Nội tiết cơ bản

"Nội tiết cơ bản 🔙 Quay lại trang tải sách pdf ebook Nội tiết cơ bản Ebooks Nhóm Zalo BQYTE B:¢NH VI:¢N B";'CH M.AI /' NOI TIET .. CO BAN. . ..-. .(GIAO TRiNH DAo T~O SAUD~ HQC) II Uft NOi - 2013 LOI GIOI THI¥U Trong ljch Sll hon 100 nam xay dung va phat tri8n, Benh vien Bach Mai luon 1:\ co sa dao tao Ion nhit cua Truong Dai hoc Y Ha NQi va ciing Ia dia chi tin c~y cua hang trieu nguoi dan Vi~t Nam khi ho din diroc cham s6c sue khoe. Cung d6, -Benh vien da ne; luc he;tro cac benh vien tuyen truce thong qua cong tac dao tao, chi dao tuyen, tang cuong can bQ y t~ v~ co 56 va d~c biet tri8n khai mo hinh binh vien v~tinh. Song song voi f)~an "Xay dung m9t s6 Benh vien v~ tinh cua Benh vien Bach Mai" dircc trien khai ru thang 8/2009 theo Quy~t dinh s6 27411QD-BYT ngay 3017/2009, Bq tnrong B9 Y t~ da giao cho Benh .vien.Bach mai nhiem vu Dao tao bac sl chuyen khoa cApI, cap II, NQi tru benh vien voi muc dich nang cao nang lire chuyen mon cho can b9 y t~ va tang cuong chAtIUQ'ngdich vu kham chua m(}teach ). .- ben vung. MQttrong cac muc tieu uu tien cua cong tac dito tao III chudn hoa heat d typ 2 tnroc day duoc goi Ia UTE> khong phu thuoc insulin, DTD (y ngiroi 1611.D~c tnrng cua DTD t)rp 2 1(\ khang insulin di kern voi thieu hut insulin tuong d6i. Trong phAn IOn thai gian bi benh, nhiing benh nhan DTD typ 2 khong cAh Insulin cho di8u tri sinh t6n. Can nguyen cua DTE>typ 2 con chua biSt r5. ...: 3.3. Cae loai DiD khac . tuu« h{ltdi truy~n chuc nang ti bao p. - Thi~u h{ltdl t,.uy~nvJ tdc i/png diu insulin. .. - Binh tuy~n tux ngo(litiAt:"viem tuy man, xo soi tuy chAn thuong tuy., . c~t tuY.toa~ bQ, un,g thu tuy xo nang tuy. . - BTl) thu' phat sau cac binh npi tiJt: benh to. dAu chi (Acromegaly), hQi ,clnrng Cushing, cuong giap,.. u tuy thtrong th~ .,..(Pheochromocytoma), u tS.bao tiSt glucagon ..~ ..,. l)iJ?; d,~t~~ac ho9c.hoa chltt:' Gluci chirng Down, ;. , " \' I ..' .' ',. '1 . . . . .Klinefelter, Turner, Wolfram, . ,j' I '.' • • ,:-' ' • I " .Dai.ihqo·:(/"',lrngth,aJ kY!~DTD · duoc phat .hi~n.l§n.qAu:tie~ trong .thai' i . ~ymang thai (loai tm. cac tnrong hop B,TD da duoc chAn doan tu truce khi co thai). . i , 4. LAM SANG Cac tri~u, chirng P4\1 thuoc vao rmrc ~Q. thi6.u:insulin, giai doan dAu thuong kho~gro,:rang.,Caetri~u clnrng lam sang xuAthi~n rAmfQ (y cac benh .,', " , nhan ~Tf) cyp I" cac benh nhan f).T~ typ 2 thuongduoc phat hi~n tinh cO' khi di kham benh hoac khi phai nh~p vien vi cac .bien clnmg cAp hoac man , , \', . . . tinh cua DTD. " .: ':' i' - M~t moi, gAy sut c6 the keo dai trong nhieu thang. - Dai nhi€u (donguyen nhan thAm thAu), gay khat va u6ng nhieu. Co th~ eo au ieu mat mroc. 'd" h'''' " , 2 - C6 the chan an (thuong 6 BTD typ 1 hoac khi eta c6 bien clnrng th§.n kinh tv' dQng cua h~ tieu hoa) hoac c6 cam giac doi nhieu, an nhieu (giai doan tang insulin mau 6 benh nhsn DTD cyp 2). - Da hay bi ngira va d~ hi. nhiem tnmg, lau li~n vet thuong, - Giam thi hrc, - Chuot rut vao ban dem, te bi chan tay. - Giam tlnh due, li~t duong, rai loankinh nguyet. . - dnguoi giaco tinh trang Ili ldn, chong mat, nga (do-mat nuoc). 5. XET NGHI~M - f)u'ltng huyit: co gia tri-nhat vi cho phep chAndoan xac dinh benh, - Duong ni?u: khong co gia tri chAn doan benh, - Lipide mau: cholesterol toan phAn, triglycerid, HDL-C va LDL-C.. . Benh nhanD'I'D thuongco tang triglicerid va giam HDL.;.C. HhA1c: danh gia tinh trang duong huy@ttrong 3thang gAnday. - Fruetosamin: cho biet duong huyettrungblnhtrongZ'tuan gAnday. - Peptld-C: duoc tao ra trong qua trinh chuyen pro insulin thanh insulin nen Ch0 phep danh 'gia chtrc nang t8 bao p tuy, Creatinin mau, ure ina". . I' ' Protein ni?u ho~c mlcroalbumin hifu. 6.CHAN 1l0AN ''', ,:, .. ' 6.1. ChAn GOan xac djnh . : .:. ". ";": , .. Tieu chuan:chan iloan DTD theo ADA (HifP hpi BTB My)' nam 2010: chan doan DTD khi co 1trong cae tieu chudn dum ddy: .' . 1. Duong huyet tuong .bAt ky 2: 11,lmmol/l kern theo cac tri~u clnrng cua tang duong huy@t(khat nhieu, ti~u nhisu, an nhieu,'g~y slit). 2. Duong huyet nrong luc d6i (nhin an > 8 gio) ~ 7 mmol/l trong 2 buoi sang khac nhau. 3. Duong huyet nrong 2 gic sau khi uang 75g glucose ~ 11,1 mmol/l. 4. HbAlc (dinh hrong b~ng phuong phap s~c ky long) ~ 6,5%. 3 Nghi?in phap tang tlU,(fnghuy;t (theo rJchuc Y TJ thJ gim) ., 'Di~ii ki~n ti~n hanh nghi~m phap . + Nhjn d6i'S - 14 gio (6 gia t5i 4 7'gia sang). + 3 ngay tnroc' khi iam nghiem phap: khAuphAn an giau carbonhydrat (150g - 20Dg/ngay). + Khong ti~n hanh nghiern phap khi dang bi h~nh c§!, tinh, suy dinh dirong, chAnthuong tamly, +, Khong tien. hanh .nghiem phap khi dang dung. thuoc: corticoid, thiazid, phenyltoin, thu6c ngira thai. .+ Khong.van d{>ngqua suc tnroc va'trong khi Iamnghiem phap, Chi djnh " ' + .R,6iJo~ndirong huyet hie d6i (duOng huyet ,d61> 5,6mmolll) + Duong huyet d6i binh thtrong kern cac yeu t6 nguy €o: ." : ,,~ Beo dang nam. , ., I. \,. . \" .. i:;'•• T~~nsir.giadinh.co nguo! bi DTD. :"*: . !'III' : . I'.':r~~n.sirde con.to > 4 kg. • R6i loan lipid rnau (tang.Triglycerid 1;lo~ctang , h6n hop). • Bieu hien lam sang nhu cac biSn chirngman tlnh.;· . • Sir dung thudc tranh thai. .'. . , . • Duong huyet dOibinh thuong nhung co duong nieu, ., Phuong phap ti@nhanh i .: + U6J1g .75g glucose hoa loang trong 250 - 300 nil mroc lee, udng trong 5 phut. '..' , .' ' +: Xet nghiem duong huyet (1:cac thai diSm: d6i 'va 120 phut d6i vai ---:c~~' . nguoi nghi ngo DTD (phuntrkhong mang thai). i l: ,I"" :1,': : •• I i . 4 - Phuong phap danh gia DR sau 'udng duong 120 phut a nguoi khong c6 thai < l,4gil (7,8 mmol/l)II-e ,II i II 1,4g11s DR <2 gil ~ 2 gil (11mmol/l) ~".~~ II Binh thmmg II Ghim dungnap II . Blii thao duongII Glucose , , J,' II Theo d5i hang namII 6.2. Chin do an th@UTI> ', 6.2.1. f)ai thao t/ldrngtjp 1 6.2.1.1. Sinh Ii' b~nh - OUt thuyet v~ benh 1)'tv mi6n dich diroc nhieu nguoi quan Him. - CO'dia (y@u t6 HLADR3 -D.~). 6.2.1.2. D(lc diJm B~t dAu< 30 tu5i Tti~u chang lamsang rAm fQ" .' The trang trung binh hoac gAy.. . .. ' i 'I' . - Ti6n sir gia dinh: c6 nguoi bi dai thao dirong yaJho~c cac benh 1)' tv mien dich khac. C6 benh ly tv mien dich ph6i hQ'P.. - Xet nghiem: + HLADR3 - D~(+) + KT khang dao tuy (++) 5 + Dinh hrong insulin mau thAp. + Test Gluccagon (6 phut sau tiem, peptid-C < 0,3 nmol/l). - Di~u,tri b~ng cac thuoc vien ha duong huyet khongco tac dung, - Bien chimg cAp tinh hay g~p: hon me nhiSm toan Xe ton. 6.2.2. Dil; thilo ilU'qng tYP 2 6.2.2.1. Sinh If benh .Co 2 yeu t6 cQ ban trong sinh ly benh cua dai. thao direng tYP 2, d6; la S\l d~ khang insulin va r6i loan tiet insulin. . .. - R6i loan ti8t insulin: dai thao dirong tYP 2 co tiet insulin nhung ti8t insulin cham S9 voi rmrc dmmg huyet. . . , . D~ khang insulin: + Tang san xuAt glucose 6' gan .. + Giam thu nap glucose 6 ngoai vi. + Giam thu th8 insulin 6 ~acrrio ngoai vi. 6.2.2.2. Dq,c diim ;~., . 'I Nguoi 100 >40 tu6i. Trieu clurng lam sang khong rAm1'Q (ph at hien tlnh co). Th8 trang beo (hay g~p beo ki8u nam). Ti~n sir: dai thao dueng thai ky 6 nu. Xetnghiem; .{_,;'. 'I + HLADR3 -DR.t (-) . + Khang th8 khang dao tuy (-) . + Test glucagon: Peptid-C > 1 mmol/l. .! . .... '..', !\' . , , - Di~u tri: di~u tri lau dai c6 hieu qua b~ng ch8 dQ an va cac ·thu6c vien ha DH va hoac bdng Insulin li~n nhau. ' (: 6.2~3.Dili thao i(U'(J'lig thlf philt (do cac nguyen nhli'n·khac) i '. G~p(1moi hra tu6i.. Xet nghiem: HLADRiDJtt (-).: Khang th8 khang dao tuy (-). - C6 nguyen nhan : benh 1y tuy, benh 1y nQi tiSt, do thudc. .... 6 7. DIEUTRJ B¥NH DA.ITHAo DlfONG .7.1. M\lc dich - Giam cac trieu chimg. + Lam sang: u6ng nhieu, ti8u nhieu, + c~ lam sang: duong huy8t gAnbinh tlnrong nhAt,khong con duong nieu, Dat can nang ly tuong (giam can voi dai thao duong typ 2 beo phi). - Cham xuAt hien cac bien chirng cAp va man tinh. Giup nguoi benh c6 cuoc s6ng binh thirong. 7.2. M\lc ti@u di~u tr] MI,w tie« kiim sod: DH thea Hi~p h~i DTlJ My (ADA) niim 2013 HbAlc < 7% duoc coi la rnuc tieu chung cho ca BTB typ 1 va cyp 2 khong rnang thai - Duong huyet luc d6i nen duy tri & mire 3,9 - 7,2 mmol/l (70 - 130mg/d,I). - Duong huyet sau an 2 gio < 10mmol/l « 180mg/dl). , . . : " " ,', ~" , . - Muc tieu kiem soat dirong huyet doi voi DID tuy theo tung benh nhan, tuy theo tu6i, th6i quen sinh hoat, tinh trang bien chimg va ihOi gian bi benh. - Di8u tri. cac y8u t6 nguy co di kern: .tang huy8t: ap, rM loan lipid mau ',. :","_. :.- '. . . ,; ! I. I'. . " .;! ,.,'. ;. , (tham khao phAn di8u tri bien clnrng man tinh cuabenh nhan DTD) . . 7.3. Ch@df) dinh dtrO'ngcho ngtrOi dai thao dirimg·· .'. . Dai thtu)·dirong ca hai th~·:cbS''dQan giam glucid, giam lipid :(iac;idbeo , bao hoa), 7.3.1.chi il~an .. 7.3.1.1. chi il9 an reit'(juan trong, la'~Jn tang co 6'a'n eua eli dr diJu tri b?nhjjtfJ; n6 c&n\phil hop va tung b?nh nha~ Vll phd! thad man dAy au 1 sa yiu .fa' co bdn sau: . I : ' - Btl chAtdarn, beo, bot, duong, vitamin, muc3ikhoang va nu6~ voi kh6i IUQ'tlghgp lY. . ! Khong lam tang dirong huyet ~hi8u sau an. - Khong lam ha duong huyet luc xa btra an. • r ,.: . - Btl duy tri hoat dQng th8 blnh thuong hang ngay, 7 """