Khoa Truyn nhim Bnh vin Bch Mai
16.8.2013
HNH CHNHBnh nhn: T.Q.T.Nam 58 tuiNgh nghip: Bun bna ch: Trng thi TP Nam nh Tnh Nam nhVo Khoa Cp cu: 2/4/2013Vo Khoa Truyn nhim: 3/4/2013L do vo vin: St Vng da Ri lon thc
BNH SBnh ngy th 7:Khi u: mt, ngy st khng r nhit , ho t m trng. nh 2 ngy, khm v iu tr khng sinh 5 ngy (Vim ph qun?) khng . Ngy th 7: st nng 39 - 400C lin tc, thc l m, chm chp, c lc git ngn vo cp cu.
Tin sBn thnHt thuc l 1 bao/ngy x 30 nmGiun chui ng mt 10 nm trc iu tr ni khoa ti BV tnh, n nhUng ru khng thng xuynGia nh: Khng c g c bitDch t hc10 nm nay qua li, sng Angola v Vit nam, khng b bnh hay au m g.t ny mi v Vit Nam 11 ngy trc.
KHM VO CP CU thc hi chm chp, Glasgow 14. Da, cng mc vng. M: 120l/pht. HA: 130/80mmHg. Th 20 l/pht, SpO2: 95%. Nhit 38,5 0C.Tim nhanh, u, khng ting thiPhi: vi ran n 2 yBng mm. Gan 3cm DBS, rung gan (-). Lch khng s thyHi chng mng no (-). Khng lit kh tr
XT NGHIMCTM: Hng cu: 4,43 T/lHb: 153g/lBch cu: 13,3 G/lTiu cu: 20,3 G/lUS: 7,5Creatinin: 69Glucose: 7,5Na/K/Cl: 130/3,7/96Bilirubin TP/TT/GT: 116/ 111,5/ 4,5AST/ALT: 30/32SA bng: Gan P to 15cm. ng mt bt. Ti mt co nh Xquang phi: m nh 2 bn y
Chn on Khoa Cp cu: TD Nhim trng ng mt -- chuyn Khoa Tiu ha.
Bnh nhn Glasgow 13 Kh th 26 30 ln/pht. SpO2 94% (O2: 4l/pht). Phi nhiu ran rt, ran ngyM: 130 l/ph, St 39.5 0C, HA 130/80mmHgDa, cng mc vng. Gan to 3cm DBS -- chuyn khoa Hi sc tch cc
XT NGHIMChp C.T. Scan s: bnh thngChc DNT: Dch trong, p lc tng nh. Protein: 0,72g/lTB: 20BC/mm3 (lympho 60%)
Sau khi khai thc yu t dch t: Ch nh XN KSTSR: Kt qu (+) cho Artesunat 60mg chuyn khoa Truyn nhim
KHM TI KHOA TRUYN NHIMBN kch thch vt v, Glasgow 13 Nhit 390C, M: 110 ln/pht, HA 130/80 mmHgKh th, nhp th 26 CK/pht, SpO2 96% (th oxy knh 4 lt/pht)Nim mc hng, da cng mc mt vng, khng xut huyt di daTim nhp uPhi RRPN r, ran n 2 bnBng mm, gan to 3 cm di b sn, lch khng to
XT NGHIMHng cu 3,82 T/l; Hb 131 g/l; Bch cu 9,16G/l; Tiu cu 8 G/lPT 42,3%; D-dimer 44,468; fibrinogen 1,776; nghim php ru (+) (im DIC = 6)Ure 19,8 mmol/l; creatinin 135 mmol/l; glucose 3,6 mmol/l; Na/K/Cl: 134/4,6/104 CRP 16mg/dl; Procalciton >120; Albumin: 19,6g/l AST/ALT: 125/45;Bilirubin TP/TT: 178/121 ProBNP: 1181. CVP: +20cm H2OKh mu: pH 7,311; pCO2 24; pO2 84,9 (Oxy 4l/p)KSTSR: P. falciparum T (++++) = 376.470 KST/mm3
Chn on: St rt nng bin chng (No, gan, thn,DIC)/Vim phi -TD NTH Ch nh iu tr: Thuc st rt: Artesunate 60 mg x 2 ng/ngy + Dalacin C 1200 mg/ngyKhng sinhTruyn khi tiu cu my, LovenoxTruyn dch, albumin, li tiu, th oxyHA tt 70/40 mmHg, SpO2 88%: t NKQ, th my, dobutamin, noradrenalin
DIN BIN (7 ngy u)
Ngy XN3/44/45/46/47/48/49/4Hng cu3,824,033,512,882,783,022,98Hb131137121939610397Tiu cu8851294050103Bch cu9,1615.018,5712,577,357,147,75T l PT42,354,278,278,280,368,960,9D-dimer44,4717,974.3344,3346,4794,356Ure19,819,319,218,54,65,85,7Creatinnin135172168153736164KSTSR/mm3(++++)376.470(++++)329.411(++++)8%HC.N(++++)6%HC.N(++++)134.814(++++)64.380Artesunat Clindamycin+++++++Meropenem 3g+++++++iu tr khcKhi TCV.MchNKQ-TMTC myKhi HCKhi HCKhi HC
DIN BIN (ngy th 8-14)
Ngy XN10/411/412/4)13/414/415/416/4Hng cu3,032,823,112,482,482,81Hb (g/L)10090101797688Tiu cu104133129180209214KSTSR/mm3++++52.558++++41.103++++19.668+++2.560+++296m tnhm tnhQuinin+++++++Doxycyclin+++++Meropenem+++++++iu tr khcAn thn TMKhi HCKhi HCKhi HCKhi HC
X-quang phi (16/4/2013)
DIN BIN (ngy th15-21)
Ngy XN17/418/419/420/421/422/423/4Hng cu3,012,742,642,633,143,2Hb93858182100100Tiu cu210254318340467549KSTSRm tnhm tnhm tnhCiprobay 0,8g+++++++Primaquin++++++Meropenem 3g+++++++iu tr khcKhi HCKhi HCCai th my
X-quang phi
Bnh nhn ra vin (2/5/2013)
BI HC KINH NGHIMKhai thc yu t dch t: Angola l vng dch t lu hnh bnh st rt. (Nhiu cng dn Vit nam ang sng, lao ng ti Angola tr v).Theo di lng KSTSR hng ngy -- pht hin tht bi iu tr. Phi hp cht ch gia cc chuyn ngnh: Truyn nhim, Vi sinh, Hi sc, Huyt hc, Dc lm sng, Dinh dng. Hi chn vi cc chuyn gia ca WHO, Vin St rt KST trung ng
Cp nht
THT BI IU TR V ST RT KHNG THUC
THT BI IU TR V ST RT KHNG THUCDu hiu hiu tht bi iu tr sm (BYT -2009):Xut hin thm du hiu nguy him ngy D1, D2, D3KSTSR ngy D2 >D1Cn KSTSR ngy D3 v nhit nch >37,5oCKSTSR ngy D3 > 25% ngy D0
Khng Artemisinin: (WHO: B.co khg.thuc SR 2000-2012)iu tr 7 ngy cn KSTSR trong muNng dihydroartemisinin trong mu bnh thng.Thi gian o thi KTSR ko diGim nhy cm invitro vi dihydroartemisinin
IU TR THT BI KHNG NG NGHA VI KHNG THUC! (WHO - 2010)Cc yu t nh hng n iu tr:iu tr sm (iu tr mun tng t vong)iu tr ng (pha 1ml NaBiCa 5%, 5ml NaCl 0,9%)Tht bi iu tr do:Liu dng khng ngCht lng thuc kmKhng tun th iu trTng tc thuc khcKhng hp thu c thuc (nn, a chy o thi nhanh, bin i sinh hc ca tin cht km)Chn on saiKHNG THUC
Xc nh khng thuc SRnh gi lm sngang iu tr - xut hin du hiu nng lnKSTSR ngy D2>D0Cn KSTSR ngy D3 v nhit > 37,5oCKSTSR ngy D3 > 25% D0Xc nh genotyp: phn bit ti pht v ti nhimXc nh tnh nhy cm ca KSTSR khi nui cyCc marker phn t ca KSTSR: thy gen khng thuc
XIN TRN TRNG CM N !
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