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Khoa Truyn nhim Bnh vin Bch Mai
16.8.2013
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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
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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X-quang phi (16/4/2013)
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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
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X-quang phi
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Bnh nhn ra vin (2/5/2013)
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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
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Cp nht
THT BI IU TR V ST RT KHNG THUC
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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
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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
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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
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XIN TRN TRNG CM N !
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