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BO CO CA DC LM SNG- TNG HUYT P

Nhm 2-T II- Lp D4


I.

TM TT BNH N:

1) Thng tin bnh nhn:


H v tn : TRN TH LNG. tui 82 N
Ngh nghip : gi . Qu qun: Ph Vang- Tha Thin
Hu
Vo vin: 10h38 ngy 15/5/2012
2) L do vo vin :
Hi hp +mt ngc
3) Qu trnh bnh l :
Bnh nhn c tin s tng huyt p,iu tr thng
xuyn 12 nm. Khong 10 ngy gn y bnh nhn i
cu phn lng,iu tr thuc . 7 ngy nay, bnh
nhn hi hp, mt ngc nhiu nn xin nhp vin iu tr
4) Tin s bnh :
Bn thn:
+tng huyt p iu tr thng xuyn 12 nm nay
+B bnh tim (suy tim) 10 nm nay,mi iu tr 5 nm
nay
+Vim i trng cch y 4-5 nm iu tr thng
xuyn
Gia nh : sng khe
5) Thm khm lm sng:
5.1-Ton thn :
Bnh nhn tnh to,tip xc tt

Da nim mc hng
Tuyn gip khng ln,hch ngoi bin khng s thy
Mt v 2 chn ph trng n lm
Mch :92 ln /pht
Nhit : 37
Huyt p : 150/80 mmHg
Nhp th : 20 ln/pht

5.2-Cc c quan
Tun hon : Hi hp ngc
Tim nhp khng u
Khng nghe ting tim bnh l
T1,T2 nghe r
H hp :

Khng ho, khng kh th


Lng ngc cn xng
RRFN r,phi khng nghe ran
Tiu ha : Bng mm khng au
n ung c,i cu bnh thng
Gan mp m b sn
Thn ,tit niu ,sinh dc :
Tiu thng,khng tiu but rt
Nc tiu vng trong
Thn kinh : Tnh to,tip xc tt
Khng c du hiu thn kinh khu tr

C,xng khp :
Cc khp vn ng trong gii hn bnh
thng
Khng teo c, cng khp
6) Cn lm sng:
Sinh ha mu :

Tn xt nghim kt qu
Glucose

4,9

Tr s bnh
thng
NL :4,1-5,9

Urea

4,7

1,7-8,3

mmol/L

Cholesterol

5,55

3,6-5,18

mmol/L

Triglycerid

1,47

0,80-2,3

mmol/L

HDLCholesterol

1,04

0,90-2,00

mmol/L

0,00-3,4

mmol/L

LDL- Cholesterol 3,85

n v
mmol/L

Na+

138

135-145

mmol/L

K+

3,0

3,5-5,0

mmol/L

9,8

0,0-8,0

mg/L

CRP

Huyt hc
Tn xt
nghim

kt qu

Tr s bnh
thng

n v

WBC

3,95

4-10

K/L

GRA

2,29

2,5-7,5

K/L

RBC

3,28

4,0-5,8

M/L

HGB

8,8

12-16,5

g/dL

HCT

30,25

34-51

MCH

26,8

28-32

pg

MCHC

29,1

32-36

g/dL

RDWs

51,6

20-42

IN TIM
Kt lun : thiu mu c tim vng sau di
X-Quang :
+ Dy tht (T) nhiu
+ Vi ha nt quai MC
+ Vim ph qun mn
7) Chn on:
Bnh nhn n 82 tui vo vin v hi hp ngc, c tin s
tng HA thng xuyn, 7 ngy nay, bnh nhn hi hp ngc
nhiu. Qua thm khm lm sng, hi bnh s rt ra:
Tng huyt p
Suy tim II
Rung nh
II.

IU TR:

Thuc
Concor 5mg,
vin,ung
Aspergic 100mg
Gi ,ung
Crestor 10mg ,
Vin , ung
Verosperon25mg
Vin,ung
Lasix 40mg
Vin,ung
Kali 0,6mg
Vin,ung
Noklot vin 75mg,
chia 2ln/ngy
Lipitor 10mg
vin,ung
Diovan 80mg
vin,ung
Vastarel MR
35 mg,vin,ung
Nuril 5mg
Vin, ung
Atormax vin
,ung
Yesom 20mg,
vin, ung
Garlicap
vin,ung
Teoramin vin,
ung

Ngy thng
15/5 16/5 17/5 18/5 19/5 20/5 21/5 22/5
1/2 1/2 1/2 1/2 1/2 1/2 1/2 1/2
1
1
1
1
1
2

Amlor 5mg
Vin, ung

III. PHN TCH V NH GI CH DNG THUC


1) Gii php iu tr: Dng thuc.
iu tr nguyn nhn:
Dng thuc h huyt p
Thuc iu tr suy tim
H lipid mu
iu tr bin chng: Tro ngc thc qun (do lot d
dy t trng).
2) nh gi bnh nhn :
Ngy Gi

Theo di din bin

15/5

11h

Mch: 92 l/pht
HA: 160/80mmHg
Nhit : 370C
Nhp th: 18 l/pht
Mt v 2 chn ph trng,
n lm. Hi hp ngc, tim
p khng u.

16/5

6h

Cn hi hp,khng kh
th
T1,T2 u ,khng nghe
ting thi
Ht ph mt , ph chn
Phi thng kh tt
Khng au bng
Nhp th :20 ln /pht

Thc hin y lnh/chm


sc
Xt nghim :
+cng thc mu
+X- quang
+in tim
Cp cu: thuc ngy
15/5(lch iu tr)
Xt nghim :
+cng thc mu
+X- quang
+in tim

HA:160/90mmHg
Nhit :37

17/5

6h

Cn hi hp
Khng ph
Tim nghe u r,khng c
m bt thng
Phi thng kh tt
Khng au bng
Nhp th :21 ln /pht
HA:130/80mmHg
Nhit :37,5

+o du hiu sng
+Pht thuc v cho
bnh nhn ung
+Bo bc s trc

18/5

6h

+o du hiu sng
+Pht thuc v cho
bnh nhn ung
+Bo bc s trc

19/5

6h

Cn hi hp
Khng ph
Tim nghe u r,khng c
m bt thng
Nhp th :20 ln /pht
HA:120/80mmHg
Nhit :37
Cn hi hp
Khng ph
Tim nghe u r,khng c
m bt thng
Nhp th :22 ln /pht
HA:130/70mmHg
Nhit :37

+o du hiu sng
+Pht thuc v cho
bnh nhn ung
+Bo bc s trc

3) Phn tch cc thuc c s dng:


1. Concor 5mg : (Bisoprolol) Thuc Chn Th Th Bta
Ch nh: Cao HA, phng nga cn au tht ngc.
Liu dng: 1/2 vin(5 mg)/ngy.
Liu chun: 1 vin (5 mg)/ngy.TH nng: c th ln
n 2 vin (10 mg)/ngy.

TDKMM: Ri lon tiu ha, au d dy, bun nn


& nn, tiu chy, suy nhc giai on u iu tr,
mt ng, c mng, hi chng Raynaud & d cm u
chi.
2. Vastarel MR (trimetazidine Dihydroclorid) thuc tim
mch

Ch nh: Phng chng cn au tht ngc

Tc dng KMM: Nhc u, bun nn, pht ban,


kh chu d dy, chn n, tng men gan.

Liu dng: ngy 2vin , chia 2 ln ung.

Liu chun: vin 35 mg, ngy 3 vin, chia 3 ln


ung.
3. Lipitor: (Atorvastatin Ca)Thuc Tr Chng Tng Lipid
Mu
Ch nh:
Gim cholesterol ton phn, gim LDL-C,
apolipoprotein B & triglyceride bnh nhn c
tng lipid mu nguyn pht.
Tng lipid mu hn hp & tng cholesterol mu c
tnh gia nh d hp t.
Gim cholesterol ton phn & gim LDL-C bnh
nhn tng lipid mu gia nh ng hp t.
Liu dng: vin 10mg, ung ngy 2 vin, chia 2 ln

Liu chun: Khi u 10 mg x 1 ln/ngy, liu iu tr:


10-80 mg/ngy, ung bt c thi im no trong ngy.
TDKMM: To bn, y hi, kh tiu, au bng, nhc
u, bun nn, au c, mt mi, tiu chy, mt ng.
4. Garlicap: Thuc ng tiu ha

Ch nh: H cholesterol, iu ha triglycerid


mu. Gip bo v tim mch , phng nga cc chng
x va ng mch, t qu, nhi mu c tim, tng
cng min dch.

Liu dng: 1 vin /ln, ngy 3 ln.

Liu chun: Ung 2 vin x 2 ln / ngy. Dng


trc ba n hoc theo s ch dn ca thy thuc
5. ATORMAX 150mg

Ch nh: Bnh gan cp tnh hoc mn tnh (Vim


gan, di chng ca vim gan, lon chc nng gan, tn
thng nhu m gan, x gan

Liu dng: 1 vin/ ln, ngy 2 ln.


6. YESOM-20 (Rabeprazole sodium): Thuc tiu ha
Ch nh: iu tr bnh tro ngc d dy-thc qun
(GERD),cha vim st d dy-thc qun.
Liu dng: vin 20mg, ngy 2 vin ung, chia 2 ln.
Liu chun: 40mg/ngy, cho 4 tun n 8 tun nu
cn.
7. Diovan-40mg( valsartan 40mg)

Ch nh:Tng huyt p suy tim( 2 n 4)


Liu chun: - Tng HA 80 mg/ngy, c th tng ti 160
mg, hoc c th thm thuc li tiu.
- Suy tim khi u 40 mg x 2 ln/ngy,
liu dng cao nht l 80 mg -160 mg x 2 ln/ngy .
Liu dng: 1vin 40mg/ngy.
Thn trng: Nn thn trng khi bt u iu tr trn
bnh nhn suy tim, Khi li xe & vn hnh my.
TKMM: au u, chng mt, nhim trng h hp trn,
ho, tiu chy, mt mi, au lng, au bng, bun nn,
au khp.
8. NURIL 5 mg (Enalapril maleate 5mg)
Ch nh:
Cao huyt p nh v va. Ph tr trong suy tim, bnh
nhn khng p ng y vi thuc li tiu v
digitalis.
TDKMM: nhc u (4,8%), chng mt (4,6%), mt mi
(2,8%),tiu chy (1,6%), ngoi ban (1,5%), h huyt p
(1,4%), ho (1,3%) v h huyt p t th ng (1,3%).
Liu dng: ngy 2 vin 10mg , chia 2.
Liu chun: 10 - 40 mg/ ngy, dng mt ln duy nht
hoc chia lm 2 ln
9. Amlor-5mg
Ch nh: iu tr tng huyt p ( ngi bnh c
nhng bin chng chuyn ha nh i tho ng) v
iu tr d phng ngi bnh au tht ngc n nh
Liu dng:
liu khi u l 5mg /1ln/ ngy.
Ti a l 10mg/1 ln/ ngy mt ln .

S dng ngi cao tui nn dng theo liu bnh


thng.
Tc dng ph:
Hay gp nht l bng mt, chng mt, nhc
u,au bng, bun nn, nh chng ngc, ng
g.
t gp hn: kh ming, Suy nhc, u lng, mt
mi, au, Tt huyt p, ngt ,Tng trng lc c,
gim cm gic/d cm, bnh thn kinh ngoi bin,
run ry, kh tiu
10.
Aspegic
Ch nh: iu tr st v cc chng au khc mc t
va n nng.
Liu dng: gi 100mg, ung
Liu chun:
Ngi ln : 500-1000 mg mi ln, ti a 3 g/ngy.
Ngi ln tui : 500-1000 mg mi ln, ti a 2 g/ngy.
TDKMM:
tai, gim thnh lc, nhc u, thng l du hiu ca
s qu liu.
Lot d dy.
Xut huyt tiu ha r rng (nn ra mu, i cu ra
mu) hoc tim n a n tnh trng thiu mu do
thiu st
11.
Crestor (Rosuvastatin)
Ch nh :
Tng cholesterol mu nguyn pht (loi IIa) hoc ri
lon lipid mu hn hp (loi IIb).
Tng cholesterol mu gia nh kiu ng hp t.
Liu dng:1 vin 10mg ,ung
Liu chun:

Liu khi u :10mg, ung ngy 1 ln. Nu cn c th


tng liu ln 20mg sau 4 tun. Vic tng liu ln 40mg
ch nn s dng cho cc bnh nhn tng cholesterol
mu nng c nguy c cao bnh tim.
Rosuvastatin c th dng bt c lc no trong ngy,
trong hoc xa ba n.
Tc dng ph:Suy nhc, xut hin protein niu, au
c.Lm tng transaminase t; phn ln cc trng hp u
nh, khng c triu chng v thong qua.
12.
Verospirol 25mg (spironolactone):
Ch nh: Tng HA, ph.
Liu chun:
Ph do suy tim:100 mg chia lm 2 ln, c th tng ln
25 - 200 mg/ngy.
Tng HA 50 - 100 mg/ngy chia lm 2 ln.
Gim K mu do thuc li tiu 25 - 100 mg.
Liu dng: 1 vin , ung
TDKMM: Tng K mu, ri lon tiu ha, bun ng, nhc
u, pht ban dng hng ban & dng dt sn, m ay
13.
Lasix (furosemide) 40mg:
Ch nh:Tng huyt p, ph
Liu chun: Ph ngi ln 80 mg, 1 ln. Nu cn sau
6-8 gi c th dng thm mt liu hoc tng liu
TDKMM: Mt cn bng nc & in gii, kh ming,
kht nc, yu sc, ng lm, chng mt, bn chn, au
hoc co rt c, mt mi c, h huyt p, nc tiu t,
nhp tim nhanh hoc lon nhp, bun nn & nn.
14.

Kali Clorid:

Ch nh: Thuc cung cp kali cho c th. Do dng mt s


thuc li niu h kali mu.
Liu chun: 1 vin , ung thuc sau ba n: Phi nut c
vin thuc khng c cn v, nhai, hoc nghin nt.Ung
nhiu nc
Liu dng: 0,6g , 1 vin ung.
TDKMM:
Tng kali mu (vi nguy c t t)
Liu cao c th gy lot d dy t trng, nguy c gy
lot rut non
15.
Noklot vin 75mg: (Clopidogrel bisulfate)
Ch nh: d phng ri lon do nghn mch huyt khi, x
va ng mch
Liu dng: 75mg chia 2 ln /ngy
Liu chun: 75mg / ngy
Tc dng khng mong mun
- Chy mu, v d nh chy mu cam, chy mu ti v tr
tim, chy mu d dy hoc rut.
- Bm tm.
- Bnh tiu chy, au bng, chng kh tiu.
16.
Teoramin 500mg (Crystallized Glucosamine
sulfate)
Ch nh: h st, gim au, chng vim (NSAID)
Liu dng: 3 ln/ ngy
Liu chun: 1 vin/ 1 ln, cch nhau 4-6h
4) Tng tc thuc:
Hot cht

Tng tc
vi hot

Mc
tng tc

Cp
chng c

Tc hi

Bisoprolol

cht
Potassium
chloride

Spironolact
one

Potassium
chloride

2-Mc 2

Good

5-Nghim
trng (Mc
5)

Well
Established

bisoprolol lm
tng c tnh
ca
potassium
chloride
spironolactone
lm tng c
tnh ca
potassium
chloride

5) Nhn xt vic s dng thuc:


So snh liu dng v liu chun ta thy liu dng
c iu chnh hu ht cc thuc. Liu gim i mt
na mt s thuc nh:
Concor 5mg. Liu chun: 1 vin/ngy.Dng:
vin/ngy.
Diovan 40mg. Liu chun: 2 vin/ngy, chia 2 ln.
Dng: 1 vin/ngy.
..
Bnh nhn cao tui (82 tui), do iu chnh liu l
hp l.
Ngy u iu tr (15/5), dng Aspegic 5mg, Crestor
10mg, Verospirol 25mg, Lasix 40mg, Kali 0,6g. i vi
ngi cao tui dng thuc li tiu kt hp thuc h
lipid mu (lipid mu tng LDL-Cholestrol 3,85 mmmol/l)
l hp l nhng v c tng tc thuc lm tng c tnh
ca kali gy xut huyt tiu ha nn i hon ton

sang thuc khc nhng ngy tip theo. ( tr Concor


vn gi nguyn) .
Sau khi i thuc , iu tr c hiu qu, huyt p gim
t 160/90mmHg( ngy 15/5) xung 130/70mmHg.
(19/5). Mc bnh thng. Bnh nhn cn hi hp,
khng ph, n ung c.
T 16/5 n 22/5, bnh nhn c dng Atormox, thuc
iu tr ch yu trong trng hp vim gan, x gan
trong iu tr vim. c th l vim ph qun ( theo kt
qu chp phim ngy 16/5) l cha hp l, ta co th
thay bi thuc Zoxtil 250mg( Cephalosporin) ngy 2
vin, chia 2.
Sau 5 ngy iu tr huyt p c gim nhng bnh nhn
vn cn hi hp, nh vy thuc p ng chm vi
bnh suy tim, nng m mu cha c theo di
thng xuyn.
6) Gii php, kim sot ch ng thuc:
Bnh nhn cao tui cn iu chnh liu mt s loi
thuc trn tuy nhin, nu khng p ng iu tr ta c
th gi nguyn liu bnh thng. ng thi theo di
huyt p, nhp tim v m mu thng xuyn c th
x l kp thi khi c bin chng xy ra, cho ti khi tnh
trng bnh nhn n nh ta s gim liu v tp tc theo
di.
Yesom, thuc chng tro ngc thc qun. nu bnh
nhn khng chua, n ung c ta c th ngng
dng thuc ny. V thuc ny lm gim hp thu ca cc
thuc dng phi hp. kt qu lm gim sinh kh dng
cc thuc khc, gim hiu qu iu tr.

Hu ht cc thuc c dng cho bnh nhn u c


tc dng ph nh au u chng mt v bun nn, do
c th cho thm thuc gim au Aspergic nh ngy
u(15/5) cc ngy tip theo.
n ch t mui, t cht bo trnh lm nng thm
tnh trng tng lipid mu, gy tng huyt p.
7) Kt lun:
Bnh tng huyt p c ci thin, tuy nhin bnh suy tim
p ng thuc chm, tin lng d dt, cn theo di v
iu tr thm.