi m da: vaselin, glycerin- Nu nhim trng: dng khng sinhTr li cu hi 2. Beclometason v betamethason thuc nhm thuc no? Nu cc tc ng ca nhm thuc nyNhmCorticoid Tc ngBeclometason &amp; Betamethason-Sinh l: trn chuyn ha (tng tng hp glucid, phn b li lipid, tng thoi ha protein)v trn m (tim mch, TKTW, tiu ha, to mu)- iu tr: khngvim, khngd ng, c ch min dch, iu tr thay th1/14/201417Tr li cu hi 3. Gii thch thut ng hot tnh glucocorticoid v hot tnh mineralcorticoid. Nu TDP ton thn v ti ch ca glucocorticoid?- Hot tnh glucococorticoid:do lp cu ca thng thn tit ra, c chc nng ti hp thu natri v bi tit hydro v kali ng thn, trn chuyn ha (tng tng hp glucid, phn b li lipid, tng thoi ha protein).- Hot tnh mineralcorticoid: iu ha nc v in gii n nh HA v nhp tim.Tr li cu hi Nu TDP ton thn v ti ch ca glucocorticoid?Ton thn Ti ch-Tng huyt p- Long xng- Tng ng huyt- Nhc c, yu c- Hi chng Cushing- Lot d dy t trng- c thy tinh th, lot gic mc- Thay i tnh tnh- Tng nhim khun- Suy thng thn cp (ngngthuc t ngt khi dng liu cao ko di)-Mn trng c, teo da, bi nhim, chm lin so- Dng xt: khn hng, nhim candida- Dng nh mt: c thy tinh thTr li cu hi 4. Thuc bi ngoi da Betnovate s dng nh th no? C s dng trong thi gian di c khng?Betnovate (betamethason): bi ti ch vng da b vim 2-3 ln mi ngy, nu triu chng gim th gim liu (1 ln/ngy hay 2 ngy bi 1 ln), bi trong thi gian ngn (khong 5 ngy).Nu dng ko di, gy trm trng thm tnh trng nhim khun, v gy tc dng ph ti ch.Ra tay sau khi bi thuc.Tr li cu hi 5. Nn ch nh khng sinh no cho bnh nhn? Ch phm dng ngoi cha corticoid v khng sinh c hiu qu khng? y bnh nhn ch nhim khun khu tr, bnh nhn c th dng corticoid v khng sinh bi ti ch (vd nh Betnovate-N: betamethason v neomycin).Nu bnh nhn eczema c tnh trng bi nhim, c th dng khng sinh ng ton thn (do S.aureus c ni c t, gy phn ng khng nguyn khng th d di gy tnh trng vim da nng hn)1/14/201418TUN 2: CA ADDISONSubjective: Thng tin ch quan Thng tin bnh nhn: bnh nhn n, 43 tui L do vo vin: mt mi, sm mu da Din bin bnh: t 3 thng nay, bnh nhn cm thy mt mi ko di, thng b bun nn, chn n v st gn 3kg, chng mt khi thay i t th, da sm mu dn d khng ra nng, thay i khu v, thm n thc n mn nh da mui. Bnh s: khng r Tin s gia nh: khng rSubjective: Thng tin ch quan Li sng: bnh nhn l gim c tip th ca mt cng ty qung co, c 2 con nh. Do tnh cht cng vic, bnh nhn thnh thong c ung ru vi i tc, khng ht thuc. Tin s dng thuc: khng c Tin s d ng: penicillin (ni ban)Objective: Thng tin khch quan Khm bnh: - Cn nng: 60kg- Chiu cao: 1m67- Huyt p: 110/70- Nhp th: 22 ln/pht- Nhit : 37oC Khm lm sng:- Bnh nhn tnh, v mt mi, tip xc tt- Tim u, phi trong, bng mm, gan lch khng s chm- Da kh, sm, khng rn, tng sc t lng bn tay, so cng tay phi sm mu1/14/201419Objective: Thng tin khch quanTr s cn lm sng Bnh nhn Bnh thngNa 127 mEq/L 135-150K 5 mEq/L 3,5-5Cl 98 mEq/L 98-110BUN 15 mg/dL 7-21Creatinin 1,1 mg/dL 0,7-1,5Glucose 103 mg/dL 80-110Cortisol 1,4 mcg/dL 8-25ACTH 2096 pg/mL 0-130Assesment: nh gi tnh trng BN Theo cc triu chng lm sng v cn lm sng, bnh nhn c chn on l bnh AddisonLm sng:- Sm da, thay i sc t da- Mt mi- St cn- H huyt p t th- Ri lon tiu haCn lm sng:- nh lng cortisol mu v ACTH khc hn bnh thngPlan: K hoch iu tr Mc tiu iu tr: gim triu chng bnh, a ch s cortisol mu v ACTH v li bnh thng ngh dng thuc: - Cortisol hay Prednisolon 20mg 30mg: dng mt ln 20mg vo bui sng sau khi n no, v 10mg vo bui chiu, cho ph hp nhp sinh l c th- Mineralcorticoid (fludrocortison) 0,05 0,2mg/ngy: duy tr cn bng Na v K trong c th, do TDP ca cortisol Plan: K hoch iu tr Theo di dng thuc: do dng corticoid di ngy trn ph n, nn theo di s mt xngKhng ngng thuc t ngt Thay i np sng, khng ung ru, khng khing vc nng, tp th dc u n (30-60 pht/ngy). B sung calci trong thi...</p>