co xuong khop.pdf

8/12/2019 Co Xuong Khop.pdf

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CHNG 5

C XNG KHP

VIM KHP DNG THPMc tiu1. M t c nguyn nhn v c ch sinh bnh ca vim khp dng thp2. Trnh by c triu chng lm sng v cn lm sng ca vim khp dng thp3. M t c tiu chun chn on v chn on phn bit.4. Trnh by c cc phng tin iu tr truyn thng vim khp dng thp5. M t c cc phng tin iu tr mi.

Ni dungI. I CNG1. nh ngh aVim khp dng thp (VKDT) l mt bnh thp khp mn, t min, ch yu n.2. D ch t hc

- L bnh thng gp nht trong cc bnh khp. Vit Nam t l mc bnh l0,5% trong nhn dn v 20% s bnh khp nm iu tr ti bnh vin. Bnh gp mi ni trn th gii, chim 0,5%-3% dn s ngi ln (theo tc gi Tr n Ngc n, hi thp khp Vit Nam)

- 70 - 80% l n gii v 60 - 70% c tui trn 30.- Mt s tr ng hp c tnh cht gia nh.

II. NGUYN NHN V C CH SINH BNH1. Nguyn nhn: L mt bnh t min vi s tham gia ca nhiu yu t

- Tc nhn gy bnh: c th l vi khun, vi rt, d nguyn ? nhng cha cxc minh chc chn.

- C a: bnh c lin quan r r t n gii v tui.- Di truyn: bnh c tnh cht gia nh v 60-70% bnh nhn mang yu t

khng nguyn ph hp t chc HLA-DR4 (trong khi ngi bnh thng l 30%)- Yu t thun li: sau sang ch n, c th suy yu, sinh , lnh m ko di...

2. C ch sinh b nhLc u tc nhn gy bnh tc ng nh khng nguyn, n gi vn cha bit lkhng nguyn g, gy bnh tr ng dng t bo T c khng nguyn kch thch trnnhng c th cm nhim di truyn trong giai on u ca bnh. Mt tiu nhm t bo T hot ho trong mng hot dch sn xut nhiu cytokine khc nhau baogm: Interferon (IFN-), interleukin 2 (IL2), IL6 v yu t hoi t u (TNF -), c tcdng gy vim mng hot dch ko di, c tr ng ca VKDT. Kch thch thm cc t bo khc trong mng hot dch (bch cu n nhn, t bo B, t bo mng hot dchging nguyn bo si), bng cytokine hoc tip xc tr c tip vi t bo T hot ho,


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s dn n giai on bnh th hai ph hu nhiu hn. Cc bch cu n nhn hotho v t bo mng hot dch ging nguyn bo si khng ch sn xut cc cytokinetin vim, khc nhau (c bit l IL.1 v TNF -) v cc yu t tng tr ng c th lm phc tp thm tnh tr ng vim, m cn kch thch s sn xut ccmetalloproteinase ca cht nn v cc protease khc. Chnh nh ng tc nhn nylm trung gian ph hu cht nn ca m khp c tr ng ca giai on ph hu trongVKDT.III. TRIU CHNG LM SNG1.Vim kh p1.1. Khi pht: 85% bt u t t, tng dn, 15% t ngt vi cc du vim cp; as bng vim mt khp, l mt trong cc khp bn tay (c tay, bn ngn, ngngn), gi. Ko di t vi tun n vi thng r i chuyn qua giai on ton pht.1.2. Ton pht: Vim nhiu khp- V tr: Sm l cc khp chi, tr i xa gc+ Chi trn: c tay, bn ngn, ngn gn nht l ngn 2 v ngn 3.+ Chi di: gi, c chn, bn ngn v ngn chn.Mun l cc khp: khuu, vai, hng, t sng c, thi dng hm, c n.- Tnh cht: Xu hng lan ra 2 bn v i xng:+ Sng, au v hn ch vn ng, t nng , c th c nc khp gi.+ au tng nhiu v m gn sng, cng khp bui sng.+ Cc ngn tay c hnh thoi, nht l cc ngn 2 v ngn 3.

+ Bin dng khp c tr ng xut hin chm hn: bn tay gi thi, bn tay lng lc.2. Tri u ch ng ngoi kh p2.1. Ton thn: St nh, da xanh, n ng km, gy, r i lon thn kinh thc vt.2.2. Biu hin cn khp- Ht di da: ni g ln khi mt da, chc, khng au d: 0,5-2cm thng gp trnxng tr gn khp khuu, trn xng chy gn khp gi, s lng t mt n viht.

- Da kh teo, ph 1 on chi, hng ban lng bn tay.- Teo c: r r t vng quanh khp vim, vim gn: hay gp gn Achille.2.3. Rt him gp trn lm sng:- Tim: Tn thng c tim kno, c th c vim mng ngoi tim.- Phi: Vim mng phi nh, x ph nang.- Lch: lch to v gim bch cu trong hi chng Felty- Xng: mt vi, gy t nhin.Ngoi ra cn c: vim gic mc, vim mng mt, p cc dy th n kinh ngoi bin,

thiu mu nhc sc, r i lon thn kinh thc vt, nhim Amyloid c biu hin ch yu thn, thng xut hin r t mun.


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IV. CN LM SNGGm X quang, du sinh hc v sinh thit1. X quang: Giai on u thy mt vi vng u xng. Sau l khuyt xnghay n mn xng phn tip gip vi sn khp, r i hp khe khp. Sau cng l hu

phn sn khp v u xng gy dnh v bin dng khp.2. D u sinh h c: Gm du vim, r i lon min dch, dch khp.- Tc lng mu tng, 2 globulin tng, hng cu gim.- Waaler Rose: Pht hin yu t thp trong huyt thanh. Phn ng dng tnh khingng kt vi pha long huyt thanh bnh nhn t 1/32.- Dch khp: gim nhy, tng bch cu, t bo hnh nho 10% s t bo dch khp.t bo hnh nho l nhng bch cu a nhn trung tnh nut nhng phc hp mindch.3. Sinh thi t: Mng hot dch hay ht di da.Sinh thit mng hot dch thy nm tn thng: s tng sinh cc hnh lng camng hot dch, tng sinh cc lp ph hnh lng, xut hin nhng m hoi t gingnh t huyt, tng sinh mch mu tn to, thm nhp nhiu t bo vim quanh ccmch mu. Khi c t ba tn thng tr ln c th hng n chn on xc nh.Sinh thit ht di da: gia l mt m hoi t dng t huyt, chung quanh baobc bi nhiu t bo Lympho v tng bo.V. CHN ON1. Ch n on xc nh: Cn phi sm iu tr c kt qu

1.1. Tiu chun ca hi thp hc M 1987: Gm 7 im, trong tiu chun t 1 - 4phi c thi gian t nht 6 tun, chn on dng tnh cn t nht 4 tiu chun, l- Cng khp bui sng: ko di t nht 1 gi.- Sng au t nht 3 nhm khp trong s 14 nhm: ngn tay gn, bn ngn tay, c tay, khuu, gi, c chn, bn ngn chn (2 bn = 14).- Sng au 1 trong 3 khp ca bn tay: ngn gn, bn ngn, c tay.- Sng khp i xng.- C ht di da.

- Phn ng tm yu t thp huyt thanh dng tnh (Waaler-Rose +).- Hnhnh X quang in hnh.1.2. Tuyn c s thiu cn lm sng: chn on c th da vo cc im sau- Ph n 30-50 tui.- Vim nhiu khp xa gc chi.- Khi u t t, tin trin t nht 6 tun.- au tr i v m v cng khp bui sng.2. Ch n on phn bi t

- Giaion u (< 6 tun): Cn phn bit vi:


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+ Thp khp cp: da vo tui, tnh cht vim...+ Thp khp phn ng: sau cc b nh nhim khun, khng i xng.+ Hi chng Reiter: Vim khp, vim niu o v kt mc mt.- Giaion sau (> 6 tun): phn bit vi+ Thoi khp: ln tui, khng c du vim.+ au khp trong bnh to keo nht l luput ban .+ Vim ct sng dnh khp: nam gii, au ct sng lng, tht lng cng chu.+ Bnh Gt: acid uric tng cao trong mu.VI. IU TR Kt hp nhiu bin php: Ni, ngoi, vt l, ch nh hnh.1. Th nh

S khp vim t, vn ng gn nh bnh thng (giaion I)- Aspirine: 1-2g/ngy, chia nhiu ln.- Chloroquine: 0,2-0,4g/ngy, tc dng c ch men tiu th.- Thuc dn tc: cy xu h, hy thim, l lt.- Tp luyn, iu tr vt l,in, siu m, nc sui khong...

2. Th trung bnh

Nhiu khp b vim, vn ng b hn ch (giaion II).- Ging nh th nh nhng cn thm:- Dng mt trong cc thuc chng vim nonsteroid: Indomethacine 50-

100mg/ngy, Diclofenac: 100 - 150mg/ngy; Piroxicam 20mg/ngy.- C th dng Corticoid liu trung bnh.

3. Th nng

Khng i li c, vn ng cn t hoc mt ht (giaion III).- Corticoid liu cao: dng ngn hn, bng ung hoc TM.- Dng mt trong cc liu php: Mui vng: tng liu 1500-2000mg; D-

Penicilamin: 300mg/ngy; Methotrexate: 7,5-10mg/tun; Cyclophosphamide: 1-2mg/kg/ngy. Bin php khc nh trn.4. i u tr m iNhng thuc mi c gii thiu sau y iu tr VKDT c th phn thnh 3 loi:- Thuc c ch Cyclo -oxygnase tp 2 (Cox 2)- Cc tc nhn sinh hc.- Thuc chng thp khp lm thay i din tin bnh (DMARD: Disease Modifying

Anti - Rheumatic Drugs).4.1. Thuc c ch Cox 2Gn y ngi ta nhn din c t nht l 2 th ng dng ca cyclooxygnase (Cox): Cox - 1 l 1 enzyme bn th, c nhiu m v ch yu lin quan


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n vic sn xut cc prostaglandin cn thit cho qu trnh hng nh ni mi bnhthng. Tri li, cox -2 l 1 enzyme cm ng c tm thy cc m lnh vi nng thp, nhng tng ln r r t trong cc m b vim v lin quan n sinh tng hpPGE2 v tr vim. V cc thuc chng vim khng steroid (AINS) thng thng cch vim va c nhiu tc dng ph. Do vy nhng thuc AINS mi c ch u tinhoc chn lc trn cox-2 th c tc dng chng vim v r t t tc dng ph, l uim ca cc loi thuc mi.- MELOXICAM (Mobic): vim 7,5mg v 15mg,ng 15mg.Liu hng ngy: 15mg/ngy, dng 1 ln trong ngy.- CELECOXIB (CELEBREX) vim 100mg v 200mg.Liu hng ngy: 100mg x 2 ln/ngy.Tc dng ph ca cc thuc trn gm cc tc dng ph chung ca AINS nhng t l v mc thp hn nhiu so vi cc thuc AINS c in.

Ni chung, cc AINS khng lm chm s tin trin ph hu khp trong VKDT.4.2. Cc tc nhn sinh hcS quan tm c tp trung nhiu vo cc tc nhn ch ng TNF -, 1cytokine vim ch yu c phng thch bi cc i thc bo mng hot dch, tc ng nh 1 phn t r tquan tr ng, ch huy cc loi t bo khc mng hot dch phng thch cc phn t tinvim v ph hu khp. Hai cht nh th, c cng nhn iu tr VKDT.- ETANERCEPT: L 1 cht nh trng hp (dimer) gm phn ngoi bo ca 2 th th TNF ho tan (75kDa) hp nht vi phn Fc trn immuno -globulin G1 (IgG1) cangi. Etanercept gn 1 cch c hiu vi 2 phn t TNF - hoc TNF - tunhon, nn chn s tng tc ca chng vi th th TNF trn b mt t bo.+ Ch nh: VKDT t va n nng trn bnh nhn p ng khng y vi 1 haynhiu DMARD.+ Liu lng, cch dng: 25mg tim di da x 2 ln/tun dng trong nhiu thng.+ Tc dng ph: Phn ng nh ti ch tim.- INFLIXIMAB: 1 khng th n dng c cu to bi (vng hng nh ca khngth ngi v cc vng thay i ca chut nhc, c dng bng ng chuyn t nhmch v kt gn c hiu cc dng TNF - ho tan v xuyn mng.+ Ch nh: VKDT hot ng

+ Liu lng v cch dng: 10mg/kg chuyn TM liu duy nht, hoc chia ra chuynTM 2 ln trong tun.+ Tc dng ph: b vim phi khi dng liu thp. S bt tin khi dng 2 loi thuctrn l tim di da v chuyn TM c th hn ch s tun th iu tr .4.3. Thuc DMARD miLEFLUNOMIDE: l 1 dn cht ca isoxazole, l thuc DMARD mi nht c cngnhn iu tr VKDT. Trong giaion khi pht bnh, t bo T CD4 hot ho, tngsinh r t nhanh leflunomidec ch s tng sinh bng cch ngn chn t bo Tsn sinh cc pyrimidine cn thit cho s tng hp DNA mi tr c khi phn bo.

- Trnh by: vim 100mg v vin 20 mg.


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- Liu lng v cch dng: 3 ngy u: 100mg/ngy.T ngy th 4 tr i: 10 - 20mg/ngy.

- Tc dng ph: Cc triu chng tiu ho, ni mn ngoi da v r ng tc, hi phcc khi ngng thuc.

ch li lm sng y ca leflunomide khi dngn c iu tr VKDT ch rrng sau khi dng hng nm.Phng php s dng DMARD hu hiuTrong phng php kim t thp truyn thng, DMARDc bt u dng tng imun trong qu trnh bnh v sau khng c s dng 1 cch nht qun. Mhnh iu tr hin nay p dng phng php r ng ca: Theo , DMARDc s dng sm sau khi khi pht VKDT vc tip tc sut qu trnh bnh vi mc chgi cho tnh tr ng mt sc ca bnh nhn gn vi mc bnh thng. Khi tc dngca thuc DMARD gim i, phc s c thay i bng cch thm 1 thuc mivo phc ang dng hoc bng cch thay thuc. Mc ch ca phng phpr ng ca l t c s ci thin c bn v kt cc lu di cho bnh nhn VKDT.


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THOI KHPMc tiu1. Trnh by c nh ngh a v dch t hc ca thoi khp.

2. M t c nguyn nhn c ch sinh bnh, v gii phu bnh.3. Trnh by c triu chng chnh v lm sng, cn lm sng v chn on thoikhp.4. Trnh by c cc phng tin iu tr ni khoa v vt l tr liu thoi khp.Ni dungI. I CNG1. nh ngh a: L mt bnh mn ca cc khp k c ct sng gy au v bin dng.2. D ch t hc

- Bnh gp mi dn tc, nam v n mc bnh ngang nhau. Tui cng tng t l cng cao.- Bnh vin Bch Mai H Ni: thoi khp chim 10,41% khoa c xng khp- Php thoi khp chim 28,6% cc bnh xng khp- M: 80% ngi > 55 tui c du X quang l thoi khp.Thoi khp theo th t thng gp l: ct sng tht lng, ct sng c, gi,

hng...II. NGUYN NHN V C CH SINH BNH

1. S lo hoL nguyn nhn chnh ca thoi khp nguyn pht, xut hin mun thng ngiln tui (>60), nhiu v tr, tin trin chm, khng nng. T bo sn gi dn, kh nng tng hp cc cht to nn si collagen v mucopolysacharide s gim v r ilon, cht lng sn km dn, tnh chu lc v n hi gim, hn na t bo sn ngi tr ng thnh khng c kh nng sinh sn v ti to.2. Y u t c hcCh yu gy thoi khp th pht, thng gp ngi tr (di 40 tui), khu tr mtvi v tr, nng v tin trin nhanh. Yu t ny th hin bng s tng bt thng lcnn trn mt khp, gi l hin tng qu ti. Gm:

- Tng cn qu mc do bo ph, tng tr ng ti do ngh nghip.- Bin dng khp th pht sau ch n thng, vim, u, lon sn lm thay i

hnh thi, tng quan ca khp.- D tt bm sinh lm thay i din tch nn ca cc mt khp.

3. Y u t khc

- Di truyn: c a gi sm- Ni tit: mn kinh,i tho ng, long xng do ni tit.

- Chuyn ho: bnh thng phong, bnh da xm nu.4. Xu h ng m i


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2.1. Hp khe khp: hp khng ng u, b khng u, ct sng thy chiu cao a m gim. Hp nhng khng bao gi dnh khp.2.2. c xng di sn: phn u xng, hm khp mm t sng c hnh m m (cn quang nhiu) trong phn xng c thy mt s hc nh sng hn.

2.3. Mc gai xng: phn tip gip gia xng, sn v mng hot dch, mpngoi ca thn t sng. Gai xng c hnh th v m (khc cu xng), mt s mnh gai xng r i ra nm trong khp hay phn mm quanh khp.

Mt s phng php chp c bit c th pht hin sm cc tn thng casn khp v a m nh: chp ct lp, chp ct lp t tr ng, chp bm thuc cnquang vo khp, vo a m.3. Xt nghi m khc

- Xt nghim mu v dch khp: khng c g thay i- Ni soi khp: thy nhng tn thng thoi ho ca sn khp pht hin cc

mnh gai xng r i trong khp.- Sinh thit mng hot dch: gin bit cc bnh khp khc.

V. CHN ON1. Ch n on xc nh

- Khi bnh: tui, tc nhn c hc, tin s...- Triu chng lm sng.- Du hiu X quang.

2. Ch n on phn bi tPhn bit vi cc bnh khp do vim: ch yu da vo cc d u vim.

VI. IU TR Cc bin php iu tr hin nay nhm lm gim au v phc hi chc nng khp.Mc tiu ca iu tr thoi khp vn l ng vin tinh thn bnh nhn, bo tn khp,luyn tp chng teo c v suy gim chc nng khp. S dng thuc gim au hocchng vim nonstroid, tim ti ch corticoid. Phi hp ni khoa, vt l, ngoi khoa.1. N i khoa

1.1. Gim au

1.1.1. Aspirine1-2g/ngy - chia nhiu ln. Acetaminophene: 1,5 -2 g/ngy.1.1.2. Chng vim nonstroid

- Diclofenac 100 - 150mg/ngy- Piroxicam 20mg/ngy- Meloxicam 15mg/ngy- Clcoxib 100-200mg/ngy.


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V nhiu bnh nhn mc bnh tui gi nn cn theo di chc nng gan thn tr cv sau khi iu tr bng thuc chng vim nonstroid, c bit i vi nhng bnhnhn dng thuc ko di.Khng dng Corticoid ton thn, khiau v sng nhiu c th dng ti ch.

1.2. Tng cng dinh dng snTc dng khng chc chn nh: ni tit t sinh dc (Testosterone),

thuc tng ng ha. Philatop, cao xng...1.3. Thuc tc dng chm.1.3.1. Glucosamine sulfate

- L hp cht sulfat ca Glucosamine aminomonosaccharide t nhin.Glucosamine, mt thnh phn t nhin cu thnh glycosaminoglycan sn khp vdch khp. C ch tc dng ca Glucosamine sulfat cho n nay cha hon tonsng t. Cc tc dng nh c ch gc t do superoxide, c ch sinh tng hp nitric

oxide cng l mt cch gii thch tc dng nhanh ca thuc trn cc th nghim lmsng ngn hn. Tuy nhin trong th nghim lm sng di hn th tc dng ca thucc l do bin i chuyn ho ca s n khp bao gm kch thch hot ng ng hanh tng tng hp proteoglycan, gim hot ng d ha ca sn khp nh tc dngtrn cc enzyme metalloprotease.

- Trnh by v liu lng: vin 0,25g, gi 1,5g.Liu hng ngy l 1,5g. Thi gian dng: nhiu nm. Thuc c an ton cao,

cha thy tc dng ph c ghi nhn.1.3.2. Chondroitine sulfate

Tc dng bng cch c ch cc men tiu sn, nht l men metalloprotase.- Trnh by di dng vin, liu trung bnh: 3 vin ngy.- Thi gian dng: t nht 1-2 thng.

1.3.3. Mt s loi thuc ang c th nghimBao gm chloroquine, Doxicycline, thuc tng hp glycoaminoglycine hoc

hyaluronate, c th tng cng s phc hi sn hoc gim s hu sn hoc baogm c hai.1.3.4. Liu php thay th cht nhn

Trong thoi khp c gim nng cng nh tr ng lng phn t ca acidehyaluronic lm gim nhy ca dich khp. V vy tim vo khp acide hyaluronicc tr ng lng phn t cao c tc dng b sung nhn ca dch khp.

- Trnh by di dng sodium hyaluronat (Hyruan)ng 200mg/2,5ml.- Liu lng v cch dng: ph thuc khp ln, khp nh. i vi khp gi: Tim vo khp 1 ln 1ng 2,5ml/tun, trong 5 tun lin tip.Tc dng ph: au nh, cm gic nng khp sau khi tim.

2. V t l tr li u- Cc bi tp th dc cho tng v tr thoi khp.- iu tr bng tay: xoa bp, n huyt, tp vn ng.


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- Bng nhit: tia hng ngoi, bn nng, parafin.- Bng nc: nc sui khong, nc nng, bi.- S dng cc dng c ch nh hnh.Cc phng php iu tr n gin gm iu tr vt l, acetaminophene hay

thuc chng vim nonstroid c tc dng gim au hn 70% bnh nhn thoi khp giai on sm.3. Ngo i khoa

Sa li cc d dng khp bng c v khot xng, iu tr thot v a m, lmcng dnh khp t th c nng, ghp khp nhn to.VII. PHNG BNH1. Trong cu c s ng hng ngy

- Chng cc t th xu trong sinh hot v lao ng.

- Trnh cc ng tc qu mnh, t ngt, sai t th khi mang, vc...- Chng bo ph bng ch dinh dng, th dc.- Kim tra nh k nhng ngi lm ngh lao ng nng pht hin v iu tr

sm.2. Pht hi n cc d t tCa xng, khp, ct sng c bin php ch nh hnh, nga thoi khp th pht.3. Ki m tra tr em

iu tr sm bnh ci xng, cc tt khp gi: chn cong, i vng kin, bn chnnga, g vo ct sng.


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BNH GTMc tiu1. Trnh by c chuyn ho ca acid uric v c ch sinh bnh Gt

2. M t c triu chng lm sng v cn lm sng3. Trnh by c tiu chun chn on.4. M t c cc bin php iu tr cn gt cp.5. Trnh by c cc phng tin iu tr hi chng tng acid uric muNi dungI. I CNG

- Bnh hay gp tng lp ngi c mc sng cao, t l mt s nc chu u khong 0,5% dn s, nam gp 10 ln so vi n. Vit Nam bnh gp cha

nhiu song trong thp nin gn y thy bnh tng ln r.- Gt l mt bnh chuyn ho, c tr ng l c nhng t vim khp cp v chin tng lng ng natri urat trong cc t chc, xy ra do tng acid uric trong mu.II. CHUYN HO CA ACID URIC

Acid uric l sn phm thoi ging ca nucleotid c base l purin. C 3 nguncung cp acid uric:

+ Do thoi ging acid nucleic t thc n a vo.+ Do thoi ging acid nucleic t cc t bo b cht+ Do tng hp ni sinh v chuyn ho purin trong c th nh cc men c

hiu. Acid uric c o thi qua nc tiu 450-500 mg/ngy v trong phn

200mg/ngy. Khi qua thn, urat c cu thn lc hon ton, r i ti hp thu gnhon ton ng ln gn cui cng c ng ln xa bi tit. Trong phn, acid uricc cc vi khun phn hu.

Nng acid uric trong mu theo hng s ca ngi Vit Nam l 4510mg/l(208-327 mol/l). Khi nng > 70mg/l (>416,5mol/l) thc gi l tng acid uricmu.

Cc nguyn nhn lm tng acid uric mu:. Tng sn xut acid uric: dng nhiu thc n c cha nhiu purin, tng thoi

ging nucleoprotein t bo, tng tng hp purin ni sinh.. Gim o thi acid uric niu: gim lc cu thn, gim bi tit ca ng thn.

i khi gim phn hy acid uric do vi khun trong phn.III. PHN LOI CC HI CHNG TNG ACID URIC MU V BNH GT1. H i ch ng t ng acid uric mu v c n v b nh gt nguyn pht

Th ny hay gp nht chim ti 85% cc tr ng hp, c tnh gia nh v ditruyn do r i lon chuyn ho purin.

2. H i ch ng t ng acid uric mu v b nh gt r i lon menNi chung th ny him gp.


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vnh tai khuu tay, ngn chn ci, gt chn, mu bn chn, gn Achille. Kch thc t vi milimetn nhiu centimet, hi chc hoc mm, khng di ng do dnh vo nnxng bn di.2.2. Bnh khp do urat: Khp b cng, au khi vn ng v lm hn ch vn ng,khp sng va, khng i xng, cng c th c tphi km theo. Trn X quang thyhp khe khp, khuyt xng, hnh hc u xng.3. Bi u hi n thn

Urat lng ng r i rc t chc k thn, b thn, niu qun.3.1. Si thn: 10 - 20% cc tr ng hp gt, iu kin thun li l pH nc tiu qutoan, nng acid uric cao. Si urat thng nh v khng cn quang.3.2. Tn thng thn: lc u ch c protein niu, c th c hng cu, bch cu vith, sau tin dn n suy thn. Suy thn hay gp th c tphi, tin trin chm v lnguyn nhn gy t vong.

VI. TIU CHUN CHN ON1. Tiu chu n Rome 1963

- Acid uric mu > 70mg/l (416,5mol/l)- C tphi- C tinh th natri urat trong dch khp hay lng ng urat trong cc t chc khi

soi knh hin vi hay kim tra ho hc.- Tin s c vim khp r, t nht lc khi u bnh, vim khp xut hin t

ngt, au d di v khi hon ton sau 1 - 2tun.

Ch cn c 2 tiu chun l chn on chc chn.2. Tiu chu n New York 1966

- t nht c 2 t vim cp mt khp chi, c khi bnh t ngt v khi sau 1-2tun.- C mt t nh trn nhng lin quan n khp bn ngn chn ci- C tphi- Dng colchicin bt vim nhiu trong 48 gi.Ch cn c 2 tiu chun l

VII. IU TR 1. Ch n- Gim cc cht c nhiu purin nh ph tng ng vt, tht, c, tm, cua... khng nqu mc. Gim calo nu bo.- Khng ung r u.- Ung nhiu nc 2 - 4l/ngy nht l nc c bicarbonat.2. Thu c

- Mc tiu iu tr + iu tr vim khp trong cn gt cp.


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+ D phng ti pht cn gt, phng lng ng urat trong cc t chc v phng ccbin chng thng qua iu tr hi chng tng acid uric mu.2.1. iu tr vim khp trong cn gt cpDng thuc chng vim loi nonsteroid:

- Colchicin: tc dng cn tr thc bo ca bch cu i vi cc vi tinh th urat, lthuc tt nht cho n nay.Cch dng: 1mg x 3 ln trong ngy u; 1mg x 2 ln trong ngy th 2 v 1mg t ngy th 3 tr i. Liu duy tr trnh cn ti pht l 0,5 -2mg/ngy (thng 1mg)ung trong 3 thng.Tc dng ph: tng nhu ng ng tiu ho d gy i lng; i khi gyc ch tyxng, r ng tc, tn thng ga, c ch h hp...- Nhiu thuc chng vim nonsteroid c nghin cu s dng, kt qu thycng tt tuy cha bng colchicin: Phenylbutazon, Indomethacin, Naproxen,

Ibuprofen, Piroxicam, Diclofenac.- Corticoid lm gim vim nhanh nhng ht thuc th khp vim tr li, mt khc lilm tng acid uric mu nn khng c dng.2.2. iu tr hi chng tng acid uric muCh nh sau khi ct cn gt cp. Thuc dng lu di c th lm cho cc tphinh li hoc mt i, cc khp cng hoc tr li bnh thng, hn ch c tintrin xu ca suy thn, gim cc t vim khp.2.2.1. Thuc lm tng o thi acid uric niuTc dng lm gim ti hp thu ca ng thn thuc d gy si thn nn cn phidng liu nh r i tng dn, ng thi cho ung thm nc bicarbonat 2 - 4l/ngy.Benziodoron (Amplivix 100mg): liu 100 - 300mg/ngy. t tc dng ph i khi c r ilon tiu ho.2.2.2. Thuc lm gim sinh tng hp acid uric Allopurinol (zyloric 100mg):c ch men xanthin-oxydase l men thoi ginghypoxanthin thnh xanthin v xanthin thnh acid uric v lm gim c sinh tng hppurin. Thuc dng c khi c suy thn.

Liu: 200 - 300mg/ngy ung 1 ln. t tc dng ph, i khi thy r i lon tiuho mn da, au u, chng mt, bun ng...2.2.3. Thuc lm tiu acid uric trong muUricozym: l men urat-oxydase tc dng lm thoi ging acid uric thnh allantoin,cht ny c ho tan gp 10 ln so vi acid uric vc d dng o thi ra ngoiqua thn. Uricozym lm gim acid uric r t mnh.Tim TM hoc TB 1000-2000n v/ngy.Trong qu trnh dng cc thuc lm gim acid uric mu, cn theo di nng acid uric muv lng acid uric niu iu ch nh liu duy tr, gi nng trong mu < 60 mg/l.


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VIM CT SNG DNH KHPMc tiu1. M t c nh ngh a v cc yu t dch t hc.

2. Trnh by c cc triu chng lm sng v cn lm sng3. Trnh by c tiu chun chn on v chn on phn bit.4. Trnh by c cc phng tin iu tr ni khoa, ch nh giai on cp, giaion sau cp.5. M t c cc phng php vt l tr liu, iu tr ngoi khoaNi dungI. I CNG1. nh ngh a

Vim ct sng dnh khp (VCSDK) l mt bnh vim khp mn tnh, cha r nguynnhn, gp ch yu nam gii tr tui, gy tn thng cc khp gc chi v ct sng,nhanh chng dn n dnh khp, bin dng v tn ph.2. D ch t hc- Gp mi ni trn th gii, nhng t l mc bnh khc nhau do c lin quan nyu t HLA - B27.- Vit Nam: VCSDK chim khong 20% s bnh nhn khp iu tr ti BV BchMai, khong 1,5/1000 nhng ngi trn 16 tui.- Nam gii chim khong 90-95%, tui di 30 chim 80%, 3-10% c tnh cht gianh.II. TRIU CHNG LM SNG1. Kh i pht- Tui mc bnh: Trn th gii: Gn 70% tr c tui 30Vit Nam: 80% tr c tui 30, 60% tr c tui 20- 70% bt t t, 30% bt u t ngt, 75% bt u t khp hng 25% bt u t ct sng.- Du hiu ban u: au vng hng, au kiu thn kinh ta, vim gn Achille...

nc ta thng bt u bng vim cc khp chi di (c chn, gi, hng) v auct sng tht lng. Cc triu chng ny ko di nhiu thng, nhiu nm.2. Ton pht

Sng au, hn ch vn ng nhiu khp, teo c, bin dng nhanh. Vim khpthng c tnh cht i xng, au tng v m.2.1. Cc khp chi- Hng: 90% thng bt u mt bn, sau c hai bn.- Gi: 80% c th c nc.

- Khp c chn: 30%, c th khng li di chng.- Khp vai: 30%, thng khi khng li di chng.


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- Cc khp khc: Him gp hn nh khuu, c n, c tay, khng bao gi thy tnthng cc khp nh bn tay.


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2.2. Ct sngThng xut hin mun hn cc khp chi.- Ct sng tht lng: 100% au lin tc v m , hn ch vn ng, teo c cnh ctsng.

- Ct sng lng: thng mun hn vng tht lng, au m , hn ch vn ng, bindng (g) hoc cng, teo c.- Ct sng c: c th mun hn hoc sm hn cc on khc, bin dng hn ch vn ng.2.3. Khp cng chu

- L du hiu sm, c hiu (ch yu trn Xquang)- au vng cng chu, lan xung i- Teo c mng

- Nghim php gin cnh chu (+)2.4. Nhng biu hin khc

- St, gy st- Mt: vim mng mt, vim mng mt th miNc ngoi: chim 20 - 30% tr ng hpVit Nam: khong 3%- Tim: 5% c r i lon dn truyn, h van ng mch ch - Cc biu hin him gp khc:+ X teo da+ X phi+ Chn p r thn kinh tu + Thot v bn, r n

3. Ti n tri n

- Xu hng chung: nng dn, dn n dnh khp, bin dng. Nu khng c iutr sm, ng, bnh nhn c nhiu t th xu, tn ph.

- Bin chng: suy h hp, tm ph mn, lao phi, lit hai chi do chn p tu v r thn kinh.- Tin lng:+ Xu: Tr tui, vim nhiu khp ngoi vi, st, gy st nhiu.+ Tt hn: B bnh sau 30 tui, th ct sng l ch yu.- 50% tin trin lin tc, 10% tin trin nhanh.III. XT NGHIM V X QUANG1. Xt nghi m

1.1. Xt nghim chung: t c gi tr chn on- Lng mu tng (90%)


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- Si huyt tng (80%)- in di Protein: Albumine gim, Globuline tng- XN min dch: Waaler Rose, khng th khng nhn, t bo Hargraves phn

ln m tnh v khng c gi tr chn on.

- Cc XN khc t thayi1.2. Dch khp: thng ly dch khp gi, dch lng v nht, lng Mucin gim, s lng t bo tng, nht l a nhn trung tnh, Dch khp ch biu hin vim khngc hiu.1.3. HLA-B27 (1973): Brewerton (Anh) v Schlosstein (M) nhn thy mi lin h cht ch gia HLA B27 v bnh VCSDK. Ngi ta thy r ng trong VCSDK, 75-95%bnh nhn mang yu t ny (Vit nam: 87%), trong khi th ngi bnh thngch c 4-8% mang HLA B27 (Vit nam 4%).2. X quang

- Du hiu sm: Vim khp cng chu 2 bn giai on 3 (hp nhiu, c ch dnh) v giaion 4 (dnh hon ton khng cn ranh gii).

- Giaion mun:+ Khp hng: hp khe khp, din khp m, khuyt xng, dnh+ Ct sng: cu xng (thn cy tre), di x (ng ray)

IV. CC TH LM SNG1. Th theo tri u ch ng

- Th gc chi: 40%, tin lng xu, biu hin vim cc khp hng, gi sm vnng.

- Th ct sng: Tin trin chm, bt u sau tui 30, di chng nh.- Th khng au: Ct sng dnh dn, khng au v khng c biu hin vim.- Th phi hp vi vim khp dng thp: c vim thm cc khp nh bn tay.

2. Th theo c a- Ph n: nh, kn o- Tr em di 15 tui: tin trin nhanh, tin lng xu, dnh v bin dng khp

tr m tr ng.- Ngi gi: nh, d nhm vi thoi ho ct sng.

3. Th bnh theo hnh nh Xquang

- Th khng c du hiu vim khp cng chu- Th c cu xng pha tr c ct sng- Th c hnh nh ph hu, khuyt xng.

V. NGUYN NHN, C CH BNH SINH V TN THNG GII PHUBNH1. Nguyn nhn, c ch bnh sinh


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Nguyn nhn cha r, khng c bng chng v min dch nhng c bng chng v vai tr ca nhim khun.


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C A:- Nam, tr tui- HLA_B27 (+)

NHIM KHU N- Tiu ho- Sinh dc- Tit niu

YU T THU N LI:Chn thng- V sinh km- Dinh dng km

KHI H N VIM KHP PH NNG VIM CSDK

KHI NHNG HAY TIPHT

Biu 1: C ch bnh sinh VCSDK

2. Gi i ph u b nh

2.1. Mng hot dch & sn khp- Giaion u: mng hot dch tng sinh, thm nhp t bo (lympho, plasmocyte)- Giaion sau: s n khp b lot, vim ni mc- Giai on mun: bao khp, mng hot dch x teo, vi ho, ct ho dn n dnhkhp.2.2. Ct sng

- T chc m gia dy chng di tr c ct sng v thn t sng b vim, viho, ct ho, hnh thnh cu xng.

- Cc dy chng ct sng x ho, vi ho di dy chng gy dnh ct sng.VI. CHN ON1. Ch n on xc nh1.1. Tiu chun ca hi thp khp NewYork, 1966

a. Lm sng:- Tin s hay hin ti au vng tht lng hay lng - tht lng.- Hn ch vn ng vng tht lng c 3 t th.- gin lng ngc gim.b. X quang: Vim khp cng chu 2 bn giai on 3, 4Chn on xc nh khi c mt tiu chun lm sng v mt tiu chun Xquang.

1.2. p dng thc t Vit Nam:

- Nam gii, tr tui- au v hn ch vn ng 2 khp hng


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- au v hn ch vn ng ct sng tht lng.- Tc lng mu tng cao- Xquang: Vim khp cng chu 2 bn giai on 2 tr ln

2. Ch n on phn bi t2.1. Vi th vim khp gc chi

- Lao khp hng- Chy mu khp trong Hemophilie- Vim khp dng thp.- Goutte

2.2. Th ct sng l ch yu- Vim ct sng do vi khun (lao, t cu...)

- Tn thng ct sng trong bnh Scheuermann: au, g, khng c biu hinvim.- D dng, di chng chn thng gy au v hn ch vn ng.- Cc bnh c cnh ct sng: vim, chn thng, chy mu

2.3. Mi quan h gia VCSDK vi cc bnh khp c HLA - B27 (+)- Hi chng Reiter, HLA B27 (+) 80%- Vim khp vy nn: HLA B27 (+) cao vi th ct sng- Vim khp mn tnh thiu nin th ct sng: HLA B27 (+) cao

VII. IU TR 1. i u tr ni khoa1.1. Nhng thuc c tc dng tt1.1.1. Phenylbutazone

Giai on u tim bp 600mg/ngy, sau chuyn sang ung 150-200mg/ngy. Ch tc dng ph ca thuc: mu, tiu ho, da, gi mui nc, timmch...1.1.2. Salazopyrine

Vim 500mg, 2 - 4 vin/ngy, thuc c dng theo c ch chng cc nhimkhun tim tng (tiu ho, sinh dc), tc dng tt 50 - 70% tr ng hp, ung ko dinhiu thng.1.1.3. Cc thuc chng vim khc: Indomethacine, diclofnac, Profnid, Naprosyn.1.2. Nhng thuc t tc dng

- Aspirine: gim au nhng khng hn ch qu trnh vim- Stroid: dng ng ton thn v ti ch u t tc dng, khng nn s dng

trong VCSDK.

- Chloroquine: khng c tc dng- Cc thuc c ch min dch: Khng s dng


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1.3. Cc phng php khcPhng php dng tia x mang li nhiu kt qu kh quan.- Dng quang tuyn X chiu vo ct sng v cc khp vim, mi ln 100r, tng

liu 400-800r.

- Dng ng v phng x: radium 224 tim t nh mch mi ln t 50-200microgam, tng liu t 1000-1500 microgam.1.4. Giai on cp

- Ngh ngi- t chi t th c nng- Chng vim khng stroid tim, ung: Phenylbutazone, Diclofenac, Profenid- Gin c: Mydocalin, coltramyl.

1.5. Giai on sau cp- Tp vn ng tng dn, khng gng sc trnh co cng th pht.- Chng vim khng Stroid: Phenylbutazone, Diclofnac, Profenid...- Gin c - Khng sinh: Salazopyrine 0,5g 2-4 vin/ngy hoc Tetracycline 0,25g 2-

4vin/ngy, khng dng cho bnh nhn di 15 tui.2. V t l tr li u2.1. Cc bin php chng dnh khp, chng t th xu

- Khi bnh ang tin trin, au nhiu, nn khp t th c nng: nm ngatrn nn cng, gi u thp, chn dui thng hi dng. Vi t th ny nu c dnhkhp th bnh nhn vn c th i li c. Tuy nhin ch c c nh trong mtthi gian ngn, khi qua giai on cp th phi cho vn ng ngay.

- Tp vn ng cng sm cng tt, vn ng mi t th v mi thi gian, yl bin php tt nht chng dnh khp.2.2. Cc phng php phc hi chc nng vn ng

- iu tr bng nhit chng hin tng co c - Dng nc (b bi), nc khong: bnh nhn tp luyn, nht l tp bi mang

li nhiu kt qu.- Xoa bp, ko lin tc, th dc tr liu.

3. Ngo i khoa

iu tr ngoi khoa c ch nh phc hi chc nng vn ng khi c dnhkhp vi t th xu.

- Ct xng hoc ghp xng ch nh li tr c ca ct sng, ca chi.- Thay khp gi bng cht do hoc kim loi: ghp khp hng, khp gi


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LAO CT SNGMc tiu1. M t c cc yu t dch t, c a

2. Trnh by c triu chng lm sng v cn lm sng ca tng giai on bnh:khi pht, ton pht v giai on cui.3. Trnh by c chn on xc nh v chn on phn bit.4. M t c cc nguyn tc dng thuc chng lao.5. Trnh by c cc phng php phc hi chc nng, bt ng, ngoi khoa.Ni dungI. I CNG- Bnh c m t ln u tin vo cui th k 19 do mt thy thuc ngoi khoa

ngi Anh tn l Percivall Pott, nn cn gi l bnh Pott.- Thng th pht nht l sau lao phi, vi khun lao n ct sng bng ng mu.- Cn gp nhiu cc nc ang pht trin, bnh chim khong 2/3 cc tr ng hplao xng khp. trung tm chn thng ch nh hnh TP. HCM nm 1998 c 191tr ng hp lao xng khp, trong lao ct sng chim 67,02%.- Thng gp 20 - 40 tui, nam v n mc bnh ngang nhau.- Tn thng on lng v tht lng chim hn 90% (t lng 8 n tht lng 2)II. TRIU CHNG1. Giai on kh i pht1.1. Du c nng ch yu l au- au ti ch: au vng ct sng b tn thng, c nh mt v tr khng thayi.

au lin tc c ngy m, tng khi vn ng, i li, gim khi ngh ngi; dng thucgim au t hiu qu.- au kiu r : Do tn thng chn p vo mt vi nhnh ca r thn kinh, au lantheo ng i ca r v dy thn kinh, c lan xung vai v gy, lng lan theody thn kinh lin sn, tht lng lan theo thn kinh ta. au tng khi ho, ht hi,r n mnh.1.2. Thm khm- Ct sng: Thy mt on ct sng cng , hn ch cc ng tc khng gin rakhi ci. C 2 bn ct sng c th co cng, g vo vng gai sau ca on tn thngthy au r.- Ton thn: C th thy du nhim lao, c tn thng lao phi hp > 50% tr nghp (phi, mng phi, hch...).1.3. Xquang v xt nghim- Xquang: Rt quan tr ng gip chn on.

+ a m hp so vi cc on khc.

+ Thn t sng b nham nh, m phn tr c v mt trn.


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+ Phn mm quanh t sng m m hn. pht hin sm tn thng cn chp ct lp, ct lp t tr ng.

- Xt nghim:+ Cng thc mu: bch cu Lympho tng+ Tc lng mu tng trong 95% tr ng hp.+ Phn ng ni b lao (IDR) dng tnh trong 90% tr ng hp.+ Chc kim cnh ct sng ht xt nghim: c th tm thy tr c khun lao

(BK).- Tm tn thng lao phi phi hp: chp phi, tm BK trongm, sinh thit hch.2. Giai n ton phtSau nhiu thng bnh tin trin, tn thng ph hy t sng v a m nhiu gybin dng ct sng, p xe v du hiu chn p.2.1. Lm sng2.1.1. C nng: au c nh, lin tc, c hi chng r thn kinh thng xuyn v rr t.2.1.2. Thm khm- Li t sng ra sau: nhn nghing thy mt t sng li ra pha sau. Dng ngn taymit nh dc theo cc gai sau t di ln trn s thy r du hiu ny.- p xe lnh: c v tr khc nhau ty v tr tn thng:+ Ct sng c: Ti p xe i ra pha tr c ngay thnh sau h ng, c th nhn thy khikhm hng, hoc i xung theo cc c cnh c n hm thng n.+ Ct sng lng: Ti p xe c th ra pha sau n i ln ngay di da.+ Ct sng tht lng: p xe ni ngay di da vng tht lng, vng mng hoc i rapha tr c xung bn, c khi xung ti kheo chn.Cc p xe lnh thng mm, khng au, mt s c th v ra chy nc vng v bu li cc vt lot v l d dai dng khng lin.- Hi chng chn p: l hu qu xu nht ca bnh, do t sng v a m b phhy nhiu, di lch, ln v c xu hng tr t ra pha sau chn p vo t y, ui nga.Ty v tr tn thng, bnh nhn c cc du hiu:

+ Lit t chi: tn thng on c.+ Lit 2 chn: tn thng on lng, tht lng trn.+ Hi chng ui nga: tn thng on tht lng di.Mc t r i lon cm gic, gim c lc n mc nng lit cng, r i lon c vng.- Du hiu ton thn: gy, suy mn, st, c th lot mng do nm lu. Tn thnglao lan r ng ra cc b phn khc nh phi, mng phi, hch.2.2. X quang v xt nghim

- X quang


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+ a m b ph hy gn nh hon ton.+ Thn t sng b ph hy nhiu, nht l phn tr c to nn hnh chm, di lchtr t ra pha sau.+ Hnhnh p xe lnh: trn phim chp thng thy hnh m quanh tn thng, c th

khng ng u, c ch vi ha m hn.- Xt nghim+ Tc lng mu tng+ Chc kim cnh ct sng d tm thy tn thng lao in hnh.+ Chc dch no ty chn on p ty v vim mng no tu.3. Giai on cu iKhng c iu tr hoc c th qu suy yu: bnh nng dn, lit nng, bi nhim,lao lan sang b phn khc nh lao mng no, lao mng tim, mng phi v cht v

suy kit.III. CHN ON1. Ch n on xc nhDa vo cc triu chng lm sng v Xquang. chn on sm cn chp ct lpv chc ht cnh t sng. Trong giai on ton pht chn on d v y ccdu hiu, nht l Xquang.2. Ch n on phn bi t- Vim ct sng do vi khun m (V d: t cu): Du nhim trng nng, iu kinkhi pht (nht, hu bi), Xquang khng c p xe lnh.- Cc tn thng u: ung th, di cn, u mu... da vo cc d u hiu ton thn,Xquang khng c hnhnh p xe lnh. Nu nghi ng, tin hnh chc ht xc nhchn on.IV. IU TR Hin nay ch yu l iu tr ni khoa bng cc thuc chng lao kt hp vi phc hichc nng. Vic bt ng v phu thut c ch nh ring cho mt s tr ng hp.1. N i khoa

Dng cc thuc chng lao theo nguyn tc sau

- iu tr cng sm cng tt.- Phi hp ti thiu 3 thuc chng lao: Rimifon, Streptomycine, Pyrazynamide,Ethambutol, Rifampicine trong 3 thng, sau gim bt mt loi v tip tc dngthuc t 6 - 12 thng.- Lu vn khng thuc ng .- Nn dng thuc mt ln trong ngy, bui sng, bng i.- Theo di tnh tr ng ton thn, tn thng ti ch, tc dng ph ca thuc.- Thc hin ch n ung, ngh ngi hp l.

2. Ph c h i ch c n ng- Xoa bp nh nhng cc c km tp luyn ct trnh teo c cng khp.


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- Sau khi ht au, ht du hiu vim bt u vn ng ct sng t t v tng dn.3. V n bt ngTr c y khi cha c thuc c hiu, iu tr ch yu l bt ng t 6 thng n 1nm. Hin nay bt ng c chn lc, ty tr ng hp thi gian t 3 - 6 thng.

- Bt ng trong sut thi gian bnh tin trin nhng khng hon ton, khng lintc. Tt nht l dng ging bt bnh nhn c th thay i t th nhiu ln trongngy, trnh hin tng cng khp teo c.- Tr ng hp tn thng nng ct sng c di lch nhiu e da chn p th cnb bt.- Nhng tn thng nh, c chn on v iu tr sm khng cn bt ng bngb bt.4. Ngo i khoa

c ch nh trong cc tr ng hp sau:- Lao ct sng c nguy c chn p ty hoc p ty.- Lao c p xe lnh ti ch hoc di chuyn xa.5. Theo di

Hng thng trong nm u, mi 3 thng trong nm th hai v mi 6 thng trong ccnm sau:- Tc dng ph ca thuc: lm sng, sinh hc.- Hiu qu ca thuc khng lao c nh gi lm sng v X quang mi 2 thng.- Tiu chun nh gi lnh bnh:+ Ht au+ Tng tr ng tt+ Ti lp kh nng lm vic, hc tp.+ Khng cn d m, p xe.+ Ti sinh xng thy trn X quang.6. Th t bi i u tr Sau 4 thng iu tr triu chng lm sng v X quang vn tn ti.

Nguyn nhn tht bi l- Khng thuc tin pht- Thiu s hp tc ca bnh nhn- Dng thuc sai- T chc iu tr khng ng mc, kim sot iu tr km:+ Khng thm khm lm sng+ Thuc khng liu+ Thi gian iu tr khng + Thuc cung cp khng u


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+ Khng gii thch cn k cho bnh nhn+ Thiu theo di y khoa u n.+ Thiu theo di bnh nhn ngng thuc+ B tc dng ph ca thuc m khng c pht hin


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- C th xut hin t nhin, nhng thng do khp vai vn ng qu mc hoc vchn thng lin tip vai.- au vai, r nh ch V ca c delta, i khi lan xung cnh tay thm ch c cngtay, mu tay. au kiu c hc, tng khi lm mt s ng tc ca vai, kh nmnghing, nht l lc t vo vai.- au tng khi nng vai ln, c th hn ch vn ng kn o do au.2.2. Thc th - Khng c hn ch vn ng ch ng v th ng.- Khng gim c lc- Khi lmng tc co cnh tay i khng th au tng.2.2.1 Du hiu vim cc c trn gai:- C im au chi di mm cng vai ngoi hoc ngay pha tr c mm cng vai,

tng ng vi v tr tn thng ca gn.- Lm ng tc i khng cnh tay, au tng ln.- au khi dang tay t 70 -90 .2.2.2. Du hiu vim gn c di gai- im au chi khin vo di mm cng vai pha sau, ngoi.- au tng khi quay ngi c i khng.2.2.3. Du hiu vim gn b di c nh u:- Khin vo rnh nh u, gy au phn trn - trong ca mt tr c cnh tay.- au khi gp cng tay trn cnh tay c i khng, hoc khi dang hoc hay a ratr c.- Tin trin c th dn n t gn.2.3 X.QuangHnh nh X quang cn phi c so snh 2 bn, d a trn phim thng t th quayngoi, quay trong v trung gian.- Khp vai ni chung l bnh thng, c th thy mt hoc nhiu im calci ho tign.

- Calci ho thng thy r nht khong di mm cng vai - mu chuyn ln.3. Ti n tri n

3.1 Thun li: Ni chung c din tin lnh tnh, a s gim dn r i khi sau vi tunn vi thng, thi gian ny c th nhanh hn nh iu tr , c th ti pht.3.2 Khng thun li hay tin trin xu- Chuyn thnh au vai cp, thm ch cng khp vai.- c bit khi triu chng au tn ti ko di d iu tr cn phi nghi ng c tcc gn c quay ngn, thng gp sau 50 tui. Xc nh chn on nh chp cnquang, v nu c th c chng minh khi lm th thut ngoi khoa ni li.


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- Gn b thoi ho tng dn khi khng iu tr , s dn n khp vai tui gi, ctr ng bi:+ Lm sng: ngoi au khi vn ng cn hn ch vn ng khi nng cnh tay ch ng.

+ Xquang cc du hiu in hnh:1. Gy mm b - cnh tay2. Mu chuyn b mm v c cc hc nh 3. Hp khe mm cng -cnh tay4. Gai xng5. Hp khe cho - Cnh tay

- Khp vai tui gi chy mu: l bin chng him gp ca t cc gn quay do gi,c chy mu trong khoang khp v ti thanh mc di mm cng -delta. Vai au dt

ngt, hon ton khng vn ng c, km vt bm tm cnh tay r t gi . Chcht c mu, xc nh chn on.III. GI LIT KHP VAI

- Biu hin bng gi lit c delta do t t ngt, r, cp, m cc gn c quay.+ Ngi ln tui (> 50 tui): Sau mt vn ng sai t th, chn thng khp vai,hoc sau mt gng sc tc ng ln m cc gn c quay b thoi ho.+ ngi tr : Him hn, chi th thao, sau mt chn thng mnh.- t phn di ca c nh u ch xy ra sau 50 tui, sau gng sc trn mt gn b thoi ho.1 Tri u ch ng c nng- au d di c khi km ting lc r c khi t t ngt m cc gn quay.- m bm tm c th xut hin sau vi ngy, phn tr c trn cnh tay.- au kt hp vi hn ch vn ng r, mt ng tc dng ch ng ca cnh tay(du hiu ca t gn trn gai) lun lun kt hp vi t gn di gai lm mt ngtc xoay ngoi ch ng ca cnh tay.- au bin mt mt cch t pht hoc do iu tr , nhng khng phc hi c kh nng vn ng. iu ny loi tr kh nng gim vn ng l do au.

2. Th c th - Cc du hin thn kinh bnh thng c th loi tr lit thc s.- Mt ng tc nng vai ch ng, trong khi vn ng th ng hon ton bnhthng. y l du khch quan r t gi .- Tr ng hp t gn phn di c nh u, khm thy t gn c phn tr cdi cnh tay, khi gp cng tay c i khng.3. Xquang

- Trn phim chp khp vai c c th c du gin tip ca khp vai ngi gi.


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- Chp khp vai ct lp vi thuc cn quang chng t c s t m cc gn c quay, do thy c hnh nh cn quang thng thng gia khoang khp v tithanh mc di mm cng - c delta.- Chp scanner khp c th thy c cc t thng km theo.

IV. CNG KHP VAIBiu hin ca co tht bao khp (vim bao khp co tht), bao khp dy lm gim vnng khp cho - cnh tay.S co cng ny ca bao khp l do r i lon thn kinh dinh dng lan to, lin quann c xng, c, mch mu v da to nn bnh cnh au do lon dng thn kinhphn x chi trn.1. Nguyn nhn

Thng gp sau 40 tui, ngi c cng thng thn kinh:- Tn thng do chn thng khp vai, bt ng b bt ko di.- Nhi mu c tim,au tht ngc nng, vim mng ngoi tim.- Lao phi, ung th phi.- Lit na ngi, bnh Parkinson, u no.- au thn kinh c - cnh tay, Zona c - cnh tay.- Cng gip, i tho ng, goutte.- Thuc: Phenobarbital, INH, Ethionamide, khng gip tng hp, Iode131.- Cng khp vai i khi kt hp vi au do lon dng bn tay: au, ph, bin i

da vi tng xut huyt, cng khp v c to nn hi chng vai tay.2. Tri u ch ng2.1. C nng- Khi u au vai kiu c hc, c thi tng v m.- Dn dn trong vi tun, au gim dn trong khi vai cng li ch yu l ng tcdng cnh tay v quay ngoi.2.2. Thc th - Hn ch vn ng ca khp vai, c ch ng v th ng.

- Hn ch mi ng tc nhng r hn c l dng v quay ngoi.- Nu c gng vn ng, s cm thy mt sc cn c hc v gy au, cc ng tccn c th lm c l nh vai tr ca din tr c b vai - lng ngc.- C th thy im au tr c hoc di mm cng vai nhng khng c duvim.2.3. Xquang- Phim chp thng: Bnh thng hoc thy long xng, khe khp cho - cnhtay bnh thng.- Chp khp vi thuc cn quang: s cho thy hp khoang khp:+ Ch cn 5-10ml trong khi bnh thng l 30- 35ml.


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+ Gim cn quang khp, cc ti cng mng hot dch bin mt.V. IU TR 1. i u tr au kh p vai n thu n- Khi t nhin sau vi tun n vi thng, c th ti pht- C th thc y nhanh qu trnh khi bnh nh iu tr :+ Ch yu nh tim corticoid ti ch: tim vo di mm cng vai ngoii vi gnc trn gai, ti a l 3 ln cch nhau 15 ngy.+ Cho thuc gim au, c th dng thuc chng vim nonsteroid.+ Cho gn b tn thng ngh ngi, c th kt hp vt l tr liu n gin nh sngngn, siu m.- Tin trin c th xu chuyn thnh au vai cp, thm ch cng khp vai. c bit khi triu chng au tn ti ko di, mc d tim ti ch, cn phi nghing c t m cc gn c quay ngn, r t thng gp v mt gii phu, sau 50 tui,tn thng tng dn dn. iu ny gii thch c im t nhin l ngho triuchng, khc hn vi bnh cnh ca gi lit khp vai, c cc du hiu t gn rrng, t ngt v mi xy ra.S t m ny thng c xc nh nh chp khp cn quang, v nu c th c chng minh khi lm th thut ngoi khoa khu li.- Khi khngiu tr , gn b thoi ho tng dn, dn n khp vai tui gi (hoc tm gn cc c quay ngn do gi) c c tr ng bi: ngoi au khi vn ng vaphi v khng hng nh, cn c hn ch vn ng khi nng cnh tay ch ng.

2. i u tr gi li t kh p vai:2.1. t m cc gn c quay2.1.1. ngi tr t m t thnh vn iu tr ngoi khoa: khu li ch t.2.1.2. ngi ln tuiCh nh ngoi khoa r t t nh, do tn thng thoi ho cc gn ln c n. Cho nn

tr c ht phi iu tr ni khoa, bao gm:- Tm thi bt ng tay t th dng.

- Cho thuc gim au v chng vim nonsteroid, c gng trnh tim corticoid ti ch n mc c th, v s lm hoi t gn tng ln.- Phc hi chc nng: vn ng liu php tch cc, nhit tr liu. iu tr ngoi khoac th c ch nh khi iu tr ni khoa tht bi.2.2. t gn b di c nh uKhng c ch nh ngoi khoa tr tr ng hp c bit.3. i u tr c ng kh p vai3.1. Thng t khi sau 1 - 2 nm

3.2. Qu trnh ny c th c rt ngn nh iu tr .- iu tr thuc gim au v chng vim nonsteroid


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- L liu php khi bt u ht au: vn ng th ng nh nhng kt hp vn ch ng.- iu tr au do lon dng: Bta bloquant, calcitonine, griseofulvine t hiu qu.3.3. iu tr ngoi khoa

Ct bao khp


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BNH A U T Y XNGMc tiu1. M t c nh ngh a v cc yu t dch t.

2. Trnh by c cc triu chng lm sng v cn lm sng3. M t c chn on xc nh, chn on phn bit v chn on giai onbnh.4. Trnh by c cc phng tin iu tr gc v cc bin php iu tr khc.5. M t c cc yu t nh gi tin trin v tin lngNi dungI. I CNG1. nh ngh a

a u tu xng l mt bnh tng sinh c tnh cht c tnh ca tng bo(plasmocyte) ty xng v mt s c quan khc.Tng sinh tng bo dn n:

- Tng cc globulin min dch trong mu.- To thnh nhiu tiu xng dn n gy xng bnh l.- Ri lon chc nng nhiu c quan: suy thn, thiu mu, tng canxi mu, cc triuchng thn kinh...2. D ch t

- T l mc bnh khong 3 - 4/100.000 dn; 1 - 2% cc bnh c tnh.- Tui thng gp: > 40 ; nam > n.- Ngi da en gp 2 ln ngi da tr ng v tui khi bnh sm hn.- Nguyn nhn v bnh sinh vn cn cha r. Tuy nhin, nghin cu v dch t hccho thy r ng liu thp phng x lm tng t l mc bnh.II. TRIU CHNGDo ngun gc v chc nng, tng bo c mt hu ht cc c quan, b phntrong c th, do khi tng sinh c tnh s biu hin triu chng nhiu ni. Bnhthng bt u t t tng dn triu chng tn mn nn d nhm vi cc bnh khc:suy sp ton thn, biu hin xng, thn, mu, thn kinh...1. Bi u hi n x ng1.1. Lm sng- au xng (90%): v tr thng gp l vng ct sng, chu hng, lng ngc, autng khi vn ng v gim khi ngh ngi, v sau au lin tc, c khi thy au theokiu p r thn kinh.- Gy xng t nhin (50%): gy xng sn, xng n, xng c, ln v di lcht sng gy g vo ct sng. Thng c pht hin qua chp Xquang.


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- U xng: 10% bnh nhn c du hiu ny; u mm khng au ni trn nn xng,ng knh t 0,5cm n 2cm; thng thy cc v tr nh xng s, xng n,xng c, xng b vai, ct sng... t thy cc xng chn tay.1.2. X Quang

- Tiu xng hnh hc, hang: trn xng s, xng sn, xng chu ctsng... cc hc hnh trn hay bu dc, ranh gii r, kch thc t vi mm n vi cm,trng nh xng b r ng.

- Tiu xng mt on hay mt phn xng di.- Khi cc hc xng nh v dy c to nn hnh nh long xng lan ta.- Thn cc t sng bin dng (lm, dt, hnh li), c th di lch gy nn g

vo.Hin nay c th dng phng php chp phng x nhp nhy, chp ct lp t

tr ng, chp cng hng t pht hin sm tn thng.

2. Bi u hi n ngoi x ng2.1. Ton thn: Gy st, mt mi, chn n, da xanh, st dai dng ko di.2.2. Thn: Tn thng thn gp trong 70% tr ng hp.- Protein niu thng l protein nhit tn (chui nh: Bence Jones), ng vn nhit 560C v tan khi si.- Suy thn mn.- V niu: xut hin t ngt do globulin tng nhiu v nhanh trong mu gy bt tcng thn.

2.3. Mu: thiu mu, xut huyt do gim tiu cu.2.4. Thn kinh: do cc khi u chn p tr c tip hay do cc globulin min dch gy tnthng.

- p ty v r thn kinh.- Tn thng cc dy thn kinh s no.- Vima dy thn kinh.- Tng p lc ni s.- Tn thng y mt.

2.5. Cn tng canxi mu- L , mt mi, tr m cm, d nhm ln.- Nn, r i lon nc v in gii, r i lon tri gic, hn m.

2.6. Cc biu hin khc- D nhim khun bi nhim.- Gan, lch, hch to.- Ri lon tiu ha.

- Thm nhim m phi (do plasmocyte).- Nhim Amyloid mt s b phn.


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III. NHNG THAY I V HUYT HC V SINH HA1. T ng sinh t ng bo (plasmocyte)

- Chc d: cc u xng ni trn da hoc cc vng c tiu xng (trn Xquang)xt nghim t bo s thy r t nhiu tng bo.

- Ty : tng bo tng cao > 15% (bnh thng < 5%). Trong mu ngoibin t khi thy tng bo tng.

V hnh thi, cc tng bo ny c th bnh thng, c th to nh khng u,nhn c nhiu ht...2. T ng gama globulin n dngDo cc tng bo bnh l tit ra, ch yu l IgG, IgA, t thy IgD v IgE, Tng gamaglobulinc th hin bng:

- Tc lng mu tng cao (tng kt dnh hng cu).

- Protid mu tng nhiu.- in di protein huyt thanh thy gama globulin tng nhiu.- in di min dch: tng 1 trong cc loi gama globulin min dch: IgG, IgA,

IgD, IgE...- Nc tiu: 50% c protein Bence Jones.

3. Cc xt nghi m khc

- Calci mu tng (> 105mg/l) l hu qu ca tiu xng nhiu, lan r ng.- Hng cu v tiu cu gim trong mu.

- Chc nng thn gim.IV. CHN ON1. Ch n on xc nh: Da vo

- Lm sng: au xng, u xng.- Xquang: tiu xng hnh hc, long xng lan ta.- Plasmocyte tng: chc d khi u, ty .- Xt nghim protid mu,in di, nc tiu.

2. Ch n on phn bi t- Cc u xng do di cn ung th.- Cc bnh gy tiu xng v long xng: cng cn gip, long xng sau

mn kinh, long xng nguyn pht.- Cc bnh mu c biu hin xng.

3. Cc th bnh

- Th mt vi lan ta ging long xng (Livre v Weissenbach).- Th khng ch v khng tit gama globulin, ch c hnh nh Xquang, khng c

thay i th dch.- Th mt u n c.


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- Cyclophosphamide 200 mg/m2/ngyPhi hp vi Prednisolon 25-60 mg/m2/ngy. Mi t 4 - 7 ngy, cch nhau 4 -

6 tun.Sau c th dng bng ng ung vi liu

Melphalan: 1 - 3 mg/ngyCyclophosphamide: 1 - 2mg/kg/ngyPrednisolone: 1mg/kg/ngyDng tng t 1 - 4 tun.Thi gian iu tr ko di 1 - 2nm. Theo di cht ch v lm sng v xt

nghim iu ch nh thuc.1.2. C th dng liu cao steroid n thun truyn t nh mch

. 200mg Prednisolone cch ngy

. Hoc Methylprednisolone 1g/m2/ngy x 5 ngy1.3. C th dng ha tr liu phi hp xen k

. Vincristin 0,4 mg/ngy x 4 ngy

. Tip: Doxorubicin 9mg/m2/ngy x 4 ngy

. Tip Dexamethason 40mg/ngy x 4 ngy.2. i u tr khc2.1. Chiu x vi th khu tr, tin trin chm, u ngoi ty xng

2.2. Phu thut: th u n c, gii phng chn p2.3. Cc iu tr triu chng phi hp

- Truyn mu- Khng sinh- Lc mu- Calcitonin- Li tiu...

VI. TIN TRIN V TIN LNG15% cht trong 3 thng, 15% cht trong 1 nm, s cn li din bin mn tnh t

2 - 5 nm.Nguyn nhn cht: - Suy thn

- Nhim trng huyt- S lan r ng ca khi u- Nhi mu c tim, bnh phi mn tnh- i ng, t qu


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LUPT BAN H THNGMc tiu1. M t c nh ngh a, yu t dch t

2. Trnh by c nguyn nhn v c ch sinh bnh.3. M t c triu chng lm sng v xt nghim4. Trnh by c tiu chun chn on xc nh v chn on phn bit.5. Trnh by c bin php iu tr bnh luptNi dungI. I CNG1. nh ngh a: L bnh c t l cao nht trong nhm bnh to keo (60%) biu hinvim lan ta hay r i rc t chc lin kt, nguyn nhn do t min.

2. D ch t - Bnh gp ch yu ph n tr , t l n/nam: 8/1.- T l mc bnh cao nht la tui 20 - 40.- Ngi da en c t l bnh v t l t vong cao gp 3 ln da tr ng, t l bnh caotheo th t: da en, Chu , da tr ng.II. NGUYN NHN V C CH BNH SINHNgy nay c xem l bnh t min trn 1 c a c bit.1. B ng ch ng v t mi n

- Trong th dch bnh nhn c nhiu t khng th: khng th khng nhn, khng th khng acid nhn (AND, ARN), khng cc huyt cu (hng cu, bch cu, tiu cu).Lng b th gim r r t trong mu (CH50, C3, C4), phn ng BW dng tnh gi,pht hin cc phc hp min dch trong mu v t chc.- T l Limpho B v T thayi trong mu.- C th gy bnh trn sc vt bng phng php min dch.- iu tr cc thuc c ch min dch c kt qu.2. Y u t c a

- Ph n, tr tui.- HLA-DR3 cao hn hn so vi ngi bnh thng.- Mt s tr ng hp c tnh cht gia nh.3. Y u t nguyn nhn

Nguyn nhn tr c tip gy bnh cha bit r. Tuy nhin c mt s yu t sau:- Mt s thuc c th gy bnh Lupt: Hydralazine, dihydralazine, procainamide,

Acbutolol, D pnicillamine, quinidine, Isoniazide, chlorpromazine, sulfasalazine,minocycline, carbamazpine, interfenon v .

- Cc sn phm k ngh: Formaldhyde, isocyanate v anhydride phtalique.


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- Cc cht cytokine nh interfon, yu t kch thch sinh bch cu ht, cc khng th dng trong lm sng nh anti TNF.- Tc nhn nhim trng: nh parvovirus B19.4. Nh ng xu h ng m i v nguyn nhn b nh sinh c a Lupt

4.1. Xc nh nhng gen c th dn ti bnh ny- Gen C4A lin quann biu hin bnh Lupt.- Thiu ht on Fc YRIIa - H131 lin quann vim thn Lupt.4.2. Bt thng trong t bo T hoc TCR- T bo T bnh nhn Lupt thiu men proteinkinase A (PKA).- S bin i protein t bo theo kiu phosphoryl ha c th lm bin i s hngnh ni mi v thm ch lm r i lon chc nng min dch.4.3. Hot ng qu mc ca t bo B v sn sinh t khng th l t tr ng ca bnhLupt- S tin trin ca Lupt lin quan n tng sn phm interlenkin 10.- Tng Apoptosis tham gia vo s pht trin ca vic gim t bo v gii phng ccthnh phn ca nhn t bo, nhng cht c th kch thch h thng min dch snsinh ra t khng th.III. TRIU CHNG1. Lm sng: Trn lm sng ch yu gp th bn cp.1.1. Khi pht

- a s bt u t t, tng dn: st dai dng khng r nguyn nhn, au khp hocvim khp ging nh VKDT.- Mt s tr ng hp khi pht nhanh, cc triu chng y ngay giai on u.- C khi bnh xut hin sau nhng nguyn nhn thun li: nhim trng, chnthng, Stress, dng cc thu c c th gy Lupt.1.2. Ton pht: Tn thng nhiu c quan.- Ton thn: st dai dng ko di, mt mi, gy st.- C xng khp: au, vim, bin dng khp, lon dng c, hoi t xng.

- Da nim mc: ban hnh cnh bm mt, ban dng a ngoi da, xm da donng, lot nim mc ming, mi, r ng tc, vim mao mch di da.- Mu v c quan to mu: thiu mu ko di, chy mu di da, lch to, hch to.- Thn kinh tm thn: r i lon tm thn, ng kinh.- Tun hon, h hp: trn dch mng tim, mng phi, vim c tim, vim ni tm mc,hi chng Raynaud, vim phi k, vim tc ng mch, t nh mch.- Thn, gan: protein niu, t bo tr niu, c tr ng, r i lon chc nng gan.- Mt: tc tuyn l (hi chng Sjogren) vim kt mc, vim vng mc.

2. Xt nghi m2.1. Cc xt nghim khng c hiu


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- Cng thc mu: gim cc dng huyt cu mt phn hay ton th, gim ngoi ty:+ Hng cu gim (thng thng l thiu mu huyt tn) 65%+ Bch cu gim, ch yu l a nhn trung tnh 32%+ Tiu cu gim 10%- Tc lng mu tng cao 92%, si huyt tng 45%- in di huyt thanh: Globulin tng 86%- Tm thy phc hp min dch trong mu.- Phn ng BW (+).2.2. Cc xt nghim c hiu2.2.1. T bo Hargraves (LE): l nhng bch cu a nhn thc bo nhng mnhnhn ca t bo khc b tiu hy do khng th khng nhn xut hin trong bnhLupt.Ngi ta thng tnh t l % ca t bo LE so vi tng s bch cu trong mu. T l 5% th c gi tr chn on. Trong Lupt 60% - 90% c t bo LE.2.2.2. Tm cc khng th th dch- KT khng nhn:c xem l dng tnh khi pha long huyt thanh > 1/32.- KT khng DNA r t c hiu trong bnh Lupt.- KT chng li cc khng nguyn nhn ha tan: KT khng Sm (+) trong 50%.- KT khng hng cu, khng Limpho bo, khng tiu cu.- B th gim trong mu.- Gim t l Lympho bo so vi t bo B.2.3. Sinh thit- Sinh thit da: lng ng globulin min dch: IgM, IgG v b th thnh mt lp giathng b v trung b ca da (+ 70%).- Thn: vim cu thn, dy mng y do lng ng IgG, IgM v b th.- Mng hot dch khp: tn thng gn ging vim khp dng thp.IV. TIN TRIN: Ty thuc th bnh

1. Th c p: Tn thng nhiu ni tng v nng, tin trin nhanh v t vong sau vithng do cc thng tn thn, thn kinh, phi nhim khun.2. Th mn: t tn thng ni tng, biu hin ngoi da nh, tin trin chm, tinlng tt.3. Th bn c p: Tin trin tng t, ngy cng nng dn. Bnh nng thm nu cthai, nhim khun, chn thng, phu thut, Stress, lm dng thuc. Thng t vong v cc bin chng thn, thn kinh, nhim khun. Thi gian sng trung bnh 5- 10 nm.4. H i ch ng Sharp: l th bnh hn hp gia Lupt v x cng b, c cc du vima khp, hi chng Raynaud, ngn tay sng to hnh khc di ln, x hp thc qun,vim a c. Do t biu hin ni tng nn tin lng tt hn v nhy cm vi Steroid.


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V. CHN ON1. Ch n on xc nh: Da vo 11 tiu chun ca hi thp hc M, c ci tin nm1997, chn on xc nh khi c t nht 4 tiu chun:- Ban hnh cnh bm mt.- Ban dng a mt, thn.- Xm da do nng.- Lot ming hoc mi hu.- Vima khp.- Vim mng tim hoc mng phi.- Tn thng thn: Protein niu > 0,5g/24 gi hoc tr niu.- Tn thng thn kinh: co git hoc lon thn.

- Ri lon v mu:+ Thiu mu tan mu (tng hng cu li); Bch cu < 4000/mm3.+ Limpho < 1500/mm3 hoc tiu cu < 100.000/mm3.- Ri lon min dch: trong mu c+ Khng th khng ADN hoc khng th khng Sm.+ Nng bt thng ca IgG hoc IgM anti - Cardiolipine, hoc hin din yu t chng ng lu hnh (anticoagulant circulant).- Khng th khng nhn (+).

2. Ch n on phn bi t- Thp khp cp.- Vim khp dng thp.- Bnh trong nhm to keo: x cng b, vim a c, vim nt quanh ng mch.- Vi cc th c bit ca Lupt cn phn bit vi cc bnh c triu chng tng t:xut huyt gim tiu cu, vim cu thn, hi chng thn h. Vim mng tim mngphi do nguyn nhn khc.3. Th c t Vi t Nam : khi c 5 yu t sau y xut hin trn 1 bnh nhn n, tr tui th c hng chn on Lupt- St dai dng ko di khng tm thy nguyn nhn.- Vim nhiu khp.- Ban hnh cnh bm mt.- Protein niu.- Tc lng mu cao.VI. IU TR Chung cho mi tr ng hp Lupt: Gio dc bnh nhn trnh nhng iu c hi nh

thuc l, trnh nh nng mt tr i tr c tip hoc gin tip, k hoch ha gia nh,trnh lm dng thuc.


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