SEMINAR CA LM SNG

TNG HUYT P

NHM 6 CH19
 PHN CNG CHUN B NI DUNG
Ni dung Ngi chun b
L Hong Minh Tm tt thng tin bnh nhn
nh gi bnh nhn
L Huy Khim Xc nh nhu cu v thuc
Mc tiu iu tr v gii quyt cc vn
lin quan n iu tr bng thuc
H Th Thu Thng Lp quy trnh chm sc s dng thuc
Theo di v gim st ch dng thuc

Bi Th Ho Lp phiu thu thp thng tin bnh nhn

Lp quy trnh gio dc bnh nhn, theo di
nh gi cc bnh mc km ca bnh nhn.
Tng hp slide
 NI DUNG

I. nh gi bnh nhn

II. Lp k hoch chm sc dc

III. Theo di gim st

3
 TM TT CA LM SNG
S thu thp thng tin bnh nhn
H tn: B. 71 tui
Gii tnh: Nam
Ngh nghip: Ngh hu
L do nhp vin: i khm kim tra tnh trng bnh tng huyt p
Tin s bnh bn thn
- i tho ng tup 2 c 1 nm, ang iu tr.
- Gout v ang iu tr c 6 thng
- Ri lon lipid mu v tng huyt p c hn 1 thng
4
 TM TT CA LM SNG

S thu thp thng tin bnh nhn (tip)

Tin s gia nh
- B tng b tng huyt p, ri lon lipid mu, mt do nhi mu
c tim nm 73 tui
- M b tng huyt p, i tho ng, mt do ung th phi
nm 65 tui
Li sng: n mn, khng ht thuc l, khng ung ru, khng
tp luyn thng xuyn

5
 TM TT CA LM SNG
S thu thp thng tin t bnh nhn (tip)

Tin s dng thuc: cc thuc ang s dng

- Glucophage (metformin) 850mg ngy 1 ln

- Naproxen 220 mg ung mi khi c au

- Allopurinol 200 mg ung ngy mt ln

- Simvastatin 40 mg ung 1 ln/ngy vo bui ti

- Coversyl (perindopril) 4 mg ung 1 ln/ngy

D ng thuc v nhng phn ng c hi ca thuc gp:

6
Thnh thong c my ay
 TM TT CA LM SNG

S Thu thp thng tin t bnh nhn (tip)

Thnh thong bnh nhn c au u chng mt vo bui
sng.
Bnh nhn thnh thong b au u v thng dng
naproxen gim au
Bnh nhn khng c triu chng vim khp trc y
nhng c phn nn thnh thong au do gout phi dng
naproxen gim au.
Bnh nhn phn nn ho rt nhiu v ra hiu thuc mua
thuc ho ung nhng khng .

7
 TM TT CA LM SNG

O Khai thc thng tin qua bnh n

- Khm lm sng:
Huyt p
Ln 1: 162/90 mmHg
Ln 2: 164/92 mmHg
Chiu cao: 1m65 BMI =
Cn nng: 78 kg 28,6
Nhp tim 76 bpm (bnh thng), nhp th 16/pht, nhit
37C

8
 TM TT CA LM SNG

O Khai thc thng tin qua bnh n

Tnh trng hin ti ca bnh nhn: Tnh trng sc khe chung
hin nay tt.
Cc c quan:
- Tai mi hng: Hi c dch xoang mi
- Tit niu/sinh dc: Tuyn tin lit ph i
- Cc c quan khc khng ghi nhn g bt thng
 TM TT CA LM SNG

Cc xt nghim cn lm sng:

Thnh phn trong nc tiu

Cng thc mu

Sinh ha mu

Siu m tim
 TM TT CA LM SNG
SINH HA MU
Xt nghim Kt qu Ngng bnh thng
Na 138 mmol/L 135-145 mmol/L
K 4,7 mmol/L 3,3-4,9 mmol/L
Cl 99 mmol/L 96-110 mmol/L
CO2 27 mmol/L 22-30 mmol/L
BUN 7,8 mmol/L 2,9-8,9 mmol/L
SCr 110 mol/L 62-115 mol/L
Glucose (i) 6,1 mmol/L 3,6-6,0 mmol/L
Uric acid 400 mol/L 179-476 mol/L
Ca 2,43 mmol/L 2,15-2,58 mmol/L
Mg 1,1 mmol/L 0,65-1,10 mmol/L
HbA1c 5,6% 4,0-6,0%
alb 40 g/L 35-50 g/L
CNG THC MU
Xt nghim Kt qa Ngng bnh
thng
Hgb 150 g/L 140-160 g/L

Hct 40% 0,38-0,5 %

RBC 4,8 X 109 /L 4,7 -6,7 X 109 /L

WBC 4,8 X 109 /L 4,5 -10,5 X 109 /L

PLT 4,8 X 109 /L 150 400 X 109 /L

Chol ton phn 4,3 mmol/L 3,9 -5,2 mmol/L

LDL 2,6 mmol/L 3,4 mmol/L

HDL 1,64 mmol/L 1,68 mmol/L

TG 1,05 mmol/L 0,46 1,88 mmol/L

 Nc tiu
Nc tiu vng, trong. Trng lng ring 1.007. pH 5,5;
protein (++), glucose (-), ceton (-),bilirubin (-), mu (-),
nitrit (-), hng cu (-), bch cu (-), vi khun (-). C mt
s t bo biu m.

Siu m tim: Ph i tm tht tri nh

BC 1: NH GI BNH NHN
 BC 1: NH GI BNH NHN

Bn pht hin mc
THA cch y 1 thng
Vo bnh vin trc cho
thuc h p m HA vn
cao
HA by gi 162/90 mm
Hg c tn thng c
quan ch (Ph i tht
tri nh ), i tho
ng

VSH/VNHA 2014 NICE 2011, CHEP 2013-2014

 CC YU T NH HNG N TIN LNG
PHN TNG NGUY C

Cac yu t nguy c
Tui ( 55 tui nam).
Ht thuc.
Ri lon lipid mu
Beo ph (BMI = 28,7)
Tin s gia nh c ngi b bnh tim mch sm ( < 55
tui vi nam v < 85 vi n )
Tn thng c quan khng co triu chng
Hiu p 60 mmHg ( ngi gi).
Ph i tht tri nh (????)
Tn thng thn
Protein niu (++) (???? > 300 mg/24 gi).
NH GI CC VN CA BNH NHN

Bnh nhn Tng huyt

p vi nguy c rt cao
 NH GI CC VN CA BNH NHN

c chn on T
typ II cch y 1 nm
ang dng thuc h
ng huyt
Mc ng huyt ca
bnh nhn hin ti ang
c kim sot tt
Ti liu chuyn mn hng dn chn on v iu tr
bnh i tho ng tp 2. B Y T (2011)
 NH GI CC VN CA BNH NHN

GOUT
- Bnh nhn iu tr c
6 thng
- Uric acid: 400 moll/L
- Bnh nhn khng c kim sot mc acid
triu chng vim khp uric mu cha tt
trc y nhng thnh
thong au do gout phi
dng naproxen gim
au
 NH GI CC VN CA BNH NHN

RI LON LIPID MU

Chn on c hn
1 thng.
ang s dng thuc
h m mu v cc ch
s lipid mu c
kim sot
(LDL: 2.6 mmol/L)

ESC/EAS Guidelines for the management

of dyslipidaemias (2011)
 nh gi cc vn ca bnh nhn
Creatinin
ClCr Triu chng lm
SUY GIM CHC Mc mu
(ml/pht) sng
NNG THN (mol/ml)

I 60-41 <130 Bnh thng

- ClCreatinin = 47,3 ml/pht

(Cockcroft- Gault) II 40-21 130-299 Thiu mu nh

- eGFR = 60,8 Triu chng tiu

ml/pht/1.73 m2 IIIa 20-11 300-499 ha.
Thiu mu va
(MDRD) Thiu mu nng.
IIIb Hi chng ure
- Protein niu (++) 10-5 500-900
mu cao
IV <5 >900 Tiu t
21
Hi thn hc Hoa K 2002
CC VN CA BNH NHN

Ph i tht tri nh, EF 60%

2013 ESH/ESC
Nguy c tim mch rt
cao

2013 ESH/ESC
 Tng huyt p

i tho ng
Cc
vn Ri lon lipid mu
ca
Gout
bnh
nhn Suy gim chc nng thn

Nguy c tim mch 24

 BC 2:
LP K HOCH CHM SC BNH NHN
 MC TIU V
CC VN LIN QUAN IU TR
1. TNG HUYT P
- Theo Phn
hi THA Vit
Nam 2014: mc
tiu HA vi
bnh nhn T
l < 140/90 (I,A)
- ESH/ESC
2013: mc tiu
HA vi ngi
bnh thn km
T hoc khng
 MC TIU V
CC VN LIN QUAN IU TR
1. TNG HUYT P

Mc tiu HA ca BN
140/90mmHg
 MC TIU V
CC VN LIN QUAN IU TR
1. TNG HUYT P
Thuc iu tr: Coversyl (perindopril) 4 mg ung 1 ln/ngy

PH HP CH
NH V
KHUYN CO

TNH AN TON
TNH HIU QU - mc liu: ph
Cha t HA mc hp [1]
tiu - Tc dng ph:
gy ho nhiu

[1] Renal
 MC TIU V
CC VN LIN QUAN IU TR
2. I THO NG
TYP 2

Hin mc HbA1C ca BN l 5,6%

cn duy tr mc HbA1C ny 2013 ESH/ESC
Hypertension
 MC TIU V
CC VN LIN QUAN IU TR
2. I THO NG TYP 2
Thuc iu tr: Glucophage (metformin) 850mg ngy
1 ln
PH HP CH
NH V
KHUYN CO

TNH HIU QU
HbA1C: 5.6% - t mc
tiu liu: ph hp vi tnh trng
- Mc
suy thn ca bnh nhn (theo SPC) TNH AN TON
- Cha thy xut hin cc TDKMM
trn BN ADA 2014
 MC TIU V
CC VN LIN QUAN IU TR
3. RI LON M
MU

2013 ESH/ESC
 MC TIU V
CC VN LIN QUAN IU TR
3. RI LON M
MU
Thuc iu tr: Simvastatin 40 mg ung 1 ln/ngy vo bui ti

ESH/ESC 2013 khuyn co s dng

TNH PH HP
statin trn BN THA nguy c tim mch
cao t mc tiu LDL-C (I,A)

LDL-C: 2,6 mmol/L - t mc tiu TNH HIU QU

- Khng cn hiu chnh liu trn BN suy

thn
- Cha xut hin TDKMM trn BN TNH AN TON
 MC TIU V
CC VN LIN QUAN IU TR
4. GOUT

Acid uric mu:

6 mg/dl = 356 mol/L
5 mg/dl = 297mol/L
2012 ACR - Gout
 MC TIU V
CC VN LIN QUAN IU TR
4. GOUT
Thuc iu tr:

Naproxen 220 mg ung mi khi c au

Allopurinol 200 mg ung ngy mt ln
ALLOPURINOL
ACR 2012 khuyn co s dng nhm
thuc c ch Xanthine oxidase (c
TNH PH HP
Allopurinol) l First line trong iu tr
gim acid uric mu (A)

Acid uric mu: 400 mol/L cha

TNH HIU QU
t mc tiu iu tr

- Liu mc cho php trn tnh

trng suy thn hin ti ca BN TNH AN TON

- Cha ghi nhn TDKMM

NAPROXEN

NSAIDS (trong Naproxen mc bng

TNH PH HP
chng A) c ACR 2012 khuyn co l firstline
iu tr cn gout cp

- Liu ang s dng mc cho

php trn tnh trng suy thn hin
ti ca bnh nhn
TNH AN TON
- Cha ghi nhn cc TDKMM
 MC TIU V
CC VN LIN QUAN IU TR
5. PHNG NGA BIN C TIM MCH
- Kim sot tt cc vn v THA, T typ 2, RLMM nh
trnh by trn
- Theo di tnh trng suy thn ca bnh nhn a ra chun on
v x tr ph hp

2013 ESH/ESC
TUN TH IU TR CA BNH NHN
Cha c thng tin c th trong TH ny

Mt s ch s sinh ha mc tiu nh HbA1C hay LDL-C nm

mc tiu cho php

kh nng BN tun th iu tr cc thuc iu tr cc vn ny

TDP gy ho khan ca Coversyl c th gy nh hng n kh

nng tun th iu tr ca BN

BN cao tui, phi ung nhiu loi thuc, thi im s dng khc
nhau cng gy nh hng n kh nng tun th iu tr ca BN
 Cc vn v thuc ca bnh nhn
Thuc Vn Bin php
Perindopril - Cha t mc tiu HA -i sang nhm ARB
- Gy TDKMM ho khan - Cn nhc phi hp
ko di trn bnh nhn thuc t mc tiu HA

Allopurinol Cha t mc tiu acid Cn nhc tng liu

uric mu

39
Aspirin - Cha c trong n - Cn nhc s dng
Aspirin liu thp
 NH GI VN LIN QUAN IU TR
(KHI C N THUC MI)
Glucophage (metformin) 850mg 1 ln/ngy
Naproxen 220 mg ung mi khi c au

Allopurinol 200 mg ung ngy mt ln

Simvastatin 40 mg ung 1 ln/ngy vo bui ti

Telmisartan 40 mg 1 ln/ngy vo bui sng

Amlodipin 5mg 1ln/ngy vo bui sng

Nhn xt:
- Gi nguyn phc iu tr vi cc vn T, RLMM, Gout
- Vn THA: kt hp ARB + chn knh Calci
 NH GI VN LIN QUAN IU TR
(KHI C N THUC MI)
1. TNG HUYT P Telmisartan 40 mg 1 ln/ngy vo bui sng
Amlodipin 5mg 1ln/ngy vo bui sng

PH HP CH NH
V KHUYN CO

2013 ESH/ESC
 NH GI VN LIN QUAN IU TR
(KHI C N THUC MI)
1. TNG HUYT P

- Amlodipin khng cn hiu chnh liu trn

BN suy thn TNH AN TON

- Telmisartan khng c khuyn co liu ti a s

dng trn BN suy thn, tuy nhin cn theo di
nng K+ mu v nng creatinin mu.
 NH GI VN LIN QUAN IU TR
(KHI C N THUC MI)

2. Gout

- Do phc iu tr khng thay i, do nguy c t mc tiu

iu tr acid uric mu l khng cao
Khng m bo tnh hiu qu ca thuc iu tr
 TNG TC THUC
Cp tng tc Hu qu Mc tng tc

Tng nng ca
simvasttin trong mu,
Simvastatin & t c th lm tng
Nghim trng
Amlodipin TDKMM trn gan,
thm ch gy tiu c
vn cp

-Cn thn trng, c bit trn BN hin cao tui, mc liu

simvastatin s dng mc cao
Lu BN c bit nu c du hiu au mi c, theo di cc ch s
men gan, men CK ca BN 44

Drugs.com
 Cc bin php can thip v thuc ca bnh nhn
(n mi)

Thuc Vn Bin php

Allopurinol Cha t mc tiu acid Cn nhc tng liu

uric mu

Aspirin Cha c trong n Cn nhc s dng

Aspirin liu thp

Tng tc Nguy c tng nng Gio dc BN, theo di cc

simvastatin simvastatin , gy TDKMM ch s cn lm sng
45
+ amlodipin
BC 3: THEO DI V GIM ST
 THEO DI- GIM ST IU TR

CC VN BIN PHP CAN THIP

Bin php khng - Gio dc bnh nhn thay i li sng
dng thuc

Phc thuc - Theo di cc ADR, tc dng khng

iu tr mong mun ca thuc iu tr
- Theo di tng tc thuc c th c
- Theo di cc ch s xt nghim cn
thit
 BIN PHP GIO DC BNH NHN

* Thay i li sng (Khuyn co ESC/ESH 2013)

Hn ch mui: 5- 6g mui/ ngy
Bnh nhn ht thuc v b c 6 thng, nn duy
tr thi quen khng ht thuc.
Hn ch bia ru, cht cn: 20-30g/ngy.
Khng ung nc p bi chm trong thi gian dng
thuc CCB, simvastatin.
Duy tr tp luyn 30 pht/ ngy t 5-7 ngy/tun.
 THEO DI V GIM ST IU TR
THUC IU TR TC DNG PH
Amlodipin+ Simvastatin - Theo di nng simvastatin trong
mu, nng Creatinin kinase.
Telmisartan - Theo di nng K+ mu v Scr
Allopurinol - Theo di c tnh do thuc nh men
gan, ban , nga
Naproxen - Theo di cc triu chng: xut huyt
tiu ha, au thng v, gim tiu cu
Metformin - Ch cc du hiu: chn n, mt mi,
ni my ay
 THEO DI V GIM ST IU TR
VN CN THEO DI KHUYN CO
Theo di huyt p hng ngy v quay li ESH/ESC 2013
khm sau 2 tun dng thuc.

- Theo di ng huyt lc i ESH/ESC 2013

- HbA1C < 7% mi 3 thng
Theo di xt nghim acid uric sau t nht 2 Hi Khp Hoa K
5 tun dng thuc 2012
 THEO DI V GIM ST IU TR
VN CN THEO DI KHUYN CO
Siu m tim, in tm theo di ph i ESH/ESC 2013
tht tri gy nguy c suy tim t nht mi 6
thng/ln.
- Theo di mc tn thng thn da vo ESH/ESC 2013
nh gi ch s: eGFR < 60ml/pht/1.73m2
t nht 3 thng/1 ln.
- Theo di protein niu, lm thm xt
nghim microalbumin
- Theo di xt nghim CK hng tun, Khuyn co lm sng ca
- Lu bnh nhn khi c du hiu au c, Hip hi Tim Hoa ky (AHA)/
mi c. Hip hi Hc vin Tim Hoa
k (ACC)/ Vin Tim Phi
Mu Quc Gia (NHLBI)