Bai 10 tiep can lam sang huong van de suc khoe danh cho lam sang
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Bai 10 tiep can lam sang huong van de suc khoe danh cho lam sang
- 1. Tiếp cận lâm sàng hướng vấn đề sức khỏe ♦Võ Thành Liêm - YHGĐ
- 2. Đề mục ♦ Trường hợp lâm sàng ♦ Vấn đề thực hành ♦ Tiếp cận lâm sàng hướng vấn đề: giải pháp ♦ Ví dụ ứng dụng lâm sàng ♦ Bài tập
- 3. Tình huống lâm sàng ♦ BN nữ 24 tuổi, đến khám vì nhức đầu ♦ Nhức đầu từng cơn, nữa bên đầu, đập theo nhịp mạch, từ 1 tuần nay, không nôn ói. ♦ Khám: chưa ghi nhận bất thường. ♦ Chẩn đoán ? ♦ Mức độ nguy hiểm? ♦ Xử trí? ♦ Theo dõi?
- 4. Tình huống lâm sàng ♦ BN nam 68 tuổi, đến khám vì nhức đầu ♦ Nhức nữa bên đầu, tăng dần từ hơn 3 tháng nay, uống thuốc nhiều nơi không đõ, không nôn ói. ♦ Khám: chưa ghi nhận bất thường. ♦ Chẩn đoán ? ♦ Mức độ nguy hiểm? ♦ Xử trí? ♦ Theo dõi?
- 5. Tình huống lâm sàng ♦ BN nữ 60 tuổi, đến khám vì nhức đầu ♦ Cách nay 4 ngày, BN có bị té xe, sau té vẫn tỉnh với vết thương da đầu. ♦ Khám: chưa ghi nhận bất thường. ♦ Chẩn đoán ? ♦ Mức độ nguy hiểm? ♦ Xử trí? ♦ Theo dõi?
- 6. Tình huống lâm sàng ♦ BN nam 15 tuổi, đến khám vì nhức đầu ♦ Đau đầu, sốt nhẹ. ♦ Cách nay 3 ngày có đau họng, ♦ Khám: chưa ghi nhận bất thường. ♦ Chẩn đoán ? ♦ Mức độ nguy hiểm? ♦ Xử trí? ♦ Theo dõi?
- 7. Tình huống lâm sàng
- 8. Tình huống lâm sàng
- 9. Tình huống lâm sàng
- 10. Tình huống lâm sàng Cần cách tiếp cận phù hợpCần cách tiếp cận phù hợp
- 11. Tình huống lâm sàng ♦ BN nữ 45 tuổi, khám vì CƯỜNG GIÁP BASEDOW ♦ Chẩn đoán bởi BS ABC ♦ Cần làm XN nào? ♦ Điều trị như thế nào? ♦ Theo dõi ra sao? ♦ Nếu dùng thuốc thì liều khởi đầu như thế nào?
- 12. Tình huống lâm sàng ♦ BN nữ 45 tuổi, khám vì CƯỜNG GIÁP BASEDOW ♦ Chẩn đoán bởi BS ABC ♦ Cần làm XN nào? ♦ Điều trị như thế nào? ♦ Theo dõi ra sao? ♦ Nếu dùng thuốc thì liều khởi đầu như thế nào? Cần cách tiếp cận phù hợpCần cách tiếp cận phù hợp
- 13. Vấn đề thực hành ♦ Mô hình bệnh tật nội trú ICD10ICD10 Tiêu hóaTiêu hóa ICPC2ICPC2 Tim mạchTim mạch Cơ xươngCơ xương KhớpKhớp Hô hấpHô hấp Tổng quátTổng quát
- 14. Vấn đề thực hành Tên mã ICPC ICPC2 N %$ % cộng dồn# Tăng huyết áp không biến chứng K86 126 11.15 11.15 Sốt A03 89 7.88 19.03 Cúm (viêm hô hấp siêu vi) R80 78 6.90 25.93 Nhiễm trùng đường hô hấp trên R74 60 5.31 31.24 Triệu chứng -phàn nàn về khớp khác L20 46 4.07 35.31 Triệu chứng - phàn nàn về thắc lưng L03 39 3.45 38.76 Đau thượng vị D02 36 3.19 41.95 Triệu chứng phàn nàn về đầu gối L15 36 3.19 45.13 Viêm xoang cấp/mãn R75 32 2.83 47.96 Viêm các tuyến bạch huyết cấp vùng họng R76 31 2.74 50.71 Triệu chứngTriệu chứng
- 15. Vấn đề thực hành Các VĐSK thường gặp: Tập trung: 9 mã/50% VĐSK 50 mã/80% VĐSK 10 VĐSK đầu: 5 than phiền-triệu chứng, 4 bệnh cấp tính, 1 bệnh mãn tính Đa phần đơn giản, điều trị ngoại trú Y tế tuyến ban đầu: gate- keeping
- 16. Vấn đề thực hành
- 17. Vấn đề thực hành
- 18. Tiếp cận lâm sàng hướng vấn đề SK ♦ Mức độ 1: – Tiếp cận chẩn đoán cho phù hợp. ♦ Mức độ 2: – Hướng xử trí, cách điều trị, theo dõi tương ứng với mỗi bước. ♦ Mức độ 3: – Phối hợp giữa các nhân viên y tế – Phối hợp giữa các chuyên khoa.
- 19. Ứng dụng tình huống lâm sàng ♦ BN nam 56 tuổi, đến khám vì mệt ♦ Tiền căn suy thận, cao huyết áp, thiếu máu ♦ CTM – Hb 10,8g/dl – Hct 29,2% – Thanh thải cầu thận 22ml/phút – THIẾU MÁU?
- 20. Ứng dụng tình huống lâm sàng ♦ BN nam 24 tuổi, đến khám vì mệt ♦ Tiền căn nhập viện nhiều lần vì thiếu máu ♦ CTM – Hb 5,5g/dl (6 – 7 g/dl) – MCV: 64,5 – ferritin, 9 ng/mL (khoảng bình thường, 29-336 ng/mL); – THIẾU MÁU?
- 21. Ứng dụng tình huống lâm sàng ♦ BN nam 24 tuổi, đến khám vì mệt ♦ Tiền căn nhập viện nhiều lần vì thiếu máu ♦ CTM – Hb 5,5g/dl (6 – 7 g/dl) – MCV: 64,5 – ferritin, 620 ng/mL (khoảng bình thường, 29-336 ng/mL); – THIẾU MÁU?
- 22. Ứng dụng tình huống lâm sàng ♦ BN nam 59 tuổi, đến khám vì đau lưng 6 tháng ♦ Xq: xẹp lún các đốt sống thắc lưng ♦ CTM – Hb 9,2g/dl – MCV: 93 – THIẾU MÁU?
- 23. Bài tập thực hành ♦ Xây dựng lược đồ tiếp cận lâm sàng/vấn đề SK ♦ Tự chọn nội dung theo ICPC2
Editor's Notes
- HT is a 56-year-old woman with previously diagnosed long-term type 2 diabetes and subsequently diagnosed chronic kidney disease (CKD), hypertension, and anemia. She is in the office for a periodic follow-up and has been compliant with her medications for hypertension, diabetes, and hypercholesterolemia. She denies cardiovascular (CV) symptoms, including angina or dyspnea during exertion. Home measurements indicate that her blood pressure is well controlled. She has been postmenopausal for 5 years and reports no orthostatic hypotension, gastrointestinal (GI) bleeding, or melena. She had a normal colonoscopy 4 years ago. She reports recurring fatigue during the past 3 months that has made it increasingly difficult to perform her work as a sales clerk. Her hemoglobin (Hb) values have slowly declined from 10.8 g/dL a year ago to 9.5 g/dL despite treatment with an oral iron supplement for 6 months, which was discontinued 2 months ago. Other laboratory values are as follows: sodium, 142 mmol/L; potassium, 4.8 mmol/L; carbon dioxide (CO2), 24 mmol/L; blood urea nitrogen (BUN), 48 mg/dL; creatinine, 3.1 mg/dL; estimated glomerular filtration rate (eGFR), 22 mL/min; white blood cell (WBC), 5.2 million/µL; hematocrit, 29.2%; and platelets, 185,000/µL. Bệnh nhân bị thiếu máu do giảm tăng sinh tủy, nguyên nhân do suy thận
- A 24-year-old Caribbean man who is currently incarcerated presents with symptomatic anemia. He is primarily complaining of exertional dyspnea, generalized fatigue, and some mild chronic nausea. He has no known history of hematemesis, melena, rectal bleeding, or hemoptysis. His family history is significant for sickle cell anemia in both his grandmother and sister. His medical history is limited to asthma controlled with salbutamol and beclomethasone inhalers and to previous admissions for symptomatic idiopathic anemia, for which he has been maintained on iron supplementation. He is a nonsmoker and does not drink alcohol. He has no history of nonsteroidal anti-inflammatory drug (NSAID) or aspirin use. He enjoys a varied, nonvegetarian diet. On physical examination, the patient appears to be well, although he does exhibit significant conjunctival pallor. His pulse is regular at 88 bpm and his blood pressure is 110/64 mm Hg. No lymphadenopathy, jaundice, clubbing, or edema is noted. A soft, pansystolic murmur is detected over the tricuspid and aortic valves, without any stigmata of endocarditis. The respiratory examination is unremarkable. No masses, tenderness, or hepatosplenomegaly are noted on the abdominal examination. A rectal examination reveals no masses, gross blood, or melena. The stool is brown and heme-negative. He has had multiple admissions within the past 5 years for symptomatic anemia, all with similar presentations. Each time, he was noted to have iron-deficiency anemia, with a hemoglobin count between 6 g/dL and 7 g/dL (3.72-4.34 mmol/L), as well as low mean corpuscular volume and low serum ferritin. He has never had documented episodes of gastrointestinal (GI) or extragastrointestinal blood loss. He has complained intermittently of nausea but has not had any vomiting. Numerous investigative procedures were completed during these previous admissions; the findings of these procedures included normal endoscopic findings (however, no D2 biopsies were taken) and negative tissue transglutaminase, with normal levels of immunoglobulin A (IgA). Autoantibodies (antinuclear antibody [ANA], antineutrophil cytoplasmic autoantibodies [ANCA], double-stranded DNA [dsDNA], and small nuclear ribonucleoprotein-Sm [anti-Sm]) were all negative. A direct Coombs test was also negative. Additionally, hemoglobin electrophoresis was normal, eliminating the possibility of sickle cell disease. During the current admission, another series of tests is performed. The results are reported as follows: hemoglobin count, 6.5 g/dL (4.03 mmol/L); mean corpuscular volume, 64.5 μm3 (64.5 fL); white blood cell count 4.2 × 103/μL (4.2 × 109/L); platelets, 405 × 103/μL (405 × 109/L); neutrophils, 1.6 × 109 cells/L (normal range, 2-2.5 × 109 cells/L); lymphocytes, 2.1 × 109 cells/L (normal range, 1.5-4 × 109 cells/L); eosinophils, 1.0 × 109 cells/L (normal range, 0-0.5 × 109 cells/L); ferritin, 9 ng/mL (9 μg/L; normal range, 29-336 ng/mL); and C-reactive protein (CRP), <5 mg/L. The tests for autoantibodies (immunoglobulin), celiac serology, liver function, hemoglobin electrophoresis, vitamin B12, and folate all return normal results. Colonoscopy is performed, and it is normal to the terminal ileum, with no underlying cause of anemia established. The patient undergoes a repeat endoscopy (having already had a normal endoscopy 1 year earlier). The appearance of the esophagus and duodenum is unremarkable. Patches of the gastric mucosa however, have an odd, nodular appearance (Figure 1). The area is biopsied; the histology is shown here (Figure 2).
- A 24-year-old Caribbean man who is currently incarcerated presents with symptomatic anemia. He is primarily complaining of exertional dyspnea, generalized fatigue, and some mild chronic nausea. He has no known history of hematemesis, melena, rectal bleeding, or hemoptysis. His family history is significant for sickle cell anemia in both his grandmother and sister. His medical history is limited to asthma controlled with salbutamol and beclomethasone inhalers and to previous admissions for symptomatic idiopathic anemia, for which he has been maintained on iron supplementation. He is a nonsmoker and does not drink alcohol. He has no history of nonsteroidal anti-inflammatory drug (NSAID) or aspirin use. He enjoys a varied, nonvegetarian diet. On physical examination, the patient appears to be well, although he does exhibit significant conjunctival pallor. His pulse is regular at 88 bpm and his blood pressure is 110/64 mm Hg. No lymphadenopathy, jaundice, clubbing, or edema is noted. A soft, pansystolic murmur is detected over the tricuspid and aortic valves, without any stigmata of endocarditis. The respiratory examination is unremarkable. No masses, tenderness, or hepatosplenomegaly are noted on the abdominal examination. A rectal examination reveals no masses, gross blood, or melena. The stool is brown and heme-negative. He has had multiple admissions within the past 5 years for symptomatic anemia, all with similar presentations. Each time, he was noted to have iron-deficiency anemia, with a hemoglobin count between 6 g/dL and 7 g/dL (3.72-4.34 mmol/L), as well as low mean corpuscular volume and low serum ferritin. He has never had documented episodes of gastrointestinal (GI) or extragastrointestinal blood loss. He has complained intermittently of nausea but has not had any vomiting. Numerous investigative procedures were completed during these previous admissions; the findings of these procedures included normal endoscopic findings (however, no D2 biopsies were taken) and negative tissue transglutaminase, with normal levels of immunoglobulin A (IgA). Autoantibodies (antinuclear antibody [ANA], antineutrophil cytoplasmic autoantibodies [ANCA], double-stranded DNA [dsDNA], and small nuclear ribonucleoprotein-Sm [anti-Sm]) were all negative. A direct Coombs test was also negative. Additionally, hemoglobin electrophoresis was normal, eliminating the possibility of sickle cell disease. During the current admission, another series of tests is performed. The results are reported as follows: hemoglobin count, 6.5 g/dL (4.03 mmol/L); mean corpuscular volume, 64.5 μm3 (64.5 fL); white blood cell count 4.2 × 103/μL (4.2 × 109/L); platelets, 405 × 103/μL (405 × 109/L); neutrophils, 1.6 × 109 cells/L (normal range, 2-2.5 × 109 cells/L); lymphocytes, 2.1 × 109 cells/L (normal range, 1.5-4 × 109 cells/L); eosinophils, 1.0 × 109 cells/L (normal range, 0-0.5 × 109 cells/L); ferritin, 9 ng/mL (9 μg/L; normal range, 29-336 ng/mL); and C-reactive protein (CRP), <5 mg/L. The tests for autoantibodies (immunoglobulin), celiac serology, liver function, hemoglobin electrophoresis, vitamin B12, and folate all return normal results. Colonoscopy is performed, and it is normal to the terminal ileum, with no underlying cause of anemia established. The patient undergoes a repeat endoscopy (having already had a normal endoscopy 1 year earlier). The appearance of the esophagus and duodenum is unremarkable. Patches of the gastric mucosa however, have an odd, nodular appearance (Figure 1). The area is biopsied; the histology is shown here (Figure 2).
- A 59-year-old white man presents to his primary care physician complaining of back discomfort for the past 6 months. Except for the back pain, the patient has been in good overall health without any major medical problems. The physician refers the patient for radiographic examination, which reveals compression fractures at multiple levels. Laboratory evaluation including a complete blood cell count with differential reveals a hemoglobin level of 9.2 g/dL, a white blood cell count of 4.1, and a platelet count of 150,000 with a normal differential. His mean corpuscle volume was normal at 93 fL (normal range: 80-96 fL). Results of a chemistry profile were unremarkable with normal renal function, normal liver enzymes, and a serum albumin of 3.6 g/dL (normal: 3.0-5.0 g/dL). The patient was referred to a hematologist/oncologist for further evaluation. This detailed workup revealed an immunoglobulin A (IgA) kappa monoclonal protein measured at 5 mg/dL. Urine immunofixation was positive for the presence of monoclonal kappa light chains, and the 24-hour urine showed 0.8 g/24 hours of monoclonal protein. Serum beta 2 microglobulin measured 4 mg/dL. A complete bone survey showed generalized osteopenia with multiple compression fractures. Additional workup for the anemia showed a negative stool fecal occult blood test, serum B12 level slightly decreased at 170 pg/mL (normal: 200-900 pg/mL), elevated methylmalonic acid at 320 mcmol/L (normal in this lab: < 270 mcmol/L), and normal serum creatine. Serum red blood cell folate was unremarkable with a normal homocysteine level. Serum ferritin was normal at 40 ng/mL (normal range: 12-300 ng/mL); however, the erythrocyte sedimentation rate was elevated at 100 mm/hr (normal: < 20 mm/hr). Bone marrow aspirate and biopsy were performed with the marrow showing hypercellularity at 50%, mild erythrodysplasia, and 40% mature monoclonal plasma cells that diffusely infiltrated the bone marrow. Bệnh nhân bị ung thư tủy gây hủy xương